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Thoracic injuries in US combat casualties: A 10-year review of Operation Enduring Freedom and Iraqi Freedom

Ivey, Katherine M. MD; White, Christopher E. MD; Wallum, Timothy E. MS; Aden, James K. PhD; Cannon, Jeremy W. MD; Chung, Kevin K. MD; McNeil, Jeffrey D. MD; Cohn, Stephen M. MD; Blackbourne, Lorne H. MD

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p S514–S519
doi: 10.1097/TA.0b013e3182754654

BACKGROUND Mortality from thoracic injuries has declined significantly from 63% in the Civil War to 3% in Vietnam. We reviewed the injury patterns, procedures, blood products, and mortality of US soldiers sustaining a thoracic injury during Operation Enduring Freedom and Iraqi Freedom (OEF/OIF).

METHODS Data on US soldiers with a thoracic injury during OEF/OIF from January 2003 to May 2011 was collected from the Joint Theater Trauma Registry. Coalition forces, civilians, and soldiers killed in action were excluded. Injuries and procedures were identified using DRG International Classification of Diseases—9th Rev. and Abbreviated Injury Scale (AIS) codes. Data are presented as mean (SD). Statistical analysis used χ2 analysis and t test where appropriate.

RESULTS Thoracic injuries occurred in 2,049 of 23,797 wounded US military personnel for a prevalence of 8.6%. Mean (SD) age was 26 (6.6) years, and mean (SD) chest AIS score was 2.9 (0.9). Penetrating trauma was the most common mechanism of injury (61.5%), and explosive devices were the most common cause of injury (61.9%). Of 6,030 thoracic injuries identified, pneumothorax and pulmonary contusions were most common (51.8% and 50.2%, respectively). Of 1,541 surgical procedures performed in theater, the most common was tube thoracostomy (47.1%). Most patients with penetrating fragmentation injuries (84%) were managed with tube thoracostomy as sole therapeutic intervention. The fresh frozen plasma–to–packed red blood cells ratio was 0.86. Overall mortality was 8.3%. Acute respiratory distress syndrome and inhalation injury were associated with mortality (p < 0.006).

CONCLUSION Most penetrating fragmentation injuries can be managed with tube thoracostomy. Mortality of patients with chest injury in OEF/OIF is higher than in Korea and Vietnam. This most likely represents advances in prehospital care, personal protective equipment, and rapid transport that have resulted in more severely injured patients arriving alive to a medical facility.

LEVEL OF EVIDENCE Epidemiologic study, level IV.

From the Department of General Surgery, San Antonio Military Medical Center Department of General Surgery (K.M.I, C.E.W., J.W.C), Fort Sam Houston Texas; the US Army Institute of Surgical Research (T.E.W., J.K.A., K.C.K, L.H.B.), Fort Sam Houston, Texas; the Department of Surgery, University of Texas Health Sciences Center at San Antonio (S.M.C.), San Antonio, Texas; and Department of Surgery, Uniformed Services University of the Health Sciences (J.W.C.), Bethesda, Maryland.

Address for reprints: Katherine M. Ivey, MD, San Antonio Military Medical Center, 4241 George C. Beach, Fort Sam Houston, TX 78234; email:

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

© 2012 Lippincott Williams & Wilkins, Inc.