Page 40 - JSOM Winter 2018

deaths on the battlefield. 1-10 Deaths from extremity hemor- Improving the care provided to casualties with NCTH due
rhage are now uncommon in combat casualties and deaths to abdominal or pelvic hemorrhage is the most significant
from junctional hemorrhages can be prevented with hemostatic opportunity to reduce preventable deaths in combat casual-
dressings, junctional tourniquets, and XStat. Deaths from air- ties. At this point in time, the two interventions that offer the
way obstruction are now infrequent with most US combat greatest potential for further reduction in preventable deaths
medical personnel being trained in TCCC airway measures. 6,11 among combat casualties are early resuscitation with whole
Deaths from tension pneumothorax have been reduced by the blood and Zone 1 REBOA, performed as soon as possible af-
use of 3.25 inch, 14 gauge needles after the study by Harcke ter wounding when indicated. This proposed change to TCCC
and colleagues. Recommendations for the management of will explore how best to employ these two interventions in the
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this disorder in TCCC have just been further updated to reflect prehospital care of the combat wounded using a resuscitation
emerging research findings and clinical experience. However, team approach.
1
noncompressible torso hemorrhage (NCTH) remains the lead-
ing cause of preventable prehospital death for which TCCC For the critically injured, indicated lifesaving interventions
currently has no definitive solution. NCTH may be either ab- must be undertaken shortly after wounding to maximize the
dominopelvic or thoracic. number of lives saved. The “Golden Hour” concept applies to
evacuation time. Evacuation to a treatment facility with a sur-
Patients with NCTH and shock who require a trauma lapa- gical capability within 60 minutes of approval of the Casualty
rotomy have been noted to have a mortality of 46% in civilian Evacuation mission has been shown to reduce mortality when
settings 13,14 and this mortality rate has not changed over the last achieved, but death can occur well before 60 minutes in ca-
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two decades. In the UK military, mortality for the subset of ca- sualties with NCTH and shock. Additionally, there may be
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sualties with abdominopelvic hemorrhage and shock is 25%. 14 further delays to achieving definitive control of noncompress-
ible hemorrhage even after the casualty arrives at a surgical
Improved prehospital control of abdominopelvic NCTH has capability. Holcomb notes that: “The peak time to death after
the potential to reduce Died of Wounds (DOW) deaths as well. severe truncal injury is within 30 minutes of injury. However,
Mortality is low if the casualty survives the prehospital phase of when adding prehospital transport time, time spent in the
care and reaches the care of a surgeon. Holcomb and colleagues emergency department, followed by the time in the operating
found DOW rates to be 6.7% in Afghanistan and 4.7% in Iraq room, it currently takes 2.1 hours to achieve definitive truncal
in the earlier years of those conflicts. Nessen and colleagues hemorrhage control.” It is clear that pre-OR hemorrhage con-
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reported this year that while US military prehospital combat trol is required to decrease deaths from truncal hemorrhage. 22
deaths (Killed in Action or KIA) decreased during the conflicts
in Iraq and Afghanistan as compared to Vietnam, the incidence Background
of DOW deaths in those who arrived alive at a Medical Treat-
ment Facility (MTF) increased (5.3% for Iraq and Afghanistan The Golden Hour
vs 3.3% for Vietnam). Through treating hemorrhagic shock In 2009, Secretary of Defense Robert Gates mandated that
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with whole blood and controlling abdominopelvic NCTH with operations in Afghanistan be planned such that all urgent
Resuscitative Endovascular Balloon Occlusion of the Aorta casualties could be evacuated to a surgical capability within
(REBOA), Advanced Resuscitative Care (ARC) in TCCC holds 60 minutes of TACEVAC mission approval. This action was
the potential to significantly decrease the incidence of DOW subsequently found to be associated with a reduction in pre-
deaths as well as KIA deaths. Buehner and colleagues noted hospital deaths among US combat casualties from 16.0% to
that 23% of 1704 casualties who arrived at a Role 3 Medical 9.9%. 20
Treatment Facility (MTF) with a systolic blood pressure (SBP)
less than or equal to 90mmHg did not survive. In 2009, Mar- This Secretary of Defense mandate was specific to the rela-
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tin found that the two leading causes of DOW deaths were tively mature combat theater in Afghanistan at the time. Even
head injury (45%) and hemorrhage (32%). Martin further in that setting, implementation of the mandate restricted op-
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found that deaths from hemorrhage usually occurred in the erational planning and caused “surgical capability” to be re-
resuscitation (31%) or operative (38%) phases of in-hospital defined. 23,24 The Golden Hour concept may be impossible to
care. It is clear that many of the casualties in the DOW cate- sustain in other combat settings, such as early entry opera-
gory have potentially preventable hemorrhagic deaths. Having tions, war with a near-peer nation, two simultaneous conflicts
a stabilized casualty with a Zone 1 REBOA catheter in place in different geographic regions, or a very large theater of con-
at the time of arrival at the MTF therefore has the potential to flict (Africa or the Pacific.) The present operational demands
save many casualties who would otherwise die from hemor- for general and trauma surgeons in the Army makes maintain-
rhage even after reaching a surgical capability. ing a sufficient number of fully trained and capable surgeons
to meet deployed surgical requirements increasingly difficult.
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The second major cause of death after reaching an MTF is head There is a need for a bridging capability to better sustain a se-
injury. Earlier control of hemorrhage, to include noncompress- verely injured casualty with NCTH from point-of-injury (POI)
ible abdominal and pelvic hemorrhage, and improved resusci- to a combat surgeon. 25,26
tation from shock has the potential to reduce deaths from head
injury as well. Avoiding prehospital hypotension was noted by A substantial portion of the observed decrease in mortality in
Spaite to decrease the incidence of death in patients who had the years between 2001 and 2009—as compared to the time
sustained moderate/severe Traumatic Brain Injury (TBI), indi- period from 2009 to 2014 after the Golden Hour mandate
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cating that improved prehospital hemorrhage control and bet- was in place—was due to other advances in battlefield trauma
ter fluid resuscitation may offer the potential to reduce deaths care that took place during the Afghanistan and Iraq conflicts,
in casualties who have both hemorrhagic shock and TBI as well including the widespread adoption of TCCC interventions and
as those who are in hemorrhagic shock without TBI. the increased use of prehospital blood products. 11,27-31

38 | JSOM Volume 18, Edition 4 / Winter 2018