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performed by the JTS staff prior to data transfer to the study TABLE 1 Classification of Traumatic Brain Injuries
team. The U.S. Army Institute of Surgical Research regulatory Category ICD-9 code(s)
office reviewed protocol H-19-018nh and determined that it Epidural hematoma 852.4, 852.5, S06.4
was exempt from institutional review board oversight. We ob-
tained only de-identified data. We executed data sharing agree- Subdural hematoma 852.2, 852.3, S06.5
ment 19-2186 prior to data transfer. Subarachnoid hemorrhage 852.0, 852.1, S06.6
Brain injury (other) 853.0, 853.1, 851.8, 851.9, 851.4,
851.0, S06.0, S06.1, S06.2, S06.3,
Prehospital Trauma Registry (PHTR) S06.8, S06.9
The JTS PHTR is a data collection and analytic tool designed to
provide near-real-time feedback to commanders. It is primarily FIGURE 1 Registered Casualties linked to the Department of
intended to improve casualty visibility, augment command de- Defense Trauma Registry (DoDTR).
cision-making processes, and direct procurement of medical re-
9
sources. Additionally, this tool can be used to reduce morbidity N=1357
and mortality through performance improvement in the areas Number of
of primary prevention (tactics, techniques, and procedures), sec- casualties within
ondary prevention (personal protective equipment), and tertiary the original data set
prevention (casualty response system and TCCC). 7,9-11 The U.S.
Central Command mandates the completion of TCCC cards
and/or TCCC AARs, which are collected and analyzed by the N=709 N=648
JTS. We have previously described the origins of the PHTR. 7,9–11 Included casualties Excluded casualties
Documentation, including clinical findings suggesting TBI, is linked to DoDTR not linked to
DoDTR
based on the records obtained from the clinician at the Role 1,
which may include structured assessments such as the Military
Acute Concussion Evaluation (MACE). 12
N=72 (10%) N=15 (7%)
Total
The DoDTR Documented Role 1
The DoDTR, formerly known as the Joint Theater Trauma TBI Documented TBI
Registry (JTTR), is the data repository for DoD trauma-
7
related injuries. The DoDTR includes documentation regard- TBI = traumatic brain injury.
ing demographics, injury-producing incidents, diagnoses, treat-
ments, and outcomes of injuries sustained by U.S./non-U.S. overwhelming majority of casualties (99%) in both groups.
military and U.S./non-U.S. civilian personnel (including host Most casualties were attributed to blast injuries—328 (51%)
nation civilians) from the point of injury to final disposition. non-TBI and 45 (63%) TBI. The non-TBI cohort had a median
Short-term outcome data are available for non-U.S. casualties. ISS of 5, compared with 14 in the TBI cohort. The survival
The DoDTR is primarily composed of patients admitted to a of non-TBI cohort was higher (98%) than in the TBI cohort
hospital with an injury diagnosis based on the International (92%). The most frequently documented injuries within the
Classification of Disease 9th Edition (ICD-9) codes ranging PHTR data were firearm wounds in the non-TBI cohort and
between 800 and 959.9, near-drowning/drowning with associ- fractures in the TBI cohort (Table 3). Subdural hematomas,
ated injury (ICD-9 994.1), inhalational injury (ICD-9 987.9), followed by subarachnoid hemorrhages were the most com-
or trauma occurring within 72 hours from presentation to a mon classifiable brain injuries (Table 4). Other nonspecific
facility with surgical capabilities. Registrars perform the scor- TBIs were documented in 85% of the TBI cohort casualties.
ing for the Abbreviated Injury Scale (AIS) and the composite
Injury Severity Score (ISS). Seventy-two cases (10%) were documented by a clinician at
the Role 1 facility. TBI based on coding or operative data was
Data Analysis found in 15 of the 72 cases (21%) at higher roles of care.
We performed all analyses using Microsoft Excel (version Based on Role 1 records, TBI was suspected in 42 (7%) of the
10, Redmond, WA) and JMP Statistical Discovery from SAS 637 cases of missed diagnoses due to coding or operative data.
(version 16, Cary, NC). Continuous variables were described
using means and 95% CIs and compared using the t test. We Discussion
described ordinal variables or non-normally distributed con-
tinuous variables using medians and interquartile ranges and TBI was documented in 72 (10%) of the entire cohort of 709
compared using the Wilcoxon rank sum test and the sign test. cases. This number is substantially lower than in other reports
We described categorical variables using numbers and percent- using deployed data. 13,14 However, we suspect that this discrep-
ages and compared them using the chi-square test or the Fisher ancy may be the result of heavy underreporting, as the PHTR
exact test if the expected cell count was <10. We classified inju- has limited data capture timeframes, most of which were de-
ries using the ICD-9 and AIS injury codes (Table 1). rived from the early war period in the absence of TBI screening
or documentation. The limitations in this bimodal distribution
of casualties within the PHTR have been reported previously.
7
Results
As expected, most of the casualties were male and injured
The original data set contained 1,357 casualties, of which 709 by an explosive mechanism. The most common TBI diagno-
were linked to the DoDTR outcome data and met the criteria ses included subdural hematoma, followed by subarachnoid
for inclusion in this analysis (Figure 1). The largest proportion hemorrhage. This is particularly informative as operative and
of casualties occurred in the age groups of 18–25 years and non-operative management differs substantially between these
26–33 years in both cohorts (Table 2). Males constituted the two pathologies, particularly when they appear in isolation.

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