Page 28 - JSOM Summer 2024

TABLE 2 Demographic Profile of Casualties TABLE 3 Injuries Documented in the Tactical Combat Casualty
Cohort, no. (%)* Care (TCCC) Cards or TCCC After-Action Reports (AARs)
Non-TBI; TBI; Cohort, no. (%)
n=637 n=72 p-value Non-TBI; TBI;
Demographics n=637 n=72 p-value
Age group, y .013 Amputations 45 (7) 1 (1) .074
18–25 274 (43) 21 (29) Bleeding 47 (7) 11 (15) .036
26–33 254 (40) 33 (46) Burns 24 (4) 0 (0) .159
34–41 68 (11) 16 (22) Deformities 32 (5) 7 (10) .102
42–49 29 (5) 2 (3) Fractures 87 (14) 14 (19) .183
50+ 12 (2) 0 (0) Gunshot wounds 196 (31) 11 (15) .006
Male 629 (99) 71 (99) 1.000 Lacerations 104 (16) 12 (17) .941
Mechanism of injury .037 Peppering 79 (12) 5 (7) .246
Blast 328 (51) 45 (63) Puncture wounds 102 (16) 12 (17) .886
Falls 22 (3) 6 (8) TBI suspected 42 (7) 15 (21) <.001
Firearms 213 (33) 13 (18) TBI = traumatic brain injury.
Motor vehicle collisions 28 (4) 3 (4) TABLE 4 Traumatic Brain Injury Diagnoses (n=72)
Others 46 (7) 5 (7)
Affiliation .638 Injury No. (%)
U.S. military 438 (69) 47 (65) Epidural hematoma 7 (10)
Coalition 9 (1) 0 (0) Subdural hematoma 20 (28)
Subarachnoid hematoma 18 (25)
U.S. civilian 21 (3) 2 (3)
Partner force 102 (16) 12 (17) Other brain injury 61 (85)
Humanitarian 67 (11) 11 (15)
ISS, median (IQR) 5 (2–12) 14 (5–29) <.001 ultrasound technology, and serum biomarker assessments us-
19-21
ing handheld point-of-care technology.
Discharge status, alive 625 (98) 66 (92) .006
Serious injuries by body region Males continue to account for a majority of TBIs; however,
Head/neck 33 (5) 37 (51) <.001 this may be directly related to exposure and jobs that were
Face 1 (<1) 2 (3) .028 previously only open to males during a conflict. 22,23 Multiple
Thorax 65 (10) 15 (21) .007 studies have identified combat casualties from recent con-
Abdomen 42 (7) 3 (4) .423 flicts, including a 2019 study identifying 56,763 U.S. casual-
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Extremities 147 (23) 12 (17) .236 ties. Our study identified 709 casualties, which equates to
Skin 13 (2) 1 (1) 1.000 only 1% of that population. It is unclear how many of these
*Unless otherwise specified. 56,753 patients underwent evaluation in the Role 1 setting or
TBI = traumatic brain injury; ISS = injury severity score; IQR = inter- required evacuation to higher echelons of care. The limited size
quartile range. and time frame of the PHTR data capture remains a limita-
tion. Additional findings among Servicemembers with severe
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Our data suggest that accurate detection of TBI is difficult TBI suggest that only 6% return to active service. Therefore,
during early levels of care. TBI is challenging to classify with- improvement in the quality of care has been a major focus of
out imaging, especially hemorrhagic injuries. However, neu- large military studies regarding casualties in recent conflicts,
roimaging is not available in the Role 1 setting. A 2009 study particularly early in the clinical course with limited diagnostic
(n=3,973) reported that 21% of soldiers who returned home facilities. Measurement of intracranial pressures, vasospasm,
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had an undiagnosed TBI, mostly minor concussive symptoms. and cerebral autoregulation have been proposed recently for
Another contrasting finding is the mechanism of injury in such TBI detection in resource-limited settings. 4
populations. The most common causes underlying civilian
TBI include falls (28%), followed by MVCs (20%), while ex- Our study demonstrates comparable findings and new data in
plosives are the predominant factor contributing to military the prehospital setting; however, it is not without limitations.
TBI. 9,10 However, this may be the result of biased reporting and Linkage between the PHTR and the DoDTR is often difficult.
inclusion procedures as minor TBIs from MVCs or falls may Thus, few cases were available for inclusion in this analysis. The
not even seek formal care beyond the unit medic or be man- DoDTR requires that a casualty arrives at a facility with surgical
aged without transfer to a higher level of care. The DoDTR capabilities with signs of life or ongoing interventions, which
has specific inclusion criteria that require transportation to a thus excludes those that died in a lower level of care. 7,16 Data col-
surgical facility, which may have led to missed cases within our lection has also changed through these conflicts. The PHTR has
data set. Previously reported data found a higher percentage limited periods of data capture for entry, so we cannot assess for
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of overall TBI during OIF and OEF due to explosions (78%), changes that may have occurred during the conflicts. The data
although the percentage related to explosions in our TBI captured has also changed frequently throughout the conflicts.
cohort was lower (63%), and the differences were not sub- Therefore, as the registry grew, the number of datapoints gen-
stantial. 17,18 Our data highlight the need for appropriate tech- erally increased. It is likely that many of the variables available
nology to accurately aid in the diagnosis of TBI in the Role 1 for capture changed throughout the study period. Further, the
setting. This gap could be filled with technologies that are study team did not have access to the raw data in the form of
currently in development such as pupillometry, advanced the TCCC cards or other written records and only had access

26 | JSOM Volume 24, Edition 2 / Summer 2024