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Penetrating Axilla Injuries and Ceramic Plate Coverage

A Special Operations Case Series

Duncan Carlton, MD *; Alexandre Nguyen, MD ; Nicholas Warner, 68W ;
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Ryan Knight, MD ; Christopher Myers, 68W ; Jonathan Auten, DO 6
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ABSTRACT

Introduction: The Department of Defense has continually re- has vexed these efforts is penetrating axilla injury. Currently,
fined body armor to mitigate battlefield injuries over the last the only protection for U.S. Servicemembers is the standard
20 years. Penetrating axilla injuries remain challenging despite four ceramic plate system seated within a soft armor Kevlar
adoption of a four-plate ceramic armor system. This study carrier. This system is born from a 1980s Defense Advanced
investigates the efficacy of current armor configurations in Research Projects Agency (DARPA) program that took a cen-
reducing mortality and morbidity associated with axilla inju- tury of innovation in ceramic armor and combined it with
ries. Methods: This was a retrospective case series using after- Vietnam-era flak jackets to create the Interceptor Vest, the first
action reports from a single Special Operations unit. Records infantry body armor rated for high velocity protection. Con-
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(786) from 2001–2018 were screened, yielding 11 meeting in- sisting initially of only front and rear ceramic plates, known
clusion criteria. Data included injuries, body armor type, clin- as small arms protective inserts (SAPIs) it found widespread
ical interventions, and outcomes. Results: Analysis revealed use during the early days of the Global War on Terrorism
significant mortality (45%) among casualties sustaining axilla (GWOT). After a few years of intense battlefield use, an Armed
injuries, with 100% mortality for those struck in uncovered Forces Institute of Pathology report reviewing 401 casualties
side-plate regions under a two-plate system. In contrast, no from 19 March 2004 to 30 June 2005 postulated that 23%
fatalities occurred when injuries were within protected side- of fatalities would have likely survived if they had also been
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plate regions of a four-plate system. Injury patterns showed wearing side ceramic plates. This led to the introduction of
consistent thoracic cavity violations, emphasizing the need the modern four-plate system, which, with minor variations
for robust protection strategies. This study underscores the in carriage system and soft armor coverage, is universal today.
efficacy of four-plate systems in reducing mortality compared
to older configurations, particularly in protecting vital struc- Despite the introduction of the four-plate system by 2006, the
tures like great vessels and the heart. However, limitations in lethality and incidence of axilla wounds persist. The Eastridge
current side-plate coverage suggest potential gaps in protec- et al. study reviewing prehospital deaths from 2001 to 2011
tion, especially superiorly. Balancing protection with mobility noted that penetrating thoracic and axilla trauma still ac-
remains crucial, as highlighted by operational challenges and counted for 24% and 13% of prehospital fatalities, respec-
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weight concerns. Conclusion: Findings support the role of side tively. This was also echoed in a British review of 7,856
plates in mitigating axilla injuries but highlight the need for casualties in Afghanistan by Poon et al., who noted that de-
expanded coverage using improved material technologies. Fu- spite changes in armor they were still encountering a 10.5%
ture research should focus on enhancing ballistic protection incidence of penetrating thoracic wounds for casualties, with
without compromising operational agility and refining trauma those patients carrying three times the mortality compared to
management protocols for optimal casualty outcomes. all comers. 6

Keywords: axilla; exsanguination; gunshot wound; mediastinal The aim of the following case series was to investigate the ef-
injury; transmediastinal gunshot wound; ballistic plates; body fectiveness of our current four-plate system and attempt to de-
armor; combat injury; military trauma fine wounding patterns despite current protection.

Methods
Introduction
This study was a retrospective case series conducted through
Over the last two decades of combat, the Department of De- review of casualty and after-action reports retained in the ar-
fense (DoD), Military Healthcare System (MHS) and the Joint chives of a single Special Operations unit to identify trends
Trauma System (JTS) have spent considerable time and effort in mortality and morbidity associated with axilla wounds.
to identify battlefield injury patterns and develop strategies to We defined the axilla as the lateral chest wall bound by the
mitigate mortality and morbidity. One of the patterns that anterior axillary line, iliac crest, posterior axillary line, and
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*Correspondence to duncanmarkcarltonmd@gmail.com
1 LCDR Duncan Carlton is affiliated with the Emergency Department, Naval Medical Training Center, San Diego, CA and the Combat Trauma
Research Group West, San Diego CA. LCDR Alexandre Nguyen is affiliated with the Emergency Department, Naval Medical Training Center,
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San Diego, CA and the Combat Trauma Research Group West, San Diego CA. SSG Nicholas Warner is affiliated with the 75th Ranger Regi-
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ment, Fort Benning, Columbus, GA. COL Ryan Knight is affiliated with the Martin Army Community Hospital, Fort Benning, Columbus, GA.
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5 SSG Christopher Myers is affiliated with the 2nd Battalion, 75th Ranger Regiment, Joint Base Lewis–McChord, Seattle, WA. CAPT Jonathan
Austen is affiliated with the Emergency Department, Naval Medical Training Center and the Combat Trauma Research Group West, San Diego CA.
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