Bottom Line: Widespread military adoption of damage control resuscitation (DCR) policies has shifted resuscitation practices at combat hospitals during conflicts.
Author: Nicholas R. Langan, M.D., and colleagues from the Madigan Army Medical Center, Tacoma, Wash.
Background: Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are the first prolonged conflicts the United States has been involved in since the Vietnam War. Medical and surgical advances have often emerged from the battlefields. One of the most important advancements in combat trauma care has been the adoption of DCR, with the basic principles of early, balanced administration of blood products, aggressive correction of coagulopathy (when blood will not clot) and the minimization of crystalloid fluids (intravenous fluids). Adoption of DCR has been credited with improvements in survival among severely injured patients.
How the Study Was Conducted: Authors analyzed injury patterns, early care and resuscitation among soldiers who died in the hospital before and after implementation of DCR policies. They reviewed data from the Joint Theater Trauma Registry (2002-2011) for combat hospitals. In-hospital deaths were divided into pre-DCR (before 2006) and DCR (2006-2011).
Results: Of 57,179 soldiers admitted to a forward combat hospital, 2,565 (4.5 percent) subsequently died at the hospital. The majority of patients (74 percent) were severely injured and 80 percent died within 24 hours of admission. DCR policies was associated with a decrease in average 24-hour crystalloid infusion volume and increased use of fresh frozen plasma. The average ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period. There was a shift in injury patterns with more severe head trauma cases in the DCR group.
Discussion: "Patients who died in a hospital during the DCR period were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients."
(JAMA Surgery. Published online July 16, 2014. doi:10.1001/jamasurg.2014.940. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Commentary: Let's Close Performance Improvement Loop on Adverse Outcomes
In a related commentary, John B. Holcomb, M.D., of the University of Texas Health Science Center at Houston, writes: "The War on Terrorism will not be over for a long time. Command attention at all levels on combat casualty care must remain a laser focus or our casualties will not have the best possible outcome."
(JAMA Surgery. Published online July 16, 2014. doi:10.1001/jamasurg.2014.961. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Media Advisory: To contact corresponding author Matthew J. Martin, M.D., call Carrie Bernard at 253-968-2968 or email carrie.bernard@us.army.mil. To contact commentary author John B. Holcomb, M.D., call Rob Cahill at 713-500-3042 or email Robert.Cahill@uth.tmc.edu.
Journal
JAMA Surgery