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Original Investigation | Pacific Coast Surgical Association

Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in US Forward Military Treatment Facilities

Nicholas R. Langan, MD1; Matthew Eckert, MD1; Matthew J. Martin, MD1
[+] Author Affiliations
1Department of Surgery, Madigan Army Medical Center, Tacoma, Washington
JAMA Surg. 2014;149(9):904-912. doi:10.1001/jamasurg.2014.940.
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Published online

Importance  Analysis of combat deaths provides invaluable epidemiologic and quality-improvement data for trauma centers and is particularly important under rapidly evolving battlefield conditions.

Objective  To analyze the evolution of injury patterns, early care, and resuscitation among patients who subsequently died in the hospital, before and after implementation of damage control resuscitation (DCR) policies.

Design, Setting, and Participants  In a review of the Joint Theater Trauma Registry (2002-2011) of US forward combat hospitals, cohorts of patients with vital signs at presentation and subsequent in-hospital death were grouped into 2 time periods: pre-DCR (before 2006) and DCR (2006-2011).

Main Outcomes and Measures  Injury types and Injury Severity Scores (ISSs), timing and location of death, and initial (24-hour) and total volume of blood products and fluid administered.

Results  Of 57 179 soldiers admitted to a forward combat hospital, 2565 (4.5%) subsequently died in the hospital. The majority of patients (74%) were severely injured (ISS > 15), and 80% died within 24 hours of admission. Damage control resuscitation policies were widely implemented by 2006 and resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and increased fresh frozen plasma use (3.2-10.1 U) (both P < .05) in this population. The mean packed red blood cells to fresh frozen plasma ratio changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period (P < .01). There was a significant increase in mean ISS between cohorts (pre-DCR ISS = 23 vs DCR ISS = 27; P < .05) and a marked shift in injury patterns favoring more severe head trauma in the DCR cohort.

Conclusions and Relevance  There has been a significant shift in resuscitation practices in forward combat hospitals indicating widespread military adoption of DCR. 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.

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Figures

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Figure 1.
Died of Wounds Rates Over Time
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Figure 2.
Percentages of Soldiers With Severe Injury, Stratified by Study Cohort and Type of Injury

Statistical significance was determined by use of the χ2 test. AIS indicates Abbreviated Injury Scale; DCR, damage control resuscitation; and ISS, Injury Severity Score

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Figure 3.
Cumulative Monthly Rolling Averages for Killed in Action (KIA) Rate, Case-Fatality Rate (CFR), and Mean Injury Severity Score (ISS) for All Wounded Patients

Data were obtained from the Joint Theater Trauma System Directors Report 2013. The dashed line indicates the time point used to divide the study population into those who were treated before the implementation of damage control resuscitation (DCR) policies and those who were treated after.

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Figure 4.
Total Volume of Blood Products Administered in the First 24 Hours

DCR indicates damage control resuscitation; FFP, fresh frozen plasma; and PRBCs, packed red blood cells.

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