Trauma and Combat Critical Care in Clinical Practice PDF



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Preface

In the early 1980s, Trunkey 1 described a pattern of trauma mortality that is still widely referred to today. His tri-modal distribution model considered that death could occur in one of three peaks. The early peak (death within minutes) is caused by catastrophic injuries with severe anatomical disruption. These injuries were, and still are, difficult or impossible to treat, although preventative measures such as car seat belts and military combat body armour have reduced the frequency. The middle peak consists of deaths occurring within the first hours following injury and mainly results from profound disruption of homeostasis and physiology. Examples include uncontrolled blood loss leading to traumatic haemorrhagic shock or failure of respiration secondary to an obstructed airway or intrinsic lung damage. A vast amount of clinical academic endeavour has been spent on reducing this second peak. Some of the multitude of examples include the adoption of standardised ATLS teaching highlighting the importance of the “Golden Hour”, the development of dedicated major trauma networks, physician-delivered prehospital care, and changes to resuscitation paradigms that emphasise the importance of physiological damage control rather than anatomical restoration and the adoption of point of care devices to prevent catastrophic haemorrhage. Many of these advances have been driven forward at pace by the Defence Medical Services of nations involved in combat operations during the first two decades of the twenty-first century, and there is no doubt that many military casualties have recovered from injuries that would have been deemed un-survivable just a few years earlier.
But what of the third peak? Trunkey attributed these late deaths to multiple organ failure occurring days or often weeks after the initial injury. However, an examination of the demographics of trauma deaths today shows that this third peak has been substantially reduced. Of the 518 British military casualties of the war in Afghanistan who received a massive transfusion at the Role 3 hospital in Camp Bastion, over 91 % survived. 2 This occurred despite an average injury severity score of over 30. Much of this success was due to a reduction in the second (early) mortality peak but not all. Of the 441 British military personnel who died from combat related injuries in the Iraq and Afghanistan conflicts, 83 % died prior to hospital admission, reflecting the persistence of Trunkey’s first peak. Of the 17 % who died after reaching hospital, 53 % died in the first 24 h, meaning that those that survived beyond 24 h had a 93 % chance of long-term survival. 3 Those 7 % who suffered late deaths can be compared with around 20 % of deaths occurring during the late peak of the original Trunkey study, many of whom were also much less severely injured.
This trend of falling late mortality is also found when examining modern civilian trauma systems. A recent randomised study 4 examining the optimal ratio of packed cells to plasma in American trauma patients who received a massive transfusion showed a lower mortality than predicted prestudy (24 % vs. 35 %) but also a low incidence of death from multiple organ failure (12.8 % of those who died and 3 % of those who were enrolled).


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