Scandinavian Journal of Surgery 0: 1 6, 2014

INTRODUCTION
Trauma casualties present a unique challenge, even
for experienced healthcare providers working under
optimal conditions. Care and management of these
casualties require experience and expertise. Timely
treatment is one of the most important variables affect-
ing outcome. Combat scenarios further complicate
matters; the austere environment and scarcity of
resources often hinder the provision of optimal care.
Geographical distances and other tactical limitations
often prolong evacuation times. These attributes of the
battlefield, along with the particular characteristics of
combat injuries, significantly differentiate military
trauma care from its civilian counterpart.
Medical care provided on the battlefield has long
been recognized as a platform for learning and for
applying lessons learned, both in military and civil-
ian medical systems. An important development in
military trauma care in recent years is the emphasis
on academic standards in a field that has long strag-
gled for the implementation of evidence-based medi-
cine. The value of learning from past experience is
A DECADE OF ADVANCES IN MILITARY TRAUMA CARE
E. Glassberg
1
, R. Nadler
1
, T. Erlich
1
, Y. Klien
2
, Y. Kreiss
1,3
, Y. Kluger
4
1
Surgeon Generals Headquarters, Israel Defense Forces, Ramat Gan, Israel
2
Department of General Surgery, Kaplan Medical Center, Rehovot, Israel
3
Department of Military Medicine, Hebrew University, Jerusalem, Israel
4
Department of General Surgery, Rambam Medical Center, Haifa, Israel
ABSTRACT
Background: While combat casualty care shares many key concepts with civilian trauma
systems, its unique features mandate certain practices that are distinct from the civilian
ones.
Methods: This is a review of the most current literature on combat casualty care, based
on computer database searches for studies on combat casualty care and military medicine.
Studies were selected for inclusion in this review based on their relevance and contribution.
Results: Over the last decade, meticulous, international data collection and research efforts
have led to significant improvements in military trauma care. Combat medicine has focused
on the causes of preventable deaths and targeted on bleeding control and resuscitation
strategies, as well as improved evacuation. En route care and forward surgical interventions
have resulted in unprecedented low fatality rates and the saving of more lives.
Conclusion: This overview of the developments in combat casualty care in recent years
emphasizes medical practices that are characteristic of combat medicine, yet with the
potential to save lives in other scenarios, as well.
Key words: Military; prehospital; point of injury; combat casualty care; preventable death; damage control
resuscitation
Correspondence:
Elon Glassberg, M.D., M.H.A.
The Trauma and Combat Medicine Branch
Medical Corps
Surgeon Generals Headquarters
Military POB 02149
Israel Defense Forces
02149, Ramat Gan
Israel.
Email: idf_trauma@idf.gov.il
523413SJS0010.1177/1457496914523413E. Glassberg, et al.Scandinavian Journal of Surgery
research-article2014
ORIGINAL ARTICLE
E. Glassberg, et al. 2
well recognized. However, the establishment of clear
definitions (1) and measurable outcomes (2), along
with continuous, focused research, is at the crux of
the explosion of data and improved outcomes
observed in recent years.
The last decade has seen major conflicts waged by
multinational coalition forces, particularly in Iraq
(Operation Iraqi FreedomOIF) and in Afghanistan
(Operation Enduring FreedomOEF). Unlike in pre-
vious large-scale conflicts, the medical care provided
in these conflicts was accompanied by meticulous
data collection and documentation. These data were
then used to characterize injury patterns, the medical
care provided, casualty outcomes, and mortality
causes. The information was in turn used to promote
and evaluate changes in the medical care provided to
trauma casualties.
A potentially salvageable death describes a casu-
alty for which the sustained injury that led to the
death would be survivable under optimal medical
care. Analysis of all combat-related mortality sus-
tained during OEF or OIF in the last decade reveals
that up to 25% of all deaths were potentially salvage-
able (2). Further exploration reveals that the vast
majority (90%) of these deaths is attributed to exsan-
guination, while a smaller proportion is related to
airway compromise (8%) and tension pneumothorax
(1%) (2). These data have both clinical and research
implications. The focus during OEF and OIF on
improving care for injuries that are classified as
causes of preventable death led to a reduction in
case of fatality rate (the ratio between mortality and
the total number of injured patients) to under 10%,
the lowest figure in the history of military medicine
(3). This dramatic improvement in the care provided
to injured personnel on the battlefield is reflected in
lower mortality rates in military casualties suffering
vascular injuries compared to a matched civilian
standard (4). Such merit of military medical care can
be attributed to prehospital tactical combat casualty
care (CCC), rapid medical evacuation to surgical
facilities, strict implementation of clinical practice
guidelines, and a trauma system constantly investi-
gating and executing necessary changes. Looking
into the future, we face the challenge of staying
updated, as we strive to implement lessons learned
and to further improve trauma and CCC.
This article will discuss some of the most signifi-
cant improvements achieved in CCC in recent years,
with an emphasis on medical practices that are
characteristic of military medicine. Hemorrhage
will be a particular focus, since it accounts for the
majority of preventable trauma-related mortality
and since the main improvement in CCC in recent
years has been the reduction of hemorrhage-related
mortality. A complete review of all advancements
made in recent years cannot be performed in the
scope of this article. We chose to focus on the
advancements relevant to most battlefields, while
regretfully omitting many important achievements
such as advancements in personal protective gear,
armed vehicles, data collection and trauma regis-
tries, and more.
TOURNIQUETS
Probably the most significant advancement in prehos-
pital trauma care in recent years is the widespread
implementation of tourniquet use. As recently as the
Vietnam War, tourniquets were considered a last resort,
and their use was instructed only following failure of
all other measures for hemorrhage control. This
approach resulted in 7.8% mortality attributed to
extremity wounds (5). At the start of the Afghanistan
conflict in 2001, many units were not equipped with
tourniquets and the recommendation was not to apply
tourniquets unless all else failed, an approach similar
to that adopted in the Vietnam War. This conservative
approach toward tourniquet application can be attrib-
uted to a possible potential for associated morbidity,
such as limb shortening in 0.4% and localized limb
palsy in 1.5% most often incomplete and temporary
(6). In 2004, following a large number of deaths from
extremity hemorrhage, and congruent with growing
clinical and laboratory data, experts on military medi-
cine issued a recommendation for the widespread dis-
tribution of tourniquets. By 2007, the majority of the
US military was equipped and trained in tourniquet
use (7). The use of tourniquets on the battlefield was
found to be associated with increased survival (8); the
death rate from extremity hemorrhage declined by
85% after full implementation of protocols for tourni-
quet use (2). Another example is evident in the Israeli
Defense Force (IDF), where tourniquets have been
widely distributed and used for the past 20 years by
both medical personnel and combatants. Until recent
years, the tourniquets used by the IDF were an elastic
silicone band for upper extremity hemorrhage or an
improvised Russian tourniquet, comprising a cotton
band twisted by a rigid stick to apply pressure for
lower extremity hemorrhage (9). As part of the IDF-
Medical Corps (IDF-MC) force buildup plan, the
Combat Application Tourniquet (CAT), a standardized
tourniquet with well-established efficacy (8), was dis-
tributed to all IDF combatants and medical personnel.
While many alternative tourniquets exist, the spe-
cific product used is not critical. Most important is the
recognition that early control of compressible extrem-
ity hemorrhage is one of the most significant aspects
of improving prehospital care. The wide distribution
of an easy-to-use rapidly applicable device, and its
application as close as possible to the point of injury,
will promote considerably the care provided to bleed-
ing casualties.
HEMOSTATIC DRESSINGS
For the last two millennia, and up until recent years,
gauze has been the only available dressing bandage.
Hemostatic dressings are new agents used to control
compressible hemorrhage. A number of active ingredi-
ents are available, which generate the desired effect of
topical clot formation. The first generation of hemo-
static agents included the use of fibrin-containing band-
ages. A number of US Food and Drug Administration
(FDA) -approved available agents have been developed
since. One of them is chitosan, a polysaccharide
Military trauma care 3
produced from crustacean shells, which cross-links red
blood cells to form a clot. Another available agent, non-
woven kaolin, aluminosilicate clay, activates the intrin-
sic coagulation pathway. Other products have also been
developed. While these agents have demonstrated
superior efficacy in compressible hemorrhage control
compared to regular gauze (10), no one alternative has
shown clear superiority over others (11). Presently, the
most frequently used hemostatic dressing is the Combat
Gauze

, which combines surgical gauze with the alu-

minosilicate kaolin. Despite several reports of positive
experience with Combat Gauze, efforts continue toward
development of a more effective hemostatic agent.
TRANEXAMIC ACID
The antifibrinolytic tranexamic acid (TXA) is a well-
known agent used for hemorrhage control at various
sites. Recent studies have demonstrated a positive
effect of TXA on the survival of bleeding patients. The
2010 Clinical Randomization of an Antifibrinolytic in
Significant Hemorrhage 2 (CRASH-2) trial, a prospec-
tive study of approximately 20,000 trauma patients,
demonstrated a significant reduction in mortality rate
among casualties who received TXA compared to a
control group who did not receive the drug. Early
administration of the drug (<1 h from injury) was
associated with the most significant reduction on mor-
tality risk (12). The CRASH-2 trial was the subject to
some degree of criticism, mainly due the possible
effect of undeveloped trauma systems, selection crite-
ria, and different attributes of the trauma centers
involved (13). Nevertheless, evidence indicating the
beneficial effect of TXA on hemorrhaging casualties
quickly led to its use in military scenarios (14, 15).
Data retrieved from military settings demonstrated a
positive effect of early administration of TXA, similar
to that observed in civilian scenarios, and particularly
pronounced in patients requiring massive hemor-
rhage (15). The use of TXA at the level of the surgical
units has become common practice in the majority of
modern militaries. Congruent with data suggesting
augmented efficacy of TXA with early administration
(12), several military medical systems have attempted
to administer this drug as early as possible. Indeed, in
the IDF, TXA is an integral part of the point of injury
treatment provided to casualties with suspected hem-
orrhage (14). The British airborne medical evacuation
unitthe Medical Emergency Response Team
(MERT)administers TXA as part of the en-route care
provided to bleeding casualties.
BLOOD PRODUCTS
Balanced component therapy is currently considered
the gold standard for the treatment of hemorrhaging
trauma patients, as part of damage control resuscita-
tion (DCR) principles. This approach supports trans-
fusion of blood products in a 1:1:1 ratio between red
blood cells, plasma, and platelets (16, 17). The imple-
mentation of this approach in advance military units
and combat support hospitals is one of the most sig-
nificant advancements of military medicine during
recent years; similar approaches have subsequently
been adopted in civilian medical systems (18). Data
collected in the last decade from deployed combat
support hospitals have indeed demonstrated an
increased ratio of transfusion plasma and platelets to
red blood cells, thus mimicking the composition of
whole blood as closely as possible (19).
The implementation of balanced component ther-
apy in the prehospital setting is challenged by signifi-
cant logistic constraints. Red blood cells require
refrigeration and are thus only available in advanced
medical units. Fresh frozen plasma, which is the most
commonly used preparation of plasma, requires deep-
freezing and a long thawing process. Platelets have a
short shelf life and require constant agitation, and are
thus irrelevant to combat scenarios. Military medical
units that can provide medical care at the point of
injury must be highly mobile. These units rarely have
refrigeration capabilities and are thus unable to use
red blood cells, platelets, or fresh frozen plasma. As
the vast majority of preventable deaths are attributed
to hemorrhage, attempts are made to implement DCR
principles as close as possible to the point of injury,
despite the logistic difficulties.
Attempts to bring blood products forward include
the use of freeze-dried or cryopreserved blood prod-
ucts, such as those currently used by The Netherlands
military. This involves specific deep-freezing tech-
niques that cause minimal derangements to the frozen
blood products. Storage time of deep-freeze blood
products is considerably longer than that of products
stored at 4C or at room temperature (20).
Unfortunately, the use of cryopreserved blood prod-
ucts is limited to medical units with refrigeration and
defrosting capabilities. Efforts to freeze dry red blood
cells and platelets continue. The use of freeze-dried
(lyophilized) plasma (FDP) will be discussed below.
FRESH WHOLE BLOOD
Fresh warm whole blood donated by uninjured sol-
diers and immediately transfused to a bleeding casu-
alty entails several advantages. The restoration of all
missing blood components is a main benefit of buddy
transfusion. Furthermore, a fresh warm blood prod-
uct is probably more effective in correcting the various
derangements caused by hemorrhage. Some evidence
suggests that one unit of fresh whole blood may
induce a hemostatic effect similar to that of 10 platelet
units (21), while other evidence suggests a similar
effect on survival compared to that afforded by com-
ponent therapy (22). Nevertheless, the use of fresh
whole blood is subject to a number of key considera-
tions. The use of nontyped whole blood requires the
transfusion of type O blood that has undergone anti-
body screening to ensure a low titer of anti-A and anti-
B antibodies (23). Such testing is not feasible in
out-of-hospital settings. Furthermore, the use of typed
whole blood requires typing both the donor and the
recipient; this can be done either before battlefield
deployment or on-spot sampling in the austere envi-
ronment of the battlefield. Both techniques entail mer-
its and significant disadvantages and both are
associated with a non-negligible chance of error (24,
25). The transmission of infectious diseases in
E. Glassberg, et al. 4
unscreened blood is another important concern, and
while mandatory screening and vaccination for all ser-
vicemen might reduce this risk (25), it remains an
important consideration.
Despite the recognized limitations, fresh whole
blood has been transfused in every major US military
conflict since World War I (24), including recent con-
flicts in Iraq and Afghanistan (25). The current US
military doctrine allows for fresh whole blood use in
emergency life-threatening scenarios in combat zones,
when tested stored blood components are unavaila-
ble, or when a patient does not respond to stored
blood component resuscitation (26). The Norwegian
navy adopted the use of fresh whole blood through a
designated training program for buddy transfusion,
named the Blood Far Forward training program (27),
while some military medical systems worldwide pre-
clude the use of fresh whole blood entirely.
FDP
Plasma can have substantial benefit as a resuscitation
fluid in the treatment of the hemorrhaging patient
(16, 18, 19). This use of plasma is based on data indi-
cating an association between the initiation of earlier
plasma transfusion in the hospital setting and posi-
tive patient outcomes (18, 28), as well as evidence of
deleterious effects of crystalloids of colloids as pri-
mary resuscitation fluids (29). The beneficial effect of
plasma resuscitation is likely due to the avoidance of
dilutional coagulopathy, the replacement of both pro-
and anticoagulant proteins, the repair of endothelial
function, and the promotion of anti-inflammatory
effects (30). Furthermore, plasma resuscitation pre-
cludes infusion of acidic crystalloids, which exacer-
bate the metabolic acidosis that is part of the lethal
triad of trauma. While, as mentioned above, the use
of Fresh Frozen Plasma is not feasible at the point of
injury, FDP is temperature stable, lightweight, and
rapidly reconstituted, making it logistically compati-
ble as a primary resuscitation fluid at the point of
injury (31). The use of FDP as a resuscitation fluid is
hardly innovative; dried plasma was already used in
World War II by the US Armed Forces. However, early
dried plasma was then pooled from as many as 1000
donors, introducing a substantial risk for blood-borne
infections (32). This changed in the 1990s, when the
French Blood Bank began producing dried plasma
pooled from approximately 10 donors. Medical units
of the French Army, as well as of the German Armed
Forces, have used FDP in conjunction with the devel-
opment of new, safer products. However, its use was
limited to advanced medical units, and point of injury
use was not attempted. Recently, the IDF-MC intro-
duced the use of the German LyoPlas

, making it the
resuscitation fluid of choice for transfusion by
advanced life support providers for patients suffering
from substantial hemorrhage (30). LyoPlas

is a single
donor FDP product (33). The use of type AB male
donors ensures universal ABO and Rh compatibility.
To date, several dozen units of LyoPlas have been
transfused at the point of injury to bleeding casual-
ties, with no adverse reactions or technical difficulties
reported (30).
MEDICAL EVACUATION
Rapid evacuation to a medical treatment facility with
advanced medical capabilities, including damage
control surgery (DCS), remains the mainstay of treat-
ment according to the vast majority of clinical prac-
tice guidelines employed by military medical systems.
The Vietnam War was the first conflict to demonstrate
extensive aeromedical evacuation using platforms
staffed with dedicated medical personnel on board;
over 900,000 casualties were evacuated. These teams
were capable of providing en-route care, including
basic hemorrhage control, fluid resuscitation surgical
airway establishment, and pain control. Modern war-
fare introduced several distinct evacuation platforms.
The US military employs both DUSTOFF evacuation
helicopters staffed with a medic capable of providing
basic life support and the PEDRO air evacuation
teams, which include on-board fighting paramedics.
Continued efforts are made to upgrade the level of
training of these teams, promoting improved medical
and operational capabilities (34). The British Royal
Air Force operates the MERT, a platform manned by
two paramedics, one physician and a nurse, capable
of providing advanced life-saving interventions,
including transfusion of blood products. Morrison
et al. examined the benefit afforded by on-board
advanced medical capabilities. In a study that com-
prised 865 casualties classified to three injury severity
scoring (ISS) categories (19, 1025, and 26+),
improvement in the hemodynamic status of casual-
ties throughout medical evacuation was demon-
strated in platforms that were capable of providing
advanced medical care but not in those providing
basic life support only (35). Other studies demon-
strated a survival benefit to platforms that provide
advanced medical care, particularly for casualties
with an intermediate ISS score (36). The IDF aerial
evacuation units consist of a medical team that
includes an intensive care physician (either a surgeon,
an emergency medicine specialist, or an anesthesiolo-
gist), a second physician in training or a paramedic,
and two combat medics. These teams can operate on
various aerial platforms and are capable of providing
advanced medical care, including life-saving inter-
ventions, advanced ventilation, and transfusion of
plasma and packed red blood cells (pRBCs). The aer-
ial evacuation force is utilized in low-threat scenarios,
including evacuation of civilians injured at locations
distant from medical treatment facilities, and also in
high-threat scenarios, in austere and hostile environ-
ments mandating combat adequacy.
The US critical care air transport (CCAT) is
designed to transport casualties to definitive-care
facilities located out of theater, up to thousands of
miles away. The teams consist of a critical care physi-
cian, a critical care nurse, and a respiratory therapist,
and are designed to augment standard aeromedical
transport teams when critical patients are trans-
ported. The teams are intended to be independently
functioning mobile intensive care units capable of
providing in-flight critical care to three ventilated
patients (37). Efforts continue to expand their capa-
bilities to provide care to sicker and sicker patients,
Military trauma care 5
including, for example, several cases of successful use
of in-flight extra-corporal lung support (38).
Operational risks and long evacuation distances
make combat aerial evacuation especially challenging.
These conditions pose substantial medical and tactical
demands, considerably different from the challenges
faced by civilian platforms. Despite the differences
between the platforms, civilian aeromedical evacua-
tion systems have developed in parallel to the intro-
duction of these capabilities to the battlefield (39).
Even today, experience gained in military scenarios
continues to have considerable influence on the devel-
opment and improvement of aerial capabilities in both
military and civilian settings.
Evacuation of trauma casualties by air entails sev-
eral significant advantages over ground evacuation,
the main advantage being timely arrival at a medical
treatment facility. This is specifically true on the bat-
tlefield, where long distances and an austere environ-
ment render fast ground-based evacuations practically
impossible. In fact, during several conflicts in Israel,
the majority of severely wounded soldiers were evac-
uated by air directly from the point of injury to a civil-
ian medical center. Despite its many benefits, aerial
evacuation can be severely compromised on the bat-
tlefield, mandating the militaries to continue to
develop and maintain also reliable, though slower,
ground evacuation capabilities.
FORWARD SURGICAL CAPABILITIES
Early surgical capabilities remain key to the medical
care provided to trauma victims in both the civilian
and military settings. Modern warfare is waged in
various scenarios. While medical support for conflicts
in close proximity to civilian populations can be
attained from civilian medical centers that serve as
definitive-care facilities (the Israeli model), the pro-
vision of medical support for remote campaigns neces-
sitates the establishment of a full medical arsenal and
deployment of advanced medical capabilities. The
recent conflicts in Iraq and Afghanistan witnessed the
most advanced combat support hospitals in the his-
tory of combat medical support. These facilities
included advanced imaging techniques and experts in
neurosurgery, cardiothoracic surgery, vascular sur-
gery, and more (40). The main disadvantage of such
robust facilities is that, similar to civilian medical cent-
ers, they are stationary. Moreover, they occasionally
mandate prolonged evacuations in order to be reached,
which may be even further delayed due to operational
considerations. The concept of allocating damage con-
trol surgical capabilities forward, in order to enable
faster access to surgical capabilities, is a relatively new
one. In the 1990 Panama conflict, the US military
deployed, for the first time, small mobile and highly
skilled medical teams capable of providing DCS. The
composition of such Forward Surgical Teams (FSTs)
varies according to their designated mission, from a
team of approximately 20, including at least four sur-
geons, eight nurses, and two surgical technicians, to
four person jump teams that consist of one surgeon,
two nurses, and one surgical technician (41). FSTs are
designed to provide high quality care (including DCS)
to a small number of patients closer to the point of
injury and on an earlier echelon of care. The main ben-
efit afforded by FSTs highly trained personnel is the
provision of expert triage and intensive care (42), with
surgical capabilities an important adjunct. In a series
describing the experience of such a team, up to 43% of
761 casualties underwent surgical treatment.
DATA GATHERING
Combat-related data collection has advanced signifi-
cantly in recent years. Recognition of the importance
of ongoing data analysis prompted the establishment
of several dedicated military trauma registries, focus-
ing on injury, medical treatment, evacuation, hospi-
talization, and outcomes of combat injuries. The
importance of international collaboration has simi-
larly been recognized, leading to the formation of
multinational learning processes, including joint
investigation of after action reports, shared regis-
tries, and more. Similar collaboration has also devel-
oped between military and civilian systems, thus
enabling more efficient and reliable knowledge crea-
tion and utilization, ultimately directed toward a
common goal shared by allsaving as many lives as
possible.
CONCLUSION
The field of CCC and military trauma care has under-
gone a substantial leap in recent years. While some of
the medical advancements of CCC will remain irrele-
vant to civilian medical systems and vice versa, others
offer great opportunities for implementation of les-
sons learned on the battlefield to civilian medical care.
Only by reciprocal learning can the full potential of
these opportunities be achieved, thus improving the
care provided to the wounded, on the battlefield and
in the civilian population, and ultimately saving lives
around the world.
CO-AUTHORSHIP STATEMENT
It should be noted that the first two authors of this paper,
Elon Glassberg and Roy Nadler, both contributed equally to
the finished manuscript.
DECLARATION OF CONFLICTING INTERESTS
The authors declare that there is no conflict of interest.
FUNDING
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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Received: October 16, 2013
Accepted: December 19, 2013