Department of Kinesiology, Health, and Nutrition, The University of Texas at San Antonio.
Department of Defense Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas.
JAMA Surg. 2019 Jul 1;154(7):600-608. doi: 10.1001/jamasurg.2019.0151.
Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict.
To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes.
Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR.
In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times.
Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.
尽管阿富汗和伊拉克冲突的美国病死率是历史上最低的，但截至目前，尚无关于冲突 16 年后的战斗伤员救治统计数据、主要干预措施或风险因素的全面评估。
分析总体战斗伤员统计数据的趋势，评估伤害和干预措施的综合指标，并模拟如果没有这些干预措施，死亡率将会如何变化。
设计、设置和参与者：对 2001 年 10 月 1 日至 2017 年 12 月 31 日期间在阿富汗和伊拉克战区受伤的 56763 名美国军人的所有可用综合和加权个人行政数据进行回顾性分析，这些数据均来自国防部数据库。将伤员结局与特定时期使用止血带、输血和在 60 分钟内运送到外科设施的比例进行比较。
主要结局是伤员状态（存活、阵亡[KIA]或因伤死亡[DOW]）和病死率（CFR）。回归、模拟和分解分析用于评估协变量、干预措施和个体伤员状态之间的关联；估计伤员的转移（KIA 转为 DOW、KIA 转为存活、DOW 转为存活）；并估计干预措施对 CFR 变化的贡献。
在 56763 名伤员的汇总数据中，阿富汗（从冲突早期的 20.0%降至后期的 8.6%）和伊拉克（从 20.4%降至后期的 10.1%）的 CFR 均有所下降。危重伤员（损伤严重程度评分 25-75[危]）的存活率从阿富汗的 2.2%增加到 39.9%，从伊拉克的 8.9%增加到 32.9%。对 23699 名个体伤员的数据进行模拟表明，如果没有评估的干预措施，阿富汗的 CFR 可能会更高（估计为 15.6%，而观察到的为 8.6%），伊拉克的 CFR 也会更高（估计为 16.3%，而观察到的为 10.1%），这相当于额外增加了 3672 例死亡（95%CI，3209-4244 例），其中 1623 例（44.2%）与所研究的干预措施有关：474 例死亡（12.9%）（95%CI，439-510 例）与使用止血带有关，873 例（23.8%）（95%CI，840-910 例）与输血有关，275 例（7.5%）（95%CI，259-292 例）与院前转运时间有关。
我们的分析表明，止血带、输血和更快的院前转运的使用增加与总死亡率降低的 44.2%有关。更多危重伤员得到了外科救治，存活率提高，这意味着院前和医院救治都有所改善。
