title: Died of wounds on the battlefield: causation and implications for improving combat casualty care.
abstract: BACKGROUND
  Understanding the epidemiology of death after battlefield injury is vital to combat casualty care performance improvement. The current analysis was undertaken to develop a comprehensive perspective of deaths that occurred after casualties reached a medical treatment facility.
  
  
  METHODS
  Battle injury died of wounds (DOW) deaths that occurred after casualties reached a medical treatment facility from October 2001 to June 2009 were evaluated by reviewing autopsy and other postmortem records at the Office of the Armed Forces Medical Examiners (OAFME). A panel of military trauma experts classified the injuries as nonsurvivable (NS) or potentially survivable (PS), in consultation with an OAFME forensic pathologist. Data including demographics, mechanism of injury, physiologic and laboratory variables, and cause of death were obtained from the Joint Theater Trauma Registry and the OAFME Mortality Trauma Registry.
  
  
  RESULTS
  DOW casualties (n = 558) accounted for 4.56% of the nonreturn to duty battle injuries over the study period. DOW casualties were classified as NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. Traumatic brain injury was the predominant injury leading to death in 225 of 271 (83%) NS cases, whereas hemorrhage from major trauma was the predominant mechanism of death in 230 of 287 (80%) PS cases. In the hemorrhage mechanism PS cases, the major body region bleeding focus accounting for mortality were torso (48%), extremity (31%), and junctional (neck, axilla, and groin) (21%). Fifty-one percent of DOW casualties presented in extremis with cardiopulmonary resuscitation upon presentation.
  
  
  CONCLUSIONS
  Hemorrhage is a major mechanism of death in PS combat injuries, underscoring the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.
authors.affiliation: United States Army Institute of Surgical Research, Fort Sam Houston, Texas 78234-6315, USA. brian.eastridge@amedd.army.mil
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Eastridge
authors.forename: Mark
authors.initials: M
authors.lastname: Hardin
authors.forename: Joyce
authors.initials: J
authors.lastname: Cantrell
authors.forename: Lynne
authors.initials: L
authors.lastname: Oetjen-Gerdes
authors.forename: Tamara
authors.initials: T
authors.lastname: Zubko
authors.forename: Craig
authors.initials: C
authors.lastname: Mallak
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: John
authors.initials: J
authors.lastname: Simmons
authors.forename: James
authors.initials: J
authors.lastname: Mace
authors.forename: Robert
authors.initials: R
authors.lastname: Mabry
authors.forename: Rose
authors.initials: R
authors.lastname: Bolenbaucher
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000209:etiology / Q000401:mortality / Q000628:therapy; D004632:Emergency Medical Services; D058734:Exsanguination / Q000209:etiology / Q000401:mortality / Q000628:therapy; D005260:Female; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008887:Military Medicine; D012042:Registries; D014947:Wounds and Injuries / Q000209:etiology / Q000401:mortality* / Q000628:therapy; D055815:Young Adult