title: Died of wounds: a mortality review.
abstract: OBJECTIVE
  Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes.
  
  
  METHODS
  This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports.
  
  
  RESULTS
  There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths.
  
  
  CONCLUSIONS
  Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.
authors.affiliation: Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: Damian Douglas
authors.identifier: http://orcid.org/0000-0002-3864-3867
authors.initials: DD
authors.lastname: Keene
authors.affiliation: Institute of Naval Medicine, Gosport, UK.
authors.forename: J G
authors.initials: JG
authors.lastname: Penn-Barwell
authors.affiliation: Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK Department of Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK.
authors.forename: P R
authors.initials: PR
authors.lastname: Wood
authors.affiliation: Forensic Pathology Services Wantage, Oxon, UK.
authors.forename: N
authors.initials: N
authors.lastname: Hunt
authors.affiliation: South West Group Practice, Bristol, UK.
authors.forename: R
authors.initials: R
authors.lastname: Delaney
authors.affiliation: Centre for Blast Injury Studies, Imperial College, London, UK.
authors.forename: J
authors.initials: J
authors.lastname: Clasper
authors.affiliation: Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: R J
authors.initials: RJ
authors.lastname: Russell
authors.affiliation: Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK Centre for Blast Injury Studies, Imperial College, London, UK.
authors.forename: P F
authors.initials: PF
authors.lastname: Mahoney
mesh_terms: D000007:Abdominal Injuries / Q000150:complications / Q000401:mortality*; D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D006259:Craniocerebral Trauma / Q000401:mortality*; D005121:Extremities / Q000293:injuries; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality*; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008889:Military Personnel; D009104:Multiple Trauma / Q000150:complications / Q000401:mortality*; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D015599:Trauma Severity Indices; D006113:United Kingdom; D014857:Warfare; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality; D055815:Young Adult
keywords: Afghan Campaign 2001; Cause of Death; Iraq War 2003-2011; United Kingdom; military