title: Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data.
abstract: BACKGROUND
  Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.
  
  
  METHODS
  The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ2and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.
  
  
  RESULTS
  We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).
  
  
  CONCLUSIONS
  Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States. Electronic address: Brandon.godfrey.4@us.af.mil.
authors: Brandon W
authors: BW
authors: Godfrey
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
authors: Ashley
authors: A
authors: Martin
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
authors: Paul J
authors: PJ
authors: Chestovich
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
authors: Gordon H
authors: GH
authors: Lee
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
authors: Nichole K
authors: NK
authors: Ingalls
authors: Department of Surgery, University of Nevada School of Medicine, Las Vegas, NV, United States.
authors: Vilas
authors: V
authors: Saldanha
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000673:Amputation, Traumatic / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D001753:Blast Injuries / Q000401:mortality / Q000628:therapy*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D003130:Combat Disorders / Q000150:complications / Q000401:mortality / Q000628:therapy*; D003422:Critical Care / Q000379:methods; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008297:Male; D008887:Military Medicine / Q000379:methods; D008889:Military Personnel; D009104:Multiple Trauma / Q000401:mortality / Q000601:surgery*; D012042:Registries; D016019:Survival Analysis; D014111:Tourniquets; D014148:Tranexamic Acid / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid
keywords: Amputation; Blast; Multiple; Transfusion; Traumatic