The Critical Edge Podcast

Combat Torso Trauma

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This episode explores the evolving landscape of combat torso trauma care, highlighting how advancements in body armor and rapid transport have increased the number of survivors reaching medical facilities with severe injuries. The authors emphasize the critical nature of noncompressible torso hemorrhage, which remains a primary cause of preventable death on the battlefield. Effective management requires a disciplined approach, prioritizing whole blood resuscitation and damage control surgery over early intubation or extensive imaging. Modern techniques like REBOA and advanced resuscitative care are increasingly utilized by specialized teams to stabilize patients in austere environments. Furthermore, the source details the unique challenges posed by high-velocity weaponry and improvised explosive devices, which cause complex tissue destruction and multisystem wounds. Ultimately, these military medical insights continue to refine global trauma protocols and drive the development of innovative therapies for life-threatening bleeding.

 

 

DISCLAIMER

The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

 

 

Combat Torso Trauma: Clinical Management and Surgical Strategies
TOP TEN TAKEAWAYS
  1. Lethality of Noncompressible Torso Hemorrhage (NCTH): Active bleeding from abdominal or thoracic structures accounts for 80% of potentially preventable deaths in combat settings.
  2. Epidemiological Shifts: While thoracic injuries have declined to approximately 6% due to improved personal protective equipment (PPE), the complexity of injuries remains high, with blasts now accounting for roughly 80% of truncal wounds.
  3. The Risk of Early Intubation: Intubation prior to adequate resuscitation in unstable patients frequently leads to cardiovascular collapse and traumatic arrest due to the loss of vascular tone from sedative and vasodilatory medications.
  4. Whole Blood Priority: Fresh whole blood (FWB) or low-titer type O whole blood (LTOWB) is the preferred resuscitative product, offering superior hemostatic properties compared to balanced component therapy.
  5. Advanced Resuscitative Care (ARC): The ARC protocol focuses on early whole blood administration and the use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to control sub-diaphragmatic bleeding.
  6. Surgical Positioning and Access: Exploratory operations on the trunk should be performed in the supine position to maintain flexibility for accessing the neck, chest, mediastinum, abdomen, and groin simultaneously.
  7. Operative Management of Solid Organ Injuries (SOI): Unlike civilian trauma, combat-related SOIs are typically managed operatively because of limited monitoring capabilities in austere settings and the severity of high-velocity wounding.
  8. Blast-Specific Intestinal Damage: Fragments from improvised explosive devices (IEDs) often create thermal injury zones surrounding small bowel defects; these burned areas must be completely excised during repair.
  9. Vascular Control for Massive Wounds: For devastating perineal or high-groin injuries, proximal aortoiliac control via laparotomy is often safer and more effective than attempting direct exposure in a distorted, actively bleeding field.
  10. The Walking Blood Bank (WBB): In austere environments where component storage is limited, the WBB remains a cornerstone of massive transfusion protocols, utilizing prescreened donors for fresh whole blood.

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    STUDY GUIDE
    I. Epidemiology and Mechanisms of Injury

    Combat trauma in the modern era is defined by high-velocity projectiles and explosive devices, most notably the improvised explosive device (IED). The distribution of wounds has shifted significantly since World War II. While head and neck injuries have increased to 30%, thoracic injuries have decreased to 6% in recent conflicts like Operation Iraqi Freedom (OIF). This decline in truncal trauma is largely attributed to the widespread use of hardened vehicles and advanced torso body armor.

    Despite the lower incidence of thoracic wounds, truncal injuries remain highly lethal. Blast mechanisms now account for approximately 80% of truncal and extremity wounds. These mechanisms produce a combination of primary blast injury, penetrating fragments, blunt trauma (e.g., vehicular rollover), and thermal injury. High-velocity military projectiles also cause significantly more tissue destruction than the low-velocity weapons typically encountered in civilian urban trauma centers.

    II. Noncompressible Torso Hemorrhage (NCTH)

    NCTH is defined by anatomic and physiologic criteria, including systolic blood pressure (SBP) < 90 mmHg or the need for emergent surgery in the presence of specific injuries:

    • Thoracic cavity injury: Odds ratio (OR) for mortality of 1.9.
    • Solid organ injury (SOI): Grade 3 or higher.
    • Named axial torso vessel injury: The most lethal pattern, with an OR for mortality of 3.4.
    • Pelvic ring disruption: Associated with significant internal bleeding.

      • Management of NCTH emphasizes minimizing delays between the emergency department and the operating room, permissive hypotension until vascular control is achieved, and the early use of procoagulant adjuncts such as tranexamic acid (TXA).

      III. Initial Evaluation and Resuscitation

      The initial evaluation must be rapid and orderly, prioritizing the identification of pneumothorax and internal hemorrhage over dramatic but non-life-threatening extremity wounds.

      Diagnostic Tools:

      • Focused Assessment with Sonography for Trauma (FAST): Universally available in forward settings to evaluate for pneumothorax, hemothorax, tamponade, and abdominal fluid.
      • Diagnostic Peritoneal Aspirate (DPA): A critical backup tool in multisystem trauma patients when ultrasound is equivocal; the identification of blood or succus mandates immediate laparotomy.

        • The Intubation Paradox: Clinicians are cautioned against early intubation in the emergency department for patients in hemorrhagic shock. The medications used (narcotics/sedatives) can cause vascular collapse. If intubation is not required for airway obstruction or profound hypoxia, it should be delayed until the patient is in the operating room, where hemodynamic monitoring and surgical hemorrhage control are immediate. Ketamine is favored for shock-state patients due to its favorable hemodynamic profile.

        IV. Advanced Resuscitative Care (ARC) and REBOA

        ARC aims to bridge the gap between injury and surgery. The two primary components are whole blood resuscitation and REBOA placement.

        Blood Products:

        • Low-Titer O Whole Blood (LTOWB): Preferred by the Committee on Tactical Combat Casualty Care (CoTCCC).
        • Fresh Whole Blood (FWB): Often drawn from a Walking Blood Bank (WBB) using prescreened donors. FWB provides functional platelets and higher concentrations of coagulation factors than 1:1 component therapy.

          • REBOA Utilization: REBOA is indicated for casualties with penetrating or blunt injury to the abdomen or pelvis who remain hypotensive (SBP < 90) after initial blood administration, provided there is no evidence of intrathoracic bleeding. In austere environments, REBOA can be placed by trained emergency medicine physicians to buy time for the surgeon. Early femoral access (4- or 5-French) is recommended in high-risk patients to facilitate rapid upsizing to a 7-French REBOA sheath if needed.

          V. Operative Principles for Combat Torso Trauma

          Combat surgery differs from elective surgery in its requirement for flexibility. The supine position is standard for exploratory operations to allow access to all vital regions.

          Thoracic Interventions:

          • Incision Choice: Anterolateral thoracotomy or median sternotomy is preferred over posterolateral approaches.
          • Damage Control: Includes manual clot evacuation, hilar clamping for rapid control, and temporary "en masse" closure with large-bore chest tubes.
          • Lung Injury: Combat wounds often macerate lung tissue, requiring stapled wedge resections or formal lobectomies rather than simple tractotomy.

            • Abdominal Interventions:

            • Solid Organ Injury: Most grade 2 or higher SOIs in combat require surgery due to the inability to perform the serial imaging and close monitoring required for nonoperative management.
            • Bowel Injury: Stapled resections are generally superior to primary repairs. Thermal zones surrounding fragment wounds must be excised to prevent delayed necrosis.
            • Perineal and Pelvic Wounds: These "devastating" injuries often involve massive hemorrhage and contamination. Management requires a multi-stage approach, starting with supine laparotomy for proximal vascular control (aortoiliac) before addressing the local wound in a lateral or prone position.
              • VI. Austere Environment Considerations

              Forward surgical teams (FSTs) often operate with limited footprints. Total intravenous anesthesia (TIVA) using propofol, narcotics, and ketamine is common due to the lack of inhaled volatile agent equipment. In cases of "Prolonged Field Care," regional anesthesia such as intercostal nerve blocks or transversus abdominis plane (TAP) blocks can facilitate early extubation and conserve sedation medication and personnel resources.

              VII. Future Directions in Combat Trauma

              Research is currently focused on:

              • "Prosurvival" Phenotypes: Using pharmacological agents like valproic acid or hydrogen sulfide to induce cellular tolerance to shock, essentially a temporary "suspended animation" state.
              • Partial REBOA: Titrating aortic occlusion to extend the safe time limits beyond the standard 30–60 minutes.
              • Prehospital Advancements: The development of freeze-dried (lyophilized) plasma and the use of advanced provider teams (e.g., the British MERT model) to deliver surgical-level care during evacuation.

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                REFERENCES
                1. Martin MJ, Eastridge B, Tadlock MD. Torso trauma on the modern battlefield. In: Pasted Text Excerpts.
                2. Owens BD, Kragh JF Jr, Wenke JC, et al. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64:295–299.
                3. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am. 2012;92:843–858.
                4. Martin M, Beekley A, eds. Front Line Surgery: A Practical Approach. New York, NY: Springer; 2010.
                5. Butler F, Holcomb JB, Shackelford S, et al. Advanced resuscitative care in tactical combat casualty care: TCCC Guidelines change 18-01. J Spec Oper Med. 2018;18:35–53.
                6. Northern DM, Manley JD, et al. Recent advance in austere combat surgery: Use of aortic balloon occlusion as well as blood challenges by special operations medical force in recent combat operations. J Trauma Acute Care Surg. 2018;85:S98–S103.
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