Lessons From the Tip of the Spear: Medical Advancements From Iraq and Afghanistan

Abstract

The conflicts in Iraq and Afghanistan have seen the advancement of combat medicine. The nature of the conflicts, with troops located in remote areas and faced with explosive ordinance designed to focus massive injuries on dismounted personnel, have forced military medical personnel to adapt accordingly. There has been a rekindling of interest in the use of tourniquets to stop exsanguination from extremity wounds, as well as in the transfusion of fresh whole blood from walking blood banks. These previously discarded techniques, born on battlefields long ago, have been refined and perfected and have led to an unprecedented survival for our wounded warriors. New developments in the field of applied hemostatic agents, damage control surgical techniques, and the implementation of an efficient evacuation system have also contributed to these results. The field of combat medicine has taken several concepts initially designed in civilian settings, such as temporary abdominal packing and vascular shunting, and adapted them to the military setting to provide state of the art trauma management to our troops in combat. In turn, developments in the resuscitation of the trauma patient, using increased blood and plasma products and less crystalloid, have been pioneered in conflict and transitioned to the civilian sector. Advancements made during the wars in Iraq and Afghanistan, as well as those still being developed, will shape the care of the injured patient, in both civilian and military settings, for the foreseeable future.

Evaluation of Prehospital Blood Products to Attenuate Acute Coagulopathy of Trauma in a Model of Severe Injury and Shock in Anesthetized Pigs

“…In any experimental study, the nature of the model used defines the limitations of the conclusions. In this study, we were attempting to model a severely injured battlefield casualty with a significant burden of injury and hemorrhagic shock, who would initially receive very limited resuscitation ( 19 , 38 , 39 ) once hemorrhage has been arrested, prior to evacuation to a hospital. Our model therefore incorporated elements of significant tissue injury and hemorrhagic shock (with associated hypoperfusion) as suggested by Frith et al ( 40 ), followed by clinically relevant resuscitation, all in the correct chronological sequence.…”

“…Our model therefore incorporated elements of significant tissue injury and hemorrhagic shock (with associated hypoperfusion) as suggested by Frith et al ( 40 ), followed by clinically relevant resuscitation, all in the correct chronological sequence. A 1-h evacuation timeline was selected because it is broadly representative of recent military ( 38 , 41 ) and civilian evacuation timelines in the United Kingdom and Europe ( 9 , 10 ) and United States ( 35 ) during which hypotensive resuscitation is practiced ( 18 , 19 ), although shorter timelines have been reported in a number of US studies ( 24 , 25 ). The endpoint of resuscitation was a pressure-driven target because this is all that there is currently available in the prehospital military setting, i.e., administration of fluid to attain a palpable carotid (corresponding approximately to a SBP of 60 mmHg) or radial (SBP 80 mmHg) pulses.…”

Belfast Limb Arterial and Skeletal Trauma (BLAST): the evolution of punishment shooting in Northern Ireland

“…However, evidence arising from literature in recent years has placed tourniquets in a favourable light. Schragner et al [ 10 ] stated that there are demonstrable benefits in using tourniquets to stem haemorrhage, in lessons learnt in Iraq and Afghanistan. Whilst the use of limb tourniquet for haemorrhage control in the civilian setting remains controversial, in military series, they have been shown to contribute to a reduction in mortality especially if applied early prior to onset of refractory shock [ 11 ].…”

Provision of Nutrition Support Therapies in the Recent Iraq and Afghanistan Conflicts

“…Casualties are evacuated as soon as feasible, with the goal of reaching surgical care within 1 hour of injury to enhance survival. In fact, this first hour is considered critical and named the “golden hour.” 7 …”