Anders Jonsson Chefsrådgivare Forskning. FömedC FÖRSVARSMEDICINCENTRUM

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1 Anders Jonsson Chefsrådgivare Forskning FömedC

2 Militärmedicinsk Målsättning Att med ett strukturerat tillvägagångssätt identifiera livshotande åtgärdbara skador samt undvika ytterligare skadeutfall. Anpassad för militär sjukvårdspersonal i stridsmiljö Omhändertagande av skadad enligt vetenskap och beprövad erfarenhet Utvecklas genom operativa erfarenheter Anpassning efter reell kompetens (läk, ssk, sjv och övrig sjvpersonal)

3 Operation Iraqi Freedom represents the first protracted, largescale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care Eastridge BJ., et al. Trauma System Development in a Theater of War: Experiences From Operation Iraqi Freedom and Operation Enduring Freedom. Journal of Trauma-Injury Infection & Critical Care. 61(6): , December 2016

4 Skadepanorama i aktuella konflikter KIA 20-25% DOW 2,3-6,4% Av KIA 49% går ej att rädda 51% går att rädda Av dessa dog 76% av blödning och av dessa hade 32% kompressibla blödningar och 68% icke kompressibla blödningar

5 According to the ACE DIRECTIVE 85-8 following Battle Casualties (BC) for an army mission can be expect Vietnam War - Total BC-rate Battalion 20,5% 4,1% 24,6% Brigade 6,9% 1,4% 8,3% Corps 1,4% 0,3% 1,7% Army 1,0% 0,2% 1.2% Battle Casualties: + Killed in Action [KIA] + Dead of wounds [DOW] + Captured and Missing in Action [CMIA] + Wounded in Action [WIA] + Battle Stress Cases [BS] Non Battle Casualties: + Diseased and Non-Battle Injured [DNBI]

6 Tidsintervall KIA+DOW Andelen av totalt antalet döda (%) Momentant 41 <5 minuter minuter 15 (81) 30min- 2 tim tim 6 >6 timmar 6

7 CASUALTY TYPE Killed in Action 364 Died of Wounds 159 Died While Missing in Action Died While Captured TOTAL HOSTILE DEATHS (THD) 762 (73%) THD + Accident 944 (90%) Accident 182 Illness 29 (3%) Homicide 10 Self-Inflicted 38 Undetermined 8 Pending** 15 TOTAL NON-HOSTILE DEATHS 282 TOTAL DEATHS 1044 TOTAL - WOUNDED IN ACTION (WIA) 5730 (18% KIA)

8 CASUALTY REASON USA (Global war on terrorism) n 4 MEDICAL, CANCER MEDICAL, HEART RELATED 37 MEDICAL, OTHER 3 MEDICAL, RESPIRATORY FAILURE 15 MEDICAL, STROKE 7 OTHER, BURNS/SMOKE INHALATION 83 OTHER, DEHYDRATION 2 OTHER, DROWNING 58 OTHER, DRUG AND/OR ALCOHOL OVERDOSE 4 OTHER, ELECTROCUTION 29 OTHER, EXPOSURE TO ELEMENTS 1 OTHER, FALL/JUMP 65 OTHER, FRACTURE OR BROKEN BONE 13 OTHER, LACERATION 83 OTHER, MILITARY EXERCISE 2 OTHER, PARACHUTE ACCIDENT 8 OTHER, PHYSICAL TRAINING -- MILITARY RELATED 4 OTHER, STAB WOUNDS 3 TRANSPORTATION, AIRCRAFT CRASH -- CREW (MC) 417 TRANSPORTATION, AUTOMOBILE ACCIDENT (PRIVATE) 2 TRANSPORTATION, PEDESTRIAN 2 TRANSPORTATION, VEHICLE CRASH (MC) 417 WEAPONRY, ARTILLERY/MORTAR/ROCKET 3364 (7%) WEAPONRY, EXPLOSIVE DEVICE (63%) WEAPONRY, GRENADE 71 WEAPONRY, GUNSHOT 5138 (11%) WEAPONRY, NUCLEAR, CHEMICAL OR BIOLOGICAL AGENTS 21 WEAPONRY, OTHER 4 WEAPONRY, ROCKET PROPELLED GRENADE 1423 (3%) NOT REPORTED/UNKNOWN/MISCELLANEOUS 5959 TOTAL 47028

9 Abbreviations: CFR, case fatality rate; DOW, died of wounds (died after arrival at treatment facility); KIA, killed in action (died before arrival at treatment facility); RTD, returned to duty; WIA, wounded in action Effect of Golden Hour Policy on themorbidity and Mortality of Combat Casualties. Russ S. Kotwal, MD, MPH; Jeffrey T. Howard, PhD; Jean A. Orman, ScD, MPH; BruceW. Tarpey, BS; Jeffrey A. Bailey, MD; JAMA Surg. 2016;151(1):15-24.

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13 Operation Iraqi Freedom 3500 hostile deaths occurred among US military personnel 32,000 wounded in action (WIA). Operation Enduring Freedom 1800 hostile deaths occurred during (in and around Afghanistan) 20,000 were WIA. A larger proportion of wounded personnel survived in Iraq and Afghanistan than during the Vietnam War, but the increased survival rates were not as high as some studies have asserted. The survival rates: 90.2% in Iraq 91.6% in Afghanistan, 86.5% in Vietnam. Amputation rates 2.6% of all WIA and 9.0% of medically evacuated WIA from the Iraq and Afghanistan theaters Elevated non-hostile death rates (including deaths due to accidents, illnesses, homicides, or suicides) resulted in about 220 more deaths in Iraq and about 200 more deaths in Afghanistan than would have been expected in peacetime among populations of the size deployed to those two conflicts. Goldberg, M,S Updated Death and Injury Rates of U.S. Military Personnel During theconflicts in Iraq and Afghanistan. Working Paper Service Congressional Budget Office, Washington DC.

14 Irak, 14 mån Afghanistan Antal totalt döda Potentiellt räddningsbara n=93 n=139 Blödningar 87% 83% Kompressibla blödningar, extremitet 30% 32% Kompressibla blödningar, hals/axill/ljumske 22% 20% Icke kompressibla blödningar, torso 48% 48% Kelly et al xx

15 Exsanguination is the major cause of death on the battlefield. Of those who die on the battlefield, it is estimated that 20% could be salvaged before exsanguination if provided with immediate care. Upon arrival at the scene, a First Responder must immediately control bleeding. If the injury is on the body surface or extremity and compressible, direct pressure or a tourniquet is current standard treatment for attempting adequate hemostasis Sondeen J et al. 7. Potential Resuscitation Strategies for Treatment of Hemorrhagic Shock, COMEDS 2016

16 The peaks of the trimodal distribution of death are: Immediate Deaths (50%). Those casualties killed outright or who die within a few minutes after injury. Early Deaths (30%). Those casualties who die within one to two hours of wounding and can be potentially saved by operation within the Golden Hour from time of wounding. Late Deaths (20%). Those casualties who die days or weeks later, mainly as a result of infection or multiple organ failure.

17 This premise is now challenged by the belief that trauma deaths are bimodal in distribution rather than trimodal, with the first peak within one hour of injury, and the second peak hours after injury: the implication is that the impact of early surgery is less than previously thought, but that lives can be saved by intervention within the first hour

18 Blast Injuries Bombs and explosions can cause unique patterns of injury seldom seen outside combat. The predominant post explosion injuries among survivors involve standard penetrating and blunt trauma. Blast lung is the most common fatal injury among initial survivors. Explosions in confined spaces (mines, buildings, or large vehicles) and/or structural collapse are associated with greater morbidity and mortality. Expect an upside-down triage - the most severely injured arrive after the less injured

19 Direkta dödsfall pga vapeneffekt (86%) beror på stötvågen (84%) eller splitter (2%). Indirekta dödsfall (14%) beror för det mesta på inhalationsskador (rökskador).

20 Slutet utrymme Öppet utrymme Signifikans Antal skadade n = 93 n = 297 Mortalitet 49% 7,8% p<0,00001 Primär stötvågsskada 77,5% 34,2% p<0,00003

21 Utmaningar Stort skadeutfall Ej medicinsk utbildad personal PreHospitalt Kommunikation Transporter Tid o Rum Gemensamma Lednings och kommunikationssystem