Injury Severity and Causes of Death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 Versus 2006

The opinion that injuries sustained in Iraq and Afghanistan have increased in severity is widely held by clinicians who have deployed multiple times. To continuously improve combat casualty care, the Department of Defense has enacted numerous evidence-based policies and clinical practice guidelines. The authors hypothesized that the severity of wounds has increased over time. In this study, they examined cause of death looking for opportunities to improve clinical research and training for the battlefield. Autopsies of the earliest combat deaths in Iraq and Afghanistan and the latest deaths in 2006 were analyzed to assess changes in injury severity and causes of death. Fatalities were classified as nonsurvivable (NS) or potentially survivable (PS). PS deaths were then reviewed in depth to analyze mechanism and cause. The results showed that there were 486 PS cases from March 2003 to April 2004 (group 1) and 496 from June 2006 to December 2006 (group 2) that met the inclusion criteria. Of the PS fatalities (group 1: 93 and group 2: 139), the injury severity score was lower in the first group (27 +/- 14 vs. 37 +/- 16, p 0.001), and had a lower number of abbreviated injury scores greater than tor equal to 4 (1.1 +/- 0.79 vs. 1.5 +/- 0.83 per person, p 0.001). The main cause of death among the PS fatalities was truncal hemorrhage (51% vs. 49%, p = NS). Deaths per month between groups doubled (35 vs. 71), whereas the case fatality rates between the two time periods were equivalent (11.0 vs. 9.8, p = NS). In the time periods of the wars studied, deaths per month have doubled, with increases in both injury severity and number of wounds per casualty. Truncal hemorrhage is the leading cause of potentially survivable death. Arguably, the success of the medical improvements during this war has served to maintain the lowest case fatality rate on record. Pub. in the Journal of Trauma: Injury, Infection, and Critical Care, v64 n2(suppl), pS21-S27, Feb 2008. Prepared in cooperation with the Department of Surgery, University of Texas Health Science Center, San Antonio, TX.