Presenter: COL Lorne Blackbourne, MD – Commander USAISR
Lecture: Decreasing KIA on the Battlefield
How do we decrease KIA and DOW (Died Of Wounds) on the battlefield? Eighty percent of KIA/DOW is due to hemorrhage. Ten percent is due to airway compromise. Remaining 10% is due to other pathology.
With regard to hemorrhage, 50% is due to torso injuries, 20% from axillary, neck, and subclavian injuries, and 30% from extremity injuries.
To reduce KIA/DOW most dramatically, we must focus on managing truncal penetrating trauma in the prehospital phase. Intervention includes injury prevention, mechanical hemorrhage control, and intravascular volume replacement.
The average human body contains approximately 5 liters of blood. A decrease in blood pressure is seen after a loss of 1/3 or about 1.5 liters. Irreversible shock occurs after a loss of ½ the total volume or about 2.5 liters. This was first published in Lancet in 1831. In the field, Hextend and LR are used for volume replacement.
The deadly triad leading to Severe Ischemic Threshold is Acidosis, Hypothermia, and Coagulopathy. Determining factors include volume of blood lost, time since injury, and injury burden.
Once the patient reaches the CSH, goals and intervention change to replacing intravascular volume while correcting or at least not worsening coagulopathy. Must switch from Hextend and crystalloid/colloid to whole blood and FFP.
NEJM published article showing this – Immediate vs. Delayed Fluid Resuscitation for Hypotensive Penetrating Torso Trauma.
http://content.nejm.org/cgi/content/...ct/331/17/1105 For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.
Crystalloid/Colloid = Coagulopathy. Coagulopathy = Death. Plasma = Survival.
RBCs dilute clotting factors. Platelets are too fragile. Fibrinogen not very effective. Plasma is just right. For increased survival, dried plasma is necessary on the battlefield, and should be available to operators and utilized.