Caroline Helwick

October 26, 2011

October 26, 2011 (San Francisco, California) — A comprehensive look at combat injuries among the almost 2 million service members deployed in Iraq and Afghanistan from 2005 to 2009 showed that 0.4% were injured, according to data from the US Army Institute of Surgical Research's Joint Theater Trauma Registry (JTTR), a prospective database of all combat-wounded patients treated in military theaters.

The analysis also revealed that the percentage of combat casualties resulting from explosive mechanisms continues to increase, and that Afghanistan has surpassed Iraq as the region with the highest casualties.

The report was presented here at the American College of Surgeons (ACS) 97th Annual Clinical Congress by Brendan McCriskin, MD, from the William Beaumont Army Medical Center/Texas Tech University Health Sciences Center in El Paso.

"This is the first investigation to characterize wounding patterns using a comprehensive military cohort, and the only study to compare the epidemiology of combat injuries between Iraq and Afghanistan," Dr. McCriskin noted.

The goal of the study was to characterize the epidemiology of war casualties, to identify populations most at risk, and to contrast injury patterns and causation between the 2 war theaters.

The JTTR, a prospective database established in 2004 in conjunction with the ACS Committee on Trauma, houses demographic and diagnostic medical treatment information on all combat-wounded patients treated at American military medical facilities in the theater of operations. The investigators queried the JTTR database for all combat casualties from 2005 to 2009, excluding people killed in action and those with nonbattle injuries and illnesses. Wounds were analyzed and compiled by body region and mechanism of injury.

Epidemiology of Combat Injuries Described

Of the 1,992,232 military service members deployed, 29,624 distinct combat wounds were identified in 7877 combat casualties. The mean age of the casualty cohort was 26 years. Combat casualties occurred predominantly in males (98.5%), army soldiers (78.1%), and junior enlisted men (59.2%), Dr. McCriskin reported.

The casualty peak in Iraq occurred in 2007, after the "troop surge," accounting for 31% of all injuries sustained during Operation Iraqi Freedom. This was followed by a sharp decline. Afghanistan casualties have increased linearly, with a zenith in 2009 preceding the 2010 troop surge and accounting for 46% of casualties during Operation Enduring Freedom.

The main distribution of combat wounds was as follows: extremities (52%), head and neck (28%), thorax (10%), and abdomen (10%). Almost 75% resulted from explosive mechanisms; just 20% were gunshot wounds.

The percentage of casualties due to explosives was 65% in the Vietnam War, 69% in the Korean War, and 73% in World War II.

Explosive mechanisms were significantly more common in Iraq than Afghanistan from 2005 to 2007 (P < .001). Over time, explosive-related casualties increased in Afghanistan; 59% of all casualties there were attributed to explosives in 2007, rising to 74% in 2008.

"The wounding patterns observed in Iraq and Afghanistan from 2005 to 2009 differ from previous conflicts in that there is a higher proportion of head and neck wounds," Dr. McCriskin noted. "Explosive mechanisms accounted for 74% of casualties, which is a higher percentage than seen in previous American conflicts. We also saw a significant increase in the use of explosive mechanisms in Afghanistan during this period."

"As things ramped up in Afghanistan, we saw more injuries caused by blast mechanisms — improved explosive devices, rocket-propelled grenades, mines. We began to see a trend for the majority of wounds to be caused by these. While Iraq was initially a more dangerous theater, the opposite has become true, with Afghanistan now being more kinetic," he said.

"Having JTTR data available to analyze not only provides a historic record of the evolving nature of the conflicts, but helps shape Army medicine's response and highlights future areas for study," Dr. McCriskin said.

The next step in this epidemiologic description of combat injuries will be to analyze specific orthopedic injury incidence and patterns, including traumatic amputations, which have been a substantial problem among these service members, he said.

Meanwhile, he said, these data identify the specifics of the populations most at risk, the mechanisms of injuries, and the most affected body parts, and can be used to better allocate medical services. "For example, new armor is being tested now that should help protect the genitals for the first time," he said.

Robert B. Simpson, MD, an orthopedic and trauma surgeon in Syracuse, New York, moderated the session in which the study was presented. He commented on the value of these findings for Medscape Medical News. "If we don't look closely at injuries, we don't know how best to support our troops. This study depicted transitional periods in the wars and showed that the nature and incidence of injuries can change. The protective equipment our troops wore into combat in the early years of the war looks completely different than today's. Knowing these data helps guide us in designing protective gear and understanding what types of supportive, protective, and resuscitative equipment our troops most need."

Dr. McCriskin and Dr. Simpson have disclosed no relevant financial relationships. Dr. McCriskin stated that the opinions and assertions of the study's authors are their private views and should not be construed as official or reflective of the views of the Department of Defense or the US government.

American College of Surgeons (ACS) 97th Annual Clinical Congress. Presented October 25, 2011.

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