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A unit of a 14-person, 6-vehicle military convoy is moving through a remote village of a combat zone. As the convoy pulls out on the open road at the end of that village, an improvised explosive device (IED) explodes under the second vehicle, manned with two soldiers. Intensive sniper fire follows, and the rest of the convoy is busily engaged in suppressing it. The nonarmored disabled vehicle is right side up and not on fire. You are the medic of the unit, and you are in an armored vehicle, next to the demolished vehicle with the two victims. As you arrive at the vehicle, you find two casualties: Casualty #1 is the driver of the vehicle. He sustained bilateral mid-thigh traumatic amputations and a penetrating injury of the pelvis and the abdomen. Furthermore, there is a large open head wound in which mangled gray matter is clearly visible. There are no vital signs—he is obviously dead. Casualty #2 is the front-seat passenger. He sustained a below-knee amputation of his left leg with heavy arterial bleeding from the stump, and multiple injuries to the left face. He has significant soft-tissue trauma, the mandibula is visible, and obviously comminuted fractured. You note moderate bleeding from the left face injury. The soldier is conscious and has a good radial pulse but the airway seems compromised due to disrupted airway anatomy (maxillofacial trauma) and bleeding into the airway.


Prehospital trauma care on the battlefield varies in many respects from prehospital trauma care as practiced in the civilian setting. Firstly, these traumas are involved in different causes, types, and severity of the injuries. In addition, these cases are often associated with the threat of hostile fire, working in the dark without using bright light, multiple casualties, limited medical equipment, and prolonged evacuation times. Therefore, treatment guidelines developed for the civilian setting do not necessarily work well in the military setting.

Using the US Mortality Trauma Registry of the Armed Forces Medical Examiner Service, Eastridge et al.1 reported that there were 4596 battlefield fatalities in Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) from October 2001 to June 2011. Majority of all injury mortality (87.3%, n = 4013) occurred in the prehospital environment. Of the prehospital deaths, 24.3% (n = 976) were deemed potentially survivable. Historically, airway compromise represents the third leading cause of potentially preventable death on the battlefield, behind hemorrhage and tension pneumothorax.2 In a retrospective review of 982 autopsies of US military personnel who died in combat in Iraq and Afghanistan between 2003 and 2006, Mabry et al.3 reported that 18 cases (1.8% of the total deaths) were found to have airway compromise as the likely mechanism of death. These include penetrating trauma to the face or neck, which were accompanied by significant hemorrhage, leading to death from airway compromise. While cricothyrotomy were attempted, the procedure failed in ...

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