We consider combat casualties to be a vulnerable patient population.
This study was reviewed and approved by the Walter Reed National Military Medical Center Institutional Review Board. Walter Reed National Military Medical Center (Study Number 352334) In the hopes of optimizing care, we sought to characterize each patient's physiologic response to injury, with the goal of developing a decision support tool to guide the timing of wound closure.Ģ.3.
However, if a wound is closed unnecessarily late, the delay and additional procedures prolong the patient's hospital stay, delay rehabilitation, and increase the risk that the patient will develop a hospital-acquired infection or other complication. When this happens, the injured service member requires additional surgical procedures that can jeopardize life, limb or residual limb length. If a combat wound is closed prematurely, it is more likely to dehisce. The timing of wound closure is important. In fact, even highly experienced military surgeons had difficulty risk-stratifying their patients' wounds ( Forsberg et al., 2014) because the conventional manner of visually assessing wounds ( Bartlett, 2003, Stromeyer, 1862, Moorhead, 1942a, Selcer, 2008) was inadequate. Complications such as delayed wound healing and dehiscence ( Forsberg et al., 2008), venous thromboembolism ( Gillern et al., 2011), and ventilator-associated pneumonia ( Landrum and Murray, 2008) occurred more frequently than expected and unanticipated outcomes such as heterotopic ossification ( Potter et al., 2007, Forsberg et al., 2009) and angioinvasive fungal infections ( Warkentien et al., 2012) were frequently observed.
This suggests that the native inflammatory system, geared toward mitigating less severe injuries, is ill-equipped to regulate the massive physiologic insults produced by blast injuries ( Hawksworth et al., 2009). Because these survivors posed substantial reconstruction and rehabilitation challenges, we organized a coordinated effort to characterize the physiologic response of military patients to these devastating injuries, and determine if particular biomarkers predict perioperative complications.Įarly in the conflicts, we noted that severely-injured patients demonstrate systemic inflammatory dysregulation and relative immunosuppression ( Hawksworth et al., 2009). Thanks to the combined effects of body armor, tourniquets, tactical combat casualty care, aggressive resuscitation techniques, and a robust trauma system, many service members who would have died in previous conflicts survived to reach tertiary care facilities ( Elster et al., 2013, Sheridan et al., 2014). These devastating injuries pushed the physiologic reserves of these generally young, previously healthy patients to the extreme. Many of them sustained systemic polytrauma, mangled extremities and traumatic amputations from blasts. During the last decade of conflict in Afghanistan and Iraq, our military health system (MHS) treated a large number of critically-wounded servicemen and women ( Casualty Report).
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