Died of Wounds on the Battlefield: Causation and Implications for
Improving Combat Casualty Care
Brian J. Eastridge, MD, Mark Hardin, MD, Joyce Cantrell, MD, Lynne Oetjen-Gerdes, MS, Tamara Zubko,
Craig Mallak, MD, Charles E. Wade, PhD, John Simmons, MD, James Mace, MD, Robert Mabry, MD,
Rose Bolenbaucher, MD, and Lorne H. Blackbourne, MD
Background: Understanding the epidemiology of death after battlefield
injury is vital to combat casualty care performance improvement. The current
analysis was undertaken to develop a comprehensive perspective of deaths
that occurred after casualties reached a medical treatment facility.
Methods: Battle injury died of wounds (DOW) deaths that occurred after
casualties reached a medical treatment facility from October 2001 to June
2009 were evaluated by reviewing autopsy and other postmortem records at
the Office of the Armed Forces Medical Examiners (OAFME). A panel of
military trauma experts classified the injuries as nonsurvivable (NS) or
potentially survivable (PS), in consultation with an OAFME forensic pathologist.
Data including demographics, mechanism of injury, physiologic and
laboratory variables, and cause of death were obtained from the Joint Theater
Trauma Registry and the OAFME Mortality Trauma Registry.
Results: DOW casualties (n 558) accounted for 4.56% of the nonreturn to
duty battle injuries over the study period. DOW casualties were classified as
NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. Traumatic brain
injury was the predominant injury leading to death in 225 of 271 (83%) NS
cases, whereas hemorrhage from major trauma was the predominant mechanism
of death in 230 of 287 (80%) PS cases. In the hemorrhage mechanism
PS cases, the major body region bleeding focus accounting for mortality
were torso (48%), extremity (31%), and junctional (neck, axilla, and groin)
(21%). Fifty-one percent of DOW casualties presented in extremis with
cardiopulmonary resuscitation upon presentation.
Conclusions: Hemorrhage is a major mechanism of death in PS combat
injuries, underscoring the necessity for initiatives to mitigate bleeding,
particularly in the prehospital environment.
Key Words: Military, War, Combat, Injury, Trauma, Died of wounds,
(J Trauma. 2011;71: S4–S8)
At the inception of current military contingency operations,
there was no organized method of combat casualty care
data collection or system for the delivery of trauma care. The
Joint Theater Trauma System was developed by military
medical leaders to provide a systematic and integrated approach
to battlefield care, resulting in minimization of morbidity
and mortality and optimization of essential casualty
injury care capabilities.1–3 The Joint Theater Trauma Registry
(JTTR) was developed to capture vital injury information for
performance evaluation and improvement as well as combat
injury epidemiology and surveillance.
Understanding the epidemiology of death after battlefield
injury is vital to improving the outcomes of combat
casualty care. The concept of a trimodal distribution of death
after injury has been popularized in both the civilian and
military settings.4,5 Major studies of both civilian and military
trauma epidemiology suggest that the majority of injury
mortality occurs in the prehospital period.6–16 From the military
perspective, the lethality of injury in this environment
can be impacted by measures aimed at prevention of injury,
particularly personal protective equipment and changes in
tactics, and through improvements in evacuation and prehospital
resuscitative care. In the continuum, casualties who
succumb to their injuries after admission to a hospital (died of
wounds [DOW]) are reflective of the relative effectiveness of
acute care of the medical treatment facility (MTF) and the
trauma system. Evaluation of deaths at this level has shown to
have significant performance improvement potential.6,17,18 A
substantial body of literature has analyzed hospital deaths
after injury in the civilian setting.5,6,16,17,19 Although other
studies of combat mortality have been developed as a result
of current contingency operations,13,18,20,21 the current analysis
is the only study to exclusively and completely investigate
the DOW combat casualty.
The current analysis was undertaken to develop a comprehensive
perspective of deaths that occurred after casualties
reached an MTF to identify potential areas for research,
development, and training.
The JTTR was used to identify Operation Iraqi Freedom
and Operation Enduring Freedom combat casualties
from October 2001 to June 2009 who died from injury after
admission to a military MTF.22 As the analysis was to
Submitted for publication March 18, 2011.
Accepted for publication April 22, 2011.
Copyright © 2011 by Lippincott Williams & Wilkins
From the United States Army Institute of Surgical Research (B.J.E., M.H.,
C.E.W., J.S., J.M., R.M., R.B., L.H.B.), Fort Sam Houston, Texas; and Office
of the Armed Forces Medical Examiner (J.C., L.O.-G., T.Z., C.M.), Rockville,
The opinions or assertions contained herein are the private views of the authors
and are not to be construed as official or as reflecting the views of the Army
Medical Command, Department of the Army, or the Department of Defense.
Address for reprints: Brian J. Eastridge, MD, U.S. Army Institute of Surgical
Research, 3400 Rawley E. Chambers Ave, Fort Sam Houston, TX 78234-
6315; email: firstname.lastname@example.org.
S4 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July Supplement 2011
specifically evaluate DOW, only battle injury casualties were
included in the study group. Exclusion criteria were nonbattle
injury and other unnatural deaths such as drowning, electrocution,
and suicide. The DOW rate was calculated by dividing
the DOW count by the total number of nonreturn to duty
battle injuries obtained from the JTTR for the corresponding
time period. The JTTR was used to compile demographics,
mechanism of injury, cause of injury, admission cardiopulmonary
resuscitation (CPR) status, admission physiology,
blood transfusion volume, Abbreviated Injury Scale score,
and Injury Severity Score (ISS).
The identified casualty population was then used as the
DOW study population for the fatality analysis at the Office
of the Armed Forces Medical Examiner (OAFME). All US
combat casualty deaths from theater are recovered and transported
to Dover, DE, where complete identification and
forensic examination are performed by the OAFME. The
autopsy reports and other perimortem records, the Mortality
Trauma Registry (MTR), and photographs on file with the
OAFME were used by the analysis group for the conduct of
the study. Cases included were DOW battle injury combat
fatalities. The review panel for this study was composed of
military trauma surgeons, a forensic pathologist, a military
emergency medicine physician, an expert wound coder with
MTR expertise, a trauma nurse, trauma epidemiologist, and
surgical residents. As in the earlier mortality review, the
panel used a consensus rule paradigm.18,23 To maintain consistency
and potential comparison value with past combat
mortality analyses, the fatalities were classified as “nonsurvivable”
(NS) or “potentially survivable” (PS)18,20 after evaluation
of the individual perimortem records listed above. As
in previous analyses, when multiple wounds were identified,
each was evaluated individually with respect to the potential
for survivability. The consensus was to err toward the
inclusion of these casualties as “potentially survivable” to
facilitate the process of combat casualty care performance
improvement. Specific wounds deemed to be NS were transcranial
brain injury, brain stem injury, perforating cardiac
injury, penetrating aortic injury, major tracheal injury below
the thoracic inlet, or open pelvic injury with large soft tissue
loss/traumatic hemipelvectomy. All patients were idealized to
have immediate access to a US military Level III MTF with
advanced surgical capabilities and more robust human, support,
and materiel resources.
Institutional Review Board review for the study was
provided by the Brooke Army Medical Center and the Armed
Forces Institute of Pathology.
For the interval of the study from 2001 to June 2009,
558 DOW fatality records were reviewed. During the same
period, there were 12,235 battle injury casualties recorded in
the JTTR, resulting in a DOW rate of 558 of 12,235 (4.6%)
over the study period. Interestingly, 232 of 456 (51%) casualties,
in whom the admission status was known, presented in
extremis with CPR in progress at admission. The casualties
were predominantly men (97.3%), with a median age of 24
years (interquartile range of 22–29 years), and military service
branch affiliation as follows: 73% Army, 15% Marine
Corps/Navy, and 2% Air Force.
Injury acuity in the DOW casualty population denoted
by ISS, Glasgow Coma Scale score, and transfusion requirements
is shown in Table 1. The distribution of injury severity
is shown in Figure 1. Eighty-six percent of all DOW casualties
had an ISS 16 consistent with moderate to severe
injury. Fifty-nine percent had an ISS 25. Explosive events
(72%) caused the majority of fatalities, followed by gunshot
wounds (25%) (Fig. 2). DOW casualties were classified as
NS in 271 (48.6%) cases and PS in 287 (51.4%) cases. After
stratifying DOW fatalities as PS or NS (Fig. 3), the lethality
in the NS group was predominantly characterized by traumatic
brain injury (TBI; 83%). In contrast, the mortality in
the PS group was predominantly acute hemorrhage (80%)
caused by explosive or firearm injuries (Fig. 4). Of the
fatalities caused by posttraumatic hemorrhage within the PS
group, the anatomic distribution was 48% truncal, 31% peripheral
extremity, and 21% junctional (Fig. 5).
Figure 1. Distribution of injury severity in DOW.
Figure 2. DOW injury agents.
TABLE 1. Presentation ISS, Glasgow Coma Scale Score, and
Transfusion Volume in DOW Casualties
ISS 30 (16) 27 (1937)
Glasgow Coma Scale score 5 (4) 3 (33)
Units red blood cells 14 (15) 8 (419)
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July Supplement 2011 Battlefield DOW
© 2011 Lippincott Williams & Wilkins S5
The review and analysis of injury deaths is paramount
to the evaluation and improvement of trauma centers and
trauma systems.24 In one post hoc analysis of combat mortality
from past conflicts, investigators surmised that improvements
in education, research, and development could
potentially decrease the incidence of in-hospital deaths by 8%
to 25%.25 Corroborating this evidence were two earlier studies
during the current conflicts from the military medical
literature. In 2004, in an analysis of a small population of
special operations combat wounded who were both killed in
action (KIA) and DOW, 12 of 82 (14.6%) casualties had PS
injuries. Of those with PS injuries, hemorrhage was the most
common mechanism of death.20 A subsequent analysis of a
casualty sample of 982 battlefield casualties composed of
75% KIA and 25% DOW by the same investigators was
significant for a PS death ratio of 24%. These studies supported
the proliferation of hemostatic adjuncts including tourniquets26–
29 and topical hemostatic agents30,31 as well as the
evolution and dissemination of the concepts of damage control
resuscitation.9,32–38 By evaluating the current population of those
who died of their injuries after reaching a battlefield MTF, our
goal was to identify opportunities for improvement across the
breadth of the military trauma system.
The initial observation of significance in this analysis
was that the 558 DOW casualties represented a DOW rate of
4.6% over the study period. This is striking as it compares
favorably to in-hospital trauma deaths recorded in the National
Trauma Data Bank and in Level I trauma centers within
the United States which report rates of 3% to 5%6,12,17,39,40 for
the general injury population and up to 15.8% for specific
penetrating injury populations.41 Erring on the side of being
more inclusive, we were critically introspective and included
even those patients who presented in extremis with CPR
(51%) ongoing at the time of presentation. These patients are
inconsistently included in classic studies of in-hospital injury
mortality. Had these patients been excluded, the DOW rate in
this population would have been an unprecedented 2.3%.
This observation is potentiated by the realization that the care
is being provided in austere, often hostile conditions with
numerous operational and tactical constraints that challenge
the provision of injury care at all levels. Furthermore, analyzing
injury variables, it was apparent that the DOW group
studied in this analysis represented a group of moderately to
severely injured casualties by ISS, with severe injuries comprising
59% of total injuries. The injury variable of low
Glasgow Coma Scale score was consistent with the large
number of casualties who presented with significant TBI or
those who presented in extremis. Likewise, the number of
units of blood per DOW casualty was indicative of a significant
number of casualties requiring massive transfusion
(10 units red blood cells/24 h) and was associated with
those who ultimately died of lethal postinjury hemorrhage.
Similar results of causal mechanisms in early in-hospital
death are substantiated by literature from both the civilian and
The causality of injury from military conflict is largely
not comparable with the civilian sector. In stark contrast to
civilian injury patterns, 72% of casualties in the current series
were caused by explosive agents. It can be difficult to sort out
primary, secondary, and tertiary explosive injury effects in
contemporary combat explosive injuries because of the severity
of the injuries. The most current practice of the
OAFME forensic pathologists is to classify the cause of death
in explosions as blast injuries without further classification.
Evaluation of those casualties deemed NS was significant
in that 83% were attributed to TBI. Numerous studies in
the contemporary trauma literature note similar outcomes for
TBI.6,10,12,46 Mitigation strategies aimed at affecting the deleterious
outcomes of TBI must stress prevention of primary
brain injury with materiel and personal protective equipment
technologies and minimization of secondary brain injury.
Postinjury hemorrhage was also a significant mechanism of
NS DOW injury. Because of the nature of the hemorrhagic
Figure 3. Mechanism of death in NS cases.
Figure 4. Mechanism of death in PS cases.
Figure 5. Main hemorrhage focus by anatomic region.
Eastridge et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July Supplement 2011
S6 © 2011 Lippincott Williams & Wilkins
source in this population including heart, aorta, and traumatic
dismemberment, prevention strategies must be the main strategy
In contrast, as reported in previous studies of
combat operations and civilian trauma centers, hemorrhage
is the most substantial focus of PS battlefield injury.
10,18,20,25,33,35,44,47 Prior studies have shown that damage
control resuscitation strategies decreased massive transfusion
mortality from 38% to consistently below 20% in the severely
injured combat casualty.1,3,33,35,38 However, our findings support
the consistent attribution of casualties who succumb to
fatality after admission to a military MTF to complications of
hemorrhage, underscoring the need to augment hemostatic
practices with research and development. In addition, these
findings champion the drive for advanced hemostatic techniques
further forward onto the battlefield with agents such as
freeze-dried plasma and novel topical hemostatic agents.
Further stratification of the anatomic site of attributable DOW
hemorrhage demonstrated that 48% was truncal, 31% peripheral
extremity, and 21% junctional. The rate of peripheral
extremity hemorrhage has decreased significantly over course
of the conflict secondary to the dissemination of tourniquets
onto the battlefield.27–29 On the other hand, the 69% combined
incidence of truncal and junctional hemorrhage as the
primary mechanism of lethality stresses that more research is
required to have hemorrhage control options in the tactical
environment before combat casualties have exsanguinated.
This study is retrospective and thus has several limitations
including the inherent limitations of large registries such
as the JTTR and MTR, including misclassification bias,
interobserver subjectivity/variability data interpretation, and
input errors. In addition, because KIA was specifically not
included in this analysis, the complete picture of the mortality
profile over the spectrum of combat injury cannot be elucidated.
Further analyses are in process by this group to correct
this critical deficiency in future analyses. Finally, based on
gross examination alone, there is potential undermeasurement
of lethal TBI because of severe rotational injuries that can
occur with the magnitude of forces casualties may experience
during explosive events. Therefore, some NS cases classified
may have been inadvertently misclassified as PS based on
gross autopsy findings.
In conclusion, this comprehensive analysis of DOW
combat casualties reiterates the necessity for operational
strategies to enhance prevention, particularly for traumatic
central nervous system injury. In addition, hemorrhage is the
major mechanism of death in PS combat injuries, emphasizing
the necessity for initiatives to mitigate bleeding, particularly
in the prehospital environment.
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S8 © 2011 Lippincott Williams & Wilkins