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J Trauma Acute Care Surg. 2017 Oct 16. doi: 10.1097/TA.0000000000001727. [Epub ahead of print]

Re-examination of a Battlefield Trauma Golden Hour Policy.

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1 US Army Institute of Surgical Research, 3698 Chambers Pass, Joint Base San Antonio-Fort Sam Houston, Texas 78234 2 Department of Defense Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio-Fort Sam Houston, Texas 78234 3 Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814 4 Texas A&M Health Science Center College of Medicine, 1114 Texas A&M University, College Station, Texas 77843 5 The Pennsylvania State University, 303 Oswald Tower, University Park, PA 16802 6 US Army, Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Ave, Tacoma, WA 98431 7 Bureau of Medicine and Surgery, US Navy, Falls Church, VA 22042-5113.



Most combat casualties who die, do so in the prehospital setting. Efforts directed toward alleviating prehospital combat trauma death, known as killed in action (KIA) mortality, have the greatest opportunity for eliminating preventable death.


4,542 military casualties injured in Afghanistan from September 11, 2001 to March 31, 2014 were included in this retrospective analysis to evaluate proposed explanations for observed KIA reduction following a mandate by Secretary of Defense Robert M. Gates that transport of injured service members occur within 60 minutes. Using inverse probability weighting to account for selection bias, data were analyzed using multivariable logistic regression and simulation analysis to estimate the effects of 1) gradual improvement, 2) damage control resuscitation, 3) harm from inadequate resources, 4) change in wound pattern, and 5) transport time on KIA mortality.


The effect of gradual improvement measured as a time trend was not significant (AOR=0.99; 95%CI 0.94-1.03; p=0.58). For casualties with military injury severity score ≥ 25, the odds of KIA mortality were 83% lower for casualties who needed and received prehospital blood transfusion (AOR=0.17; 95%CI 0.06-0.51; p=0.002); 33% lower for casualties receiving initial treatment by forward surgical teams (AOR=0.67; 95%CI 0.58-0.78; p<0.001); 70%, 74%, and 87% lower for casualties with dominant injuries to head (AOR=0.30; 95%CI 0.23-0.38; p<0.001), abdomen (AOR=0.26, 95%CI 0.19-0.36; p<0.001) and extremities (AOR=0.13; 95%CI 0.09-0.17; p<0.001); 35% lower for casualties categorized with blunt injuries (AOR=0.65; 95%CI 0.46-0.92; p=0.01); and 39% lower for casualties transported within one hour (AOR=0.61; 95%CI 0.51-0.74; p<0.001). Results of simulations in which transport times had not changed after the mandate indicate that KIA mortality would have been 1.4% higher than observed, equating to 135 more KIA deaths (95%CI 105-164).


Reduction in KIA mortality is associated with early treatment capabilities, blunt mechanism, select body locations of injury, and rapid transport.


Retrospective/Case-control, Level III.

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