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J R Army Med Corps. 2019 Jun 17. pii: jramc-2019-001231. doi: 10.1136/jramc-2019-001231. [Epub ahead of print]

For debate: advanced bleeding control potentially saves lives in armed forces and should be considered.

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Surgery, Alrijne Ziekenhuis locatie Leiderdorp, Leiderdorp, The Netherlands
Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.
Surgery, Alrijne Ziekenhuis locatie Leiderdorp, Leiderdorp, The Netherlands.
Defense Healthcare Department, Ministry of Defence, Utrecht, The Netherlands.
Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Leiden University Medical Centre, Leiden, The Netherlands.



Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel.


The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control.


There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61).


Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.


REBOA; advanced bleeding control; military; non-compressible torso haemorrhage


Conflict of interest statement

Competing interests: None declared.

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