SPECIAL ARTICLE SPECIAL ARTICLE
Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts Paul Klimo Jr, MD, MPH*‡ Brian T. Ragel, MD§ G. Morgan Jones, PharmD, BCPS‡¶ Randall McCafferty, MDk *Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee; ‡Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee; §Department of Neurosurgery, Mercy Hospital and Clinic, Springfield, Missouri; ¶Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee; kWilford Hall Medical Center, Lackland Air Force Base, Texas Correspondence: Paul Klimo Jr, MD, MPH, Semmes-Murphey Neurologic & Spine Institute, 6325 Humphreys Blvd, Memphis, TN 38120. E-mail: [email protected] Received, January 7, 2015. Accepted, February 18, 2015. Published Online, March 23, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
BACKGROUND: Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. OBJECTIVE: To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). METHODS: A retrospective review of children (,18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code .3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. RESULTS: We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. CONCLUSION: This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts. KEY WORDS: Head injury, Improvised explosive device, Operation enduring freedom, Operation Iraqi freedom, Pediatric, Penetrating Neurosurgery 77:1–7, 2015
DOI: 10.1227/NEU.0000000000000743
T
he events of September 11, 2001, ignited several military campaigns for the United States and its allies, collectively known as the Global War on Terrorism. The largest and most well-documented conflicts were Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan. OIF began in March 2003 and concluded in December 2011 with the withdrawal of all US military personnel. OEF began in October 2001 and continues to
ABBREVIATIONS: CI, confidence interval; GCS, Glasgow Coma Score; ICP, intracranial pressure; IED, improvised explosive device; JTTR, Joint Theater Trauma Registry; LN, local national; MTF, military treatment facility; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom
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this day, although the vast majority of US military personnel will be withdrawn by January 2015. It has become the longest continuous military conflict in US history. Both of these conflicts required enormous investment of medical personnel, equipment, and support. The primary focus of medical operations was to care for coalition (US and other participating nations) force casualties; however, local nationals (LNs) were also eligible for care, as depicted in Figure 1. If LNs, including children, sustained battlefield injuries as a direct result of coalition combat operations, they could be cared for at a coalition military treatment facility (MTF). Cases that were not combat-related or completely unrelated to the war were entertained on a case-by-case basis with 2 main criteria: (1) the nature and prognosis of the pathology in
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KLIMO ET AL
FIGURE 1. Medical rules of engagement (ROE) in a combat environment. LLE, life, limb, eyesight; LN, local national; OPS, operations.
by the Canadian military, and then transitioned back to US control and provided additional neurosurgical capability. Unlike Iraq where neurosurgeons were present at the onset of OIF, neurosurgeons were not on the ground in Afghanistan until 2007, with general surgeons caring for head injuries. In addition, in Afghanistan and Iraq, there was a vast network of MTFs that provided immediate care for LNs with neurosurgical injuries or ailments, typically by general surgeons or trauma surgeons.1 Such level II teams and facilities, called forward surgical teams and forward operating bases, respectively, would typically stabilize LNs and then expeditiously transfer them to a higher level of care at another MTF or a LN facility, if possible.2-5 Children have and will always be unfortunate victims of any military conflict, with OIF and OEF being no exception. Many authors have documented their experience treating children injured during these campaigns.1,6-14 We and others have detailed our experience treating children with neurosurgical injuries and diseases during these 2 conflicts, typically over a finite time period.15-17 This project was undertaken to describe the epidemiologic features and outcomes associated with isolated severe head injury in children treated at military medical facilities during OIF and OEF with the use of the Joint Theater Trauma Registry (JTTR). Specifically, we sought to identify predictors of in-hospital mortality for both conflicts individually and combined. Although the injuries seen and treated during OIF and OEF were likely quite similar, the availability of pediatric assets and the extreme difference in geography may have resulted in different outcomes. Similar to other battlefield injuries,18 it is critical to collect and analyze epidemiologic data from each conflict to compare results to prior conflicts, and to identify deficiencies and aspects of care that need improvement so that outcomes will improve with future conflicts.
METHODS question and the likelihood that treatment would positively impact the LNs quality of life and (2) the availability of coalition resources, such as bed space (designated as green = available; amber = near-capacity; and red = critical capacity), medical or surgical specialties, equipment, nursing care, and the expenditure of such resources needed to adequately treat the condition. There are 5 echelons of medical care in the military. Level I represents first responders, such as a corpsman or medic. Level II is a forward operating base where the focus is on continuing resuscitative efforts, damage control, and stabilization. Level III is a fully equipped and staffed hospital within the theatre of military operations. Level IV is a hospital outside the theater of operations, and level V is a medical center in the United States. Neurosurgical assets in OEF and OIF were limited to a few level III MTFs. The main facility in Iraq was initially in Bagdad but transitioned to Joint Base Balad early in the conflict. In Afghanistan, Bagram Air Field served as the primary US level III facility. The level III medical facility at Kandahar Air Field in southern Afghanistan was originally established by the US Army, followed
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The JTTR is a stand-alone, store-and-forward software application used by deployed triservice (Army, Air Force, and Navy) trauma nurse coordinators to collect battlefield injury demographics, care, and outcomes for both military and civilian casualties (http://www.mc4.army. mil/apps/JTTR). It is the world’s largest repository of traumatic injury data and is part of the US Army’s Medical Communications for Combat Casualty Care (MC4) program. The JTTR program facilitates the creation of trauma records that are transferred to and maintained by the US Army Institute of Surgical Research. After submission of an institutional review board- and US Army Institute of Surgical Research-approved study protocol (Study # [377430-5] FWH20110033H), the JTTR was searched for all children (,18 years old) who sustained an isolated serious head injury (defined as an Abbreviated Injury Score Severity Code of greater than 3) during OEF or OIF from January 1, 2004, through December 31, 2012.19 The JTTR was able to provide us with the following information: age, sex, date of injury, admission and discharge Glasgow Coma Score (GCS), campaign, injury type, injury mechanism, need for craniotomy or craniectomy or placement of an intracranial pressure monitor (based on International Classification of Diseases, Ninth Revision codes), length of stay, and disposition at time of discharge.
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
TABLE 1. Characteristics of All Children (,18 Years of Age) With Severe Isolated Head Injuries Found in Our Search of the Joint Theater Trauma Registry Using Abbreviated Injury Scale Severity Code of .3a,b
Characteristic Age, y Age subgroups, n (%) Infant Toddler Child Preteen Adolescent Male, n (%) Glasgow Coma Scale Admission Discharge Length of stay, d Injury type, n (%) Open Penetrating Closed Injury mechanism, n (%) Improvised explosive device (IED) Blast (not specified) Gunshot wound Mortar Blunt Other Survival, n (%) Discharge status, n (%) Morgue Home Local national facility Coalition facility Unknown
All Children (n = 647)
Operation Enduring Freedom (n = 337)
Operation Iraqi Freedom (n = 268)
8 [5-12]
8 [5-12]
8 [5-12]
35 (5.4) 73 (11.3) 275 (42.5) 147 (22.7) 117 (18.1) 492 (76.0)
13 (3.9) 35 (10.4) 141 (41.8) 91 (27) 57 (16.9) 264 (78.3)
21 (7.8) 31 (11.6) 113 (42.2) 47 (17.5) 56 (20.9) 203 (75.7)
7 [3-15] 15 [3-15] 3 [1-7]
7 [3-14] 15 [3-15] 3 [1-6]
7 [3-15] 15 [3-15] 3 [1-7]
202 (31.2) 392 (60.6) 53 (8.2)
90 (26.7) 207 (61.4) 40 (11.9)
94 (35.1) 163 (60.8) 11 (4.1)
245 (37.9)
97 (28.8)
132 (49.3)
162 (25.0) 96 (14.8) 75 (11.6) 28 (4.3) 41 (6.8) 491 (75.6)
97 (28.8) 59 (17.5) 32 (9.5) 15 (4.5) 37 (11) 263 (78)
4 (20.1) 31 (11.6) 35 (13.1) 12 (4.5) 4 (1.5) 199 (74.3)
156 (24.1) 264 (40.8) 124 (19.2) 92 (14.2) 11 (1.7)
74 (22.0) 133 (39.5) 73 (21.7) 52 (15.4) 5 (1.5)
69 (25.7) 117 (43.7) 44 (16.4) 32 (11.9) 6 (2.2)
a
Data are presented as median [25%-75% interquartile range] unless otherwise noted. b The Abbreviated Injury Scale (AIS), first developed in 1971 by the Association for the Advancement of Automotive Medicine, is an anatomically based, consensusderived, global severity scoring system that classifies each injury by body region according to its relative importance using a post-dot digit number on a 6-point ordinal scale. The AIS post-dot digit codes the severity of the primary injury in a body region (body region 1 is “Head and Neck”) on a scale from 0.1 to 0.6, the most severe being post-dot digit 0.6: 0.1 = minor; 0.2 = moderate; 0.3 = serious; 0.4 = severe; 0.5 = critical; 0.6 = virtually nonsurvivable.
Statistical Analysis The primary outcome was in-hospital mortality. We also sought to determine predictors of survival in both the overall cohort and the individual conflicts. Characteristics of those who survived their hospitalization were compared with those who did not in 3 separate univariate analyses: the entire cohort of injured children and those wounded in OIF and OEF separately.
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For the entire cohort of patients, we described clinical characteristics, including age, sex, injury type and mechanism, military campaign, admission and discharge GCS, length of stay, and need for craniotomy/ craniectomy or intracranial pressure (ICP) monitoring. For descriptive purposes, patients in the entire cohort were further divided into the following age groups: infant (0-1 year), toddler (2-3), child (4-9), preteen (10-12), and adolescent (13-17). Data from the JTTR classified injury types into open, penetrating, and closed categories. Primary cause of injury was stratified based on the following mechanisms: improvised explosive device (IED), mortar, blast (not otherwise specified), gunshot wound, blunt, or other. Blast injuries were defined as those occurring from any explosive device. We also examined the time period in which patients were treated. An injury was considered “early” if it occurred between 2004 to 2007 (inclusive) for OEF and 2003 to 2009 (inclusive) for OIF. Time periods were based on troop surges that took place for both conflicts (2007 for OIF; 2010 for OEF), which resulted in a dramatic increase in personnel and equipment. Nominal data were evaluated by using either the x2 test or the Fisher exact test. Continuous data were analyzed by using the Student t test for parametric data and Mann-Whitney test for nonparametric data. Stepwise multivariable logistic regression was then conducted to determine independent predictors for survival. All values with a P , .2 in the univariate analysis of those who survived and those who did not were placed into the model. Results are reported as adjusted odds ratio (OR) with corresponding 95% confidence intervals (CIs). Two-tailed statistical tests were used, and a P , .05 was determined to represent statistical significance. All data were analyzed by using SPSS software (IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York).
RESULTS Our searched identified 647 children with severe isolated head injuries: 337 for OEF, 268 for OIF, and 42 that could not be categorized. Table 1 depicts the characteristics for the group as a whole and by individual conflict. The majority (76%) of children treated were male with a median age of 8 years (range 0.3-17). Penetrating injuries were the most common type (60.6%), with the most common causes being IED (37.9%) or blast (25%). Overall, 330 (51%) children underwent a craniotomy or craniectomy and 227 (35%) had an ICP monitor placed. Nearly one-quarter of children with an isolated serious head injury died during their hospital stay (156 of 647, or 24.1%). The median length of hospitalization was relatively short (3 days), but ranged from 0 to 43 days across the entire cohort. The majority (60%) of children who survived their hospital admission were sent home or to another LN medical facility for further convalescence. Table 2 shows the results of our univariate analysis for all patients and those injured in the individual conflicts. Patients who survived their injuries had a significantly higher median admission GCS (3 vs 9; P , .001) and were more likely to be male (69.9% vs 78%; P = .04). Although there was a statistical trend for closed injuries to be more common in those who survived (5.1% vs 9.2%; P = .11), this did not reach statistical significance. For the individual conflicts, 183 patients in OEF
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98 (49.2) 41 (20.6) 25 (12.6) 23 (11.6) 8 (4.0) 4 (2)
..99 .75 .39 .22 .54 .56
were injured early, compared with 89 in OIF. There was no difference in survival for either conflict among those who were injured early or later in the war. Our multivariate analysis identified admission GCS (OR 1.32, 95% CI 1.24-1.40) and being male (OR 1.94, 95% CI 1.20-3.13) as independent predictors of survival among all children injured during the Global War on Terrorism (Table 3). Each 1-point increase in GCS resulted in a 32% increased odds of survival, with being male increasing the odds by 94%. Although closed head injuries did not reach statistical significance (P = .07), they improved the predictive ability of our multivariate model. Admission GCS and male sex were independent predictors of survival for OEF, but only admission GCS for OIF (Table 4).
DISCUSSION This study represents the largest collection of children with severe isolated head injuries not only during the Iraq and Afghanistan wars, but for any military conflict thus far. The majority were boys in either the child or preteen years. Boys are disproportionately represented in pediatric trauma publications from the Afghanistan and Iraq conflicts because, as stated by Borgman and colleagues, they tend to congregate around soldiers, are combatants themselves, or are more likely to be involved in accidental trauma.7,11 Unlike more conventional wars of the past, these conflicts have been characterized by the use of remotely detonated explosives and other blast weaponries.20 Previous research has identified penetrating projectiles as the most common mechanism of pediatric trauma seen in both wars, with IEDs being the most likely mechanism of blast injury (Figure 2).7,9,11 Specific to pediatric head injury, we and other authors have found this same epidemiologic pattern.21,22 There were very few closed head injuries, with falls and motor vehicle accidents being likely etiologies. This underrepresentation is due in part to 2 reasons. First, blunt head injury is less likely directly related to combat operations and so would have been classified as humanitarian care and, therefore, would not have automatically been accepted for care at an MTF (Figure 1). Second, blunt head injuries are often associated with other organ system injuries, which we excluded.
TABLE 3. Predictors of Survival Among All Children With Severe Isolated Head Injuries (n = 647)a,b
Admission GCS Male Closed injury
Odds Ratio
95% Confidence Interval
P
1.32 1.94 2.41
1.24-1.40 1.20-3.13 0.93-6.20
,.001 .007 .07
a
GCS, Glasgow Coma Score; CI, confidence interval. Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.79 (0.750.83); Hosmer and Lemeshow Goodness-of-fit Test = 0.48.
b
a
Data are presented as median [25%-75% interquartile range] unless otherwise noted.
186 (37.9) 123 (25.1) 73 (14.9) 55 (11.2) 19 (3.9) 35 (7.1) (37.8) (25.0) (14.7) (12.8) (5.8) (3.8) 59 39 23 20 9 6
.99 .99 .97 .58 .31 .14
18 25 15 5 5 6
(24.2) (33.8) (20.3) (6.8) (6.8) (8.1)
79 (30) 72 (27.4) 44 (16.7) 27 (10.3) 10 (3.8) 31 (11.8)
.34 .28 .48 .36 .34 .31
34 (49.3) 13 (18.8) 6 (8.7) 12 (17.4) 4 (5.8) 0 (0)
.95 .77 .73 70 (35.2) 120 (60.3) 9 (4.5) 152 (31.0) 294 (59.9) 45 (9.2) 50 (32.1) 98 (62.8) 8 (5.1)
.80 .51 .11
21 (28.4) 48 (64.9) 5 (6.8)
69 (26.2) 159 (60.5) 35 (13.3)
.71 .49 .12
24 (34.8) 43 (62.3) 2 (2.9)
.78 .46 ,.001 .96 8 [5-12] 153 (76.9) 10 [3-15] 67 (33.7) 8 [5-11] 50 (72.5) 3 [3-15] 23 (33.3) .49 .03 ,.001 .40 8 [5-12] 213 (81) 9 [3-15] 146 (55.5) 8 [5-12] 51 (68.9) 3 [3-4] 37 (50) .94 .04 ,.001 — 8 [5-12] 383 (78) 9 [3-15] — 8 [5-11] 109 (69.9) 3 [3-6] —
Age, y Male, n (%) Admission Glasgow Coma Scale Early injury, n (%) Injury type, n (%) Open Penetrating Closed Injury mechanism, n (%) Improvised explosive device (IED) Blast (not specified) Gunshot wound Mortar Blunt Other
Expired (n = 69) Survived (n = 199) Expired (n = 74) Survived (n = 263) Expired (n = 156) Survived (n = 491) Characteristic
TABLE 2. Univariate Analysis for Survivala
All Children
P
Operation Enduring Freedom
P
Operation Iraqi Freedom
P
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
TABLE 4. Predictors of Survival Based Upon Individual Conflicta Conflict Operation Enduring Freedomb
Admission GCS Male
Operation Iraqi Freedomc
Odds Ratio
95% Confidence Interval
P
Odds Ratio
95% Confidence Interval
P
1.36 3.13
1.23-1.50 1.51-6.48
,.001 .002
1.26 1.33
1.17-1.37 0.66-2.69
,.001 .43
a
GCS, Glasgow Coma Score; CI, confidence interval. Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.81 (0.76-0.86); Hosmer and Lemeshow Goodness-of-fit Test = 0.46. c Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.76 (0.70-0.82); Hosmer and Lemeshow Goodness-of-fit Test = 0.22. b
Just over half of the children in our study required a craniotomy or craniectomy, with another 35% having an ICP monitor placed. Presumably, many of the patients that did not require a craniotomy or craniectomy had local wound care only with or without ICP monitoring. Data from the Iran-Iraq conflict support the use of such a strategy in those patients without mass lesion or gross contamination.23 Although there was a wide range of length of stay (up to 43 days), many children had a relatively short duration at the military medical facility, which reflects the priority given to discharging or transferring these children to another LN facility at the earliest possible opportunity. This rapid transfer was done to ensure that the limited bed space and other resources were ready for coalition casualties.6,24 This priority is particularly notable because many coalition admissions would present as a sudden influx of numerous patients, called a “mass casualty.”25 Our overall mortality was 24.4%, which is similar to other pediatric combat studies, and comparable to or higher than civilian studies.9,26-30 We presume that the cause of death in the vast majority of these children was due to their head injury, because we selected only children with severe, isolated head injuries as defined by the Abbreviated Injury Scale. Numerous studies have demonstrated that the overall pediatric mortality during these
wars (5.4%-8.5%) was greater than the mortality rates for coalition troops and LN adults and that the most common causes of death for young patients were burns and penetrating head injury.7,9,11,24,31 Similar to civilian and other military pediatric head injury reports, we found that admission GCS was predictive of survival for patients with head injury.7,13,14,26-30,32 Looking at their entire study population of pediatric trauma regardless of injury type or mechanism, Patregnani et al33 found that coagulopathy and hypovolemic shock on presentation were independently associated with the high incidence of mortality in children injured during the Iraq and Afghanistan wars. These 2 variables have been identified in pediatric civilian head injury studies as well.27-29 Anecdotally, deployed neurosurgeons perceived a high incidence of coagulopathy and hypotension when receiving young patients with head injury; however, objective data from abstraction were not readily available for analysis. As other authors have reported, we did not demonstrate an increased mortality risk with younger aged children.11,13,26,27,31 We also found that males were less likely to die as a result of an isolated head injury in OEF, but not OIF. Borgman et al7 reported the same finding when analyzing their combined data from both conflicts. The reason for this is not readily apparent, but we
FIGURE 2. An example of a child with a penetrating head injury. A, this 4-year-old girl was caught in the middle of an urban firefight between US soldiers and the Taliban and sustained a gunshot wound to the head with the entry site being through her left eye. She arrived at Bagram Air Field with a GCS of 9. B, computed tomography scan showed a bifrontal trajectory of the bullet. An external ventricular drain was placed, but she required a bifrontal decompressive craniectomy because of sustained intracranial hypertension. C, the intraoperative picture demonstrates a tense dura and the bullet’s exit point on the right side. She eventually had her bone flap replaced and was discharged to the care of her father 5 weeks after admission. She required a cranioplasty revision 8 months later owing to aseptic bone resorption. GCS, Glasgow Coma Score.
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speculate that this may be due to a lower value placed on a female’s life as opposed to a male’s in the Afghan culture. This cultural disparity may possibly result in a delay of care sought by the victim’s family. Finally, we evaluated the date at which the child was injured as a possible contributor to mortality. We hypothesized that earlier in the individual conflicts the resources available, including smaller networks of forward operating bases and fewer pediatric trained providers, to treat children may not have been as established as in the later years. In particular, aeromedical evacuation in the Afghanistan theater was much more of a challenge because of rugged, remote, and austere geographic landscape and unpredictable weather in comparison to the flat, hot endless desert of Iraq. Nonetheless, children injured “early” in either conflict, as we have defined, did not have a higher mortality than those injured late. There was a statistical trend, suggesting that a closed head injury was also an independent predictor of survival (P = .07), which would not be unexpected, but did not reach significance because of the small number of patients we had with this type of injury. Many others have used the JTTR for research32-34 with inhospital mortality10,13,24,32,33,35 as the primary outcome; however, the JTTR has significant limitations, as detailed by others.36 The JTTR was designed to capture demographic and outcome data for process improvement, such as the development of clinical practice guidelines. It was not specifically intended for research, especially for LNs, and some data are simply unavailable. There are no provider notes, such as computed tomography results or operative reports, which makes it impossible to know the details of each head injury and what specifically was done at the time of surgery and why. JTTR data from 2001 through 2003 were retrospectively collected—which is why we excluded these dates in our search—and dedicated nurse data collection personnel at each site were not available until 2006. Some measures may not be entirely accurate, such as the admission GCS ideally being recorded after adequate resuscitation and free of medications (paralytics or sedatives), and there are no readily available means to assess the accuracy of the data. Validated outcome measures for adults and children, such as the King Outcome Scale, are not part of the JTTR.37 As stated by O’Connell, the limitations associated with the use of the JTTR data are also due to variations in individual provider’s documentation habits and the condition under which the data are entered.36 The consistency of data input has also increased with time, especially since 2008.36 Finally, the study of LNs is limited to short-term outcomes, which is the reason in-hospital mortality is one of the few reliable and meaningful outcomes in the JTTR. There were neither the mechanisms nor the resources by which many LNs could be consistently and safely followed long-term as an outpatient at US combat support hospitals.
CONCLUSION Many children have been injured as a result of combat operations or nonbattlefield causes during OEF and OIF. Almost
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one-quarter of children with isolated severe head injuries died, with the most common mechanism being IED. Admission GCS and sex were found to be independent predictors of survival. Given the challenging environment and limited available resources, coalition forces were able to provide quality, timely, and lifesaving care to many children. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Wilson KL, Schenarts PJ, Bacchetta MD, Rai PR, Nakayama DK. Pediatric trauma experience in a combat support hospital in eastern Afghanistan over 10 months, 2010 to 2011. Am Surg. 2013;79(3):257-260. 2. Beekley AC, Watts DM. Combat trauma experience with the United States Army 102nd Forward Surgical Team in Afghanistan. Am J Surg. 2004;187(5): 652-654. 3. Eastridge BJ, Stansbury LG, Stinger H, Blackbourne L, Holcomb JB. Forward Surgical Teams provide comparable outcomes to combat support hospitals during support and stabilization operations on the battlefield. J Trauma. 2009;66 (4 suppl):S48-S50. 4. Nessen SC, Cronk DR, Edens J, et al. US Army two-surgeon teams operating in remote Afghanistan—an evaluation of split-based Forward Surgical Team operations. J Trauma. 2009;66(4 suppl):S37-S47. 5. Peoples GE, Gerlinger T, Craig R, Burlingame B. Combat casualties in Afghanistan cared for by a single Forward Surgical Team during the initial phases of Operation Enduring Freedom. Mil Med. 2005;170(6):462-468. 6. Arul GS, Reynolds J, DiRusso S, et al. Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan. Ann R Coll Surg Engl. 2012;94(1):52-57. 7. Borgman M, Matos RI, Blackbourne LH, Spinella PC. Ten years of military pediatric care in Afghanistan and Iraq. J Trauma Acute Care Surg. 2012;73(6 suppl 5): S509-S513. 8. Coppola CP, Leininger BE, Rasmussen TE, Smith DL. Children treated at an expeditionary military hospital in Iraq. Arch Pediatr Adolesc Med. 2006;160(9): 972-976. 9. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, Adelman W. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions. J Trauma. 2009;67(4):762-768. 10. Edwards MJ, Lustik M, Burnett MW, Eichelberger M. Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012. J Am Coll Surg. 2014;218(5):1018-1023. 11. Edwards MJ, Lustik M, Eichelberger MR, Elster E, Azarow K, Coppola C. Blast injury in children: an analysis from Afghanistan and Iraq, 2002-2010. J Trauma Acute Care Surg. 2012;73(5):1278-1283. 12. Fuenfer MM, Spinella PC, Naclerio AL, Creamer KM. The U.S. military wartime pediatric trauma mission: how surgeons and pediatricians are adapting the system to address the need. Mil Med. 2009;174(9):887-891. 13. Matos RI, Holcomb JB, Callahan C, Spinella PC. Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in Baghdad, Iraq, 2004. Pediatrics. 2008;122(5):e959-e966. 14. McGuigan R, Spinella PC, Beekley A, et al. Pediatric trauma: experience of a combat support hospital in Iraq. J Pediatr Surg. 2007;42(1):207-210. 15. Klimo P Jr, Ragel BT, Scott WH Jr, McCafferty R. Pediatric neurosurgery during Operation Enduring Freedom. J Neurosurg Pediatr. 2010;6(2):107-114. 16. Martin JE, Teff RJ, Spinella PC. Care of pediatric neurosurgical patients in Iraq in 2007: clinical and ethical experience of a field hospital. J Neurosurg Pediatr. 2010;6 (3):250-256. 17. Mathew P, Gibbons AJ, Christie M, Eisenburg MF. Operative treatment of paediatric penetrating head injuries in southern Afghanistan. Br J Neurosurg. 2013; 27(4):489-496. 18. Belmont PJ, Schoenfeld AJ, Goodman G. Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Orthop Adv. 2010;19(1):2-7.
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
19. Rating the severity of tissue damage. I. The abbreviated scale. JAMA. 1971;215(2): 277-280. 20. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64(2):295-299. 21. Ling G, Bandak F, Armonda R, Grant G, Ecklund J. Explosive blast neurotrauma. J Neurotrauma. 2009;26(6):815-825. 22. Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 2009;66(4 suppl):S104-S111. 23. Amirjamshidi A, Abbassioun K, Rahmat H. Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries. Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran-Iraq conflict. Surg Neurol. 2003;60(2): 105-110; discussion 110-101. 24. Burnett MW, Spinella PC, Azarow KS, Callahan CW. Pediatric care as part of the US Army medical mission in the global war on terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics. 2008;121(2):261-265. 25. Beekley AC, Martin MJ, Spinella PC, Telian SP, Holcomb JB. Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom. J Trauma. 2009; 66(4 suppl):S129-S137. 26. Pineda JA, Leonard JR, Mazotas IG, et al. Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol. 2013;12(1):45-52. 27. Tude Melo JR, Di Rocco F, Blanot S, et al. Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery. 2010;67(6):1542-1547. 28. Ducrocq SC, Meyer PG, Orliaguet GA, et al. Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med. 2006;7(5): 461-467. 29. White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med. 2001;29(3):534-540. 30. Feickert HJ, Drommer S, Heyer R. Severe head injury in children: impact of risk factors on outcome. J Trauma. 1999;47(1):33-38. 31. Spinella PC, Borgman MA, Azarow KS. Pediatric trauma in an austere combat environment. Crit Care Med. 2008;36(7 suppl):S293-S296. 32. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics. 2011;127(4):e892-e897. 33. Patregnani JT, Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals. Pediatr Crit Care Med. 2012;13(3):273-277. 34. Orman JA, Geyer D, Jones J, et al. Epidemiology of moderate-to-severe penetrating versus closed traumatic brain injury in the Iraq and Afghanistan wars. J Trauma Acute Care Surg. 2012;73(6 suppl 5):S496-S502. 35. Martin M, Oh J, Currier H, et al. An analysis of in-hospital deaths at a modern combat support hospital. J Trauma. 2009;66(4 suppl):S51-S60; discussion S60-S61.
36. O’Connell KM, Littleton-Kearney MT, Bridges E, Bibb SC. Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care. Mil Med. 2012;177(5):546-552. 37. Klimo P Jr, Kestle JR. Potentially useful outcome measures for clinical research in pediatric neurosurgery. J Neurosurg. 2005;103(3 suppl):207-212.
Acknowledgments The authors wish to thank Andrew J. Gienapp, BA, (Department of Medical Education, Methodist University Hospital, Memphis, Tennessee, and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee) for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript.
COMMENT
T
his is a landmark study with a unique and often ignored patient population from a combat zone environment. Unfortunately, it is the local civilian population that bares the greatest burden of war in any conflict throughout history. The number of pediatric patients treated at MTFs are remarkable because this was not a “mission,” as the authors point out, that we were initially resourced or, in some cases, authorized to perform. Early in the conflict 2003 to 2004 we lacked the basics of pediatric equipment; Foley catheters, pediatric IVs, central lines, ventriculoperitoneal shunts, antiepileptics, and endotracheal tubes. The major dilemma is coming up with a criteria of who you can and more importantly can’t help in this limited resourced environment. The goal is to treat without creating vegetative survivors who lack access to further care and, in some cases, were subsequently abandoned by their family who lacked the means for providing basic care. The JTTR lacks the necessary granularity to identify the criteria for patient selection for surgery; detailed examinations, neuro-imaging, time delay to surgery from onset of injury, hypotension, and other important vitals before neurosurgical care are often absent. Improvements to this register would include the above as well as accompanied database manager at each site to ensure that accurate records are kept. The ability to input the neurosurgeon’s preoperative assessment, his surgical findings, and postoperative care are some of the most important elements of understanding the 1/4 mortality that accompanied patients in this category. Unfortunately, in this group of patients, more so than others, did we feel as powerless and limited to the ravages of war among the innocent. Rocco A. Armonda Washington, DC
Commentary provided by Ryan P. Morton and Richard G. Ellenbogen on page 8.
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Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts Paul Klimo Jr, MD, MPH*‡ Brian T. Ragel, MD§ G. Morgan Jones, PharmD, BCPS‡¶ Randall McCafferty, MDk *Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee; ‡Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee; §Department of Neurosurgery, Mercy Hospital and Clinic, Springfield, Missouri; ¶Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee; kWilford Hall Medical Center, Lackland Air Force Base, Texas Correspondence: Paul Klimo Jr, MD, MPH, Semmes-Murphey Neurologic & Spine Institute, 6325 Humphreys Blvd, Memphis, TN 38120. E-mail: [email protected] Received, January 7, 2015. Accepted, February 18, 2015. Published Online, March 23, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
BACKGROUND: Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. OBJECTIVE: To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). METHODS: A retrospective review of children (,18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code .3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. RESULTS: We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. CONCLUSION: This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts. KEY WORDS: Head injury, Improvised explosive device, Operation enduring freedom, Operation Iraqi freedom, Pediatric, Penetrating Neurosurgery 77:1–7, 2015
DOI: 10.1227/NEU.0000000000000743
T
he events of September 11, 2001, ignited several military campaigns for the United States and its allies, collectively known as the Global War on Terrorism. The largest and most well-documented conflicts were Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan. OIF began in March 2003 and concluded in December 2011 with the withdrawal of all US military personnel. OEF began in October 2001 and continues to
ABBREVIATIONS: CI, confidence interval; GCS, Glasgow Coma Score; ICP, intracranial pressure; IED, improvised explosive device; JTTR, Joint Theater Trauma Registry; LN, local national; MTF, military treatment facility; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom
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this day, although the vast majority of US military personnel will be withdrawn by January 2015. It has become the longest continuous military conflict in US history. Both of these conflicts required enormous investment of medical personnel, equipment, and support. The primary focus of medical operations was to care for coalition (US and other participating nations) force casualties; however, local nationals (LNs) were also eligible for care, as depicted in Figure 1. If LNs, including children, sustained battlefield injuries as a direct result of coalition combat operations, they could be cared for at a coalition military treatment facility (MTF). Cases that were not combat-related or completely unrelated to the war were entertained on a case-by-case basis with 2 main criteria: (1) the nature and prognosis of the pathology in
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KLIMO ET AL
FIGURE 1. Medical rules of engagement (ROE) in a combat environment. LLE, life, limb, eyesight; LN, local national; OPS, operations.
by the Canadian military, and then transitioned back to US control and provided additional neurosurgical capability. Unlike Iraq where neurosurgeons were present at the onset of OIF, neurosurgeons were not on the ground in Afghanistan until 2007, with general surgeons caring for head injuries. In addition, in Afghanistan and Iraq, there was a vast network of MTFs that provided immediate care for LNs with neurosurgical injuries or ailments, typically by general surgeons or trauma surgeons.1 Such level II teams and facilities, called forward surgical teams and forward operating bases, respectively, would typically stabilize LNs and then expeditiously transfer them to a higher level of care at another MTF or a LN facility, if possible.2-5 Children have and will always be unfortunate victims of any military conflict, with OIF and OEF being no exception. Many authors have documented their experience treating children injured during these campaigns.1,6-14 We and others have detailed our experience treating children with neurosurgical injuries and diseases during these 2 conflicts, typically over a finite time period.15-17 This project was undertaken to describe the epidemiologic features and outcomes associated with isolated severe head injury in children treated at military medical facilities during OIF and OEF with the use of the Joint Theater Trauma Registry (JTTR). Specifically, we sought to identify predictors of in-hospital mortality for both conflicts individually and combined. Although the injuries seen and treated during OIF and OEF were likely quite similar, the availability of pediatric assets and the extreme difference in geography may have resulted in different outcomes. Similar to other battlefield injuries,18 it is critical to collect and analyze epidemiologic data from each conflict to compare results to prior conflicts, and to identify deficiencies and aspects of care that need improvement so that outcomes will improve with future conflicts.
METHODS question and the likelihood that treatment would positively impact the LNs quality of life and (2) the availability of coalition resources, such as bed space (designated as green = available; amber = near-capacity; and red = critical capacity), medical or surgical specialties, equipment, nursing care, and the expenditure of such resources needed to adequately treat the condition. There are 5 echelons of medical care in the military. Level I represents first responders, such as a corpsman or medic. Level II is a forward operating base where the focus is on continuing resuscitative efforts, damage control, and stabilization. Level III is a fully equipped and staffed hospital within the theatre of military operations. Level IV is a hospital outside the theater of operations, and level V is a medical center in the United States. Neurosurgical assets in OEF and OIF were limited to a few level III MTFs. The main facility in Iraq was initially in Bagdad but transitioned to Joint Base Balad early in the conflict. In Afghanistan, Bagram Air Field served as the primary US level III facility. The level III medical facility at Kandahar Air Field in southern Afghanistan was originally established by the US Army, followed
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The JTTR is a stand-alone, store-and-forward software application used by deployed triservice (Army, Air Force, and Navy) trauma nurse coordinators to collect battlefield injury demographics, care, and outcomes for both military and civilian casualties (http://www.mc4.army. mil/apps/JTTR). It is the world’s largest repository of traumatic injury data and is part of the US Army’s Medical Communications for Combat Casualty Care (MC4) program. The JTTR program facilitates the creation of trauma records that are transferred to and maintained by the US Army Institute of Surgical Research. After submission of an institutional review board- and US Army Institute of Surgical Research-approved study protocol (Study # [377430-5] FWH20110033H), the JTTR was searched for all children (,18 years old) who sustained an isolated serious head injury (defined as an Abbreviated Injury Score Severity Code of greater than 3) during OEF or OIF from January 1, 2004, through December 31, 2012.19 The JTTR was able to provide us with the following information: age, sex, date of injury, admission and discharge Glasgow Coma Score (GCS), campaign, injury type, injury mechanism, need for craniotomy or craniectomy or placement of an intracranial pressure monitor (based on International Classification of Diseases, Ninth Revision codes), length of stay, and disposition at time of discharge.
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
TABLE 1. Characteristics of All Children (,18 Years of Age) With Severe Isolated Head Injuries Found in Our Search of the Joint Theater Trauma Registry Using Abbreviated Injury Scale Severity Code of .3a,b
Characteristic Age, y Age subgroups, n (%) Infant Toddler Child Preteen Adolescent Male, n (%) Glasgow Coma Scale Admission Discharge Length of stay, d Injury type, n (%) Open Penetrating Closed Injury mechanism, n (%) Improvised explosive device (IED) Blast (not specified) Gunshot wound Mortar Blunt Other Survival, n (%) Discharge status, n (%) Morgue Home Local national facility Coalition facility Unknown
All Children (n = 647)
Operation Enduring Freedom (n = 337)
Operation Iraqi Freedom (n = 268)
8 [5-12]
8 [5-12]
8 [5-12]
35 (5.4) 73 (11.3) 275 (42.5) 147 (22.7) 117 (18.1) 492 (76.0)
13 (3.9) 35 (10.4) 141 (41.8) 91 (27) 57 (16.9) 264 (78.3)
21 (7.8) 31 (11.6) 113 (42.2) 47 (17.5) 56 (20.9) 203 (75.7)
7 [3-15] 15 [3-15] 3 [1-7]
7 [3-14] 15 [3-15] 3 [1-6]
7 [3-15] 15 [3-15] 3 [1-7]
202 (31.2) 392 (60.6) 53 (8.2)
90 (26.7) 207 (61.4) 40 (11.9)
94 (35.1) 163 (60.8) 11 (4.1)
245 (37.9)
97 (28.8)
132 (49.3)
162 (25.0) 96 (14.8) 75 (11.6) 28 (4.3) 41 (6.8) 491 (75.6)
97 (28.8) 59 (17.5) 32 (9.5) 15 (4.5) 37 (11) 263 (78)
4 (20.1) 31 (11.6) 35 (13.1) 12 (4.5) 4 (1.5) 199 (74.3)
156 (24.1) 264 (40.8) 124 (19.2) 92 (14.2) 11 (1.7)
74 (22.0) 133 (39.5) 73 (21.7) 52 (15.4) 5 (1.5)
69 (25.7) 117 (43.7) 44 (16.4) 32 (11.9) 6 (2.2)
a
Data are presented as median [25%-75% interquartile range] unless otherwise noted. b The Abbreviated Injury Scale (AIS), first developed in 1971 by the Association for the Advancement of Automotive Medicine, is an anatomically based, consensusderived, global severity scoring system that classifies each injury by body region according to its relative importance using a post-dot digit number on a 6-point ordinal scale. The AIS post-dot digit codes the severity of the primary injury in a body region (body region 1 is “Head and Neck”) on a scale from 0.1 to 0.6, the most severe being post-dot digit 0.6: 0.1 = minor; 0.2 = moderate; 0.3 = serious; 0.4 = severe; 0.5 = critical; 0.6 = virtually nonsurvivable.
Statistical Analysis The primary outcome was in-hospital mortality. We also sought to determine predictors of survival in both the overall cohort and the individual conflicts. Characteristics of those who survived their hospitalization were compared with those who did not in 3 separate univariate analyses: the entire cohort of injured children and those wounded in OIF and OEF separately.
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For the entire cohort of patients, we described clinical characteristics, including age, sex, injury type and mechanism, military campaign, admission and discharge GCS, length of stay, and need for craniotomy/ craniectomy or intracranial pressure (ICP) monitoring. For descriptive purposes, patients in the entire cohort were further divided into the following age groups: infant (0-1 year), toddler (2-3), child (4-9), preteen (10-12), and adolescent (13-17). Data from the JTTR classified injury types into open, penetrating, and closed categories. Primary cause of injury was stratified based on the following mechanisms: improvised explosive device (IED), mortar, blast (not otherwise specified), gunshot wound, blunt, or other. Blast injuries were defined as those occurring from any explosive device. We also examined the time period in which patients were treated. An injury was considered “early” if it occurred between 2004 to 2007 (inclusive) for OEF and 2003 to 2009 (inclusive) for OIF. Time periods were based on troop surges that took place for both conflicts (2007 for OIF; 2010 for OEF), which resulted in a dramatic increase in personnel and equipment. Nominal data were evaluated by using either the x2 test or the Fisher exact test. Continuous data were analyzed by using the Student t test for parametric data and Mann-Whitney test for nonparametric data. Stepwise multivariable logistic regression was then conducted to determine independent predictors for survival. All values with a P , .2 in the univariate analysis of those who survived and those who did not were placed into the model. Results are reported as adjusted odds ratio (OR) with corresponding 95% confidence intervals (CIs). Two-tailed statistical tests were used, and a P , .05 was determined to represent statistical significance. All data were analyzed by using SPSS software (IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York).
RESULTS Our searched identified 647 children with severe isolated head injuries: 337 for OEF, 268 for OIF, and 42 that could not be categorized. Table 1 depicts the characteristics for the group as a whole and by individual conflict. The majority (76%) of children treated were male with a median age of 8 years (range 0.3-17). Penetrating injuries were the most common type (60.6%), with the most common causes being IED (37.9%) or blast (25%). Overall, 330 (51%) children underwent a craniotomy or craniectomy and 227 (35%) had an ICP monitor placed. Nearly one-quarter of children with an isolated serious head injury died during their hospital stay (156 of 647, or 24.1%). The median length of hospitalization was relatively short (3 days), but ranged from 0 to 43 days across the entire cohort. The majority (60%) of children who survived their hospital admission were sent home or to another LN medical facility for further convalescence. Table 2 shows the results of our univariate analysis for all patients and those injured in the individual conflicts. Patients who survived their injuries had a significantly higher median admission GCS (3 vs 9; P , .001) and were more likely to be male (69.9% vs 78%; P = .04). Although there was a statistical trend for closed injuries to be more common in those who survived (5.1% vs 9.2%; P = .11), this did not reach statistical significance. For the individual conflicts, 183 patients in OEF
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98 (49.2) 41 (20.6) 25 (12.6) 23 (11.6) 8 (4.0) 4 (2)
..99 .75 .39 .22 .54 .56
were injured early, compared with 89 in OIF. There was no difference in survival for either conflict among those who were injured early or later in the war. Our multivariate analysis identified admission GCS (OR 1.32, 95% CI 1.24-1.40) and being male (OR 1.94, 95% CI 1.20-3.13) as independent predictors of survival among all children injured during the Global War on Terrorism (Table 3). Each 1-point increase in GCS resulted in a 32% increased odds of survival, with being male increasing the odds by 94%. Although closed head injuries did not reach statistical significance (P = .07), they improved the predictive ability of our multivariate model. Admission GCS and male sex were independent predictors of survival for OEF, but only admission GCS for OIF (Table 4).
DISCUSSION This study represents the largest collection of children with severe isolated head injuries not only during the Iraq and Afghanistan wars, but for any military conflict thus far. The majority were boys in either the child or preteen years. Boys are disproportionately represented in pediatric trauma publications from the Afghanistan and Iraq conflicts because, as stated by Borgman and colleagues, they tend to congregate around soldiers, are combatants themselves, or are more likely to be involved in accidental trauma.7,11 Unlike more conventional wars of the past, these conflicts have been characterized by the use of remotely detonated explosives and other blast weaponries.20 Previous research has identified penetrating projectiles as the most common mechanism of pediatric trauma seen in both wars, with IEDs being the most likely mechanism of blast injury (Figure 2).7,9,11 Specific to pediatric head injury, we and other authors have found this same epidemiologic pattern.21,22 There were very few closed head injuries, with falls and motor vehicle accidents being likely etiologies. This underrepresentation is due in part to 2 reasons. First, blunt head injury is less likely directly related to combat operations and so would have been classified as humanitarian care and, therefore, would not have automatically been accepted for care at an MTF (Figure 1). Second, blunt head injuries are often associated with other organ system injuries, which we excluded.
TABLE 3. Predictors of Survival Among All Children With Severe Isolated Head Injuries (n = 647)a,b
Admission GCS Male Closed injury
Odds Ratio
95% Confidence Interval
P
1.32 1.94 2.41
1.24-1.40 1.20-3.13 0.93-6.20
,.001 .007 .07
a
GCS, Glasgow Coma Score; CI, confidence interval. Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.79 (0.750.83); Hosmer and Lemeshow Goodness-of-fit Test = 0.48.
b
a
Data are presented as median [25%-75% interquartile range] unless otherwise noted.
186 (37.9) 123 (25.1) 73 (14.9) 55 (11.2) 19 (3.9) 35 (7.1) (37.8) (25.0) (14.7) (12.8) (5.8) (3.8) 59 39 23 20 9 6
.99 .99 .97 .58 .31 .14
18 25 15 5 5 6
(24.2) (33.8) (20.3) (6.8) (6.8) (8.1)
79 (30) 72 (27.4) 44 (16.7) 27 (10.3) 10 (3.8) 31 (11.8)
.34 .28 .48 .36 .34 .31
34 (49.3) 13 (18.8) 6 (8.7) 12 (17.4) 4 (5.8) 0 (0)
.95 .77 .73 70 (35.2) 120 (60.3) 9 (4.5) 152 (31.0) 294 (59.9) 45 (9.2) 50 (32.1) 98 (62.8) 8 (5.1)
.80 .51 .11
21 (28.4) 48 (64.9) 5 (6.8)
69 (26.2) 159 (60.5) 35 (13.3)
.71 .49 .12
24 (34.8) 43 (62.3) 2 (2.9)
.78 .46 ,.001 .96 8 [5-12] 153 (76.9) 10 [3-15] 67 (33.7) 8 [5-11] 50 (72.5) 3 [3-15] 23 (33.3) .49 .03 ,.001 .40 8 [5-12] 213 (81) 9 [3-15] 146 (55.5) 8 [5-12] 51 (68.9) 3 [3-4] 37 (50) .94 .04 ,.001 — 8 [5-12] 383 (78) 9 [3-15] — 8 [5-11] 109 (69.9) 3 [3-6] —
Age, y Male, n (%) Admission Glasgow Coma Scale Early injury, n (%) Injury type, n (%) Open Penetrating Closed Injury mechanism, n (%) Improvised explosive device (IED) Blast (not specified) Gunshot wound Mortar Blunt Other
Expired (n = 69) Survived (n = 199) Expired (n = 74) Survived (n = 263) Expired (n = 156) Survived (n = 491) Characteristic
TABLE 2. Univariate Analysis for Survivala
All Children
P
Operation Enduring Freedom
P
Operation Iraqi Freedom
P
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
TABLE 4. Predictors of Survival Based Upon Individual Conflicta Conflict Operation Enduring Freedomb
Admission GCS Male
Operation Iraqi Freedomc
Odds Ratio
95% Confidence Interval
P
Odds Ratio
95% Confidence Interval
P
1.36 3.13
1.23-1.50 1.51-6.48
,.001 .002
1.26 1.33
1.17-1.37 0.66-2.69
,.001 .43
a
GCS, Glasgow Coma Score; CI, confidence interval. Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.81 (0.76-0.86); Hosmer and Lemeshow Goodness-of-fit Test = 0.46. c Receiver operator characteristic (ROC) area under the curve (95% CI) = 0.76 (0.70-0.82); Hosmer and Lemeshow Goodness-of-fit Test = 0.22. b
Just over half of the children in our study required a craniotomy or craniectomy, with another 35% having an ICP monitor placed. Presumably, many of the patients that did not require a craniotomy or craniectomy had local wound care only with or without ICP monitoring. Data from the Iran-Iraq conflict support the use of such a strategy in those patients without mass lesion or gross contamination.23 Although there was a wide range of length of stay (up to 43 days), many children had a relatively short duration at the military medical facility, which reflects the priority given to discharging or transferring these children to another LN facility at the earliest possible opportunity. This rapid transfer was done to ensure that the limited bed space and other resources were ready for coalition casualties.6,24 This priority is particularly notable because many coalition admissions would present as a sudden influx of numerous patients, called a “mass casualty.”25 Our overall mortality was 24.4%, which is similar to other pediatric combat studies, and comparable to or higher than civilian studies.9,26-30 We presume that the cause of death in the vast majority of these children was due to their head injury, because we selected only children with severe, isolated head injuries as defined by the Abbreviated Injury Scale. Numerous studies have demonstrated that the overall pediatric mortality during these
wars (5.4%-8.5%) was greater than the mortality rates for coalition troops and LN adults and that the most common causes of death for young patients were burns and penetrating head injury.7,9,11,24,31 Similar to civilian and other military pediatric head injury reports, we found that admission GCS was predictive of survival for patients with head injury.7,13,14,26-30,32 Looking at their entire study population of pediatric trauma regardless of injury type or mechanism, Patregnani et al33 found that coagulopathy and hypovolemic shock on presentation were independently associated with the high incidence of mortality in children injured during the Iraq and Afghanistan wars. These 2 variables have been identified in pediatric civilian head injury studies as well.27-29 Anecdotally, deployed neurosurgeons perceived a high incidence of coagulopathy and hypotension when receiving young patients with head injury; however, objective data from abstraction were not readily available for analysis. As other authors have reported, we did not demonstrate an increased mortality risk with younger aged children.11,13,26,27,31 We also found that males were less likely to die as a result of an isolated head injury in OEF, but not OIF. Borgman et al7 reported the same finding when analyzing their combined data from both conflicts. The reason for this is not readily apparent, but we
FIGURE 2. An example of a child with a penetrating head injury. A, this 4-year-old girl was caught in the middle of an urban firefight between US soldiers and the Taliban and sustained a gunshot wound to the head with the entry site being through her left eye. She arrived at Bagram Air Field with a GCS of 9. B, computed tomography scan showed a bifrontal trajectory of the bullet. An external ventricular drain was placed, but she required a bifrontal decompressive craniectomy because of sustained intracranial hypertension. C, the intraoperative picture demonstrates a tense dura and the bullet’s exit point on the right side. She eventually had her bone flap replaced and was discharged to the care of her father 5 weeks after admission. She required a cranioplasty revision 8 months later owing to aseptic bone resorption. GCS, Glasgow Coma Score.
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KLIMO ET AL
speculate that this may be due to a lower value placed on a female’s life as opposed to a male’s in the Afghan culture. This cultural disparity may possibly result in a delay of care sought by the victim’s family. Finally, we evaluated the date at which the child was injured as a possible contributor to mortality. We hypothesized that earlier in the individual conflicts the resources available, including smaller networks of forward operating bases and fewer pediatric trained providers, to treat children may not have been as established as in the later years. In particular, aeromedical evacuation in the Afghanistan theater was much more of a challenge because of rugged, remote, and austere geographic landscape and unpredictable weather in comparison to the flat, hot endless desert of Iraq. Nonetheless, children injured “early” in either conflict, as we have defined, did not have a higher mortality than those injured late. There was a statistical trend, suggesting that a closed head injury was also an independent predictor of survival (P = .07), which would not be unexpected, but did not reach significance because of the small number of patients we had with this type of injury. Many others have used the JTTR for research32-34 with inhospital mortality10,13,24,32,33,35 as the primary outcome; however, the JTTR has significant limitations, as detailed by others.36 The JTTR was designed to capture demographic and outcome data for process improvement, such as the development of clinical practice guidelines. It was not specifically intended for research, especially for LNs, and some data are simply unavailable. There are no provider notes, such as computed tomography results or operative reports, which makes it impossible to know the details of each head injury and what specifically was done at the time of surgery and why. JTTR data from 2001 through 2003 were retrospectively collected—which is why we excluded these dates in our search—and dedicated nurse data collection personnel at each site were not available until 2006. Some measures may not be entirely accurate, such as the admission GCS ideally being recorded after adequate resuscitation and free of medications (paralytics or sedatives), and there are no readily available means to assess the accuracy of the data. Validated outcome measures for adults and children, such as the King Outcome Scale, are not part of the JTTR.37 As stated by O’Connell, the limitations associated with the use of the JTTR data are also due to variations in individual provider’s documentation habits and the condition under which the data are entered.36 The consistency of data input has also increased with time, especially since 2008.36 Finally, the study of LNs is limited to short-term outcomes, which is the reason in-hospital mortality is one of the few reliable and meaningful outcomes in the JTTR. There were neither the mechanisms nor the resources by which many LNs could be consistently and safely followed long-term as an outpatient at US combat support hospitals.
CONCLUSION Many children have been injured as a result of combat operations or nonbattlefield causes during OEF and OIF. Almost
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one-quarter of children with isolated severe head injuries died, with the most common mechanism being IED. Admission GCS and sex were found to be independent predictors of survival. Given the challenging environment and limited available resources, coalition forces were able to provide quality, timely, and lifesaving care to many children. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Wilson KL, Schenarts PJ, Bacchetta MD, Rai PR, Nakayama DK. Pediatric trauma experience in a combat support hospital in eastern Afghanistan over 10 months, 2010 to 2011. Am Surg. 2013;79(3):257-260. 2. Beekley AC, Watts DM. Combat trauma experience with the United States Army 102nd Forward Surgical Team in Afghanistan. Am J Surg. 2004;187(5): 652-654. 3. Eastridge BJ, Stansbury LG, Stinger H, Blackbourne L, Holcomb JB. Forward Surgical Teams provide comparable outcomes to combat support hospitals during support and stabilization operations on the battlefield. J Trauma. 2009;66 (4 suppl):S48-S50. 4. Nessen SC, Cronk DR, Edens J, et al. US Army two-surgeon teams operating in remote Afghanistan—an evaluation of split-based Forward Surgical Team operations. J Trauma. 2009;66(4 suppl):S37-S47. 5. Peoples GE, Gerlinger T, Craig R, Burlingame B. Combat casualties in Afghanistan cared for by a single Forward Surgical Team during the initial phases of Operation Enduring Freedom. Mil Med. 2005;170(6):462-468. 6. Arul GS, Reynolds J, DiRusso S, et al. Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan. Ann R Coll Surg Engl. 2012;94(1):52-57. 7. Borgman M, Matos RI, Blackbourne LH, Spinella PC. Ten years of military pediatric care in Afghanistan and Iraq. J Trauma Acute Care Surg. 2012;73(6 suppl 5): S509-S513. 8. Coppola CP, Leininger BE, Rasmussen TE, Smith DL. Children treated at an expeditionary military hospital in Iraq. Arch Pediatr Adolesc Med. 2006;160(9): 972-976. 9. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, Adelman W. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions. J Trauma. 2009;67(4):762-768. 10. Edwards MJ, Lustik M, Burnett MW, Eichelberger M. Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012. J Am Coll Surg. 2014;218(5):1018-1023. 11. Edwards MJ, Lustik M, Eichelberger MR, Elster E, Azarow K, Coppola C. Blast injury in children: an analysis from Afghanistan and Iraq, 2002-2010. J Trauma Acute Care Surg. 2012;73(5):1278-1283. 12. Fuenfer MM, Spinella PC, Naclerio AL, Creamer KM. The U.S. military wartime pediatric trauma mission: how surgeons and pediatricians are adapting the system to address the need. Mil Med. 2009;174(9):887-891. 13. Matos RI, Holcomb JB, Callahan C, Spinella PC. Increased mortality rates of young children with traumatic injuries at a US army combat support hospital in Baghdad, Iraq, 2004. Pediatrics. 2008;122(5):e959-e966. 14. McGuigan R, Spinella PC, Beekley A, et al. Pediatric trauma: experience of a combat support hospital in Iraq. J Pediatr Surg. 2007;42(1):207-210. 15. Klimo P Jr, Ragel BT, Scott WH Jr, McCafferty R. Pediatric neurosurgery during Operation Enduring Freedom. J Neurosurg Pediatr. 2010;6(2):107-114. 16. Martin JE, Teff RJ, Spinella PC. Care of pediatric neurosurgical patients in Iraq in 2007: clinical and ethical experience of a field hospital. J Neurosurg Pediatr. 2010;6 (3):250-256. 17. Mathew P, Gibbons AJ, Christie M, Eisenburg MF. Operative treatment of paediatric penetrating head injuries in southern Afghanistan. Br J Neurosurg. 2013; 27(4):489-496. 18. Belmont PJ, Schoenfeld AJ, Goodman G. Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Orthop Adv. 2010;19(1):2-7.
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PEDIATRIC HEAD INJURY DURING GLOBAL WAR ON TERRORISM
19. Rating the severity of tissue damage. I. The abbreviated scale. JAMA. 1971;215(2): 277-280. 20. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64(2):295-299. 21. Ling G, Bandak F, Armonda R, Grant G, Ecklund J. Explosive blast neurotrauma. J Neurotrauma. 2009;26(6):815-825. 22. Bell RS, Vo AH, Neal CJ, et al. Military traumatic brain and spinal column injury: a 5-year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 2009;66(4 suppl):S104-S111. 23. Amirjamshidi A, Abbassioun K, Rahmat H. Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries. Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran-Iraq conflict. Surg Neurol. 2003;60(2): 105-110; discussion 110-101. 24. Burnett MW, Spinella PC, Azarow KS, Callahan CW. Pediatric care as part of the US Army medical mission in the global war on terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics. 2008;121(2):261-265. 25. Beekley AC, Martin MJ, Spinella PC, Telian SP, Holcomb JB. Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom. J Trauma. 2009; 66(4 suppl):S129-S137. 26. Pineda JA, Leonard JR, Mazotas IG, et al. Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol. 2013;12(1):45-52. 27. Tude Melo JR, Di Rocco F, Blanot S, et al. Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery. 2010;67(6):1542-1547. 28. Ducrocq SC, Meyer PG, Orliaguet GA, et al. Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med. 2006;7(5): 461-467. 29. White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med. 2001;29(3):534-540. 30. Feickert HJ, Drommer S, Heyer R. Severe head injury in children: impact of risk factors on outcome. J Trauma. 1999;47(1):33-38. 31. Spinella PC, Borgman MA, Azarow KS. Pediatric trauma in an austere combat environment. Crit Care Med. 2008;36(7 suppl):S293-S296. 32. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics. 2011;127(4):e892-e897. 33. Patregnani JT, Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals. Pediatr Crit Care Med. 2012;13(3):273-277. 34. Orman JA, Geyer D, Jones J, et al. Epidemiology of moderate-to-severe penetrating versus closed traumatic brain injury in the Iraq and Afghanistan wars. J Trauma Acute Care Surg. 2012;73(6 suppl 5):S496-S502. 35. Martin M, Oh J, Currier H, et al. An analysis of in-hospital deaths at a modern combat support hospital. J Trauma. 2009;66(4 suppl):S51-S60; discussion S60-S61.
36. O’Connell KM, Littleton-Kearney MT, Bridges E, Bibb SC. Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care. Mil Med. 2012;177(5):546-552. 37. Klimo P Jr, Kestle JR. Potentially useful outcome measures for clinical research in pediatric neurosurgery. J Neurosurg. 2005;103(3 suppl):207-212.
Acknowledgments The authors wish to thank Andrew J. Gienapp, BA, (Department of Medical Education, Methodist University Hospital, Memphis, Tennessee, and Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee) for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript.
COMMENT
T
his is a landmark study with a unique and often ignored patient population from a combat zone environment. Unfortunately, it is the local civilian population that bares the greatest burden of war in any conflict throughout history. The number of pediatric patients treated at MTFs are remarkable because this was not a “mission,” as the authors point out, that we were initially resourced or, in some cases, authorized to perform. Early in the conflict 2003 to 2004 we lacked the basics of pediatric equipment; Foley catheters, pediatric IVs, central lines, ventriculoperitoneal shunts, antiepileptics, and endotracheal tubes. The major dilemma is coming up with a criteria of who you can and more importantly can’t help in this limited resourced environment. The goal is to treat without creating vegetative survivors who lack access to further care and, in some cases, were subsequently abandoned by their family who lacked the means for providing basic care. The JTTR lacks the necessary granularity to identify the criteria for patient selection for surgery; detailed examinations, neuro-imaging, time delay to surgery from onset of injury, hypotension, and other important vitals before neurosurgical care are often absent. Improvements to this register would include the above as well as accompanied database manager at each site to ensure that accurate records are kept. The ability to input the neurosurgeon’s preoperative assessment, his surgical findings, and postoperative care are some of the most important elements of understanding the 1/4 mortality that accompanied patients in this category. Unfortunately, in this group of patients, more so than others, did we feel as powerless and limited to the ravages of war among the innocent. Rocco A. Armonda Washington, DC
Commentary provided by Ryan P. Morton and Richard G. Ellenbogen on page 8.
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