Mortality Review of US Special Operations Command Battle-Injured Fatalities

BACKGROUND: Comprehensive analyses of battle-injured fatalities, incorporating a multi-disciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFI) to increase survivability. METHODS: A mortality review was conducted on United States Special Operations Command (USSOCOM) battle-injured fatalities who died from September 11, 2001 to September 10, 2018. Fatalities were analyzed by demographics, operational posture, mechanism of injury, cause of death, mechanism of death, classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared to injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable injuries (PS-S) using tactical data and documented medical interventions. RESULTS: Of 369 USSOCOM battle-injured fatalities (median age, 29 years; male, 98.6%), most were killed in action (89.4%) and more than half died from injuries sustained during mounted operations (52.3%). The cause of death was blast injury (45.0%), gunshot wound (39.8%), and multiple/blunt force injury (15.2%). The leading mechanism of death was catastrophic tissue destruction (73.7%). Most fatalities sustained non-survivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of mechanism of death (88.4%); however, the mechanism of death was multifactorial in the majority of these fatalities (58.9%). Only 5.4% of all fatalities and 21.1% of fatalities with PS-S injuries had comparable injury patterns among survivors. Accounting for tactical situation, a minority of deaths were potentially preventable (5.7%) and a few preventable (1.1%). Time to surgery (93.7%) and prehospital blood transfusion (89.5%) were the leading OFI for PS-S fatalities. Most fatalities with PS-S injuries requiring blood (83.5%) also had an additional prehospital OFI. CONCLUSIONS: Comprehensive mortality reviews of battlefield fatalities can identify OFI in combat casualty care and prevention. Standardized lexicon is essential for translation to civilian trauma systems. LEVEL OF EVIDENCE: Performance Improvement and Epidemiological, level IV.