To evaluate battlefield survival in a novel command-directed casualty response system that comprehensively integrates Tactical Combat Casualty Care guidelines and a prehospital trauma registry. Design: Analysis of battle injury data collected during combat deployments.

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BACKGROUND Comprehensive analyses of battle-injured fatalities, incorporating a multidisciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFIs) to increase survivability. METHODS A mortality review was conducted on United States Special Operations Command 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 (MOD), classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared with injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable (PS-S) injuries using tactical data and documented medical interventions. RESULTS Of 369 United States Special Operations Command 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 MOD was catastrophic tissue destruction (73.7%). Most fatalities sustained nonsurvivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of MOD (88.4%); however, the MOD 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. CONCLUSION 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 Epidemiological, level IV.

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