Assessing the evolution of pre-hospital combat casualty care: A comparative study of two conflicts a decade apart

Combat casualty care has advanced significantly with the implementation of evidence-based protocols designed to lower combat-related mortality. Over the last decade, two major urban conflicts in southern Israel have challenged the evolving military trauma system. This study aimed to assess differences in prehospital care and compare the outcomes of aeromedically evacuated casualties from the 2014 and 2023 conflicts.

This retrospective registry-based cohort study utilized records from the Military Airborne Combat Evacuation Unit (MACEU) and the Israeli National Trauma Registry. Eligible patients evacuated by MACEU between 07.17.14 and 08.16.14 and between 10.27.23 and 03.17.24 were compared. Ground-evacuated casualties were excluded. Demographics, prehospital interventions, and clinical outcomes were compared.

During the 2014 conflict, 251 patients were evacuated alive, compared to 940 in 2023. Both conflicts involved mostly young males injured by explosions, with comparable injury distributions across body regions. The time from injury to hospital arrival decreased from 65 min (IQR 47-94) in 2014 to 60 min (IQR 47-180) in 2023 (d = 0.5, p < 0.001). The proportion of severely injured patients (ISS ≥ 16) increased from 18.3 % to 25.2 % (OR 1.5 [95 % CI 1.06-2.14], p = 0.03), and critically injured patients (ISS ≥ 25) from 7.6 % to 12.8 % (OR 1.79 [95 % CI 1.08-2.96], p = 0.03). Prehospital advanced airway interventions and tube thoracostomies decreased from 11.6 % to 6.0 % (OR 0.48 [95 % CI 0.30-0.76], p < 0.001) and from 7.0 % to 2.1 % (OR 0.28 [95 % CI 0.15-0.54], p < 0.001), respectively. Prehospital blood transfusions use increased from 6.6 % to 16.4 % (OR 2.78 [95 % CI 1.64-4.76], p < 0.001). In-hospital mortality rates remained stable (2.7 % vs. 2.5 %, OR 1.12 [95 % CI 0.44-2.81], p = 0.99). Although not statistically significant, lower mortality rates were recorded among the severely (13.0 % vs. 8.4 %, OR 0.61 [95 % CI 0.23-1.61, p = 0.48) and critically injured (26.3 % vs. 15.8 %, OR 0.53 [95 % CI 0.17-1.64], p = 0.32).

Over the past decade, there has been a decline in prehospital airway interventions and thoracostomies, coupled with an increase in early blood transfusions. Despite greater injury severity, mortality rates have remained stable. Although not statistically significant, lower mortality rates were recorded among the severely and critically injured. These findings support the "less is more" approach in modern prehospital combat casualty care.