• Stacy A Brethauer, Alex Chao, Lowell W Chambers, Donald J Green, Carlos Brown, Peter Rhee, and Harold R Bohman.
• Department of Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, M61, Cleveland, OH 44195, USA. brethas@ccf.org
• Arch Surg. 2008 Jun 1;143(6):564-9.

HypothesisThe transition from maneuver warfare to insurgency warfare has changed the mechanism and severity of combat wounds treated by US Marine Corps forward surgical units in Iraq.DesignCase series comparison.SettingForward Resuscitative Surgical System units in Iraq.PatientsThree hundred thirty-eight casualties treated during the invasion of Iraq in 2003 (Operation Iraqi Freedom I [OIF I]) and 895 casualties treated between March 2004 and February 2005 (OIF II).InterventionsDefinitive and damage control procedures for acute combat casualties.Main Outcome MeasuresMechanism of injury, procedures performed, time to presentation, and killed in action (KIA) and died of wounds (DOW) rates.ResultsMore major injuries occurred per patient (2.4 vs 1.6) during OIF II. There were more casualties with fragment wounds (61% vs 48%; P = .03) and a trend toward fewer gunshot wounds (33% vs 43%; P = .15) during OIF II. More damage control laparotomies (P = .04) and more soft tissue debridements (P < .001) were performed during OIF II. The median time to presentation for critically injured US casualties during OIF I and OIF II were 30 and 59 minutes, respectively. The KIA rate increased from 13.5% to 20.2% and the DOW rate increased from 0.88% to 5.5% for US personnel in the First Marine Expeditionary Force area of responsibility.ConclusionsThe transition from maneuver to insurgency warfare has changed the type and severity of casualties treated by US Marine Corps forward surgical units in Iraq. Improvised explosive devices, severity and number of injuries per casualty, longer transport times, and higher KIA and DOW rates represent major differences between periods. Further data collection is necessary to determine the association between transport times and mortality rates.

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