of temporary vascular shunts, closure of blind handles bowels, chest tube placement, decompressive craniotomy, external fixation in pelvis and long bones fractures, the regulated amputations of catastrophic members, realization of decompressive fasciotomies in limbs and VAC® (Vacuum Assisted Closure) therapy129-130. Damage control pathophysiologic analysis is the essential basis that sustains most of casualty treatment in operations area and national territory131. These principles have improved the prognosis of combat casualties by explosive device or gunshot weapon (Figure 7)132-136. Figure 7: Role 2E Spanish of Herat (Afghanistan) Capabilities: triage, CT, operating room and intensive care unit.
and recombinant VII factor were recommended to achieve physiological, haematological and biochemical targets143-145. This therapy has been used succesfully in casualties with massive hemorrhage146 (Figure 8). Figure 8: Left: drugs (complex prothrombin, Fibrinogen, calcium, tranexamic acid, factor VII activated), haemocomponents (concentrated red blood cells unit, fresh frozen plasma unit and frozen platelets unit) and devices employed (fluids, rapid fluid Infuser heater) in order to bleeding control in Spanish Role 2E Herat (Afghanistan). Right: Consumption of drugs and haemocomponents after a combat casualty with massive hemorrhage in the Spanish Role 2E of Herat (Afghanistan).
There was also a logistic progress that allowed the shipment of fresh frozen plasma and frozen platelets to the area of operation. A coagulation pack (tranexamic acid, fibrinogen, prothrombinic complex and calcium) was also designed to facilitate the early administration of these blood components. Hemocomponents trazability in the area of operations is very important. One paper analyzes the hemocomponents sent to Afghanistan from 2008 until 2014. Only 15,7%, 66,1% and 31% of the of red blood cells units, fresh frozen plasma and frozen platelets respectively, were used in the Spanish Role 2 in Herat (Afghanistan), while the rest was destroyed 147. During this period of time no transfusional reaction was detected according to information from Transfusion Center of the Spanish Armed Forces (CTFAS). Also the use of tranexamic acid employment has been audited in casualties attended in this Medical Treatment Facility finding an administration in 100% of the cases before 3 hours148. Also the frozen platelets efficacy has been evaluated in vitro by thromboelastometry149, 150. Finally the use of frozen red blood cells is being evaluated for future deployments in the area of operations151.
From the point of view of the authors, damage control treatment of casualties deserves special mention137. In a study conducted between 2006 and 2014 were analyzed 211 combat casualties diagnosed with traumatic brain injury in the Spanish 2 Role of Herat (Afghanistan). Of these, most were caused by improvised explosive devices 138. This damage control should start from the time of the attack, continue during the evacuation and remain as long as the patient is treated at a surgical level, giving bleeding control priority respect other body areas affected.
EVACUATIONS TO NATIONAL ROLE 4
Employing specialized medical evacuation teams in fixed-wing aircraft has allowed to maintain continuously treatment from the first medical echelon deployed to the country in Europe or North America. This capacity has increased the survival of the casualties152. A study conducted between 2008 and 2013, analyzed patients evacuated from all the areas of operations where Spanish troops were deployed to the fourth medical echelon located in national territory. Of a total of 232 evacuees, 110 (47.4%) came from Afghanistan, being this area of operations that more evacuations originated 153. Two articles describe the evacuations of Spanish military from Afghanistan. The first one details repatriations for medical causes from 2009 to 2012 (139 evacuees), 48 (35%) were for non-combat injuries, 41 (29,4%) for injuries and 18 (12,9%) for psychiatric illness 154. The second
MASSIVE HAEMORRHAGE TREA