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For debate: advanced bleeding control potentially saves lives in armed forces and should be considered
  1. Boudewijn Borger van der Burg1,
  2. P Keijzers2,
  3. T van Dongen3,4,
  4. O van Waes5 and
  5. R Hoencamp1,3
  1. 1Alrijne Zorggroep, Leiderdorp, The Netherlands
  2. 2Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
  3. 3Defense Healthcare Department, Ministry of Defence, Utrecht, The Netherlands
  4. 4Surgery, Alrijne Ziekenhuis locatie Leiderdorp, Leiderdorp, The Netherlands
  5. 5Trauma Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
  1. Correspondence to Boudewijn Borger van der Burg, Alrijne Zorggroep, Leiderdorp 2353GA, The Netherlands; blsborgervanderburg{at}


Introduction Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel.

Methods The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control.

Results There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61).

Conclusion Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

  • advanced bleeding control
  • military
  • non-compressible torso haemorrhage

Statistics from


  • Contributors BBvdB, TvD and RH prepared the study. TvD performed the statistical analyses. BBvdB, TvD and RH prepared the manuscript. TvD prepared the tables. BBvdB, TvD, PK, OvW and RH contributed to the final version of the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defence or Dutch government. Several authors are employees of the Dutch government.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was conducted under a protocol reviewed and approved by the Dutch Ministry of Defence (MoD).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.

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