Casualty evacuation timelines: an evidence-based review.

There is no tri-modal death distribution demonstrable in modern military conflict. Recent UK, Palestinian and Israeli data suggests that nine out of every ten injured soldiers that die do so within minutes of wounding from insurvivable, unsalvagable trauma. Having the surgeon on the battlefield with the soldier has been shown to make no difference to these survival rates. Early definitive airway control using rapid sequence induction and intubation is of benefit to the head and airway injured. Once this airway is secured, these early survivors may be transported for up to 2 hours receiving intensive care level treatment: Hypotensive resuscitation with blood transfusion, administration of adjunctive clotting factors, hypothermia mitigation, administration of antibiotics, analgesics, novel haemostatics, splintage, FAST scanning can all be performed in flight. The second peak of death comes from truncal bleeding and CNS injury. Those with truncal (or junctional) bleeding require significant surgical, logistic and haemostatic support. Those with CNS injury require CT scanning and specialized neurosurgical care. These subgroups do best in large well-resourced hospital units which have the infrastructure, blood, climate control, knowledge and staffing levels to deal with them. Stopping elsewhere en-route to these larger centres is of uncertain benefit. Our resources must be optimised to save the many that could be saved, rather than dispersed for the few who will not. Wounded soldiers need to be undergoing surgery in the operating theatres of these large centres within three hours of wounding.