Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004–2014)

Introduction: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. Methods: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004–2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). Results: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5–75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%). In the KIA cohort, the median time to death was 0.0 (IQR 0.0–21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. Conclusion: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase