a b s t r a c t

Background: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting.

Methods: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016.

Results: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and Gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were Packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed Imaging study.

Conclusions: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, adminis- tered blood products, and obtained diagnostic imaging studies.

Introduction

Background

During the recent conflicts in Afghanistan and Iraq, the United States (US) military achieved the lowest recorded case fatality rates for combat casualties in the history of American warfare [1,2]. This accomplishment was largely due to improvements in the care delivered quickly after injury along with improvements in surgical stabilization [3-6]. Many interventions occur in the emergency department (ED) including hem- orrhage control and procedures such as tube thoracostomy and endo- tracheal intubation [1,2,5,7]. Despite this, previously published data focusing on improvements in deployment medicine focuses on the

* Corresponding author at: 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States.

E-mail address: [email protected] (S.G. Schauer).

prehospital and surgical settings with little published from the ED set- ting [8-11].

The US military has worked to redesign the deployed medical sys- tem to better match the missions that have occurred over the past 17 years of continuous war. The US military previously developed the forward surgical team to push surgical care closer to the point-of- injury, further expanding the coveted “Golden hour” after wounding [2,12]. As the battlespace evolves as part of the war on terrorism, the military has continued to adapt its medical support elements to create more mobile, forward-staged medical capabilities. The US Army has re- cently started developing and deploying forward, mobile Expeditionary Resuscitation Surgical Teams (ERST) which incorporate the stabilization and resuscitation skills of emergency medicine physicians into these highly adaptable units in and around the US Central Command (CENTCOM) and US Africa Command (AFRICOM) areas of responsibility [13,14]. Little published data currently exists on the role of EDs in the deployed setting. Such knowledge would better inform medical

https://doi.org/10.1016/j.ajem.2018.04.068 0735-6757/

planners, allowing them to accurately order medical supplies and re- duce material waste [15-18].

Goal of this study

We describe the emergency department care of casualties during the recent conflicts in Iraq and Afghanistan.

Methods

Data acquisition

We identified subjects using a series of ED procedures codes within the Department of Defense Trauma Registry (Appendix A). This is a ret- rospective review of prospectively collected data within the registry. We included amputations proximal to the digits.

The US Army Institute of Surgical Research (USAISR) regulatory of- fice reviewed protocol H-16-005 and determined it was exempt from Institutional Review Board oversight. We obtained only de-identified data.

Department of Defense Trauma Registry (DODTR) description

The DODTR, formerly known as the Joint Theater Trauma Registry (JTTR), is the data repository for DoD trauma-related injuries [19,20]. The DODTR includes documentation regarding demographics, injury- producing incidents, diagnoses, treatments, and outcomes of injuries sustained by US/non-US military and US/non-US civilian personnel in wartime and peacetime (including humanitarian) from the point of in- jury to final disposition. Short-term outcome data are available for non- US casualties. The DODTR comprises all patients admitted to a Role 3 (fixed-facility) or forward surgical team (FST) with an injury diagnosis using the International Classification of Disease 9th Edition (ICD-9) be- tween 800 and 959.9, near-drowning/drowning with associated injury (ICD-9994.1) or inhalational injury (ICD-9987.9) and trauma occurring within 72 h from presentation. We defined the prehospital setting as any location prior to reaching a FST or a combat support hospital (CSH) to include the Role 1 (point of injury, casualty collection point, battalion aid station) and Role 2 (temporary limited-capability forward-positioned hospital inside combat zone without surgical sup- port). We considered interventions performed upon arrival at the FST or CSH as performed in the ED and not prehospital.

Analysis

We performed all statistical analysis using Microsoft Excel (version 10, Redmond, Washington) and JMP Statistical Discovery from SAS (version 13, Cary, NC). We compared study variables using a student t-test for continuous variables, Wilcoxon Rank Sum test for ordinal var- iables, and chi-squared test for nominal variables. We reported categor- ical variables as numbers with percentages, ordinal variables reported as medians with interquartile ranges, and continuous variables as means with standard deviations. We categorized the injury severity scores (ISS) into groups minor (1-15), moderate (16-25), severe (26-50), and critical (51-75) [21].

Results

From January 2007 to August 2016 there were 38,769 encounters within the DODTR of which our predefined searched codes captured 28,222 (72.8%). The median age of causalities in this dataset was 25 years and most (96.9%, n = 27,359) were male. US military person- nel (41.3%, n = 11,665) comprised the largest proportion of subjects, with a significant percentage deployed in support of Operation Endur- ing Freedom (OEF, 66.9%). The overwhelming majority survived to hos- pital discharge (95.5%, n = 26,931, Table 1). Subjects primarily sustained injuries from explosives (55.3%, n = 15,606) or by gunshot wound (GSW, n = 6662, 23.6%, Table 1). Of note, 6.7% (n = 1899) had an amputation proximal to the digits documented. Most subjects had an ISS that was considered minor (74.1%, n = 20,901), while the preponderance of critically injured casualties sustained injuries by ex- plosive (0.7%, n = 119). Based on AIS, the most frequently seriously in- jured body region was the extremities (23.9%, n = 6765, Table 2). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%, n = 7449) and fresh frozen plasma (FFP, 23.5%, n = 6637). Subjects with gunshot wounds required blood product adminis- tration more often than subjects suffering other mechanisms of injury (Table 3). Endotracheal intubation was the most frequently performed procedure (11.9%, n = 3371) along with imaging studies, including ul- trasound (22.2%, n = 6276), X-ray (79.9%, n = 22,550) and computed tomography (73.5% (20,747)(Table 4).

Discussion

We report ED interventions performed on adult trauma casualties during the recent conflicts in Iraq and Afghanistan. We found that US

Table 1

Demographics, Injury scores and outcome data of causalities treated in the ED.

		Overall	Explosive (15606)	GSW (6662)	MVC (2540)	Other (3414)	p-Value
Demographics	Age	25 (21-30)	25 (21-30)	25 (21-30)	31 (25-40)	34 (26-44)	b0.001
	Gender	96.9% (27359)	97.5% (15217)	97.2% (6474)	96.4% (2447)	94.4% (3221)	b0.001
Patient category	US military	41.3% (11665)	62.3% (7266)	15.5% (1805)	5.8% (685)	16.4% (1909)	b0.001
	Coalition	8.0% (2259)	66.7% (1507)	19.2% (434)	3.5% (79)	10.6% (239)
	Host nation forces	24.1% (6795)	51.6% (3504)	32.3% (2195)	11.5% (780)	4.7% (316)
	Humanitarian	20.4% (5760)	44.4% (2558)	35.6% (2048)	12.6% (726)	7.4% (428)
	Contractor	5.7% (1616)	43.8% (708)	9.5% (154)	15.8% (256)	30.8% (498)
	Other	0.5% (127)	49.6% (63)	20.5% (26)	11.0% (14)	18.9% (24)
Military Operation	Operation Iraqi Freedom	30.6% (8638)	50.2% (4335)	24.7% (2136)	10.0% (867)	15.1% (1300)	b0.001
	Operation Enduring Freedom	66.9% (18868)	58.3% (10999)	23.1% (4363)	8.4% (1590)	10.2% (1916)
	Operation Freedoms Sentinel	1.3% (358)	41.6% (149)	30.2% (108)	8.4% (30)	19.8% (71)
	Operation New Dawn	1.3% (358)	34.4% (123)	15.4% (55)	14.8% (53)	35.5% (127)
Injury Scores	Composite	9 (4-16)	9 (4-17)	9 (4-17)	9 (4-17)	5 (2-9)	b0.001
	AIS (head/neck)	0 (0-2)	0 (0-2)	0 (0-0)	1 (0-2)	0 (0-2)	b0.001
	AIS (face)	0 (0-1)	0 (0-1)	0 (0-0)	0 (0-1)	0 (0-0)	b0.001
	AIS (thorax)	0 (0-0)	0 (0-0)	0 (0-0)	0 (0-1)	0 (0-0)	b0.001
	(AIS abdomen)	0 (0-0)	0 (0-0)	0 (0-0)	0 (0-0)	0 (0-0)	b0.001
	AIS (extremities)	0 (0-2)	0 (0-3)	0 (0-3)	0 (0-2)	0 (0-2)	b0.001
	AIS (superficial/skin)	1 (0-1)	1 (1-1)	1 (0-1)	1 (0-1)	1 (0-1)	b0.001
Outcome	Survival to discharge	95.5% (26931)	96.0% (14979)	93.2% (6203)	94.8% (2409)	97.9% (3340)	b0.001

AIS = Abbreviated Injury Scale.

Table 2

Serious injuries by body region based on an AIS of 3 or greater (binary).

		Overall	Explosive	GSW	MVC	Other	p-Value
Composite	Minor	74.1% (20901)	72.5% (11307)	71.5% (4768)	73.8% (1874)	86.5% (2952)	b0.001
	Moderate	15.9% (4501)	16.1% (2516)	19.0% (1267)	15.9% (405)	9.1% (313)
	Severe	9.3% (2631)	10.7% (1664)	8.8% (589)	9.8% (248)	3.8% (130)
	Critical	0.7% (189)	0.7% (119)	0.6% (38)	0.5% (13)	0.6% (19)
Abbreviated	Head/neck	14.8% (4183)	14.4% (2254)	14.1% (937)	24.3% (617)	10.9% (375)	b0.001
	Face	0.5% (136)	0.5% (81)	0.4% (28)	0.7% (18)	0.3% (9)	0.069
	Thorax	11.8% (3344)	10.6% (1659)	16.3% (1087)	14.0% (356)	7.1% (242)	b0.001
	Abdomen	7.4% (2093)	6.9% (1075)	11.9% (797)	4.3% (109)	3.3% (112)	b0.001
	Extremities	23.9% (6765)	27.7% (4332)	27.0% (1800)	14.7% (373)	7.6% (260)	b0.001
	Superficial/skin	2.2% (621)	2.6% (412)	1.5% (101)	0.1% (3)	3.1% (105)	b0.001

military males comprised the largest proportion and most were injured by explosives in Afghanistan. Blood products administration occurred more frequently among subjects with gunshot wounds than those with blast injuries. Endotracheal intubation was the most frequently performed procedure, while plain radiographs were the most fre- quently obtained diagnostic imaging study.

US service members comprised the largest demographic in our study. This finding is consistent with previously published data that in- corporated host nation personnel [22-30]. Host nation military, para- military, and civilian personnel, however, combined to form a significant proportion of our study population. Medical treatment of host nation casualties may introduce unique challenges including re- source prioritization, post-hospitalization coordination, communication barriers, and additional Security measures [31-34].

Explosives were the most common mechanism of injury in our study, followed by GSW. Previous studies also found explosives were the most prevalent mechanism of injury with rates of 44.1%-87.9% [3,5,7,22-24,26,27,29,30,35-39]. Despite a significant proportion of our subjects suffering explosive or GSW injuries, overall mortality was 4.5% which is consistent with previously published mortality rates of 1.8%-6.9% [7,22,23,40,41]. Our observed mortality rate–similar to the cited studies–does not include prehospital fatalities.

The most frequent cause of death among combat casualties with po- tentially survivable injuries is hemorrhage [3,5,7,38,42]. Intravascular

(IV) or intraosseous (IO) access is necessary for vascular resuscitation, and IV access may be difficult to obtain in casualties in hypovolemic shock [43]. We found IO access was rare in the ED. United Kingdom (UK) military studies evaluating IO utilization reported a total of 345 IOs, with the majority established in the prehospital setting [27,44,45]. The very low rate of IO utilization in our study may be due to exclusion of Prehospital interventions and missed documentation of ED interven- tions. Future studies evaluating wartime ED IO utilization rates, inser- tion locations, and failure rates would be useful.

Blood is the fluid of choice for the resuscitation of the severely in- jured, hypovolemic trauma patient [2,9-11]. ED providers administered PRBCs and FFP to a significant proportion of our study population. Pub- lished military data reports massive transfusion rates of 4.2%-8.4% in the general trauma population, and as high as 25% among trauma casu- alties receiving at least one blood product [22-24,46]. Deployed ED pro- viders and nursing staff should review JTS Clinical Practice Guidelines (CPG) and train with equipment issued to FSTs and CSHs for

administration of blood products. Many subjects did not receive blood products that more closely mimic a 1:1:1 ratio of PRBC:FFP:platelets [47]. This is likely due to a both training and availability of blood prod- ucts. Locations, especially further forward from the logistical supply hubs, may not have access to all Blood components due to transporta- tion and storage limitations. Moreover, the use of low-titer type-O whole blood was not available at the time. The US military should con- tinue to promote use of low-titer type-O whole blood availability throughout the battlespace [48].

airway compromise is the second most common cause of prevent- able death on the battlefield [3-5,42]. We found that endotracheal intu- bation (ETI) was the most frequent procedure performed by ED providers. Previous military reports on ETI are limited to the prehospital setting, with the exception of a single study that describes an emer- gency airway registry prospectively maintained at two CSHs [8,49,50]. This study found a lower rate of ETI with 3.7% of 6875 consecutive trauma patients intubated on arrival; however, the majority of their subjects underwent intubation at an FST (70.8%; 179 of 253) with a high success rate (97.2%; 174 of 179) [49]. Limitations in the available data preclude us from evaluating ED ETI techniques and outcomes. Fu- ture studies on wartime ED ETI are necessary and should evaluate rates of success, complications, rapid sequence intubation, direct laryn- goscopy, video laryngoscopy, airway adjuncts, and Difficult airways.

We found that ED interventions for chest injuries were uncommon. resuscitative thoracotomy was performed on 0.5% of all subjects, while 4.6% underwent tube thoracostomy. Previous studies on wartime thora- cotomy demonstrated survival rates of 12.0%-21.5%, typically among casualties that arrested inside the ED [30,51]. Unfortunately, we are un- able to characterize the location of arrest and survival rate of subjects undergoing ED RT in our study due to limitations with the available data. Deploying ED providers should review the JTS CPG for thoracot- omy in preparation to perform this procedure.

Diagnostic imaging is an integral component of the ED trauma eval- uation [52,53]. In our study, ED providers frequently obtained plain ra- diographs and computed tomography (CT) examinations. Published military research evaluating ED utilization of diagnostic imaging for adult trauma casualties is limited [52,54-56]. The high rates of CT utili- zation we observed may be due to the complexities of explosive injuries, which produce penetrating, blunt, and thermal injury patterns. Military surgeons have reported success with CT examination in place of manda- tory Exploratory laparotomy for penetrating abdominal injuries [57,58].

Table 3

Blood product administration proportions.

	Overall	Explosive	GSW	MVC	Other	p-Value
Whole blood	1.5% (435)	1.8% (281)	2.0% (134)	0.4% (11)	0.3% (9)	b0.001
PRBC	26.4% (7449)	28.4% (4429)	36.6% (2442)	14.1% (357)	6.5% (221)	b0.001
Platelets	11.1% (3136)	13.6% (2124)	12.7% (849)	3.7% (95)	1.9% (68)	b0.001
FFP	23.5% (6637)	25.6% (3988)	31.7% (2114)	13.2% (334)	5.9% (201)	b0.001
Cryoprecipitate	7.0% (1979)	8.9% (1389)	7.7% (513)	1.8% (47)	0.9% (30)	b0.001

PRBC = packed red blood cells. FFP = fresh frozen plasma.

Table 4

Proportions of casualties with select interventions/studies performed.

	Overall	Explosive	GSW	MVC	Other	p-Value
Endotracheal intubation	11.9% (3371)	13.1% (2042)	13.1% (872)	9.9% (253)	6.0% (204)	b0.001
Cricothyrotomy	0.2% (48)	0.2% (25)	0.2% (15)	0.2% (5)	0.1% (3)	0.432
Nasogastric intubation	1.4% (401)	1.5% (233)	1.4% (92)	1.7% (43)	0.9% (33)	0.071
Tube thoracostomy	4.6% (1310)	3.8% (596)	8.3% (552)	3.5% (89)	2.1% (73)	b0.001
Thoracotomy	0.5% (130)	0.5% (79)	0.7% (45)	0.1% (2)	0.1% (4)	b0.001
CPR	1.1% (320)	1.1% (168)	1.7% (111)	1.1% (27)	0.4% (14)	b0.001
IO access	0.1% (36)	0.1% (22)	0.2% (12)	0.0% (1)	0.0% (1)	0.122
Arterial access	4.7% (1332)	5.0% (784)	5.6% (372)	4.1% (103)	2.1% (73)	b0.001
Canthotomy	0.1% (37)	0.2% (24)	0.1% (9)	0.1% (2)	0.1% (2)	0.470
Orthopedic reduction	1.5% (426)	0.6% (93)	0.1% (8)	2.3% (58)	7.8% (267)	b0.001
Fasciotomy	0.1% (16)	0.1% (12)	0.1% (3)	0.0% (1)	0.0% (0)	0.340
Ultrasound	22.2% (6276)	29.5% (4610)	13.3% (884)	12.7% (323)	13.4% (459)	b0.001
X-ray	79.9% (22550)	81.3% (12690)	84.5% (5632)	75.4% (1916)	67.7% (2312)	b0.001
Computed tomography	73.5% (20747)	80.9% (12620)	56.7% (3778)	86.4% (2194)	63.1% (2155)	b0.001

CPR = cardiopulmonary resuscitation. IO = intraosseous.

CT’s high utilization rate in our study suggests it is a valuable diagnostic capability for military treatment facilities.

Our study has several limitations. First, for inclusion within the DODTR subjects must arrive at the FST or CSH alive or with on-going in- terventions. Therefore, we are unable to characterize subjects that ex- pired in the prehospital setting. Second, the available data does not permit us to describe and evaluate the level of training of the person who performed the procedure inside the ED. Trauma resuscitation teams in military fixed-facilities may comprise of combat medics, nurses, certified registered nurse anesthetists (CRNA), physician assis- tants (PA), and physicians of multiple specialties. Consequently, an emergency medicine physician, anesthesiologist, intensivist, internist, otolaryngologist, CRNA, or PA may have performed an ETI in the ED. The level of training of the individual that performed the procedure may be useful when evaluating procedural success and complication rates. Third, the available data does not permit us to evaluate specific features of the procedures, such as indications for procedures, success rates, documented causes of failed attempts, times initiated, times com- pleted, specific equipment and supplies utilized, patient clinical param- eters during procedural performance, etc. Conversely, we do not have data on which equipment may not have been available to the clinician within each location. This information would be necessary to make rec- ommendations for pre-deployment training, unit equipment fielding, fixed-facility staffing, etc. As a result, we are only able to describe the overall incidence of a procedure and offer suggestions for future re- search. Lastly, data in the trauma registry is dependent upon documen- tation in austere combat conditions, and previous studies have demonstrated poor documentation rates [59,60].

Conclusions

US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, adminis- tered blood products, and obtained diagnostic imaging studies.

Author contributions

SGS is the principal investigator and takes overall responsibility for all aspects of the manuscript including the research protocol, data anal- ysis and interpretation, manuscript development, manuscript revisions and publication. JFN, JJO, and JKM assisted with the Data interpretation, manuscript development, manuscript revisions and publication. MDA assisted with the protocol development, data interpretation, manu- script revisions and publication.

Disclosures

None.

Funding

We received no funding for this study.

Disclaimer

Opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, the Department of the Army, or the Department of Defense.

Acknowledgements

We would like to thank the Joint Trauma system Data Analysis Branch for their efforts with data acquisition.

Appendix A. DODTR international classification of disease (version 9) search codes

01.09, Other cranial puncture

01.10, Intracranial pressure monitoring 01.24, Other craniotomy

01.25, Other craniectomy 01.39, Other incision of brain*

01.59, Other excision or destruction of lesion or tissue of brain 03.31, Spinal tap

06.02, Reopening of wound of thyroid field 06.09, Other incision of thyroid field

08.51, Canthotomy

08.52, Blepharorrhaphy

08.59, Other operation of lid position 11.64, Other penetrating keratoplasty

21.00, Control of epistaxis, not otherwise specified 21.01, Control of epistaxis by anterior nasal packing

21.02, Control of epistaxis by posterior (and anterior) packing 21.03, Control of epistaxis by cauterization (and packing) 21.04, Control of epistaxis by ligation of ethmoidal arteries

21.05, Control of epistaxis by (transantral) ligation of the maxillary artery 21.06, Control of epistaxis by ligation of the external carotid artery

21.07, Control epistaxis by excision nasal mucosa/Skin graft septum-lateral wall 21.09, Control of epistaxis by other means

21.71, closed reduction of nasal fracture 21.72, open reduction of nasal fracture 21.29, Other Diagnostic procedures on nose 27.51, Suture of laceration of lip

(continued on next page)

27.52, Suture of laceration of other part of mouth 29.0, Pharyngotomy

29.11, Pharyngoscopy

29.31, Cricopharyngeal myotomy

31.1, Temporary tracheostomy

31.12, Tracheostomy, percutaneous (pre 2004)

31.21, Mediastinal tracheostomy 31.29, Other permanent tracheostomy 31.74, Revision of tracheostomy 31.71, Suture of laceration of trachea 31.63, Revision of laryngostomy 31.61, Suture of laceration of larynx

31.42, Laryngoscopy and other tracheoscopy 31.41, Tracheoscopy through artificial stoma 31.3, Other incision of larynx or trachea 33.22, Fiber-optic bronchoscopy

33.21, Bronchoscopy through artificial stoma 33.23, Other bronchoscopy

33.93, Puncture of lung 34.01, Incision of chest wall

34.02, Exploratory thoracotomy

34.04, Insertion of intercostal catheter for drainage 34.71, Suture of laceration of chest wall

34.72, Closure of thoracostomy

34.71, Suture of laceration of chest wall 34.84, Other repair of diaphragm 34.89, Other operations on diaphragm 34.91, Thoracentesis

34.92, Injection into thoracic cavity 34.99, Other operations on thorax 37.0, Pericardiocentesis

37.10, Incision of heart, not otherwise specified 37.11, Cardiotomy

37.12, Pericardiotomy

37.31, Pericardiectomy

37.29, Other Diagnostic procedures on heart and pericardium 37.49, Other repair of heart and pericardium

37.71, Initial insertion of transvenous lead [electrode] into ventricle 37.72, Initial insertion of transvenous leads into atrium and ventricle 37.74, Insert/replace epicardial lead [electrode] into epicardium 37.78, Insertion of temporary transvenous pacemaker system

, Open chest cardiac massage

, Injection of therapeutic substance into heart

, Injection of therapeutic substance into pericardium 37.99, Other operation on heart and pericardium

, Incision of vessels, unspecified

, Incision of vessels, intracranial vessels

, Incision of vessels, other vessels of head and neck 38.03, Incision of vessels, upper limb vessels

, Incision of vessels, aorta

, Incision of vessels, other thoracic vessels 38.06, Incision of vessels, abdominal arteries 38.07, Incision of vessels, abdominal veins 38.08, Incision of vessels, lower limb arteries 38.09, Incision of vessels, lower limb veins 38.7, Interruption of vena cava

, Other surgical occlusion of vessels, unspecified

, Other surgical occlusion of vessels, intracranial vessels

, Other surgical occlusion of vessels, other vessels of head and neck 38.83, Other surgical occlusion of vessels, upper limb vessels

38.84, Other surgical occlusion of vessels, aorta, abdominal 38.85, Other surgical occlusion of vessels, thoracic vessel 38.86, Other surgical occlusion of vessels, abdominal arteries 38.87, Other surgical occlusion of vessels, abdominal veins 38.88, Other surgical occlusion of vessels, lower limb arteries 38.89, Other surgical occlusion of vessels, lower limb veins 38.91, arterial catheterization

38.92, Umbilical vein catheterization

38.93, venous catheterization, not elsewhere classified 38.94, Venous cutdown

38.97, Central venous catheter placement with guidance 38.98, Other puncture of artery

38.99, Other puncture of vein

39.30, Suture of unspecified blood vessel 39.31, Suture of artery

39.32, Suture of vein 39.97, Other perfusion

39.98, Control of hemorrhage, not otherwise specified 54.25, Peritoneal lavage

54.29, Other diagnostic procedures on abdominal region 57.94, Insertion of indwelling urinary catheter

57.95, Replacement of indwelling urinary catheter 74.4, cesarean section of other specified type 71.71, Suture of laceration of vulva or perineum 71.79, Other repair of vulva and perineum

74.1, Low cervical cesarean section 74.0, Classical cesarean section

74.91, Hysterotomy to terminate pregnancy 74.99, Other cesarean section of unspecified type

78.10, Application of external fixation device, unspecified site

78.11, Application of external fixation device, scapula, clavicle, and thorax 78.12, Application of external fixation device, humerus

78.13, Application of external fixation device, radius and ulna

78.14, Application of external fixation device, carpals and metacarpals 78.15, Application of external fixation device, femur

, Application of external fixation device, patella

, Application of external fixation device, tibia and fibulas

, Application of external fixation device, tarsals and metatarsals 78.19, Application of external fixation device, other

79.00, Closed reduction of fracture without internal fixation, unspecified site 79.01, Closed reduction of fracture without internal fixation, humerus

79.02, Closed reduction of fracture without internal fixation, radius and ulna 79.03, Closed reduction of fracture w/o internal fixation, carpals & metacarpals 79.04, Closed reduction of fracture without internal fixation, phalanges of hand 79.05, Closed reduction of fracture without internal fixation, femur

79.06, Closed reduction of fracture without internal fixation, tibia and fibula 79.07, Closed reduction of fracture w/o internal fixation, tarsals & metatarsals 79.08, Closed reduction of fracture without internal fixation, phalanges of foot 79.09, Closed reduction of fracture w/o internal fixation, other specified bone 79.41, Closed reduction of separated epiphysis, humerus

79.42, Closed reduction of separated epiphysis, radius and ulna 79.46, Closed reduction of separated epiphysis, tibia and fibula 79.70, Closed reduction of dislocation of unspecified site

79.71, Closed reduction of dislocation of shoulder 79.72, Closed reduction of dislocation of elbow 79.73, Closed reduction of dislocation of wrist

79.74, Closed reduction of dislocation of hand and finger 79.75, Closed reduction of dislocation of hip

79.76, Closed reduction of dislocation of knee 79.77, Closed reduction of dislocation of ankle

79.78, Closed reduction of dislocation of foot and toe

79.79, Closed reduction of dislocation of other specified sites 81.91, Arthrocentesis

87.03, Computerized axial tomography of head 87.41, Computerized axial tomography of thorax 87.71, Computerized axial tomography of kidney 87.76, Retrograde cystourethrogram

87.44, Routine chest X-ray, so described 87.49, Other chest X-ray

88.01, Computerized axial tomography of abdomen 89.60, Continuous intra-arterial blood gas monitoring 89.61, Systemic arterial pressure monitoring

89.62, Central venous pressure monitoring

89.65, Measurement of systemic arterial blood gases 89.66, Measurement of mixed venous blood gases 93.90, Non-invasive mechanical ventilation

93.91, Intermittent positive pressure breathing [ippb] 93.93, Nonmechanical methods of resuscitation

93.94, Respiratory Medication administered by nebulizer 93.95, Hyperbaric oxygenation

93.96, Other oxygen enrichment 93.97, Decompression chamber 93.99, Other respiratory procedures

96.01, Insertion of nasopharyngeal airway 96.02, Insertion of oropharyngeal airway

96.03, Insertion of esophageal obturator airway 96.04, Insertion of endotracheal tube

96.05, Other intubation of respiratory tract 96.06, Insertion of Sengstaken tube

96.07, Insertion of other (naso-)gastric tube 96.08, Insertion of (naso-)intestinal tube 96.51, Irrigation of eye

96.52, Irrigation of ear

96.70, Continuous invasive mechanical ventilation of unspecified duration 96.71, Continuous invasive mechanical ventilation for b96 consecutive hours 96.72, Continuous invasive mechanical ventilation for >=96 consecutive hours

99.00, Perioperative autologous transfusion of whole blood or blood components 99.03, Other transfusion of whole blood

99.04, Transfusion of packed cells 99.05, Transfusion of platelets

99.06, Transfusion of coagulation factors 99.07, Transfusion of other serum

99.08, Transfusion of blood expander 99.19, Injection of anticoagulant

99.20, Injection or infusion of platelet inhibitor 99.21, Injection of antibiotic

99.22, Injection of other anti-infective 99.23, Injection of steroid

99.63, Closed chest cardiac massage 99.81, Hypothermia (central) (local)

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