Afghanistan is famous for its history, culture and hospitality. It is country, which is characterised of very mountainous regions, with hills over 7.000 meters and desert areas. The United States Operation Enduring Freedom started in Afghanistan in 2001 as a consequences of the attacks on the World Trade Center and Pentagon on 9/11. The NATO started operatinos in Kabul in AFG In august 2003. The NATO ISAF is made of 37 nations from NATO and non-NATO states, reflecting the level of international support for the mission. Multinational medical teams work together in NATO, ISAF (International Security Assistance Force), as part of the overall international community effort and as mandated by the United Nations Security Council. POLITICS DAILY, David Wood, Chief Military Correspondent, Posted: 09/1/09 Wounded GIs in Afghanistan: Casualties More Seriously Injured Than in Iraq „All military medical staff, from medics to surgeons and pilots, are on call 24/7, and they jump to the sound of an alarm -- most often a "nine-line'' radio request for casualty evacuation from a soldier or Marine kneeling for cover in a firefight. They work 12- to 14-hour days with no days off. It is a high-stress business.” Civilien trauma is typically caracterised as penetrating or blunt injuries. The casualties in this military enviroment present with injury patterns, that are not seen in routine surgical practice at home. Combat injured patients often present with combination of penetrating, blunt and thermal injuries. The medical challenges are often more complicated than just a simple clinical case problem. Their solution requires not only clinical skills, but also effective communication, cool head and confidence. The cause of injury for Afghanistan are grenades (especially roadside bombs, IED-Improvised Explosive Device) with a high-energy fragmentation effect, gun-shot wounds, airplane accidents and the consequences of terrorist attacks are important. The explosive devices triggered by a mobile phone (IED) . Fragments of high-energy explosive grenades cause 50-70% of all wounds, approximately three times more than gun-shot wounds, though these are responsible for approx. 60% of all fatalities. The main cause of death are thoracic, abdominal and head injuries. These injuries include primarily: 60% Hemorrhagic shock due to bleeding from extremity wounds Uncotrolled hemorrhage remains the leading cause of potencially preventable death in the present conflict in AFG. 33% Tension pneumothorax. Combat casualty care can and does prevent deaths. However, the lethality of the weapon and the anatomical location of wound remain dominant. Most of those who are killed in combat, die quickly and before lifesaving surgery is possible. The total number of combat casualties has little to do with medical care. The protective equipment should make for a less lethal battlefield ( KIA- Killed in action- are mainly thoracic, abdominal and head injuries) because armor decreased the lethality of weapons. Wearing body armour has caused the rate of thoraco-abdominal trauma in hostile-related injuries to be almost halved. Due to the ballistic protection of the torso and the frequent use of antipersonal Improvised Explosive Devices with devastating effect on the soft tissues of the extremis, the amputation rate has doubled compared to earlier wars. The patients with potentially fatal wounds who are evacuated from the battlefield alive, but who then die in the hospital (DOW- death of wound). Extensive combat wounds often result in profound shock, requiring immediate assessment, recognation and resuscitation. Having an experienced trauma team assembled and prepared is critical to patient survival. An early decision to use damage control techniques, base on patient’s physiologic condition is often the most important deadly triad of hypothermia, coagulopathy and acidosis. Important factors Immediate triage Rapid transportation Emergency thoracotomy Aggressive surgical management The „ chain of survival” for the wounded patient- from the point of wounding on the battlefield (TCCC- care under fire, tactical field care, tactical evacuation care) , through resuscitation, initial surgery, further resuscitation, critical care transport to definitive care- requires global team effort (medical support is multinational task forces). Thoraco-abdominal injuries, especially at the level of the „nipple line” (T4) or below, carry a high incidence of intraperitoneal injury. When the patient remain present with penetrating truncal injury, proceed with ATLS protocol. Interventions made in the first few minutes mostly determine life or death. All medical support concept will fail, without sufficent and immediate first aid help by the soldiers. The nature of the military patient care pathway, including force protection measures (particularly body armour) and first response with haemorrhage control, differenties the military from the civil environment. The new “10-1-2 Rule” for medical timelines on current and contingent NATO operations, from which is derived the 90 minute MEDEVAC standard (from notification to “wheels down” at the destination hospital). The first 10 minutes, as expressed in the “10-1-2 Rule, were presented as extremely important for haemorrhagic control in order to prevent haemorrhagic shock and disturbance in the treatment triangle of ‘Temperature, Metabolism and Coagulation’.The importance of stopping bleeding and securing the airway within the first ten minutes of wounding, and that those who require surgery (mainly to stop internal bleeding) should be on the operating table within 120 minutes of wounding.Should the patient remain unstable, the amount of chest tube output may immediate thoracotomy.The resuscitative thoracotomy in combat zone should be limited to patients in extremis with penetrating thoracic injuries. With massive intraperitoneal and thoracic injuries, the priority is hemorrhage control. Massive hemoptysis is a rare complication of pulmonar injury and contusion, but it needs multimodal intervention because of impaired ventillation and gas exchange. Recently, recombinant activated coagulation factor VII has been proposed as an adjuvant therapy for exsanguinating trauma patients with coagulopathy. The use of rFVIIa in trauma- releated hemoptysis has been limited diffuse hemorrhage from coagulopathy after blunt chest injury. This may accomplished with packing of the abdomen after bleeding has been controlled. The thoracic cavity can also be packed once hemorrhage control has been achived. Temporary closure of both cavities can be used and the patient returned to the ICU for further resuscitation and warming prior to return to the OR for definitive treatment.