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Outcome after vascular trauma in a deployed military trauma system

Military injuries to named blood vessels are complex limb‐ and life‐threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq.

Optimal clinical timelines--a consensus from the academic department of military surgery and trauma.

There are no published studies directly addressing the issue of what is an acceptable timeline from point of wounding to surgical intervention within the military context. The proximal threshold has previously been determined by personal opinion, tactical, logistic and practical imperatives rather than by clinical demands. The aimof this paper is to review all relevantmilitary and civilian studies where timelines have been quoted and to reach a number of unambiguous consensus statements to state the perceived ideal upper limits from point of wounding to holistic and realistic surgical care in modern war. An injured casualty should be transferred to an appropriate surgeon in an appropriate facility in as short a time from wounding as practical. It is clear that the best trauma surgery is performed in large, well resourced, well-supplied, airconditioned hospitals. Current advances aimed to stretch timelines from wounding to surgical intervention are exciting and hold potential but remain scientifically unproven and are currently without any firm evidence base. Further critical research is therefore necessary. The effect of pre-hospital haemostatic resuscitation, provided by the enhanced Medical Emergency Response Team (MERTe) on patient outcome and effective timelines is currently unknown and unproven: it does have intuitive medical merit. There is also a very significant moral and morale component. MERTe serves two main functions; reduction in time from point of wounding to advanced / haemostatic resuscitation and provision of in-flight diagnostics. Continuation of in-flight resuscitation then allows physician-led decision making on critically unstable casualties. This allows either an expedited straight move from the HLS direct to the operating theatre or direct transfer to a regional neurosurgical centre. To prevent avoidable death, our unequivocal conclusion is that there must be an upper limit of 2 hours from wounding to surgical intervention (surgical haemorrhage control) for all casualties.

A survey of major trauma centre staffing in England

Introduction Trauma care delivery in England has been transformed by the development of trauma networks, and the designation of trauma centres. A specialist trauma service is a key component of such centres. The aim of this survey was to determine to which extent, and how, the new major trauma centres (MTCs) have been able to implement such services. Methods Electronic questionnaire survey of MTCs in England. Results All 22 MTCs submitted responses. Thirteen centres have a dedicated major trauma service or trauma surgery service, and a further four are currently developing such a service. In 7 of these 17 centres, the service is or will be provided by orthopaedic surgeons, in 2 by emergency medicine departments, in another 2 by general or vascular surgeons, and in 6 by a multidisciplinary group of consultants. Discussion A large proportion of MTCs still do not have a dedicated major trauma service. Furthermore, the models which are emerging differ from other countries. The relative lack of involvement of surgeons in MTC trauma service provision is particularly noteworthy, and a potential concern. The impact of these different models of service delivery is not known, and warrants further study.

Field Trauma Care in the 21st Century

The nature of trauma care on the modern battlefield is changing quickly. Leading figures in UK field trauma care spoke at a recent meeting of the Haywood Club. The challenge of modern warfare, the evolving evacuation chain and the command and governance of field trauma care were explored.

Military treatment of splenic injury in the era of non-operative management

Objectives Management of blunt splenic injury (BSI) in battlefield casualties is controversial. Splenectomy is the traditional treatment, as setting the conditions for selective non-operative management (SNOM) is difficult in the operational environment. On mature operations, it may be feasible to adopt a more conservative approach and manage the patient according to civilian protocols. The aim of this study was to document the contemporary practice of deployed military surgeons when dealing with BSI and to compare this against a matched cohort of civilian BSI patients. Method The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine, Birmingham, was thoroughly examined to yield patients with BSI. The study encompassed a 55-month period ending September 2009. Data abstracted included patient demographics, injury epidemiology, grade of splenic injury, treatment and outcome. These data were compared with a registry database from a UK civilian major trauma centre. Result Of 1516 military trauma patients, 16 (1%) had a splenic injury, of which five were excluded either because of fatalities due to overwhelming injury or penetrating trauma. The remaining 11 had a blunt component. Median (IQR) injury severity score (ISS) was 17 (15–21). Nine underwent a splenectomy with median (IQR) ISS of 17 (12–18). Of this group, organ injury grades were documented in 10 patients (four Grade V injuries, three Grade IV and three Grade II). All patients survived surgery. There were no complications in survivors as a result of splenic conservation in the military group. Data from the civilian major trauma centre database showed 160 (2%) patients sustained a splenic injury, of which 131 (82%) had a blunt mechanism, 43/160 (27%) and 9/160 (6%) patients underwent splenectomy and angio-embolisation, respectively. Conclusions Patients with BSI, an uncommon finding in combat casualties, are occasionally selected for conservative management, contrary to previous military surgical paradigms but in keeping with the civilian shift to SNOM. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.

Venous thromboembolism: reducing the risk in a Role 3 setting

Background Venous thromboembolism (VTE) represents a significant preventable cause of hospital mortality. VTE assessment and prophylaxis rates are key patient safety and quality of care indicators. The aim of this study was to audit low molecular weight heparin (LMWH) and graduated elasticated compression stockings (GECS) prescriptions compared with the current Clinical Guidelines for Operations. Methods Complete audit loop in the Role 3 Hospital, Camp Bastion, Afghanistan. A multifaceted intervention programme incorporating physician and nurse education and pre-printed medication charts was introduced to improve VTE assessment and prophylaxis rates. Results Only 111/301 (36.9%) of patients in the pre-intervention cohort had a VTE risk assessment performed; this improved to 142/155 (91.6%, p<0.0001) post-intervention. A total of 57/88 (64.8%) patients prescribed LMWH pre-intervention had a documented assessment of bleeding risk performed; this rose to 65/66 (98.5%, p=0.0003) post-intervention. In pre-intervention, only 63/213 (29.6%) patients had a documented reassessment of VTE and bleeding risk at 24 h; reassessment rates rose to 68.8% (66/96 patients, p<0.0001) post-intervention. Of those patients at risk of VTE without ongoing bleeding risk, 62/96 (64.6%) had LMWH prescribed pre-intervention; this rose to 57/62 (91.9%) post-intervention (p<0.0001). Inappropriate LMWH prescription rates fell from 26/190 (13.7%) to 4/85 (4.7%, p=0.035) post-intervention. In those patients in whom GECS were not contraindicated, prescription rates rose from 23/95 (24.2%) to 42/62 (67.7%, p<0.0001) post-intervention. Conclusions Inclusion of pre-printed LMWH/GECS prescriptions and risk assessment stickers in the mediction chart significantly improved rates of VTE risk assessment and prophylaxis. These easily reproducible and low-cost interventions could improve patient safety on deployment.

The modified ‘Jo'burg’ technique for securing intercostal chest drains

Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.

Vascular trauma: survivability and surgical outcome in a deployed military trauma system

Objective: Military vascular injuries are complex limb and life-threatening wounds which pose significant difficulties in pre-hospital and surgical management. Our aim was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury amongst service personnel deployed on operations in Afghanistan and Iraq. Method: Analysis of the British Military Trauma Registry was combined with hospital record and post-mortem review of all cases of vascular trauma in deployed service personnel over a 5-year period ending in January 2008. Results: Of 1203 trauma patients, 121 sustained injuries to named vessels. Seventy-seven of 121 died prior to any opportunity for surgical intervention. All 19 patients who sustained an injury to a named vessel in the abdomen or thorax died; 18 did not survive to undergo surgery, one in extremis casualty underwent a thoracotomy and died. Six out of 15 patients with cervical vascular injuries survived to surgical intervention; two died following surgery. Of 87 patients with extremity vascular injuries, 37 survived to surgery with two postoperative deaths. Interventions on 38 limbs included 19 damage control (15 primary amputations, four vessel ligations) and 19 definitive limb revascularisation procedures (11 interposition vein grafts, eight direct repairs) of which four failed, necessitating three amputations. Conclusion: In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life, but favourable limb salvage rates are achievable in casualties able to withstand revascularisation. Despite marked progress in contemporary battle-field trauma care, torso vascular injury is usually not amenable to surgical intervention.