Resuscitation in northern Iraq

Controversies in advanced trauma life support

Since its introduction to the UK in 1988, the Advanced Trauma Life Support (ATLS) course has become the accepted standard for the care of victims of trauma during the ‘golden hour’. Yet despite this success, ATLS has been criticized over the years for its philosophy, the course contents, the rigid regulations, cost to participants and lack of validation. The aim of this article is to explore these and other frequently voiced concerns in the light of evidence gathered over the 20 years since ATLS was first introduced in the USA.

Spinal injuries after improvised explosive device incidents: implications for Tactical Combat Casualty Care

BACKGROUND

Tactical Combat Casualty Care aims to treat preventable causes of death on the battlefield but deemphasizes the importance of spinal immobilization in the prehospital tactical setting. However, improvised explosive devices (IEDs) now cause the majority of injuries to Canadian Forces (CF) members serving in Afghanistan. We hypothesize that IEDs are more frequently associated with spinal injuries than non-IED injuries and that spinal precautions are not being routinely employed on the battlefield.

METHODS

We examined retrospectively a database of all CF soldiers who were wounded and arrived alive at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, from February 7, 2006, to October 14, 2009. We collected data on demographics, injury mechanism, anatomic injury descriptions, physiologic data on presentation, and prehospital interventions performed. Outcomes were incidence of any spinal injuries.

RESULTS

Three hundred seventy-two CF soldiers were injured during the study period and met study criteria. Twenty-nine (8%) had spinal fractures identified. Of these, 41% (n = 12) were unstable, 31% (n = 9) stable, and 28% indeterminate. Most patients were injured by IEDs (n = 212, 57%). Patients injured by IEDs were more likely to have spinal injuries than those injured by non-IED-related mechanisms (10.4% vs. 2.3%; p < 0.01). IED victims were even more likely to have spinal injuries than patients suffering blunt trauma (10.4% vs. 6.7%; p = 0.02). Prehospital providers were less likely to immobilize the spine in IED victims compared with blunt trauma patients (10% [22 of 212] vs. 23.0% [17 of 74]; p < 0.05).

CONCLUSIONS

IEDs are a common cause of stable and unstable spinal injuries in the Afghanistan conflict. Spinal immobilization is an underutilized intervention in the battlefield care of casualties in the conflict in Afghanistan. This may be a result of tactical limitations; however, current protocols should continue to emphasize the judicious use of immobilization in these patients.

Prehospital management of earthquake casualties buried under rubble

Earthquakes continue to exact a heavy toll on life, injury, and loss of property. Survival of casualties extricated from under the rubble depends upon early medical interventions by emergency teams on site. The objective of this paper is to review the pertinent literature and to analyze the information as a practical guideline for the medical management of casualties accidentally buried alive.

Hypothermia and severe trauma

During the period from May 1992 until April 1993, 108 patients were admitted to Liverpool Hospital with Injury Severity Scores (ISS) > 15. Temperatures had been recorded in 100. Of these, 17 had a core temperature of less than 35 degrees C documented within 24 h of arrival. The hypothermic group presented with more severe injuries and contained a disproportionate number of females. Hypothermia was found to be more common in the winter months, but it was not associated with a delay in reaching hospital from the time of injury. When injuries were ranked by ISS, both hypothermic and normothermic patients were equally likely to have received a blood transfusion; however, the mean number of units of packed cells transfused was greater for the hypothermic group with ISS < 41 than for the similarly injured normothermic group. Two patients in the hypothermic group had sustained burns, and both of these were hypothermic on arrival. All of the hypothermic patients who required surgery developed hypothermia in the operating theatre.