The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services

Counterfactual reasoning using causal Bayesian networks as a healthcare governance tool

BACKGROUND

Healthcare governance (HG) is a quality assurance processes that aims to maintain and improve clinical practice. Clinical decisions are routinely reviewed after the outcome is known to learn lessons for the future. When the outcome is positive, then practice is praised, but when practice is suboptimal, the area for improvement is highlighted. This process requires counterfactual reasoning, where we predict what would have happened given both what happened and the possible different decisions. Causal models that capture the mechanisms that generate events can support counterfactual reasoning.

OBJECTIVE

This study is an initial attempt to show how counterfactual reasoning with causal Bayesian networks (CBNs) can be used as a HG tool to assess what would have happened if treatments other than those occurred had been selected.

METHODS

Motivated by the Defence Medical Services (DMS) mortality and morbidity (M&M) review meeting, in this paper we (1) extended the use of counterfactual reasoning in CBNs to review decisions, where the alternative treatment strategies and its effect belong to different stages of care, (2) placed counterfactual reasoning in a specific clinical context to examine how it can be used as a HG tool.

RESULTS

Using three realistic examples, we demonstrated how the proposed counterfactual reasoning can be used to assist the DMS M&M review meetings.

CONCLUSIONS

Useful lessons can be learned by assessing decisions after they are made. M&M review meetings are fruitful ground for counterfactual reasoning. The use of a clinical decision support tool that can assist clinicians in assessing counterfactual probabilities will be beneficial.

Exploring Saudi paramedics' experiences in managing adult trauma cases: a qualitative study

BACKGROUND

Saudi paramedics face numerous challenges while providing care for adult trauma patients affecting their care but little is known about these specific challenges.

METHODS

A qualitative study was conducted using a purposive sample of Saudi paramedics from the Saudi Red Crescent Authority (SRCA) across various cities. Data were collected through online semi-structured interviews and analyzed using the framework method.

RESULTS

A total of 20 paramedics were recruited and interviewed. They identified challenges in trauma response, including coordinating care, ensuring the accuracy and accessibility of patient information, and maintaining confidence and readiness. Participants emphasized the need for independent knowledge acquisition through courses, simulations, and peer discussions. They also highlighted the need for more paramedics, strategies to reduce burnout, and the importance of accurately assessing patient conditions. Additionally, they also stressed the importance of raising public awareness to enhance trauma care.

CONCLUSION

This study explored Saudi paramedics' experiences in managing adult trauma patients. standardized handovers, more staff, and greater public awareness are the main key needs to improve daily practice.

Whole Blood Resuscitation and Association with Survival in Injured Patients with an Elevated Probability of Mortality

BACKGROUND

Low-titer group O whole blood (LTOWB) resuscitation is becoming common in both military and civilian settings and may represent the ideal resuscitation intervention. We sought to characterize the safety and efficacy of LTOWB resuscitation relative to blood component resuscitation.

STUDY DESIGN

A prospective, multicenter, observational cohort study was performed using 7 trauma centers. Injured patients at risk of massive transfusion who required both blood transfusion and hemorrhage control procedures were enrolled. The primary outcome was 4-hour mortality. Secondary outcomes included 24-hour and 28-day mortality, achievement of hemostasis, death from exsanguination, and the incidence of unexpected survivors.

RESULTS

A total of 1,051 patients in hemorrhagic shock met all enrollment criteria. The cohort was severely injured with >70% of patients requiring massive transfusion. After propensity adjustment, no significant 4-hour mortality difference across LTOWB and component patients was found (relative risk [RR] 0.90, 95% CI 0.59 to 1.39, p = 0.64). Similarly, no adjusted mortality differences were demonstrated at 24 hours or 28 days for the enrolled cohort. When patients with an elevated prehospital probability of mortality were analyzed, LTOWB resuscitation was independently associated with a 48% lower risk of 4-hour mortality (relative risk [RR] 0.52, 95% CI 0.32 to 0.87, p = 0.01) and a 30% lower risk of 28-day mortality (RR 0.70, 95% CI 0.51 to 0.96, p = 0.03).

CONCLUSIONS

Early LTOWB resuscitation is safe but not independently associated with survival for the overall enrolled population. When patients were selected with an elevated probability of mortality based on prehospital injury characteristics, LTOWB was independently associated with a lower risk of mortality starting at 4 hours after arrival through 28 days after injury.

Paediatric Major Trauma: A Retrospective Observational Comparison of Mortality in Prehospital Bypass and Secondary Transfer in the East of England

Background More than half of seriously injured children are not initially treated at a major trauma centre (MTC). Children may be transported by private vehicle to a trauma unit (TU). Children may also be transported by emergency medical services (EMS) to the nearest TU with approximately one in five of these undergoing secondary transfer to an MTC. Most trauma networks permit TU bypass to an MTC. However, the evidence on outcomes between transfer and bypass is limited. This study aimed to evaluate the use of the trauma network by comparing outcomes between paediatric major trauma patients by the method of presentation. Methods In this retrospective observational study, a consecutive sample of paediatric (<16 years old) major trauma patients transported to the regional MTC (Cambridge University Hospitals NHS Foundation Trust (CUH)) between 1st January 2015 and 31st December 2020 was included. Patients were excluded if they arrived at the MTC >24 hours post-injury or were transported to the MTC as the nearest hospital. Patients were divided into four groups: self-presented to MTC, MTC as nearest hospital, bypass and secondary transfer. Results A total of 315 patients (28 'self-presented', 55 'nearest', 58 'bypass' and 174 'secondary transfers') were included. The median age was 9.4 [3.7-13.6] years, and n=209 (66.3%) were male. The median Injury Severity Score (ISS) was 16.0 [9.0-25.0] and n=190 (60.3%) had an ISS >15. There was no difference in 30-day mortality between the 'bypass' and 'secondary transfer' groups. There was a significantly longer hospital and intensive care unit length of stay (LOS) in the bypass group compared to other groups, both p<0.001. The median time to definitive care was five hours greater in the secondary transfer group compared to 'bypass' (bypass 117.6 minutes [100.8-136.6], secondary transfer 418.8 minutes [315.6-529.8]). Conclusion There was no significant difference in 30-day mortality of paediatric major trauma patients who underwent secondary transfer compared to those transported directly from the scene to the MTC, despite significant time delays in reaching definitive care.

Inflammatory cytokines associated with outcomes in orthopedic trauma patients independent of New Injury Severity score: A pilot prospective cohort study

Traumatic injury is the leading cause of mortality in patients under 50. It is associated with a complex inflammatory response involving hormonal, immunologic, and metabolic mediators. The marked elevation of cytokines and inflammatory mediators subsequently correlates with the development of posttraumatic complications. The aim was to determine whether elevated cytokine levels provide a predictive value for orthopedic trauma patients. A prospective cohort study of patients with New Injury Severity Score (NISS) > 5 was undertaken. IL-6, IL-8, IL-10, and migration inhibitory factor levels were measured within 24-h of presentation. Demographic covariates and clinical outcomes were obtained from the medical records. Fifty-eight patients (83% male, 40 years) were included. Addition of IL-6 to baseline models significantly improved prediction of pulmonary complication (LR = 6.21, p = 0.01), ICU (change in R²  = 0.31, p < 0.01), and hospital length of stay (change in R²  = 0.16, p < 0.01). The addition of IL-8 significantly improved the prediction of acute kidney injury (LR = 9.15, p < 0.01). The addition of postinjury IL-6 level to baseline New Injury Severity Score model is better able to predict the occurrence of pulmonary complications as well as prolonged ICU and hospital length of stay.

Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice

BACKGROUND

The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines.

METHODS

The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA.

RESULTS

To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses.

CONCLUSIONS

To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.

External validation of International Classification of Injury Severity Score to predict mortality in a Greek adult trauma population

INTRODUCTION

The International Classification of diseases- based Injury Severity Score (ICISS) obtained by empirically derived diagnosis-specific survival probabilities (DSPs) is the best-known risk-adjustment measure to predict mortality. Recently, a new set of pooled DSPs has been proposed by the International Collaborative Effort on Injury Statistics but it remains to be externally validated in other cohorts. The aim of this study was to externally validate the ICISS using international DSPs and compare its prognostic performance with local DSPs derived from Greek adult trauma population.

MATERIALS AND METHODS

This retrospective single-center cohort study enrolled adult trauma patients (≥ 16 years) hospitalized between January 2015 and December 2019 and temporally divided into derivation (n = 21,614) and validation cohorts (n = 14,889). Two different ICISS values were calculated for each patient using two different sets of DSPs: international (ICISSint) and local (ICISSgr). The primary outcome was in-hospital mortality. Models' prediction was performed using discrimination and calibration statistics.

RESULTS

ICISSint displayed good discrimination in derivation (AUC = 0.836 CI 95% 0.819-0.852) and validation cohort (AUC = 0.817 CI 95% 0.797-0.836). Calibration using visual analysis showed accurate prediction at patients with low mortality risk, especially below 30%. ICISSgr yielded better discrimination (AUC = 0.834 CI 95% 0.814-0.854 vs 0.817 CI 95% 0.797-0.836, p ˂ .05) and marginally improved overall accuracy (Brier score = 0.0216 vs 0.0223) compared with the ICISSint in the validation cohort. Incorporation of age and sex in both models enhanced further their performance as reflected by superior discrimination (p ˂ .05) and closer calibration curve to the identity line in the validation cohort.

CONCLUSION

This study supports the use of international DSPs for the ICISS to predict mortality in contemporary trauma patients and provides evidence regarding the potential benefit of applying local DSPs. Further research is warranted to confirm our findings and recommend the widespread use of ICISS as a valid measure that is easily obtained from administrative data based on ICD-10 codes.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care

PURPOSE

Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location.

METHODS

We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS.

RESULTS

There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay.

CONCLUSIONS

The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Injury scoring systems for blast injuries: a narrative review

Injury scoring systems can be used for triaging, predicting morbidity and mortality, and prognosis in mass casualty incidents. Recent conflicts and civilian incidents have highlighted the unique nature of blast injuries, exposing deficiencies in current scoring systems. Here, we classify and describe deficiencies with current systems used for blast injury. Although current scoring systems highlight survival trends for populations, there are several major limitations. The reliable prediction of mortality on an individual basis is inaccurate. Other limitations include the saturation effect (where scoring systems are unable to discriminate between high injury score individuals), the effect of the overall injury burden, lack of precision in discriminating between mechanisms of injury, and a lack of data underpinning scoring system coefficients. Other factors influence outcomes, including the level of healthcare and the delay between injury and presentation. We recommend that a new score incorporates the severity of injuries with the mechanism of blast injury. This may include refined or additional codes, severity scores, or both, being added to the Abbreviated Injury Scale for high-frequency, blast-specific injuries; weighting for body regions associated with a higher risk for death; and blast-specific trauma coefficients. Finally, the saturation effect (maximum value) should be removed, which would enable the classification of more severe constellations of injury. An early accurate assessment of blast injury may improve management of mass casualty incidents.

Primary Blast Lung Injury: The UK Military Experience

INTRODUCTION

Primary blast lung injury occurs when an explosive shock wave passes through the thorax and transits through tissues of varying densities. It requires close proximity to an explosion and presents quick with respiratory distress in survivors.

MATERIALS AND METHODS

The Joint Theatre Trauma Registry and the Defence Statistics (Health) Database were interrogated for casualties injured as a result of an explosion during the conflict in Afghanistan. The case notes and imaging of casualties meeting the criteria for diagnosis were reviewed. Demographic and clinical data on casualties with primary blast lung injury were analyzed.

RESULTS

848 blast-exposed casualties survived to discharge from intensive care, and 238 blast-exposed casualties were killed in action. Following exclusions, 111 case notes and all postmortem reports were reviewed in detail. About, 25 casualties had isolated primary blast lung injury (2.9% of casualties surviving to discharge from intensive care) and 31 nonsurvivors (13% of nonsurvivors) had the disease documented at postmortem. Severe cases of primary blast lung injury required an estimated average of 4.5 days of conventional mechanical ventilation.

CONCLUSIONS

8.1% of blast exposed casualties suffered primary blast lung injury. It was a less severe disease than other nontraumatic forms of acute lung injury and did not cause deaths once a casualty had reached a combat support hospital. It was well managed with a relatively brief period of conventional mechanical ventilation.

A Comparative Study Between Two Combat Injury Severity Scores

INTRODUCTION

In recent years, specific trauma scoring systems have been developed for military casualties. The objective of this study was to examine the discrepancies in severity scores of combat casualties between the Abbreviated Injury Scale 2005-Military (mAIS) and the Military Combat Injury Scale (MCIS) and a review of the current literature on the application of trauma scoring systems in the military setting.

METHODS

A cross-sectional, descriptive, and retrospective study was conducted between May 1, 2005, and December 31, 2014. The study population consisted of all combat casualties attended in the Spanish Role 2 deployed in Herat (Afghanistan). We used the New Injury Severity Score (NISS) as reference score. Severity of each injury was calculated according to mAIS and MCIS, respectively. The severity of each casualty was calculated according to the NISS based on the mAIS (Military New Injury Severity Score-mNISS) and MCIS (Military Combat Injury Scale-New Injury Severity Score-MCIS-NISS). Casualty severity were grouped by severity levels (mild-scores: 1-8, moderate-scores: 9-15, severe-scores: 16-24, and critical-scores: 25-75).

RESULTS

Nine hundred and eleven casualties were analyzed. Most were male (96.37%) with a median age of 27 years. Afghan patients comprised 71.13%. Air medevac was the main casualty transportation method (80.13). Explosion (64.76%) and gunshot wound (34.68%) mechanisms predominated. Overall mortality was 3.51%. Median mNISS and MCIS-NISS were similar in nonsurvivors (36 [IQR, 25-49] vs. [IQR, 25-48], respectively) but different in survivors, 9 (IQR, 4-17) vs. 5 (IQR, 2-13), respectively (P < .0001). The mNISS and MCIS-NISS were discordant in 34.35% (n = 313). Among cases with discordant severity scores, the median difference between mNISS and MCIS-NISS was 9 (IQR, 4-16); range, 1 to 57.

CONCLUSION

Our study findings suggest that discrepancies in injury severity levels may be observed in one in three of the casualties when using mNISS and MCIS-NISS.

Surviving traumatic cardiac arrest: Identification of factors associated with survival

INTRODUCTION

The endpoint of resuscitative interventions after traumatic injury resulting in cardiopulmonary arrest varies across institutions and even among providers. The purpose of this study was to examine survival characteristics in patients suffering torso trauma with no recorded vital signs (VS) in the emergency department (ED).

METHODS

The National Trauma Data Bank was analyzed from 2007 to 2015. Inclusion criteria were patients with blunt and penetrating torso trauma without VS in the ED. Patients with head injuries, transfers from other hospitals, or those with missing values were excluded. The characteristics of survivors were evaluated, and statistical analyses performed.

RESULTS

A total of 24,191 torso trauma patients without VS were evaluated in the ED and 96.6% were declared dead upon arrival. There were 246 survivors (1%), and 73 (0.3%) were eventually discharged home. Of patients who responded to resuscitation (812), the survival rate was 30.3%. Injury severity score (ISS), penetrating mechanism (odds ratio [OR] 1.99), definitive chest (OR 1.59) and abdominal surgery (OR 1.49) were associated with improved survival. Discharge to home (or police custody) was associated with lower ISS (OR 0.975) and shorter ED time (OR 0.99).

CONCLUSION

Over a recent nine-year period in the United States, nearly 25,000 trauma patients were treated at trauma centers despite lack of VS. Of these patients, only 73 were discharged home. A trauma center would have to attempt over one hundred resuscitations of traumatic arrests to save one patient, confirming previous reports that highlight a grave prognosis. This creates a dilemma in treatment for front line workers and physicians with resource utilization and consideration of safety of exposure, particularly in the face of COVID-19.

Study protocol for a prospective, longitudinal cohort study investigating the medical and psychosocial outcomes of UK combat casualties from the Afghanistan war: the ADVANCE Study

INTRODUCTION

The Afghanistan war (2003-2014) was a unique period in military medicine. Many service personnel survived injuries of a severity that would have been fatal at any other time in history; the long-term health outcomes of such injuries are unknown. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study aims to determine the long-term effects on both medical and psychosocial health of servicemen surviving this severe combat related trauma.

METHODS AND ANALYSIS

ADVANCE is a prospective cohort study. 1200 Afghanistan-deployed male UK military personnel and veterans will be recruited and will be studied at 0, 3, 6, 10, 15 and 20 years. Half are personnel who sustained combat trauma; a comparison group of the same size has been frequency matched based on deployment to Afghanistan, age, sex, service, rank and role. Participants undergo a series of physical health tests and questionnaires through which information is collected on cardiovascular disease (CVD), CVD risk factors, musculoskeletal disease, mental health, functional and social outcomes, quality of life, employment and mortality.

ETHICS AND DISSEMINATION

The ADVANCE Study has approval from the Ministry of Defence Research Ethics Committee (protocol no:357/PPE/12) agreed 15 January 2013. Its results will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences, and through participant and stakeholder communications.

TRIAL REGISTRATION NUMBER

The ADVANCE Study is registered at ISRCTN ID: ISRCTN57285353.

The Effect of Chest Compression Location and Aortic Perfusion in a Traumatic Arrest Model

BACKGROUND

Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional compressions. Selective aortic arch perfusion (SAAP) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using SAAP.

MATERIALS AND METHODS

Transthoracic echo was used to mark the location of the aortic root (Traditional location) and the center of the LV on animals (n = 24), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation (VF) was induced to simulate TCA. After a period of 10 min of VF, basic life support (BLS) with mechanical CPR was initiated and performed for 10 min, followed by advanced life support (ALS) for an additional 10 min. SAAP balloons were inflated at min 6 of BLS. Hemodynamic variables were averaged over the final 2 min of the BLS and ALS periods. Survival was compared between this SAAP cohort and a control group without SAAP (No-SAAP) (n = 26).

RESULTS

There was no significant difference in ROSC between the two SAAP groups (P = 0.67). There was no ROSC difference between SAAP and No-SAAP (P = 0.74).

CONCLUSIONS

There was no difference in ROSC between LV and Traditional compressions when SAAP was used in this swine model of TCA. SAAP did not confer a survival benefit compared to historical controls.

The Effect of Chest Compression Location and Occlusion of the Aorta in a Traumatic Arrest Model

BACKGROUND

Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA.

MATERIALS AND METHODS

Transthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n = 26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10 min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 min followed by advanced life support for an additional 10 min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2 min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n = 26).

RESULTS

There was no significant difference in ROSC between the two REBOA groups (P = 0.24). Survival was higher with REBOA group versus no-REBOA group (P = 0.02).

CONCLUSIONS

There was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

Refining the Trauma and Injury Severity Score (TRISS) to Measure the Performance of the UK Combat Casualty Care System

INTRODUCTION

The Trauma and Injury Severity Score (TRISS) methodology is used in both the UK and US Military trauma registries. The method relies on dividing casualties according to mechanism, penetrating or blunt, and uses different weighting coefficients accordingly. The UK Military Joint Theatre Trauma Registry uses the original coefficients devised in 1987, whereas the US military registry uses updated civilian coefficients, but it is not clear how either registry analyzes explosive casualties according to the TRISS methodology. This study aims to use the UK Military Joint Theatre Trauma Registry to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The secondary aim of this study is to apply the revised TRISS coefficients to examine the survival trends of UK casualties from recent military conflicts.

MATERIALS AND METHODS

The Joint Theatre Trauma Registry was searched for all UK casualties injured or killed in Iraq and Afghanistan by explosive or gunshot mechanisms between January 1, 2003 and December 31, 2014. Details of these casualties including injuries and vital signs were reviewed. Logistic regression analysis was performed to devise new TRISS coefficients; these were then used to examine survival over the 12 yr of the study.

RESULTS

Comparing the predictions from the gunshot TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy of 97.8%. With respect to the explosive TRISS model, there is a sensitivity of 98.6%, a specificity of 97.4%, and an overall accuracy of 98.4%. When this updated and mechanism-specific TRISS methodology was used to measure changes in survival over the study period, survival following these injuries improved until 2012 when performance was maintained for the last 2 yr of the study.

CONCLUSION

This study for the first time refines the TRISS methodology with coefficients appropriate for use within combat casualty care systems. This improved methodology reveals that UK combat casualty care performance appears to have improved until 2012 when this standard was maintained.

Cardiac massage for trauma patients in the battlefield: An assessment for survivors

INTRODUCTION

Survival from traumatic cardiopulmonary arrest (TCA) has been reported at a rate as low as 0-2.6% in the civilian pre-hospital setting, and many consider resuscitation of this group to be futile. The aim of this investigation was to describe patients who received cardiac massage during TCA in a battlefield setting; we also aimed to identify predictors of survival.

METHODS

We conducted a review of the Department of Defense Trauma Registry to identify patients who received cardiac massage in the battlefield between 2007 and 2014. Patients were also grouped according to location of cardiac arrest: pre-hospital (PH) and in-hospital (IH). The groups were compared and evaluated by injury, transport time, type of resuscitation, and pre-hospital procedures. Outcome variables included survival to discharge and 30-day survival. Categorical variables were analysed using chi-square or Fisher's exact tests. Wilcoxon tests were performed for continuous variables. Regression modelling was used to assess for predictors of survival.

RESULTS

75 of all 582 patients (13%, 95% CI 10-16) survived to 30 days, and all survivors were transported out of the battlefield; 23 PH (7.8%, 95% CI 5.2-12) and 52 IH (17%, 95% CI 13-22) patients survived to 30 days (p < 0.001). Closed-chest cardiac massage with the administration of intravenous medications was associated with 30-day survival among IH patients.

CONCLUSIONS

We report a 13% survival to 30 days among all patients receiving cardiac massage in a battlefield setting. Closed-chest cardiac massage predicted survival among IH TCA victims who also received intravenous medications in this review of combat-related TCA.

Comorbidities in Trauma Injury Severity Scoring System: Refining Current Trauma Scoring System

The revised trauma score combined with the Injury Severity Score (ISS) remains the mostly commonly used system for predicting trauma mortality, but these scoring systems do not account for the patient's comorbidities. This study aims to evaluate the effect of comorbidities on ISS-related mortality and length of stay. A review of our trauma center's data registry from 2014 to 2016 was carried out. Patients were divided according to ISS into two groups: ISS ≤ 15 and ISS > 15. Each ISS group was then subdivided by number of comorbidities into two groups: 1 to 2 or ≥3 comorbidities. Demographic characteristics and outcome measures were compared. ANOVA, chi-squared, and t tests were used with significance defined as P < 0.05. A total 9845 adult trauma patients were admitted to our trauma center during the three-year study period. In the ISS ≤ 15 group, patients with <3 comorbidities had significantly higher mortality rate compared with patients with 1 to 2 comorbidities (1.50% vs 0.12%, P << 0.000007). Comparing the ISS ≤ 15 group with ≥3 comorbidities with the ISS > 15 group with 1 to 2 comorbidities, the mortality rate was significantly higher (23.40% vs 4.50%, P << 0.000002). The ICU length of stay was significantly higher in the ISS ≤ 15 groups (17 vs 10 days, P < 0.05) but similar in the ISS > 15 groups (31 vs 29 days) (P > 0.05). It was concluded that when controlling for injury severity, increased comorbidities are associated with a significantly higher mortality, indicating that they may serve as a marker of lower physiologic reserve and be an independent variable. Adding comorbidity parameters to the current trauma scoring systems can assist in predicting more accurate/reliable outcomes.

Military application of mechanical CPR devices: a pressing requirement?

Maintaining high-quality chest compressions during cardiopulmonary resuscitation following cardiac arrest presents a challenge. The currently available mechanical CPR (mCPR) devices are described in this review, coupled with an analysis of the evidence pertaining to their efficacy. Overall, mCPR appears to be at least equivalent to high-quality manual CPR in large trials. There is potential utility for mCPR devices in the military context to ensure uninterrupted quality CPR following a medical cardiac arrest. Particular utility may be in a prohibitive operational environment, where manpower is limited or where timelines to definitive care are stretched resulting in a requirement for prolonged resuscitation. mCPR can also act as a bridge to advanced endovascular resuscitation techniques should they become more mainstream therapy.

Endotracheal Intubation for Traumatic Cardiac Arrest by an Australian Air Medical Service

OBJECTIVE

Traumatic cardiac arrest (TCA) has been associated with poor outcome, but there are survivors with good neurological outcome. Treatment of hypoxia plays a key part in resuscitation algorithms, but little evidence exists on the ideal method of airway management in TCA.

METHODS

LifeFlight Retrieval Medicine is an aeromedical retrieval service based in Queensland, Australia. Data regarding all intubations performed over a 28-month period were accessed from an electronic airway registry.

RESULTS

13/22 TCA patients were male, age range 2-81 years. 7/22 (31.8%) survived to hospital admission. During the same period 271 patients were intubated due to trauma, but were not in cardiac arrest (N-TCA). There was no difference in the likelihood of difficult laryngoscopy in the TCA group (16/22 (72.7%) compared to N-TCA (215/271 (79.3%); p = 0.46). The first attempt success rate was similar in TCA group (19/22 (86.4%)) and N-TCA (241/271 (88.9%) p = 0.71.). TCA patients were more likely to be intubated while lying on the ground than the N-TCA group (11/22 (50%) versus 17/271 (6.3%) p = <0.001).

CONCLUSION

Resuscitation for predominantly blunt TCA is not futile. The endotracheal intubation first attempt success rate for TCA is comparable to that of N-TCA trauma patients.

Fatal head and neck injuries in military underbody blast casualties

Introduction

Death as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification.

Methods

This retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared.

Results

129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture.

Conclusion

Improvement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.

The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry

Background

The UK military was continuously engaged in armed conflict in Iraq and Afghanistan between 2003 and 2014, resulting in 629 UK fatalities. Traumatic cardiac arrest (TCA) is a precursor to traumatic death, but data on military outcomes are limited. In order to better inform military treatment protocols, the aim of this study was to define the epidemiology of TCA in the military population with a particular focus on survival rates and injury patterns.

Methods

A retrospective database analysis of the UK Joint Theatre Trauma Registry was undertaken. Patients who were transported to a UK deployed hospital between 2003 and 2014 and suffered TCA were included. Those patients injured by asphyxiation, electrocution, burns without other significant trauma and drowning were excluded. Data included mechanism of injury, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) for each body region and survival to deployed (Role 3) field hospital discharge.

Results

424 TCA patients were identified during the study period; median age was 23 years, with a median ISS of 45. The most common mechanism of injury was explosive (55.7%), followed by gunshot wound (38.9%), road traffic collision (3.5%), crush (1.7%) and fall (0.2%). 45 patients (10.6% (95% CI 8.0% to 13.9%)) survived to deployed (Role 3) hospital discharge. The most prevalent body region with a severe to maximum AIS injury was the head, followed by the lower limbs, thorax and abdomen. Haemorrhage secondary to abdominal and lower limb injury was associated with survival; traumatic brain injury was associated with death.

Conclusions

This study has shown that short-term survival from TCA in a military population is 10.6%. With appropriate and aggressive early management, although unlikely, survival is still potentially possible in military patients who suffer traumatic cardiac arrest.

Medical support to military airborne training and operations

INTRODUCTION

Airborne operations enable large numbers of military forces to deploy on the ground in the shortest possible time. This however must be balanced by an increased risk of injury. The aim of this paper is to review the current UK military drop zone medical estimate process, which may help to predict the risk of potential injury and assist in planning appropriate levels of medical support.

METHOD

In spring 2015, a British Airborne Battlegroup (UKBG) deployed on a 7-week overseas interoperability training exercise in the USA with their American counterparts (USBG). This culminated in a 7-day Combined Joint Operations Access Exercise, which began with an airborne Joint Forcible Entry (JFE) of approximately 2100 paratroopers.The predicted number of jump-related injuries was estimated using Parachute Order Number 8 (PO No 8). Such injuries were defined as injuries occurring from the time the paratrooper exited the aircraft until they released their parachute harness on the ground.

RESULTS

Overall, a total of 53 (2.5%) casualties occurred in the JFE phase of the exercise, lower than the predicted number of 168 (8%) using the PO No 8 tool. There was a higher incidence of back (30% actual vs 20% estimated) and head injuries (21% actual vs 5% estimated) than predicted with PO No 8.

CONCLUSION

The current method for predicting the incidence of medical injuries after a parachute drop using the PO No 8 tool is potentially not accurate enough for current requirements. Further research into injury rate, influencing factors and injury type are urgently required in order to provide an evidence base to ensure optimal medical logistical and clinical planning for airborne training and operations in the future.

Validation of trauma scales: ISS, NISS, RTS and TRISS for predicting mortality in a Colombian population

BACKGROUND

Our purpose was to validate the performance of the ISS, NISS, RTS and TRISS scales as predictors of mortality in a population of trauma patients in a Latin American setting.

MATERIALS AND METHODS

Subjects older than 15 years with diagnosis of trauma, lesions in two or more body areas according to the AIS and whose initial attention was at the hospital in the first 24 h were included. The main outcome was inpatient mortality. Secondary outcomes were admission to the intensive care unit, requirement of mechanical ventilation and length of stay. A logistic regression model for hospital mortality was fitted with each of the scales as an independent variable, and its predictive accuracy was evaluated through discrimination and calibration statistics.

RESULTS

Between January 2007 and July 2015, 4085 subjects were enrolled in the study. 84.2% (n = 3442) were male, the mean age was 36 years (SD = 16), and the most common trauma mechanism was blunt type (80.1%; n = 3273). The medians of ISS, NISS, TRISS and RTS were: 14 (IQR = 10-21), 17 (IQR = 11-27), 4.21 (IQR = 2.95-5.05) and 7.84 (IQR = 6.90-7.84), respectively. Mortality was 9.3%, and the discrimination for ISS, NISS, TRISS and RTS was: AUC 0.85, 0.89, 0.86 and 0.92, respectively. No one scale had appropriate calibration.

CONCLUSION

Determining the severity of trauma is an essential tool to guide treatment and establish the necessary resources for attention. In a Colombian population from a capital city, trauma scales have adequate performance for the prediction of mortality in patients with trauma.

Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military

BACKGROUND

Medical practitioners face difficult decisions over whether to amputate or to salvage a lower limb that has undergone trauma. To our knowledge, there has been little evidence reporting the impact of different surgical decisions on functional and mental health outcomes following intensive rehabilitation that might inform decision-making.

METHODS

This study is a retrospective, independent-group comparison of rehabilitation outcomes from a U.K. military complex trauma rehabilitation center. There were 100 procedures examined: 36 unilateral amputations (11 immediate-below-the-knee amputations, 15 delayed below-the-knee amputations, and 10 immediate above-the-knee amputations), 43 bilateral amputations, and 21 single-limb salvages (including 13 below-the-knee limb salvages); the patients had a mean age (and standard deviation) of 29 ± 6 years and a mean New Injury Severity Score of 34 ± 15 points. The outcome measures at completion of rehabilitation included a 6-minute walk test (6MWT), Defence Medical Rehabilitation Centre mobility and activities of daily living scores, screening for depression (Patient Health Questionnaire [PHQ-9]) and general anxiety disorder (General Anxiety Disorder 7-item scale [GAD-7]), mental health support, and pain scores.

RESULTS

On completion of their rehabilitation, the unilateral amputation group walked significantly farther in 6 minutes (564 ± 92 m) than the limb-salvage group (483 ± 108 m; p < 0.05) and the bilateral amputation group (409 ± 106 m; p < 0.001). The delayed below-the-knee amputation group (595 ± 89 m) walked significantly farther than the group with limb salvage below the knee (472 ± 110 m; p < 0.05), and there was no significant difference between the group with delayed below-the-knee amputation and the group with immediate below-the-knee amputation (598 ± 63 m; p > 0.05). The limb-salvage group was less capable of running independently compared with all amputee groups. No significant differences (p > 0.05) were reported in mean mental health outcomes between the below-the-knee injury groups, and depression and anxiety scores were comparable with population norms. At discharge, 97% of all patients were able to control their pain.

CONCLUSIONS

After completing a U.K. military interdisciplinary rehabilitation program, the unilateral amputation group demonstrated a significant functional advantage over the limb-salvage and bilateral amputation groups. We found that patients electing for delayed amputation below the knee after attempted limb salvage achieved superior functional gains in mobility compared with patients who underwent limb salvage below the knee and experienced no functional disadvantage compared with patients who underwent immediate amputation. The mental health outcomes were comparable with general population norms, optimizing the prospect of full integration back into society.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology and aetiology of traumatic cardiac arrest in England and Wales - A retrospective database analysis

BACKGROUND

Historically, reported survival from traumatic cardiac arrest (TCA) was extremely low. More recent publications have recorded survival to discharge of up to 8%. This improvement is likely to be multi-factorial; however, there are currently no published data describing the epidemiology or aetiology of TCA in England and Wales to guide future practice improvement.

METHODS

Population-based analysis of 2009-2015 Trauma Audit and Research Network (TARN) data. The primary aim was to describe the 30-day survival following TCA. Patients of all ages with traumatic cardiac arrest pre-hospital or in the emergency department (ED) were included. Data are described as number (%), and median [interquartile range]. Two-group analysis with Chi-squared test was performed.

RESULTS

During the study period 227,944 patients were included in the TARN database. Seven hundred and five (0.3%) suffered TCA: 74.3% were male, aged 44.3 [25.2-83.2] years, ISS 29 [21-75], and 601 (85.2%) had blunt injuries. 612 (86.8%) had a severe traumatic brain injury and or severe haemorrhage. Overall 30-day survival was 7.5% (95%CI 5.6-9.5) - 'pre-hospital only' TCA 11.5%, 'ED only' TCA 3.9%, p<0.02. No patients who were in TCA both pre-hospital and in the ED survived.

CONCLUSION

This study has shown that short-term survival from TCA in this large civilian registry is 7.5%. Early and aggressive management of patients with TCA, using protocols that target the reversible causes of TCA, should be initiated. Further work to establish novel ways to manage patients with reversible causes of TCA is indicated. Resuscitation in this patient group is not futile.

Gun-shot injuries in UK military casualties - Features associated with wound severity

INTRODUCTION

Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound.

METHODS

The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity.

RESULTS

There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006).

CONCLUSIONS

More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

Impact of Injury Severity on Dynamic Inflammation Networks Following Blunt Trauma

INTRODUCTION

Clinical outcomes following trauma depend on the extent of injury and the host's response to injury, along with medical care. We hypothesized that dynamic networks of systemic inflammation manifest differently as a function of injury severity in human blunt trauma.

STUDY DESIGN

From a cohort of 472 blunt trauma survivors studied following institutional review board approval, three Injury Severity Score (ISS) subcohorts were derived after matching for age and sex: mild ISS (49 patients [33 males and 16 females, aged 42 ± 1.9 years; ISS 9.5 ± 0.4]); moderate ISS (49 patients [33 males and 16 females, aged 42 ± 1.9; ISS 19.9 ± 0.4]), and severe ISS (49 patients [33 males and 16 females, aged 42 ± 2.5 years; ISS 33 ± 1.1]). Multiple inflammatory mediators were assessed in serial blood samples. Dynamic Bayesian Network inference was utilized to infer causal relationships based on probabilistic measures.

RESULTS

Intensive care unit length of stay, total length of stay, days on mechanical ventilation, Marshall Multiple Organ Dysfunction score, prevalence of prehospital hypotension and nosocomial infection, and admission lactate and base deficit were elevated as a function of ISS. Multiple circulating inflammatory mediators were significantly elevated in severe ISS versus moderate or mild ISS over both the first 24 h and out to 7 days after injury. Dynamic Bayesian Network suggested that interleukin 6 production in severe ISS was affected by monocyte chemotactic protein 1/CCL2, monokine inducible by interferon γ (MIG)/CXCL9, and IP-10/CXCL10; by monocyte chemotactic protein 1/CCL2 and MIG/CXCL9 in moderate ISS; and by MIG/CXCL9 alone in mild ISS over 7 days after injury.

CONCLUSIONS

Injury Severity Score correlates linearly with morbidity, prevalence of infection, and early systemic inflammatory connectivity of chemokines to interleukin 6.

Challenging the dogma of traumatic cardiac arrest management: a military perspective

Attempts to resuscitate patients in traumatic cardiac arrest (TCA) have, in the past, been viewed as futile. However, reported outcomes from TCA in the past five years, particularly from military series, are improving. The pathophysiology of TCA is different to medical causes of cardiac arrest, and therefore, treatment priorities may also need to be different. This article reviews recent literature describing the pathophysiology of TCA and describes how the military has challenged the assumption that outcome is universally poor in these patients.

Died of wounds: a mortality review

OBJECTIVES

Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes.

METHODS

This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports.

RESULTS

There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths.

CONCLUSIONS

Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Functional and Mental Health Status of United Kingdom Military Amputees Postrehabilitation

OBJECTIVES

To evaluate the functional and mental health status of severely injured traumatic amputees from the United Kingdom military at the completion of their rehabilitation pathway and to compare these data with the published normative data.

DESIGN

Retrospective independent group comparison of descriptive rehabilitation data recorded postrehabilitation.

SETTING

A military complex trauma rehabilitation center.

PARTICIPANTS

Amputees (N=65; mean age, 29±6 y) were evaluated at the completion of their rehabilitation pathway; of these, 54 were operationally (combat) injured (23 unilateral, 23 bilateral, 8 triple) and 11 nonoperationally injured (all unilateral).

INTERVENTIONS

Continuous ∼4-week inpatient, physician-led, interdisciplinary rehabilitation followed by ∼4-weeks of patient-led, home-based rehabilitation.

MAIN OUTCOME MEASURES

The New Injury Severity Score at the point of injury was used as the baseline reference. The 6-minute walk test, Amputee Mobility Predictor with Prosthesis, Special Interest Group in Amputee Medicine, Defence Medical Rehabilitation Centre mobility and activity of daily living scores as well as depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7), mental health support, and pain scores were recorded at discharge and compared with the published normative data.

RESULTS

The mean New Injury Severity Score was 40±15. After 34±14 months of rehabilitation, amputees achieved a mean 6-minute walk distance of 489±117 m compared with age-matched normative distances of 459 to 738 m. The 2 unilateral groups walked (544 m) significantly further (P>.05) than did the bilateral amputee (445±104 m) and triple amputee (387±99 m) groups. All groups demonstrated mean functional mobility scores consistent with scores of either active adults or community ambulators with limb loss. In total, 85% could walk/run independently and 95% could walk and perform activities of daily living independently with an aid/adaptation. No significant difference in mental health outcome was reported between the groups (P>.05). At discharge, 98% of patients were able to control their pain.

CONCLUSIONS

Severely injured military amputees who completed intensive interdisciplinary rehabilitation achieved levels of physical function comparable with those in age-matched healthy adults. Mental health outcomes were indicative of preparedness for full integration back into society.

Paediatric traumatic cardiac arrest: data from the Joint Theatre Trauma Registry

BACKGROUND

Traumatic cardiac arrest (TCA) in children is associated with a low probability of survival and poor neurological outcome in survivors. Since 2003, over 600 seriously injured local national children have been treated at deployed UK military medical treatment facilities during the Iraq and Afghanistan conflicts. A number of these were in cardiac arrest after sustaining traumatic injuries. This study defined outcomes from paediatric TCA in this cohort.

METHODS

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry. This includes UK military, coalition military, civilians and local security forces personnel who prompted trauma team activation. All children in this series were local nationals. Patients aged less than 18 years who presented between January 2003 and April 2014, and who underwent cardiopulmonary resuscitation, were included.

RESULTS

27 children with TCA were included. Four children survived to discharge from the medical treatment facility (14.8%), though limited data are available regarding the long-term neurological outcome in these patients.

CONCLUSIONS

This study demonstrates that the outcomes for paediatric TCA in our military field hospitals were similar to other paediatric civilian and adult military studies, despite patients being injured by severe blast injuries. Further work is needed to define the optimal management of paediatric TCA.

Clinical and microbiological evaluation of epidural and regional anaesthesia catheters in injured UK military personnel

INTRODUCTION

The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust.

METHODS

Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded.

RESULTS

Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed.

CONCLUSIONS

With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice.

Traumatic cardiac arrest

Traumatic cardiac arrest is known to have a poor outcome, and some authors have stated that attempted resuscitation from traumatic cardiac arrest is futile. However, advances in damage control resuscitation and understanding of the differences in pathophysiology of traumatic cardiac arrest compared to medical cardiac arrest have led to unexpected survivors. Recently published data have suggested that outcome from traumatic cardiac arrest is no worse than that for medical causes of cardiac arrest, and in some groups may be better. This review highlights key areas of difference between traumatic cardiac arrest and medical cardiac arrest, and outlines a strategy for the management of patients in traumatic cardiac arrest. Standard Advanced Life Support algorithms should not be used for patients in traumatic cardiac arrest.

Outcome of penetrating intracranial injuries in a military setting

BACKGROUND

Penetrating intracranial injuries are common in the deployed military medical environment. Early assessment of prognosis includes initial conscious level. There has been no previous identification of different outcomes depending on mechanism of penetrating injury. The aim of this study was to define outcome from penetrating head injury in our population, and to compare outcome between gunshot wound (GSW) and blast fragment injury, in order to detect a difference in survival.

METHODS

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry (JTTR) between the dates 2003 and 2011 to identify all cases of penetrating head injury. Data collected included mechanism of injury, first recorded GCS, injury severity score (ISS), abbreviated injury scale (AIS) head score, concomitant extracranial injury, surgical intervention, hospital length of stay, and survival.

RESULTS

813 patients sustained a penetrating head injury, of whom 625 were injured by blast fragmentation and 188 were injured by GSW; overall 336 patients (41.3%) died. There was a significant difference between survival from GSW (41.5%) and blast fragment (63.8%; p<0.001). In addition, the GCS in patients injured by GSW was significantly lower than that in patients injured by blast fragment. 157 cases sustained isolated head injury (79 GSW, 78 blast). The difference in injury severity between these groups was marked; median AIS was higher in the GSW group, survival lower (42% vs. 88%; p<0.001) and distribution of GCS categories less favourable (p<0.001). 338 of 343 patients (98.5%) with a best recorded GCS>5, survived to discharge.

CONCLUSION

Most patients who present following penetrating intracranial injury, who have a GCS>5, survive to discharge. There is a significant difference in survival to hospital discharge following penetrating injury caused by blast fragment compared to those caused by GSW, partly attributable to a difference in injury severity. This is the first study to specifically highlight and define this difference.

Intensive Care Follow-up in UK Military Casualties: A One-Year Pilot

Military casualties requiring intensive care were reviewed in a pilot follow-up clinic at approximately three to six months post discharge. All patients reviewed had suffered traumatic injuries in Afghanistan with a median New Injury Severity Score (NISS) of 41. Approximately 50% of casualties reviewed reported hallucinations while on ICU which were often intense and unpleasant. The predominant sedative agents used were morphine and midazolam. Occipital alopecia and pressure sores were reported as an unexpected finding in 35% of casualties. This appears to be permanent in 25% of cases and has required surgery in a small number of cases. Personality changes and anger are common and this cohort of patients can be sensitive to perceived stigmatising concerns regarding referral to psychiatric support services. Patient diaries, which were begun on intensive care in Afghanistan and continued through until discharge in the UK, were found to be very helpful. A significant proportion of clinic attendees thought the pilot clinic was helpful with a quarter of survey responders finding it very helpful. However, this was commonly based on the perception that they were helping the defence medical services improve delivery of care.

Modelling the blast environment and relating this to clinical injury: experience from the 7/7 inquest

This paper addresses the computational modelling of a series of specific blast-related incidents and the relationships of clinical and engineering interpretations. The Royal Centre for Defence Medicine and the Defence Science and Technology Laboratory were tasked in 2010 by the UK Ministry of Defence to assist the Coroner's inquests into the 7 July 2005 London bombings. A three phase approach was taken. The first phase included an engineering expert in blast effects on structures reviewing photographs of the damaged carriages and bus to give a view on the likely physical effects on people close to the explosions. The second phase was a clinical review of the evidence by military clinicians to assess blast injury in the casualties. The third phase was to model the blast environment by structural dynamics experts to assess likely blast loading on victims to evaluate the potential blast loading on individuals. This loading information was then assessed by physiology experts. Once all teams (engineering, clinical and modelling/physiological) had separately arrived at their conclusions, the information streams were integrated to arrive at a consensus. The aim of this paper is to describe the methodology used as a potential model for others to consider if faced with a similar investigation, and to show the benefit of the transition of military knowledge to a civilian environment.