Haemorrhage and coagulopathy in the Defence Medical Services

Followership in complex trauma

Recent conflicts in Iraq and Afghanistan have highlighted the importance of human factors in complex trauma management. A reorganisation of trauma services in England has led to the creation of Major Trauma Centres and Major Trauma Collaboratives, with dedicated Trauma Teams. Much attention has been devoted to the role of team leader and leadership skills, with the human factor concept of followership largely overlooked. This article examines the importance of followership in the trauma team, scrutinising several different followership styles. Followership should be highlighted during trauma team training, promoting the practice of good followership to support the team leader and improve patient care.

Regenerative medicine and war: a front-line focus for UK defence

The recent prolonged conflicts in Iraq and Afghanistan saw the advancement of deployed trauma care to a point never before seen in war. The rapid translation of lessons from combat casualty care research, facilitated by an appetite for risk, contributed to year-on-year improvements in care of the injured. These paradigms, however, can only ever halt the progression of damage. Regenerative medicine approaches, in contrast, hold a truly disruptive potential to go beyond the cessation of damage from blast or ballistic trauma, to stimulate its reversal, and to do so from a very early point following injury. The internationally distributed and, in parts austere environments in which operational medical care is delivered provide an almost unique challenge to the development and translation of regenerative medicine technologies. In parallel, however, an inherent appetite for risk means that Defence will always be an early adopter. In focusing our operational priorities for regenerative medicine, the authors conducted a review of the current research landscape in the UK and abroad and sought wide clinical opinion. Our priorities are all applicable very far forward in the patient care pathway, and are focused on three broad and currently under-researched areas, namely: (a) blood, as an engineered tissue; (b) the mechanobiology of deep tissue loss and mechanobiological approaches to regeneration, and; (c) modification of the endogenous response. In focusing on these areas, we hope to engender the development of regenerative solutions for improved functional recovery from injuries sustained in conflict.

Human factors in contingency operations

The UK Defence Medical Services are currently supporting contingency operations following a period of intensive activity in relatively mature trauma systems in Iraq and Afghanistan. Among the key lessons identified, human factors or non-technical skills played an important role in the improvement of patient care. This article describes the importance of human factors on Role 2 Afloat, one of the Royal Navy's maritime contingency capabilities, and illustrates how they are vital to ensuring that correct decisions are made for patient care in a timely manner. Teamwork and communication are particularly important to ensure that limited resources such as blood products and other consumables are best used and that patients are evacuated promptly, allowing the facility to accept further casualties and therefore maintain operational capability. These ideas may be transferred to any small specialist team given a particular role to perform.

Use of tranexamic acid in combat casualties. Experience of the Spanish medical corps. Clinical series and literature review

OBJECTIVE

To describe the experience with tranexamic acid (TXA) during the care of combat causalities treated in the Spanish military hospital based in Herat (Afghanistan) and to perform an analysis of the literature related to the military setting.

MATERIAL AND METHODS

With the approval of the appropriate military institutions, an analysis was performed on the use of TXA in combat casualties treated between March and May 2014. Of the 745 patients seen, 10 were due to a firearm/explosive device (combat casualties). A descriptive analysis was performed on the data collected. Absolute and relative frequencies (%) were used for the categorical variables. For central tendency measurements, the arithmetic mean and standard deviation or the median and interquartile range was calculated. The data were obtained from the military records of patients treated in the Herat military hospital.

RESULTS

All the patients in this series received TXA within the first 3 hours after the attack. The most frequent dose used was one gram i.v, with bleeding was controlled in 100% of cases. All the patients survived and none of them had secondary effects. These data agree with that recommended in the combat casualties treatment guide followed by military health in other countries in this setting.

CONCLUSION

All combat casualties were treated with TXA within the first 3 hours. The most frequent dose used was one gram iv and bleeding was controlled in all cases. All the patients survived with no adverse effects being observed.

Diagnosis and treatment of coagulopathy following percutaneous cryoablation of liver tumors: experience in 372 patients

Coagulopathy after liver cryoablation was first reported many years ago; the cause is local platelet trapping and destruction within the margin of the cryolesion. However, the prognosis and therapeutic effects of coagulopathy remain unclear. This study retrospectively reviewed clinical data from 372 patients (525 sessions) who underwent liver cryoablation in our hospital during the past 4.5 years. Small tumors (major diameter < 6 cm) were treated with a single complete ablation; massive tumors (major diameter 6-10 cm or >10 cm) were divided into two or three parts that were dealt with in turn. Platelet counts decreased to an average of (46.12 ± 68.13) × 10(9)/L after each session of cryoablation. The decline was most evident in patients with high pretreatment platelet counts, while those with low pretreatment counts had the highest risk of coagulopathy. Change in platelet count was not correlated with the diameter of the tumor. Slight coagulopathy (platelet count (70-100) × 10(9)/L) can resolve without treatment within 1 week and administration of recombinant human interleukin-11 can assist recovery from severe coagulopathy (platelet count < 70 × 10(9)/L).

Intra-operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock

We assessed acidosis, coagulopathy and hypothermia, before and after surgery in 51 combat troops operated on for severe blast injury. Patients were transfused a median (IQR [range]) of 27 (17-38 [5-84]) units of red cell concentrate, 27 (16-38 [4-83]) units of plasma, 2.0 (0.5-3.5 [0-13.0]) units of cryoprecipitate and 4 (2-6 [0-17]) pools of platelets. The pH, base excess, prothrombin time and temperature increased: from 7.19 (7.10-7.29 [6.50-7.49]) to 7.45 (7.40-7.51 [7.15-7.62]); from -9.0 (-13.5 to -4.5 [-28 to -2]) mmol.l⁻¹ to 4.5 (1.0-8.0 [-7 to +11]) mmol.l⁻¹; from 18 (15-21 [9-24]) s to 14 (11-18 [9-21]) s; and from 36.1 (35.1-37.1 [33.0-38.1]) °C to 37.4 (37.0-37.9 [36.0-38.0]) °C, respectively. Contemporary intra-operative resuscitation strategies can normalise the physiological derangements caused by haemorrhagic shock.