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Kriener K, Whiting H, Storr N, Homes R, Lala R, Gabrielyan R, Kuang J, Rubin B, Frails E, Sandstrom H, Futter C, Midwinter M. Applied use of biomechanical measurements from human tissues for the development of medical skills trainers: a scoping review. JBI Evid Synth 2023; 21:2309-2405. [PMID: 37732940 DOI: 10.11124/jbies-22-00363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The objective of this review was to identify quantitative biomechanical measurements of human tissues, the methods for obtaining these measurements, and the primary motivations for conducting biomechanical research. INTRODUCTION Medical skills trainers are a safe and useful tool for clinicians to use when learning or practicing medical procedures. The haptic fidelity of these devices is often poor, which may be because the synthetic materials chosen for these devices do not have the same mechanical properties as human tissues. This review investigates a heterogeneous body of literature to identify which biomechanical properties are available for human tissues, the methods for obtaining these values, and the primary motivations behind conducting biomechanical tests. INCLUSION CRITERIA Studies containing quantitative measurements of the biomechanical properties of human tissues were included. Studies that primarily focused on dynamic and fluid mechanical properties were excluded. Additionally, studies only containing animal, in silico , or synthetic materials were excluded from this review. METHODS This scoping review followed the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sources of evidence were extracted from CINAHL (EBSCO), IEEE Xplore, MEDLINE (PubMed), Scopus, and engineering conference proceedings. The search was limited to the English language. Two independent reviewers screened titles and abstracts as well as full-text reviews. Any conflicts that arose during screening and full-text review were mediated by a third reviewer. Data extraction was conducted by 2 independent reviewers and discrepancies were mediated through discussion. The results are presented in tabular, figure, and narrative formats. RESULTS Data were extracted from a total of 186 full-text publications. All of the studies, except for 1, were experimental. Included studies came from 33 countries, with the majority coming from the United States. Ex vivo methods were the predominant approach for extracting human tissue samples, and the most commonly studied tissue type was musculoskeletal. In this study, nearly 200 unique biomechanical values were reported, and the most commonly reported value was Young's (elastic) modulus. The most common type of mechanical test performed was tensile testing, and the most common reason for testing human tissues was to characterize biomechanical properties. Although the number of published studies on biomechanical properties of human tissues has increased over the past 20 years, there are many gaps in the literature. Of the 186 included studies, only 7 used human tissues for the design or validation of medical skills training devices. Furthermore, in studies where biomechanical values for human tissues have been obtained, a lack of standardization in engineering assumptions, methodologies, and tissue preparation may implicate the usefulness of these values. CONCLUSIONS This review is the first of its kind to give a broad overview of the biomechanics of human tissues in the published literature. With respect to high-fidelity haptics, there is a large gap in the published literature. Even in instances where biomechanical values are available, comparing or using these values is difficult. This is likely due to the lack of standardization in engineering assumptions, testing methodology, and reporting of the results. It is recommended that journals and experts in engineering fields conduct further research to investigate the feasibility of implementing reporting standards. REVIEW REGISTRATION Open Science Framework https://osf.io/fgb34.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Harrison Whiting
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, Royal Brisbane Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas Storr
- Gold Coast University Hospital, Southport, QLD Australia
| | - Ryan Homes
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Raushan Lala
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Robert Gabrielyan
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Jasmine Kuang
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Bryn Rubin
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
- Ochsner Clinical School, Jefferson, LA, United States
| | - Edward Frails
- Department of Chemical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Hannah Sandstrom
- Department of Exercise Science and Sport Management, Kennesaw State University, Kennesaw, GA, United States
| | - Christopher Futter
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Anaesthesia and Intensive Care Program, Herston Biofabrication institute, Brisbane, QLD, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
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Kriener K, Ding-Farrington C, Rodgers S, Midwinter M. Tools measuring high haptic fidelity of procedural skills trainers in physician training and education: a scoping review protocol. JBI Evid Synth 2023; 21:2127-2133. [PMID: 37435682 DOI: 10.11124/jbies-22-00348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVE The objective of this scoping review is to identify instruments that measure the physical haptic fidelity of procedural skills trainers. INTRODUCTION Procedural skills trainers have demonstrated beneficial outcomes for clinicians when used to practice and rehearse procedures. Despite this, several design flaws currently limit the widespread implementation of such trainers. One notable deficit in current trainer designs is haptic fidelity. Identifying measurements of haptic fidelity may maximize the benefit of using certain training devices as well as guiding future design. INCLUSION CRITERIA This review will consider studies that assess the high fidelity haptics of procedural skills training devices in adult physicians above the level of an intern physician. Studies that do not include physicians will be excluded. METHODS The review will follow the JBI methodology for scoping reviews and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Both published and unpublished studies will be searched for in MEDLINE (PubMed), Scopus, Web of Science Core Collection, Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), CINAHL (EBSCOhost), ProQuest Dissertations and Theses (ProQuest), and Google Scholar. There will be no date, setting, or geographical limits, but only studies in English will be included. REVIEW REGISTRATION Open Science Framework osf.io/pvazu/.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Lala R, Homes R, Pratt S, Goodwin W, Midwinter M. Comparison of sublingual microcirculatory parameters measured by sidestream darkfield videomicroscopy in anesthetized pigs and adult humans. Animal Model Exp Med 2023; 6:499-503. [PMID: 37661363 PMCID: PMC10614120 DOI: 10.1002/ame2.12348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND This study aimed to compare sublingual microcirculatory parameters between anesthetized pigs and conscious adult humans using sidestream darkfield videomicroscopy. The overarching aim of the work was to validate the pig as an experimental model of changes in microcirculatory function following traumatic haemorrhagic shock and resuscitation. METHODS Fourteen large white pigs and 14 humans were recruited for the study. Sublingual sidestream darkfield videomicroscopy clips were captured in anesthetized pigs and conscious humans. Clips underwent manual analysis in Automated Vascular Analysis 3.2 software. The total vessel density (TVD), perfused vessel density (PVD), proportion of perfused vessels (PPVs) and microvascular flow index (MFI) were quantified. An independent samples t test was used for between species comparison of microcirculatory parameters. RESULTS AND CONCLUSIONS Conscious humans had a significantly lower TVD, PVD and MFI than anesthetized pigs. No significant difference in PPVs was observed between the species. Perfusion of the microcirculation is a critical determinant of tissue metabolic function and viability. Whilst it may not be surprising that some interspecies differences in the sublingual microcirculatory anatomy were identified between pig and human subjects, it is interesting to report the insignificant difference in PPVs. This direct microcirculatory measure represents a relative change which should hold translatable value across species. We therefore conclude the pig is a suitable model for microcirculatory research and may be a suitable species to investigate changes in microcirculatory perfusion following perturbations in cardiovascular homeostasis, for example during traumatic haemorrhagic shock and resuscitation.
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Affiliation(s)
- Raushan Lala
- School of Biomedical SciencesThe University of QueenslandSt LuciaQldAustralia
- School of Veterinary SciencesThe University of QueenslandGattonQldAustralia
- Jamieson Trauma Institute, Royal Brisbane and Women's HospitalHerstonQldAustralia
- Traumatic Injury Sciences GroupThe University of QueenslandSt LuciaQldAustralia
| | - Ryan Homes
- School of Biomedical SciencesThe University of QueenslandSt LuciaQldAustralia
| | - Shaun Pratt
- School of Veterinary SciencesThe University of QueenslandGattonQldAustralia
- Traumatic Injury Sciences GroupThe University of QueenslandSt LuciaQldAustralia
| | - Wendy Goodwin
- School of Veterinary SciencesThe University of QueenslandGattonQldAustralia
- Traumatic Injury Sciences GroupThe University of QueenslandSt LuciaQldAustralia
| | - Mark Midwinter
- School of Biomedical SciencesThe University of QueenslandSt LuciaQldAustralia
- School of Veterinary SciencesThe University of QueenslandGattonQldAustralia
- Jamieson Trauma Institute, Royal Brisbane and Women's HospitalHerstonQldAustralia
- Traumatic Injury Sciences GroupThe University of QueenslandSt LuciaQldAustralia
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Homes R, Clark D, Moridzadeh S, Tosovic D, Van den Hoorn W, Tucker K, Midwinter M. Comparison of a Wearable Accelerometer/Gyroscopic, Portable Gait Analysis System (LEGSYS+ TM) to the Laboratory Standard of Static Motion Capture Camera Analysis. Sensors (Basel) 2023; 23:537. [PMID: 36617135 PMCID: PMC9824443 DOI: 10.3390/s23010537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
Examination of gait patterns has been used to determine severity, intervention triage and prognostic measures for many health conditions. Methods that generate detailed gait data for clinical use are typically logistically constrained to a formal gait laboratory setting. This has led to an interest in portable analysis systems for near clinical or community-based assessments. The following study assessed with the wearable accelerometer/gyroscopic, gait analysis system (LEGSYS+TM) and the standard of static motion capture camera (MOCAP) analysis during a treadmill walk at three different walking speeds in healthy participants (n = 15). To compare each speed, 20 strides were selected from the MOCAP data and compared with the LEGSYS+ strides at the same time point. Both scatter and bland-Altman plots with accompanying linear regression analysis for each of the parameters. Each stride parameter showed minimal or a consistent difference between the LEGSYS+ and MOCAP, with the phase parameters showing inconsistencies between the systems. Overall, LEGSYS+ stride parameters can be used in the clinical setting, with the utility of phase parameters needing to be taken with caution.
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Affiliation(s)
- Ryan Homes
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
| | - Devon Clark
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
| | - Sina Moridzadeh
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
| | - Danijel Tosovic
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
| | - Wolbert Van den Hoorn
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD 4072, Australia
- ARC ITTC Joint Biomechanics, Queensland Unit for Advanced Shoulder Research, Movement Neuroscience Group, Injury Prevention Group, Exercise & Movement Science, School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD 4067, Australia
| | - Kylie Tucker
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, The University of Queensland, Brisbane, QLD 4067, Australia
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Kriener K, Whiting H, Futter C, Midwinter M. Applied use of biomechanical measurements from human tissues for the development of medical skills trainers: a scoping review protocol. JBI Evid Synth 2022; 20:3067-3075. [PMID: 36065947 DOI: 10.11124/jbies-22-00073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this scoping review is to identify the availability of quantitative biomechanical measurements from human tissues. This review will also consider the primary motivations for collecting biomechanical measurements of human tissues. The overall purpose of our research is to develop medical skills trainers that provide better haptic fidelity than those that are currently available. INTRODUCTION Medical skills trainers are commonly used in clinician training, but trainers do not always have the same haptic properties as patients. This could be due to the limited availability or application of documented biomechanical properties of human tissues when developing trainers. INCLUSION CRITERIA This scoping review will examine studies that have quantitatively measured the mechanical properties of human tissues. Only macroscopic specimens will be included, and articles primarily considering optical, acoustic, and thermal properties will be excluded. Included sources of evidence are from primary research, systematic reviews, meta-analyses, and conference proceedings. METHODS This review will follow the JBI methodology for scoping reviews. Sources of evidence will be extracted from CINAHL, IEEE Xplore, MEDLINE, Scopus, and biomedical engineering conference proceedings. The search is limited to articles in English. Full articles will be retrieved if their title or abstract meet the inclusion criteria. Tabular, visual, and narrative summaries will be used to present the results. SCOPING REVIEW PROTOCOL REGISTRATION Open Science Framework https://osf.io/fgb34.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Harrison Whiting
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,School of Clinical Medicine, Royal Brisbane Clinical Unit, The University of Queensland, Brisbane, QLD, Australia
| | - Christopher Futter
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Anaesthesia and Intensive Care Program, Herston Biofabrication Institute, Brisbane, QLD, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Farley E, Hindmarch J, Eizenberg N, Midwinter M. Surgical applied anatomy: alive and kicking. ANZ J Surg 2021; 91:832-836. [PMID: 33734548 DOI: 10.1111/ans.16680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Contention exists amongst anatomists, clinicians and surgeons about how much anatomical knowledge medical students need, although what is taught should be aligned with current surgical practice. The aim of this study was to explore the scope of recent advances in applied anatomy as highlighted in the ANZ Journal of Surgery in each of the surgical specialties. METHODS The 2018 volume of the ANZ Journal of Surgery was narrowed to 254 articles by applying the search term 'anatomy'. The main topic was extracted from each paper. The content of the paper was assessed for 'novel description' or 'novel application' of anatomical knowledge and classified accordingly. RESULTS Most papers with an anatomical focus were from general surgery, which focused on surgical techniques, outcomes and management. Vascular surgery had the highest percentage of papers with a novel description and application of anatomy. Although cardiothoracic and paediatric surgery had no papers with a novel description of anatomy, novel applications of anatomy were a focus in each speciality. CONCLUSION The trend towards novel applications of anatomical knowledge in all surgical specialties should encourage medical schools to shape their anatomy curricula in tandem with such advances as they evolve. The high proportion of novel applications and descriptions of anatomy in general surgery indicates continued growth as a benchmark of anatomical understanding. Vascular surgery's proportion of novel application and description of anatomy may change the way students will learn vascular anatomy to incorporate endovascular, radiologically based approaches.
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Affiliation(s)
- Edward Farley
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jake Hindmarch
- Melbourne Clinical School, The University of Notre Dame, Melbourne, Victoria, Australia
| | - Norman Eizenberg
- Melbourne Clinical School, The University of Notre Dame, Melbourne, Victoria, Australia
| | - Mark Midwinter
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Holley AD, Dulhunty J, Udy A, Midwinter M, Lukin B, Stuart J, Boots R, Lassig-Smith M, Holley RB, Paratz J, Lipman J. Early Sequential Microcirculation Assessment In Shocked Patients as a Predictor of Outcome: A Prospective Observational Cohort Study. Shock 2020; 55:581-586. [PMID: 32826808 DOI: 10.1097/shk.0000000000001578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES A dysfunctional microcirculation is universal in shock and is often dissociated from global hemodynamic parameters. Persistent microcirculatory derangements reflect ongoing tissue hypoperfusion and organ injury. The initial microcirculatory dysfunction and subsequent resolution could potentially guide therapy and predict outcomes. We evaluated the microcirculation early in a heterogenous shocked population. Microcirculatory resolution was correlated with measures of tissue perfusion and global hemodynamics. The relationship between the microcirculation over 24 h and outcome were evaluated. DESIGN We prospectively recruited patients with all forms of shock, based on global hemodynamics and evidence of organ hypoperfusion. SETTING A 30-bed adult intensive care unit (ICU). PATIENTS Eighty-two shocked patients. MEASUREMENTS AND MAIN RESULTS Following the diagnosis of shock, patients underwent a sublingual microcirculation examination using Sidestream Dark Field Imaging. The median age of patients was 66 years old (interquartile range [IQR] 54-71), with an Acute Physiology and Chronic Health Evaluation II of 27 (IQR 20-32). Microcirculatory parameters included Percentage Perfused Vessels (PPV), De Backer Score, and a heterogeneity index in patients with septic shock, according to the second consensus guidelines Additional parameters collected: temperature, heart rate and arterial pressure, cumulative fluid balance, and vasopressor use. Arterial blood samples were taken at the time of microcirculatory assessments, providing HCO3, lactate concentrations, PaO2, and PaCO2 measurements. A statistically significant improvement in PPV and the heterogeneity index was demonstrated. This improvement was mirrored by biomarkers of perfusion; however, the global hemodynamic parameter changes were not significantly different over the 24-h period. The early microcirculatory improvement was not predictive of an improvement in acute kidney injury, length of stay, ICU, or hospital mortality. CONCLUSIONS Early sequential evaluation of the microcirculation in shocked patients, demonstrated statistically significant improvement in the PPV and microvascular heterogeneity with standard care. These improvements were mirrored by biomarkers of organ perfusion; however, the changes in global hemodynamics were not as pronounced in this early phase. Early improvement in the microcirculation did not predict clinical outcome.
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Affiliation(s)
- Anthony D Holley
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Medicine, The University of Queensland, Queensland, Australia.,The Jamieson Trauma Institute, Queensland, Australia
| | - Joel Dulhunty
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Medicine, The University of Queensland, Queensland, Australia.,Redcliffe Hospital, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Queensland, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Mark Midwinter
- School of Biomedical Sciences, University of Queensland, Queensland, Australia
| | - Bill Lukin
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Janine Stuart
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Robert Boots
- School of Medicine, The University of Queensland, Queensland, Australia.,Department of Thoracic Medicine. Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Melissa Lassig-Smith
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Robert B Holley
- The James Cook University, Townsville, Queensland, Australia
| | - Jenny Paratz
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Queensland, Australia
| | - Jeffrey Lipman
- Intensive Care Services, Royal Brisbane and Women's Hospital, Queensland, Australia.,School of Medicine, The University of Queensland, Queensland, Australia.,The Jamieson Trauma Institute, Queensland, Australia
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Woolley T, Gwyther R, Parmar K, Kirkman E, Watts S, Midwinter M, Lucca JD, Hunt BJ. A prospective observational study of acute traumatic coagulopathy in traumatic bleeding from the battlefield. Transfusion 2020; 60 Suppl 3:S52-S61. [PMID: 32478880 DOI: 10.1111/trf.15658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute trauma coagulopathy (ATC) after military trauma has not been comprehensively studied. ATC is defined as a prolonged prothrombin time ratio (PTr) or reduced clot amplitude (A5) in viscoelastic testing. Compared to civilian trauma, military trauma has more injuries from explosions and gunshot wounds (GSWs), potentially leading to a different pathophysiology for traumatic coagulopathy. This study aimed to characterize military ATC on admission to a military hospital in Afghanistan and to explore any differences due to the mechanism of injury. METHODS Severely injured military casualties were enrolled in the study. Blood samples were taken on admission and after routine testing, waste plasma was prepared, frozen, and transported to the United Kingdom for in-depth hemostatic analysis. RESULTS Seventy-seven percent of casualties had ATC defined by a PTr greater than 1.2 and 19% when defined by rotational thromboelastometry (ROTEM) A5 less than 36 mm. Coagulation factor depletion correlated with degree of shock, particularly factor V (p < 0.01), factor X (p < 0.01), and fibrinogen levels (p < 0.01). Thrombin generation was well preserved. Fibrinolytic biomarkers were raised correlating with the degree of shock (p < 0.01), and 8% of casualties had hyperfibrinolysis on ROTEM analysis. Plasmin-antiplasmin complexes (p < 0.01) and d-dimer levels (p = 0.01) were higher and clot firmness lower (p = 0.02) in those injured by explosion compared to GSW's. CONCLUSIONS ATC was present and correlated with shock, similar to civilian trauma. Thrombin generation remained adequate. Fibrinogen and factor V levels were disproportionately low but still sufficient to allow clot formation. Fibrinolysis is a key feature, probably due to a tissue plasminogen activator surge at the time of injury. Blast injuries are associated with a greater activation of fibrinolysis than GSWs.
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Affiliation(s)
- Tom Woolley
- Anaesthetics and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Robert Gwyther
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Kiran Parmar
- St Thomas' Hospital, Thrombosis and Vascular Biology Group, Rayne Institute, Westminster, UK
| | - Emrys Kirkman
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Sarah Watts
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Mark Midwinter
- School Biomedical Science, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Juandir Dalle Lucca
- Armed Forces Radiobiology Research Institute, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Beverley J Hunt
- St Thomas' Hospital, Thrombosis & Haemophilia Centre & Thrombosis and Vascular Biology Group, London, UK
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Dinsdale RJ, Hazeldine J, Al Tarrah K, Hampson P, Devi A, Ermogenous C, Bamford AL, Bishop J, Watts S, Kirkman E, Dalle Lucca JJ, Midwinter M, Woolley T, Foster M, Lord JM, Moiemen N, Harrison P. Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury. Br J Surg 2019; 107:391-401. [PMID: 31502663 PMCID: PMC7079039 DOI: 10.1002/bjs.11310] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/21/2019] [Accepted: 06/08/2019] [Indexed: 01/25/2023]
Abstract
Background Circulating cell‐free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury. Methods Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months. Results Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1–28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D‐binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels. Conclusion The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA‐induced host tissue damage and thrombosis.
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Affiliation(s)
- R J Dinsdale
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J Hazeldine
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - K Al Tarrah
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - P Hampson
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A Devi
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - C Ermogenous
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A L Bamford
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Bishop
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Watts
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - E Kirkman
- Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - J J Dalle Lucca
- Translational Medical Division, Department of Chemical and Biological Technologies, Defense Threat Reduction Agency, Fort Belvoir, Virginia, USA
| | - M Midwinter
- School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - T Woolley
- ICT Centre, Birmingham Research Park, Birmingham, UK.,Chemical, Biological and Radiological (CBR) Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - M Foster
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - J M Lord
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - N Moiemen
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - P Harrison
- Scar Free Foundation, Birmingham Centre for Burns Research, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Kuravi SJ, Yates CM, Foster M, Harrison P, Hazeldine J, Hampson P, Watson C, Belli A, Midwinter M, Nash GB. Changes in the pattern of plasma extracellular vesicles after severe trauma. PLoS One 2017; 12:e0183640. [PMID: 28837705 PMCID: PMC5570308 DOI: 10.1371/journal.pone.0183640] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background Extracellular vesicles (EV) released into the circulation after traumatic injury may influence complications. We thus evaluated the numbers of EV in plasma over 28 days after trauma and evaluated their pro-coagulant and inflammatory effects. Methods and findings 37 patients suffering trauma with an injury severity score >15 were studied along with 24 healthy controls. Plasma samples were isolated by double centrifugation (2000g 20min; 13000g 2min) from blood collected from within an hour up to 28 days after injury. Plasma EV were counted and sized using nanoparticle tracking analysis (NTA); counts and cellular origins were also determined by flow cytometry (FC) using cell-specific markers. Functional effects were tested in a procoagulant phospholipid assay and in flow-based, leukocyte adhesion assay after endothelial cells (EC) were treated with EV. We found that EV concentrations measured by NTA were significantly increased in trauma patients compared to healthy controls, and remained elevated over days. In addition, or FC showed that patients with trauma had higher numbers of EV derived from platelets (CD41+), leukocytes (CD45+) and endothelial EC (CD144+). The increases were evident throughout the 28-day follow-up. However, the FC count represented <1% of the count detected by NTA, and only 1–2% of EV identified using NTA had a diameter >400nm. The procoagulant phospholipid activity assay showed that patient plasma accelerated coagulation on day 1 and day 3 after trauma, with coagulation times correlated with EV counts. Furthermore, treatment of EC for 24 hours with plasma containing EV tended to increase the recruitment of peripheral flowing blood mononuclear cells. Conclusions EV counted by FC represent a small sub-population of the total load detected by NTA. Both methods however indicate a significant increase in plasma EV after severe traumatic injury that have pro-coagulant and pro-inflammatory effects that may influence outcomes.
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Affiliation(s)
- Sahithi J. Kuravi
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Clara M. Yates
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Harrison
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jon Hazeldine
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Peter Hampson
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Chris Watson
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Midwinter
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gerard B. Nash
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail:
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Feeney C, Sharp DJ, Hellyer PJ, Jolly AE, Cole JH, Scott G, Baxter D, Jilka S, Ross E, Ham TE, Jenkins PO, Li LM, Gorgoraptis N, Midwinter M, Goldstone AP. Serum insulin-like growth factor-I levels are associated with improved white matter recovery after traumatic brain injury. Ann Neurol 2017; 82:30-43. [PMID: 28574152 PMCID: PMC5601275 DOI: 10.1002/ana.24971] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
Objective Traumatic brain injury (TBI) is a common disabling condition with limited treatment options. Diffusion tensor imaging measures recovery of axonal injury in white matter (WM) tracts after TBI. Growth hormone deficiency (GHD) after TBI may impair axonal and neuropsychological recovery, and serum insulin‐like growth factor‐I (IGF‐I) may mediate this effect. We conducted a longitudinal study to determine the effects of baseline serum IGF‐I concentrations on WM tract and neuropsychological recovery after TBI. Methods Thirty‐nine adults after TBI (84.6% male, median age = 30.5 years, 87.2% moderate–severe, median time since TBI = 16.3 months, n = 4 with GHD) were scanned twice, 13.3 months (range = 12.1–14.9) apart, and 35 healthy controls were scanned once. Symptom and quality of life questionnaires and cognitive assessments were completed at both visits (n = 33). Our main outcome measure was fractional anisotropy (FA), a measure of WM tract integrity, in a priori regions of interest: splenium of corpus callosum (SPCC) and posterior limb of internal capsule (PLIC). Results At baseline, FA was reduced in many WM tracts including SPCC and PLIC following TBI compared to controls, indicating axonal injury, with longitudinal increases indicating axonal recovery. There was a significantly greater increase in SPCC FA over time in patients with serum IGF‐I above versus below the median for age. Only the higher IGF‐I group had significant improvements in immediate verbal memory recall over time. Interpretation WM recovery and memory improvements after TBI were greater in patients with higher serum IGF‐I at baseline. These findings suggest that the growth hormone/IGF‐I system may be a potential therapeutic target following TBI. Ann Neurol 2017;82:30–43
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Affiliation(s)
- Claire Feeney
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's and Charing Cross Hospitals, London, United Kingdom
| | - David J Sharp
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Peter J Hellyer
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Amy E Jolly
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - James H Cole
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Gregory Scott
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - David Baxter
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham, United Kingdom
| | - Sagar Jilka
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ewan Ross
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Timothy E Ham
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Peter O Jenkins
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lucia M Li
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nikos Gorgoraptis
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Mark Midwinter
- Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham, United Kingdom.,Academic Section for Musculoskeletal Disease, Chapel Allerton Hospital, University of Leeds, Leeds
| | - Anthony P Goldstone
- Computational, Cognitive, and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom.,Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, St Mary's and Charing Cross Hospitals, London, United Kingdom.,PsychoNeuroEndocrinology Research Group, Neuropsychopharmacology Unit, Centre for Psychiatry, Division of Brain Sciences, Imperial College London, Hammersmith Hospital, London, United Kingdom
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12
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Asehnoune K, Balogh Z, Citerio G, Cap A, Billiar T, Stocchetti N, Cohen MJ, Pelosi P, Curry N, Gaarder C, Gruen R, Holcomb J, Hunt BJ, Juffermans NP, Maegele M, Midwinter M, Moore FA, O'Dwyer M, Pittet JF, Schöchl H, Schreiber M, Spinella PC, Stanworth S, Winfield R, Brohi K. The research agenda for trauma critical care. Intensive Care Med 2017; 43:1340-1351. [PMID: 28756471 DOI: 10.1007/s00134-017-4895-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/20/2017] [Indexed: 01/18/2023]
Abstract
In this research agenda on the acute and critical care management of trauma patients, we concentrate on the major factors leading to death, namely haemorrhage and traumatic brain injury (TBI). In haemostasis biology, the results of randomised controlled trials have led to the therapeutic focus moving away from the augmentation of coagulation factors (such as recombinant factor VIIa) and towards fibrinogen supplementation and administration of antifibrinolytics such as tranexamic acid. Novel diagnostic techniques need to be evaluated to determine whether an individualised precision approach is superior to current empirical practice. The timing and efficacy of platelet transfusions remain in question, while new blood products need to be developed and evaluated, including whole blood variants, lyophilised products and novel red cell storage modalities. The current cornerstones of TBI management are intracranial pressure control, maintenance of cerebral perfusion pressure and avoidance of secondary insults (such as hypotension, hypoxaemia, hyperglycaemia and pyrexia). Therapeutic hypothermia and decompressive craniectomy are controversial therapies. Further research into these strategies should focus on identifying which subgroups of patients may benefit from these interventions. Prediction of the long-term outcome early after TBI remains challenging. Early magnetic resonance imaging has recently been evaluated for predicting the long-term outcome in mild and severe TBI. Novel biomarkers may also help in outcome prediction and may predict chronic neurological symptoms. For trauma in general, rehabilitation is complex and multidimensional, and the optimal timing for commencement of rehabilitation needs investigation. We propose priority areas for clinical trials in the next 10 years.
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Affiliation(s)
- Karim Asehnoune
- Department of Anesthesiology and Critical Care Medicine, Hôtel Dieu, Centre hospitalier universitaire (CHU) de Nantes, 44000, Nantes, France.
- Laboratory EA 3826, University of Nantes, Nantes, France.
| | - Zsolt Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Neurointensive Care Unit, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Andre Cap
- US Army Institute of Surgical Research, San Antonio, TX, USA
| | - Timothy Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mitchell J Cohen
- University of Colorado School of Medicine, Denver Health Medical Center, Aurora, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Nicola Curry
- Oxford University Hospital NHS Trust, John Radcliffe Hospital, Oxford, UK
| | | | - Russell Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University, Nanyang, Singapore
| | - John Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA
| | - Beverley J Hunt
- Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Mark Midwinter
- Rural Clinical School (Bundaberg), University of Queensland, Bundaberg, QLD, Australia
| | | | - Michael O'Dwyer
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Jean-François Pittet
- Critical Care Division, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Martin Schreiber
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University in St Louis School of Medicine, Washington, USA
| | - Simon Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | | | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
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13
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Penn-Barwell JG, Sargeant ID, Bennett P, Fries C, Kendrew J, Midwinter M, Bishop J, Rickard R, Sargeant I, Porter K, Rowlands T, Mountain A, Kay A, Mortiboy D, Stevenson T, Myatt R. Gun-shot injuries in UK military casualties - Features associated with wound severity. Injury 2016; 47:1067-71. [PMID: 26948689 DOI: 10.1016/j.injury.2016.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 02/07/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jowan G Penn-Barwell
- Institute of Naval Medicine, Trauma and Orthopaedic Registrar Royal Navy, United Kingdom.
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Marsden MER, Sharrock AE, Hansen CL, Newton NJ, Bowley DM, Midwinter M. British Military surgical key performance indicators: time for an update? J ROY ARMY MED CORPS 2015; 162:373-378. [DOI: 10.1136/jramc-2015-000521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/20/2015] [Indexed: 11/03/2022]
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15
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Marsden M, Sharrock A, Hansen C, Newton N, Midwinter M. The utility of surgical key performance indicators in British military trauma. Int J Surg 2015. [DOI: 10.1016/j.ijsu.2015.07.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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O'Reilly D, Lordan J, Streets C, Midwinter M, Mirza D. Maintaining surgical skills for military general surgery: the potential role for multivisceral organ retrieval in military general surgery training and practice: Table 1. J ROY ARMY MED CORPS 2015; 162:236-8. [DOI: 10.1136/jramc-2015-000444] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/02/2015] [Indexed: 11/04/2022]
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17
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Barker T, Spencer P, Kirkman E, Lambert A, Midwinter M. An evaluation of the normal range of StO₂measurements at rest and following a mixed exercise protocol. J ROY ARMY MED CORPS 2014; 161:327-31. [PMID: 25168755 DOI: 10.1136/jramc-2014-000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 07/29/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Assessment of local tissue oxygenation (StO₂) using near infrared spectroscopy is an emerging technique in medical practice with applications in trauma/sepsis management, diagnosis of acute compartment syndrome and assessment of tissue viability. Despite this, there have been little published data on the range of StO₂values in normal subjects. METHODS StO₂measurements were recorded in 105 infantry soldiers using an INVOS System Monitor (Somanetics) from both deltoids, the anterior compartment of the leg and the frontal lobe of the brain. Measurements were taken at rest and following completion of a mixed exercise protocol, consisting of overarm pull-ups, sit-ups and a 3-mile run. RESULTS StO₂values at rest were found to have a wide normal range with a skew left distribution. Mean StO₂was similar between the deltoids (left deltoid 80%, right deltoid 79%), but significantly different between other anatomical sites (leg 68%, brain 73%). However, all sites demonstrated a similar lower range cut-off at approximately 40%. Following exercise, there was a significant increase in StO₂values at all sites (left deltoid by 3.1 ± 2.0%, right deltoid by 2.6 ± 2.3%, leg by 8.0 ± 2.3% and brain by 8.6 ± 1.9%), which persisted for at least 10 min. CONCLUSIONS There were statistically significant differences in mean StO₂values recorded at different anatomical sites, although the reference ranges were wide and substantially overlapped. StO₂increased at all sites after exercise with the effect persisting for at least 10 min. The interaction between exercise and pathological phenomena remains unknown and is an area for further study.
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Affiliation(s)
- Tom Barker
- Academic Department of Military Surgery and Trauma, The Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - P Spencer
- Defence Science & Technology Laboratory, Salisbury, UK
| | - E Kirkman
- Defence Science & Technology Laboratory, Salisbury, UK
| | - A Lambert
- Department of Surgery, Ministry of Defence Hospital Unit Derriford, Plymouth, UK
| | - M Midwinter
- Academic Department of Military Surgery and Trauma, The Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
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18
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Penn-Barwell JG, Bennett PM, Kay A, Sargeant ID, Bennett P, Fries C, Cooper J, Kendrew J, Midwinter M, Rickard R, Sargeant I, Porter K, Rowlands T, Mountain A, Kay A, Jeffrey S, Evirviades D, Cubison T. Acute bilateral leg amputation following combat injury in UK servicemen. Injury 2014; 45:1105-10. [PMID: 24598278 DOI: 10.1016/j.injury.2014.01.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/27/2013] [Accepted: 01/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aims to characterise the injuries and surgical management of British servicemen sustaining bilateral lower limb amputations. METHODS The UK Military Trauma Registry was searched for all cases of primary bilateral lower limb amputation sustained between March 2004 and March 2010. Amputations were excluded if they occurred more than 7 days after injury or if they were at the ankle or more distal. RESULTS There were 1694 UK military patients injured or killed during this six-year study period. Forty-three of these (2.8%) were casualties with bilateral lower limb amputations. All casualties were men with a mean age of 25.1 years (SD 4.3): all were injured in Afghanistan by Improvised Explosive Devices (IEDs). Six casualties were in vehicles when they were injured with the remaining 37 (80%) patrolling on foot. The mean New Injury Severity Score (NISS) was 48.2 (SD 13.2): four patients had a maximum score of 75. The mean TRISS probability of survival was 60% (SD 39.4), with 18 having a survival probability of less than 50% i.e. unexpected survivors. The most common amputation pattern was bilateral trans-femoral (TF) amputations, which was seen in 25 patients (58%). Nine patients also lost an upper limb (triple amputation): no patients survived loss of all four limbs. In retained upper limbs extensive injuries to the hands and forearms were common, including loss of digits. Six patients (14%) sustained an open pelvic fracture. Perineal/genital injury was a feature in 19 (44%) patients, ranging from unilateral orchidectomy to loss of genitalia and permanent requirement for colostomy and urostomy. The mean requirement for blood products was 66 units (SD 41.7). The maximum transfusion was 12 units of platelets, 94 packed red cells, 8 cryoprecipitate, 76 units of fresh frozen plasma and 3 units of fresh whole blood, a total of 193 units of blood products. CONCLUSIONS Our findings detail the severe nature of these injuries together with the massive surgical and resuscitative efforts required to firstly keep patients alive and secondly reconstruct and prepare them for rehabilitation.
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Affiliation(s)
- J G Penn-Barwell
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK; Institute of Naval Medicine, Gosport, Hampshire, UK.
| | - P M Bennett
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK
| | - A Kay
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK
| | - I D Sargeant
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK
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Smith JE, Kehoe A, Harrisson SE, Russell R, Midwinter M. Outcome of penetrating intracranial injuries in a military setting. Injury 2014; 45:874-8. [PMID: 24398079 DOI: 10.1016/j.injury.2013.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/22/2013] [Accepted: 12/06/2013] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK; Emergency Department, Derriford Hospital, Plymouth, UK.
| | - A Kehoe
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - S E Harrisson
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK; Department of Neurosurgery, Wessex Neurological Centre, Southampton, UK
| | - R Russell
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
| | - M Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, UK
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Hutchings SD, Howarth G, Rees P, Midwinter M. Conducting clinical research in the deployed Intensive Care Unit: challenges and solutions. ACTA ACUST UNITED AC 2013. [DOI: 10.1136/jrnms-99-151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Penn-Barwell JG, Fries CA, Bennett PM, Midwinter M, Baker AB. The Injury Burden of Recent Combat Operations: Mortality, Morbidity, and Return to Service of U.K. Naval Service Personnel Following Combat Trauma. Mil Med 2013; 178:1222-6. [DOI: 10.7205/milmed-d-13-00180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Senanayake E, Poon H, Midwinter M, Graham T. 211 * UK SPECIALIST CARDIOTHORACIC MANAGEMENT OF THORACIC INJURIES IN MILITARY CASUALTIES SUSTAINED IN THE WARS IN IRAQ AND AFGHANISTAN. Interact Cardiovasc Thorac Surg 2013. [DOI: 10.1093/icvts/ivt372.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Baxter D, Sharp DJ, Feeney C, Papadopoulou D, Ham TE, Jilka S, Hellyer PJ, Patel MC, Bennett AN, Mistlin A, McGilloway E, Midwinter M, Goldstone AP. Pituitary dysfunction after blast traumatic brain injury: The UK BIOSAP study. Ann Neurol 2013; 74:527-36. [PMID: 23794460 PMCID: PMC4223931 DOI: 10.1002/ana.23958] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/08/2013] [Accepted: 05/24/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Pituitary dysfunction is a recognized consequence of traumatic brain injury (TBI) that causes cognitive, psychological, and metabolic impairment. Hormone replacement offers a therapeutic opportunity. Blast TBI (bTBI) from improvised explosive devices is commonly seen in soldiers returning from recent conflicts. We investigated: (1) the prevalence and consequences of pituitary dysfunction following moderate to severe bTBI and (2) whether it is associated with particular patterns of brain injury. METHODS Nineteen male soldiers with moderate to severe bTBI (median age = 28.3 years) and 39 male controls with moderate to severe nonblast TBI (nbTBI; median age = 32.3 years) underwent full dynamic endocrine assessment between 2 and 48 months after injury. In addition, soldiers had structural brain magnetic resonance imaging, including diffusion tensor imaging (DTI), and cognitive assessment. RESULTS Six of 19 (32.0%) soldiers with bTBI, but only 1 of 39 (2.6%) nbTBI controls, had anterior pituitary dysfunction (p = 0.004). Two soldiers had hyperprolactinemia, 2 had growth hormone (GH) deficiency, 1 had adrenocorticotropic hormone (ACTH) deficiency, and 1 had combined GH/ACTH/gonadotrophin deficiency. DTI measures of white matter structure showed greater traumatic axonal injury in the cerebellum and corpus callosum in those soldiers with pituitary dysfunction than in those without. Soldiers with pituitary dysfunction after bTBI also had a higher prevalence of skull/facial fractures and worse cognitive function. Four soldiers (21.1%) commenced hormone replacement(s) for hypopituitarism. INTERPRETATION We reveal a high prevalence of anterior pituitary dysfunction in soldiers suffering moderate to severe bTBI, which was more frequent than in a matched group of civilian moderate to severe nbTBI subjects. We recommend that all patients with moderate to severe bTBI should routinely have comprehensive assessment of endocrine function.
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Affiliation(s)
- David Baxter
- Computational Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences Imperial College London, Hammersmith Hospital, London; Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham
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Sharrock AE, Midwinter M. Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care. Ann R Coll Surg Engl 2013; 95:177-83. [PMID: 23827287 DOI: 10.1308/003588413x13511609958253] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. METHODS The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. FINDINGS A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.
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Affiliation(s)
- A E Sharrock
- Vascular Surgery Department, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK.
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Woolley T, Midwinter M, Spencer P, Watts S, Doran C, Kirkman E. Utility of interim ROTEM(®) values of clot strength, A5 and A10, in predicting final assessment of coagulation status in severely injured battle patients. Injury 2013; 44:593-9. [PMID: 22487164 DOI: 10.1016/j.injury.2012.03.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 03/13/2012] [Accepted: 03/15/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Proactive management of trauma-related coagulopathy requires early identification and rapid assessment in order to allow targeted resuscitation. This study determined whether early (interim) ROTEM(®) (TEM International GmbH, Munich, Germany) values could predict hypocoagulopathy in seriously injured military patients. METHODS Normal ranges for ROTEM(®) values were obtained from 50 volunteers. 108 samples were collected during the early phase of clinical management from 48 severe trauma patients. The blood was subject to EXTEM analysis and compared to the 95% tolerance limits from the volunteers. Coagulopathy (was deemed to be present if EXTEM MCF was below 40 mm, which is in the range indicating clinical concern defined by the ROTEM(®) Expert Working Group. RESULTS The normal range data was broadly similar to ROTEM(®) published data. Admission samples were available from 31 battlefield casualties, and 39% of these were coagulopathic 51% of the samples from all 48 patients were coagulopathic (EXTEM MCF<40 mm) and interim EXTEM values of these at 5 and 10 min (A5 and A10) predicted coagulopathy with sensitivities/specificities of 0.96/0.58 (A5) and 1.00/0.70 (A10). In addition, statistical comparison of clotting domains between normal volunteers and trauma patients suggests a difference in clot strengths due to a difference in platelet function rather than platelet number (mean 142 × 10(9)l(-1)). CONCLUSIONS The A10 value of ROTEM(®) provides an early sensitive and specific assessment of coagulopathy after military trauma and may be of utility in guiding bespoke resuscitation. We found some speculative evidence that in major trauma platelet function is particularly affected.
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Affiliation(s)
- T Woolley
- Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Building, Birmingham, Research Park, Vincent Drive, Birmingham B15 2SQ, United Kingdom.
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Mossadegh S, Midwinter M, Sapsford W, Tai N. Military treatment of splenic injury in the era of non-operative management. J ROY ARMY MED CORPS 2013; 159:110-3. [DOI: 10.1136/jramc-2013-000039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Mossadegh S, Midwinter M, Parker P. Developing a cumulative anatomic scoring system for military perineal and pelvic blast injuries. J ROY ARMY MED CORPS 2013; 159 Suppl 1:i40-4. [DOI: 10.1136/jramc-2013-000020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hutchings SD, Howarth G, Rees P, Midwinter M. Conducting clinical research in the deployed intensive care unit: challenges and solutions. J R Nav Med Serv 2013; 99:151-153. [PMID: 24511805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Conducting research in the deployed environment is challenging but if the various obstacles are overcome then the data captured can be vital in developing future treatment strategies. Perhaps the most important aspect is having an enthusiastic individual who is dedicated to research and can thus concentrate on maximising the potential of this unique environment.
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Affiliation(s)
- S D Hutchings
- Department of Critical Care, Kings College Hospital, Denmark Hill, London.
| | - G Howarth
- Ministry of Defence Hospital Unit, Portsmouth
| | - P Rees
- Consultant Cardiologist, Barts Health NHS Trust
| | - M Midwinter
- Defence Professor of Surgery & Head of Department, Academic Department of Military Surgery & Trauma
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Mossadegh S, Tai N, Midwinter M, Parker P. Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management. J Trauma Acute Care Surg 2012; 73:S24-31. [PMID: 22847089 DOI: 10.1097/ta.0b013e3182625f82] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pelviperineal injuries, primarily due to blast mechanisms, are becoming the signature injury pattern on operations in Afghanistan. This study set out to define these injuries and to refine our team-based surgical resuscitation strategies to provide a resuscitation-debridement-diversion didactic on our Military Operational Surgical Training predeployment course to optimize our field care of these injuries. METHODS A retrospective study of the UK Joint Theatre Trauma Registry was performed looking at consecutive data from January 2003 to December 2010, identifying patients with perineal injuries. Data abstracted included patient demographics, mechanism of injury, Injury Severity Score (ISS), management, and outcomes. RESULTS Of 2204 UK military trauma patients, 118 (5.4%) had a recorded perineal injury and 56 (47%) died . Pelvic fractures were identified in 63 (53%) of 118 patients of which only 17 (27%) of 63 survived. Mortality rates were significantly different between the combined perineal and pelvic fracture group compared with the pelvic fractures or perineal injuries alone (107 [41%] of 261 and 11 [18%] of 56, respectively, p < 0.001). The median (interquartile range) ISS for all patients was 38 (29-57). The ISS for those with pelvic fractures were significantly higher than those with perineal injuries alone, 50 (38-71) versus 30 (15-35) (p < 0.001). CONCLUSION Improvised explosive device-related perineal injuries with pelvic fractures had the highest rate of mortality compared with perineal injuries alone. Early aggressive resuscitation (activation of the massive hemorrhage protocol) is essential to survival in this cohort. Our recommendations are uncompromising initial debridement, immediate fecal diversion, and early enteral feeding.
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Jansen JO, Thomas GOR, Adams SA, Tai NRM, Russell R, Morrison J, Clasper J, Midwinter M. Early management of proximal traumatic lower extremity amputation and pelvic injury caused by improvised explosive devices (IEDs). Injury 2012; 43:976-9. [PMID: 21907338 DOI: 10.1016/j.injury.2011.08.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 06/19/2011] [Accepted: 08/18/2011] [Indexed: 02/02/2023]
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Allcock EC, Woolley T, Doughty H, Midwinter M, Mahoney PF, Mackenzie I. The clinical outcome of UK military personnel who received a massive transfusion in Afghanistan during 2009. J ROY ARMY MED CORPS 2012; 157:365-9. [PMID: 22319979 DOI: 10.1136/jramc-157-04-03] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The UK Defence Medical Services has developed a Massive Transfusion Protocol (MTP) that forms part of the initial Damage Control Resuscitation process for severely injured combat casualties. The key objectives of this retrospective review of MTP recipients are to document the survival rates, level of critical care support required and the blood components transfused as part of the Massive Transfusion Protocol in Afghanistan during 2009. In addition to providing a measure of our current effectiveness it should also provide a reference point for future reviews as the MTP continues to evolve. METHODS This was a collaborative project involving the Royal Centre for Defence Medicine and the Critical Care Department, University Hospitals Birmingham. It was limited to UK military personnel who were injured in 2009 and received massive transfusions (defined as the transfusion of 10 or more units of packed red blood cells over a 24-hour period) at Camp Bastion Role 3 Medical Facility, Afghanistan. RESULTS During the 12-month period, 59 personnel received massive transfusions. 51 (86%) personnel survived to be discharged from hospital in the UK. 48 (92%) personnel required ventilatory support for a median of 3 (2-8) days. The longest period of ventilation was 40 days; 29 (55%) personnel required vasopressor support and eight personnel (15%) required renal replacement therapy. The median total transfusion of blood components was 45 (28.5-62) units. There were seven transfusions of more than 100 units. Five of the personnel in this group (including the recipient of a 237-unit transfusion) survived to be discharged from University Hospitals Birmingham. On average, 1.21 (SD 0.28) units of packed red blood cells were transfused for every unit of fresh frozen plasma. CONCLUSIONS The use of the current MTP was associated with a high rate of survival. Survivors require a continuity of critical care with a median demand for 3 days. The early use of plasma and platelets can be successfully delivered in the battlefield despite operational and logistic constraints.
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Affiliation(s)
- E C Allcock
- ST6 Anaesthetics & ICU, Institute of Naval Medicine, Gosport, Hants.
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Abstract
Continuous compartment pressure monitoring, for acute compartment syndrome, remains an infrequently performed procedure despite the potential benefits some patients may derive from it. This state of affairs may, in part, be attributed to a lack of clinician awareness of an easy and cheap system by which compartment pressures can be monitored. In this article, we describe a simple pressure monitoring set-up that we have successfully employed in a variety of trauma patients, and how we believe the measurements obtained from it can be best interpreted to assist in the diagnosis of compartment syndrome.
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Affiliation(s)
- Tom Barker
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Mark Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Keith Porter
- Academic Department of Clinical Traumatology, New Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
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Jaffer U, Aslam M, Kasivisvanathan V, Patni R, Midwinter M, Standfield N. Evaluation of rapid training in ultrasound guided tourniquet application skills. Int J Surg 2012; 10:563-7. [DOI: 10.1016/j.ijsu.2012.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 07/17/2012] [Accepted: 08/22/2012] [Indexed: 11/25/2022]
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Morrison JJ, Hunt N, Midwinter M, Jansen J. Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices. Br J Surg 2011; 99:362-6. [PMID: 22190142 DOI: 10.1002/bjs.7765] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Improvised explosive devices (IEDs) pose a significant threat to military personnel, often resulting in lower extremity amputation and pelvic injury. Immediate management is haemorrhage control and debridement, which can involve lengthy surgery. Computed tomography is necessary to delineate the extent of the injury, but it is unclear whether to perform this during or after surgery. METHODS The UK Joint Theatre Trauma Registry was searched to identify all UK service personnel who had a traumatic lower extremity amputation following IED injury between January 2007 and December 2010. Data were collected on injury pattern and survival. RESULTS There were 169 patients who sustained 278 traumatic lower extremity amputations: 69 were killed in action, 16 died from their wounds and 84 were wounded in action, but survived. The median (interquartile range) Injury Severity Score was 75 (21) for those killed in action, 46 (23) for those who died from wounds and 29 (12) for survivors. There were significantly more severe head, chest and abdominal injuries (defined as a body region Abbreviated Injury Scale score of 3 or more) in patients who were killed in action than in those reaching hospital (P < 0·001). Hindquarter amputations were the most lethal, with a mortality rate of 95 per cent. Of the 100 casualties who reached hospital alive, there were nine thoracotomies, one craniotomy and 34 laparotomies. All head or torso injuries that required immediate operation were clinically apparent on admission. CONCLUSION Higher levels of amputation were associated with greater injury burden and mortality. Intraoperative computed tomography had little value in identifying clinically significant covert injuries.
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Affiliation(s)
- J J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Edgbaston, Birmingham, UK.
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Fries CA, Penn-Barwell J, Tai N, Hodgetts T, Midwinter M, Bowley D. Management of Intestinal Injury in Deployed UK Hospitals. J ROY ARMY MED CORPS 2011; 157:370-3. [DOI: 10.1136/jramc-157-04-04] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Breeze J, Gibbons A, Hunt N, Monaghan A, Gibb I, Hepper A, Midwinter M. Mandibular fractures in British military personnel secondary to blast trauma sustained in Iraq and Afghanistan. Br J Oral Maxillofac Surg 2011; 49:607-11. [DOI: 10.1016/j.bjoms.2010.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
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Morrison JJ, Mellor A, Midwinter M, Mahoney PF, Clasper JC. Is pre-hospital thoracotomy necessary in the military environment? Injury 2011; 42:469-73. [PMID: 20362287 DOI: 10.1016/j.injury.2010.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 02/12/2010] [Accepted: 03/08/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Exsanguination from penetrating torso injury is a major source of mortality on the battlefield. Advanced Life Support guidelines suggest 'on-scene' thoracotomy for patients in cardiac arrest following penetrating chest trauma. This requires significant resourcing and training. Experience from published series (31 pre-hospital thoracotomies with 3 survivors) suggests that when this manoeuvre is applied to a well selected group it is a significant and life-saving procedure. Can this be applied to military injuries? METHODS Over a 12 month period on Operation Herrick all patients who sustained significant thoracic trauma were retrospectively reviewed. Parameters were recorded to allow detailed analysis of injury pattern and operative management. Our main objective was to determine if an early (pre-hospital) thoracotomy would have influenced the outcome. RESULTS Over the period, 81 patients required operative intervention following thoracic trauma: 8 patients underwent emergency thoracotomy (performed as part of the resuscitation) and 14 underwent urgent thoracotomy (performed after physiology partly restored). There were 9 fatalities--7 undergoing emergency thoracotomy and 2 post-operatively from multi-organ failure. Of the 7 intra-operative deaths 4/7 patients had thoracic injury and 6/7 had additional abdominal injuries. The median predicted survival of fatalities was 2.0% using Trauma Injury Severity Scoring. DISCUSSION Emergency thoracotomy should be performed in cardiac arrest following penetrating trauma as soon as possible. Highest survival rates in both in-hospital and pre-hospital thoracotomy are found in isolated cardiac stab wounds (19.4%). Poorest survival is found in multiply, ballistic injured patients (0.7%). The latter best reflects the injury pattern of military patients who have cardiac arrest following penetrating torso injury. CONCLUSION As our injury pattern suggests, any pre-hospital thoracotomy on military patients is likely to require complex intervention in very challenging environments. Our evidence does not support the notion that earlier thoracotomy could improve survival.
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Affiliation(s)
- J J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, United Kingdom.
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Abstract
Acute compartment syndrome of the lower limb is a significant problem in surgical practice, the successful management of which depends upon swift diagnosis and intervention. Conventionally, diagnosis has been based upon clinical assessment; however, this can be unreliable and the potential for missed compartment syndrome remains. The supplementary use of compartment pressure monitoring has addressed some of these issues, but it remains an invasive technique, the exact role of which is still debated in the literature. Near infrared spectroscopy (NIRS) is an emerging technique in medical practice which provides a non-invasive, continuous and real time measure of local tissue oxygenation. Early experimental work and subsequent clinical studies have demonstrated that NIRS provides an accurate means of detecting compartment syndrome, and that its sensitivity in some circumstances may exceed that of monitoring compartment pressures. Despite this promise, limitations of the technique, such as difficultly monitoring the deep posterior compartment of leg using current systems, and the relative expense of the equipment, have hindered broader adoption.
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Affiliation(s)
- Tom Barker
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham, B15 2SQ, UK,
| | - Mark Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham, B15 2SQ, UK
| | - Keith Porter
- Academic Department of Clinical Traumatology, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
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Tai NRM, Brooks A, Midwinter M, Clasper JC, Parker PJ. Optimal clinical timelines--a consensus from the academic department of military surgery and trauma. J ROY ARMY MED CORPS 2011; 155:253-6. [PMID: 20397599 DOI: 10.1136/jramc-155-04-04] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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 aim of this paper is to review all relevant military 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, air-conditioned 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.
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Affiliation(s)
- N R M Tai
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham
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Abstract
Abstract
Background
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.
Methods
Data from the British Joint Theatre Trauma Registry were combined with hospital records to review all cases of vascular trauma in deployed service personnel over a 5-year interval ending in January 2008.
Results
Of 1203 injured service personnel, 110 sustained injuries to named vessels; 66 of them died before any surgical intervention. All 25 patients who sustained an injury to a named vessel in the abdomen or thorax died; 24 did not survive to undergo surgery and one casualty in extremis underwent a thoracotomy, but died. Six of 17 patients with cervical vascular injuries survived to surgical intervention; two died after surgery. Of 76 patients with extremity vascular injuries, 37 survived to surgery with one postoperative death. Interventions on 38 limbs included 19 damage control procedures (15 primary amputations, 4 vessel ligations) and 19 definitive limb revascularization procedures (11 interposition vein grafts, 8 direct repairs), four of which failed necessitating three amputations.
Conclusion
In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life. Favourable limb salvage rates are achievable in casualties able to withstand revascularization. Despite marked progress in contemporary battlefield trauma care, torso vascular injury is usually not amenable to surgical intervention.
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Affiliation(s)
- A Stannard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
| | - K Brown
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
| | - C Benson
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
| | - J Clasper
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
| | - M Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
| | - N R Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK
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Morrison JJ, Clasper JC, Gibb I, Midwinter M. Management of Penetrating Abdominal Trauma in the Conflict Environment: The Role of Computed Tomography Scanning. World J Surg 2010; 35:27-33. [PMID: 20845038 DOI: 10.1007/s00268-010-0782-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK.
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Abstract
INTRODUCTION Surgical decision-making in torso trauma is complex. This paper looks at the role of the computed tomography (CT) scan in this decision-making process. PATIENTS AND METHODS Patients with significant torso trauma (high velocity gunshot wound [HVGSW], blast, stab) admitted to a military role 2 (enhanced) hospital facility during a 7-week period of Operation HERRICK 9 (Afghanistan, October to November 2008) are reported. The management of those patients undergoing a CT scan as part of the decision-making process at the time of admission is discussed. RESULTS Twenty eight patients with significant torso trauma were admitted to the facility during the study period; HVGSW (n = 15), blast (n = 9), stab (n = 4). Thirteen patients underwent a CT scan as part of the surgical decision-making process; HVGSW (n = 5), blast (n = 8). Imaging confirmed torso integrity in 12 patients, one of whom subsequently had a laparotomy for vascular control for on-table haemorrhage during lower limb surgery. One patient had a confirmed thoraco-abdominal injury, which was treated conservatively with tube thoracostomy and 'active observation'. CONCLUSIONS A CT scan formed part of the surgical decision-making process in about half of the patients admitted with significant torso trauma, and helped prevent unnecessary laparotomy in this forward military environment. Those patients with a blast injury were more likely to undergo CT scanning than those where the mechanism of injury was a HVGSW.
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Affiliation(s)
- J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
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Breeze J, Gibbons A, Hunt N, Monaghan A, Hepper A, Midwinter M. 49 Mandible fracture patterns seen in British servicemen subjected to blast injury. Br J Oral Maxillofac Surg 2010. [DOI: 10.1016/s0266-4356(10)60050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ramasamy A, Hinsley DE, Edwards DS, Stewart MPM, Midwinter M, Parker PJ. Skill sets and competencies for the modern military surgeon: lessons from UK military operations in Southern Afghanistan. Injury 2010; 41:453-9. [PMID: 20022003 DOI: 10.1016/j.injury.2009.11.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 10/11/2009] [Accepted: 11/23/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION British military forces remain heavily committed on combat operations overseas. UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province, in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team. METHOD A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation. RESULTS During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF), 27% were Afghan security forces (ANSF) and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures, by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further 4% (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 cases, p<0.05). DISCUSSION Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deployment military surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments.
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Affiliation(s)
- Arul Ramasamy
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, West Wing, Birmingham Research Park, Vincent Drive, Birmingham B5 1SQ, United Kingdom.
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Abstract
INTRODUCTION Since the invasion of Iraq in 2003, the conflict has evolved from asymmetric warfare to a counter-insurgency operation. This study investigates the pattern of wounding and types of injuries seen in casualties of hostile action presenting to a British military field hospital during the present conflict. PATIENTS AND METHODS Data were prospectively collected on 100 consecutive patients either injured or killed from hostile action from January 2006 who presented to the sole coalition field hospital in southern Iraq. RESULTS Eighty-two casualties presented with penetrating missile injuries from hostile action. Three subsequently died of wounds (3.7%). Forty-six (56.1%) casualties had their initial surgery performed by British military surgeons. Twenty casualties (24.4%) sustained gunshot wounds, 62 (75.6%) suffered injuries from fragmentation weapons. These 82 casualties were injured in 55 incidents (mean, 1.49 casualties; range 1-6 casualties) and sustained a total 236 wounds (mean, 2.88 wounds) affecting a mean 2.4 body regions per patient. Improvised explosive devices were responsible for a mean 2.31 casualties (range, 1-4 casualties) per incident. CONCLUSIONS The current insurgency in Iraq illustrates the likely evolution of modern, low-intensity, urban conflict. Improvised explosive devices employed against both military and civilian targets have become a major cause of injury. With the current global threat from terrorist bombings, both military and civilian surgeons should be aware of the spectrum and emergent management of the injuries caused by these weapons.
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Affiliation(s)
- A Ramasamy
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
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Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury 2009; 40:1342-5. [PMID: 19616210 DOI: 10.1016/j.injury.2009.06.168] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Revised: 06/04/2009] [Accepted: 06/22/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today's global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties. METHODS We retrospectively reviewed the medical records of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention was recorded. RESULTS During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 of these (7%) actually survived to reach hospital. Four of this six subsequently died from injuries within 72 h. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. CONCLUSIONS Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life-threatening conditions.
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Affiliation(s)
- Arul Ramasamy
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
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Abstract
INTRODUCTION In the UK, general surgical specialist trainees have limited exposure to general surgical trauma. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees. PATIENTS AND METHODS A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available. RESULTS A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies. CONCLUSIONS A training opportunity currently exists on Operation HERRICK for military general surgical specialist trainees. If the tempo of the last 12 months is maintained, a 2-month deployment would essentially provide trainees with the equivalent trauma surgery experience to the whole of their surgical training in the UK NHS. Trainees would gain experience in military trauma as well as specific organ injury management.
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Affiliation(s)
- Adam J Brooks
- Department of Surgery, Role 2 (Enhanced) Medical Treatment Facility, UK Medical Group, Camp Bastion, Operation HERRICK, Afghanistan.
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Arora S, Kassab E, Davies S, Cox C, Midwinter M, Nadine M, Mahoney P, Sevdalis N. Large-scale, simulation-based training in nontechnical skills: Efficacy of the British Army's HospEx simulation exercise. J Am Coll Surg 2009. [DOI: 10.1016/j.jamcollsurg.2009.06.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stannard A, Brown K, Benson C, Hodgetts T, Clasper J, Midwinter M, Tai N. Vascular trauma: survivability and surgical outcome in a deployed military trauma system. Br J Surg 2009. [DOI: 10.1002/bjs.6507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- A Stannard
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - K Brown
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - C Benson
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - T Hodgetts
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - J Clasper
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - M Midwinter
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
| | - N Tai
- Academic Department of Military Surgery and Trauma, Academic Department of Emergency Medicine, Royal Centre for Defence Medicine
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