Volume 03 / Issue 04 / December 2015
boa.ac.uk
Page 26
JTO Features
Lessons of War Colonel Paul Parker L/RAMC Co-authors: Surg Capt Sarah Stapley RN, Professor Sir Keith Porter
“That men do not learn the lessons of history is the greatest lesson that history has to teach”*
Fifteen years of conflict has produced a burden of over 2,500 trauma-injured casualties for the United Kingdom. Five thousand have suffered disease and nonbattle injury related illness (DNBI). These numbers are small in comparison to the World Wars of the 20th century (0.5% of the 1.6 million UK casualties of the Great War). Yet our casualty survivorship after the devastating ‘unsurvivable’ injuries produced by blast and ballistic trauma has significantly improved - why?
Colonel Paul Parker L/RAMC
94% of combat deaths occur in the first 30 minutes after wounding, mainly from exsanguination. The ability to stem even a fraction of this blood loss after injury is vital and all troops now carry tourniquets. Our Combat Medical Technicians (CMTs) are trained in Battlefield Advanced Trauma Life Support (BATLS), a version of Advanced Trauma Life Support (ATLS®) with its ‘ABC’ approach. BATLS recognises that in military injury - if the airway and breathing are dealt with before major haemorrhage control (the ‘big <C>’), the patient will exsanguinate. BATLS therefore teaches <C>ABC. Our CMTs apply tourniquets (after returning fire), insert surgical airways, decompress pneumothoraces, perform intra-osseous infusions and apply pelvic binders - 40% of blast-related, bilateral above knee amputations have a concomitant pelvic fracture.
Management of junctional trauma remains problematic. These are injuries occurring at the boundary areas of anatomically distinct zones such as the root of an extremity and its adjacent torso cavity. These very proximal injuries often have a perineal component and are not amenable to standard limb tourniquets. If this bleeding had been controlled in some way in the field, a number could have been saved. These were identified by our preventable mortality review process. Prehospital haemorrhage control thus remains challenging: Research into abdominal tourniquets, junctional tourniquets and abdominal foams continues to show promise. Helicopter-borne Medical Emergency Response Teams (MERT) arrive within an hour of injury. Warmed blood and plasma are transfused, definitive airway control is undertaken, tranexamic acid (TXA) and antibiotics are given. In Afghanistan between 2008 and 2011, 417 casualties received a massive transfusion. Overall survival increased from 76% to 84%. These results have now influenced UK air ambulance service provision; most carry pelvic binders and several now carry blood and plasma. Yet we first took citrated whole blood forward at the 3rd Battle of Ypres in 1917 and transfused it in the trenches1. This early military use of tranexamic acid has been shown
to reduce mortality following trauma2. It competitively inhibits the activation of plasminogen to plasmin. Work by the MATTERS group3 demonstrated a significant decrease in mortality associated with its early use in haemorrhage. We give it in the pre-hospital environment, where we also advocated the early use of fibrinogen and cryoprecipitate. Yet this was the standard surgical practice in the UK campaign in the Dhofar in 1972, where we also liberally used the precursor of TXA, ε-aminocaproic acid (ε-AHX)4. In-flight the helicopter team snap-brief the Emergency Department (ED) about casualty numbers and injuries. On arrival, a rapid ‘AT-MIST’ report is given for each casualty: Age, Time of injury, Mechanism of injury, Injuries sustained, vital Signs and Treatment given. Patients immediately receive horizontal resuscitation; the ED consultant directs the ‘Orchestra’ with immediate input from specialty consultants in T&O, General Surgery and Plastic Surgery. An anaesthetic consultant takes the lead on the airway. Damage control resuscitation algorithms allow three choices; the operating theatre, the CT scanner or the ITU. Prevarication kills and the team will all have trained together in the UK prior to deployment. Civilian best practices are rapidly adopted: We do not fear change. Karim Brohi coined the term ACOTS - acute coagulopathy of trauma, noting however that it had been postulated in an original paper from the Vietnam War in 19695. This syndrome increases transfusion requirements, organ dysfunction, length of stay in ITU, morbidity and mortality. Our current military response6 is