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Summary

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

Over the past 12 years, the United Kingdom Defence Medical Services have evolved an integrated ‘damage control resuscitation – damage control surgery’ sequence for the management of patients sustaining complex injuries. During 2009, over 3200 units of blood products were administered as massive transfusions to severely injured UK personnel. An important part of the approach to traumatic bleeding is the early, empirical use of predefined ratios of blood and clotting products. As soon as control of bleeding is achieved, current practice is to switch towards a tailored transfusion, based on clinical and laboratory assessments, including point-of-care coagulation testing. A key goal is to provide resuscitation seamlessly throughout surgery, so that patients leave the operating room with their normal physiology restored. This article outlines the current management of haemorrhage and coagulation employed in Afghanistan from the point of wounding to transfer back to the National Health Service.

For over 12 years, the United Kingdom Defence Medical Services (UK-DMS) have been involved in continuous operations in either Afghanistan or Iraq. This prolonged and busy operational period has allowed the refinement of techniques in the management of patients with serious injuries [1]. This paper outlines how the UK-DMS deals with the management of casualties with traumatic bleeding, including some of the practical aspects required by the trauma team. Successful management requires a blend of logistics, leadership and clinical decision-making.

During 2009, over 3200 units of blood products were administered as massive transfusions to severely injured UK personnel [2]. This amount of blood product equates to that of a large district general hospital, with a greater demand for universal components, such as group O RhD-negative packed red blood cells (PRCBs) and group AB fresh frozen plasma (FFP) [3]. All UK personnel who meet the criteria to activate the trauma team (Table 1) have their details collated in the Joint Theatre Trauma Registry [4]. A search of this database from 1 April 2008 to 30 March 2010 identified that 27% of casualties required a blood transfusion with 11% receiving 10 or more units of PRBCs [3]. A review of UK military personnel who received a massive transfusion in Afghanistan during 2009 showed that the mean blood component use per patient was approximately 22 units and that 12% received more than 100 units [2]. The UK military base the management of these casualties around damage control resuscitation (DCR). The elements of DCR have been described as permissive hypotension, haemostatic resuscitation and damage control surgery (DCS) [5] but this is now evolving into an integrated ‘damage control resuscitation – damage control surgery’ sequence [6] demanding clear clinical leadership and logistic support. Permissive hypotension is when fluid administration is restricted, whilst accepting a limited period of suboptimum end-organ perfusion until haemorrhage is controlled [5]. Haemostatic resuscitation will be described below.

Table 1. Military trauma team activation criteria (adapted from Clinical Guidelines for Operations, with permission [16]).
  1. IED, improvised explosives device; BSA, body surface area.

Mechanism of injury or history
Penetrating traumaGunshot or shrapnel wound Blast injury (landmine/IED/grenade) Stab wound
Blunt traumaMotor vehicle crash with ejection Motorcyclist or pedestrian hit by vehicle > 30 km.h−1 Fall > 5 m Fatality in the same vehicle Entrapment and/or crush injury Inter-hospital trauma transfer meeting activation criteria
Anatomy and physiology of casualty
AnatomyInjury to two or more body regions Fracture of two or more long bones Spinal cord injury Amputation of a limb Penetrating injury to head, neck, torso, or proximal limb Burns > 15% BSA in adults or > 10% in children or airway burns Airway obstruction
PhysiologySystolic blood pressure < 90 mmHg or pulse > 120 beats.min−1 (adults) Respiratory rate < 10 or > 30 per minute (adults) SpO2 < 90% Depressed level of consciousness or fitting Deterioration in the emergency department Age > 70 years Pregnancy > 24 weeks with torso injury

Damage control surgery requires the completeness of initial surgical repair to be sacrificed in order to curtail initial operating times and mitigate the combined physiological insults of trauma and surgery [7].

All UK-DMS anaesthetists work embedded in NHS hospitals and then deploy for 2–3 months approximately every 12–18 months. On deployment, one crucial difference from routine NHS practice is the casemix, which is predominantly due to blast (54%) and high velocity gunshot wounds (30%) [8]. These usually occur in young, fit males who have often sustained high and multiple traumatic amputations. Over 50% of casualties have an injury severity score between 36 and 75 [8]. The prevailing enemy weapon in the current Afghanistan conflict is the improvised explosive device (IED) accounting for 60% of casualties in 2009–2010 [1]. There are also many soldiers injured by ballistics. UK civilian trauma patients are also often young men, but suffering blunt trauma from motor vehicle collision [9].

The trauma team

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

In the deployed setting, human factors are vital to the functioning of the complex trauma team [10] who may have to work in an environment which is hot, dusty and noisy.

The complex trauma team currently deployed at Camp Bastion is a large multi disciplinary, international team outlined in Table 2. This grouping allows consultant delivered care from the ‘front door’, ensuring experienced, early, robust decision-making. Many people have now deployed several times and already have predefined mental models of how to deal with particular cases. An intensive pre-deployment training programme, often run by those who have just returned from the front line, allows individuals to undertake a short induction phase and then ‘hit the ground running’, with many being involved in caring for major trauma within their first 48 h in Afghanistan.

Table 2. The Deployed Complex Trauma Team (consultants are in bold)
  1. ED, emergency department; SpR, specialist registrar; ODP, operating department practitioner.

Team Leader (emergency consultant)
Primary Survey Doctor (ED SpR)
Anaesthetist 1 (airway)
Anaesthetist 2 (central venous access)
ODP
Scribe (trauma nurse co-ordinator)
ED Nurse 1 (i.v. access and first blood sample)
ED Nurse 2 (drugs)
ED Nurse 3 (rapid infuser)
ED Nurse 4 (rapid infuser)
Runner
Orthopaedic Surgeon
General Surgeon
Plastic Surgeon
Radiologist
Radiographer
Deployed Medical Director
Laboratory Technician
Theatre Manager
Ward Master
Interpreter
Regimental Sgt Major
Padre

Patient journey

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

Figure 1 describes the initial patient journey from point of wounding to the operating theatre in Camp Bastion. The most common cause of death on the battlefield is from major bleeding and so the military have undertaken a paradigm change from the traditional ‘airway, breathing, circulation (ABC)’ to ‘< C> ABC’ where < C> stands for catastrophic haemorrhage [11]. All soldiers are now trained in the application of the combat application tourniquet (C-A-T®) (Composite Resources, Rock Hill, SC, USA) both to themselves and their colleagues and in the use of haemostatic dressings [11]. All casualties injured by an IED are assumed to have a pelvic fracture and so fitted with a pelvic binder [1].

image

Figure 1.  Trauma patient pathway. The acronym ‘AT-MIST’ is described in Table 3. Computerised tomography (CT) refers to transfer to the radiology department for a CT scan.

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From the point of wounding, a radio signal is sent to the operations room detailing the patient’s location and injuries sustained. Knowing the tactical situation on the ground, a helicopter can then be tasked to collect the casualty and if this is a seriously injured patient then usually the Medical Emergency Response Team (MERT) will respond onboard a Chinook CH47 helicopter. The MERT has an anaesthetist or emergency physician onboard so that the hospital is effectively ‘projected out to the desert’, allowing haemostatic resuscitation to commence immediately and rapid sequence induction of anaesthesia if required.

Acute traumatic coagulopathy

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

The lethal triad of coagulopathy, acidosis and hypothermia has been recognised for some time [12]. More recently, it has become apparent that coagulopathy may also develop directly following trauma before a patient reaches hospital or receives large volumes of fluid resuscitation. This acute traumatic coagulopathy (ATC) was first described in trauma patients in 2003 by Brohi et al., who found that 24% of trauma patients presenting to a London trauma centre had established coagulopathy on arrival in the emergency department [13]. Subsequent work has confirmed ATC as an independent predictor of mortality [13, 14]. Tissue hypoxia has been implicated as the key driver of this process, resulting in the release of multiple humoral factors to oppose coagulation and promote fibrinolysis [13].

Prioritising the maintenance of tissue perfusion has been instrumental in developing the UK military approach to DCR-DCS with the emphasis placed on early haemostasis, control of coagulopathy maintenance of tissue oxygenation [7, 15] and limited essential surgical intervention. These concepts are now firmly established within UK military doctrine [16].

Trauma team activation

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

The criteria for activation of the trauma team have been set out above in Table 1. The team is summoned via the hospital bleep system 20 min before the casualty’s arrival. This allows a period of preparation for equipment checks and contingency planning. A runner is sent to collect a ‘shock pack box’ from the transfusion laboratory containing 2 units of PRBC and 2 units of FFP as the helicopter lands. This initial emergency blood is less than 14 days old as older blood may be associated with increased transfusion complications [17].

Haemostatic resuscitation

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

An important part of the UK-DMS approach to traumatic bleeding is the early, empirical use of predefined ratios of blood and clotting products for anticipated massive transfusion. Early evidence for higher ratios of FFP to RBC in military trauma came from a retrospective study of patients receiving massive transfusion at a US Combat Support Hospital in Iraq from 2003 to 2005 [18]. After correcting for other factors, the authors found that higher ratios of FFP:PRBC were independently associated with survival and that the best results were seen in a group receiving a median FFP:PRBC ratio of 1:1.4.

A subsequent study from 16 US trauma centres between 2005 and 2006 reported similar findings, with retrospective analysis showing improved survival with ratios of FFP:PRBC greater than 1:2 [19]. These results, and the biologically plausible concept of treating haemorrhage with component ratios approaching those of whole blood, have led to the development of guidelines recommending early empirical use of FFP in traumatic bleeding [20]. Introducing massive transfusion protocols with increased ratios of FFP:PRBC has been shown to improve survival when compared with historical controls [21], but these findings are yet to be confirmed in a randomised trial.

The current UK-DMS massive transfusion protocol recognises the limitations of this evidence and makes recommendations based on the available literature and pragmaticism [22]. This includes an initial 1:1 ratio of FFP:PRBC, followed by recommendations for the use of platelets and cryoprecipitate [3] (Fig. 2). As soon as control of bleeding is achieved, our current practice is to switch towards tailored transfusion, based on clinical and laboratory assessments, including point-of-care coagulation testing with ROTEM® (Pentapharm, Munich, Germany) [23]. Typical ROTEM traces are shown in Fig. 3.

image

Figure 2.  Massive transfusion diagram. Reproduced from [3] with permission of the Editor of The Journal of the Royal Army Medical Corps. RCC, packed red blood cells; FFP, fresh frozen plasma; ATD, adult therapeutic dose; ABG, arterial blood gases; Hct, haematocrit; Plt, platelet concentration.

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image

Figure 3.  Typical ROTEM traces. (a) platelet deficiency: (i) EXTEM trace, (ii) FIBTEM trace: the EXTEM Maximum Clot Firmness (MCF) is very low whilst FIBTEM MCF is in the normal range. Therefore the loss in maximum clot firmness (MCF) EXTEM is not attributable to fibrinogen, but platelets. (b) Fibrinogen deficiency: (i) EXTEM trace, (ii) FIBTEM trace MCF can be explained by low fibrinogen. (c) Hyperfibrinolysis, EXTEM trace: EXTEM trace shows clot forming well; however, clot strength disappears to zero by 30 min, indicating hyperfibrinolysis. The UK Defence Medical Services use the EXTEM and FIBTEM traces.

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An audit of outcomes for 59 UK military patients receiving massive transfusion in Afghanistan in 2009 would seem to support this approach, with an 86% overall rate of survival and five of seven patients who received transfusions over of 100 donor units subsequently surviving to hospital discharge [2]. Some authors have questioned the evidence for the highest ratios of FFP:PRBC, and have suggested that the optimal empirical ratio may be closer to 1:2 [24]. Although 1:1 transfusion of FFP:PRBC reduced coagulopathy in Kashuk et al.’s retrospective study of 133 patients from a US trauma centre, a ratio of 1:2 appeared to offer the highest rates of survival. Again, these results are yet to be confirmed in a randomised trial, but it is important to remember that transfusion can cause harm as well as clinical benefit.

Other recent research into the management of traumatic bleeding has also impacted upon the UK-DMS approach to transfusion. The CRASH-2 [25] and MATTERS [26] studies demonstrated a survival benefit with tranexamic acid in civilian and military trauma, and this is now given routinely as part of the UK-DMS massive transfusion protocol. Although early case series of recombinant human activated factor VII (rFVIIa) appeared promising, a subsequent randomised control trial [27] was abandoned due to lack of apparent benefit and rFVIIa is now used only rarely by the UK-DMS in cases of refractory coagulopathic bleeding. Occasionally, fresh whole blood from prescreened in-theatre donors in Afghanistan has been used in Bastion Role 3 Hospital, for cases of refractory coagulopathy and ongoing bleeding. Although anecdotal evidence suggests that fresh whole blood may be a highly effective treatment of coagulopathic bleeding, caution must be exercised due to the potential for life-threatening transfusion reactions [28].

The trauma handover

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

The prehospital doctor hands over the casualty to the complex trauma team in exactly the same way every time. A handover using the AT-MIST acronym is demonstrated in Table 3. This process is practised in pre-deployment training and ensures that the team can switch on to the crucial information in complete silence. This handover might trigger a protocol where the patient bypasses the trauma bay and is taken immediately to the operating theatre (Fig. 4) [29]. This demands an early and robust decision from the team leader in conjunction with his surgical and anaesthetic team.

Table 3. Example of a handover from the Medical Emergency Response Team (MERT) pre-hospital doctor. The AT-MIST acronym is used and defined in the table.
  1. FAST, FAST1® Intraosseous Infusion System (PYNG Medical, BC, Canada). HR, heart rate; BP, blood pressure; MERT, medical emergency response team; PRBC, packed red blood cells; FFP, fresh frozen plasma.

Age25 years
Time of injury17:00
Mechanism of injuryDismounted improvised explosive device
Injuries sustainedBilateral through-knee amputation Left through-humeral amputation Injury to right arm
Signs and symptomsIntubated – SaO2 98%, FIO2 100%, Resp rate 12, HR 140, BP 85/40, sedated
Treatment givenTourniquets applied and morphine given by medics at the incident Care delivered by MERT: FAST and humeral intraosseous access Rapid sequence induction  Ketamine 100 mg  Suxamethonium 200 mg  Fentanyl 200 μg and further 50 mg ketamine  Tranexamic acid 1 g  2 units PRBC  2 units FFP
image

Figure 4.  Trauma patient pathway showing the decision on whether to bypass the emergency department and transfer the patient directly to the operating theatre.

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Primary survey and damage control resuscitation

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

By having a designated team leader, the primary survey and other subsequent tasks can occur in a ‘horizontal fashion’ [30]. The team leader is responsible for the co-ordination of the team’s activity and maintaining situational awareness. He/she is also responsible for crowd control and communication amongst the team. Senior, robust decision-making is required throughout and this includes whether to load the rapid infuser with blood products (from the shock pack) or return them to the laboratory, move immediately to theatre or to proceed to the CT scan (Fig. 5). During this process, the rest of the team must display exceptional followership. Typical initial actions required are summarised in Table 4.

image

Figure 5.  Trauma patient pathway showing the decision on whether to go for computerised tomography scan or to theatre. This decision is made after a period of approximately 15 min.

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Table 4. Typical initial actions of the complex trauma team.
  1. *This is typically a 9-Fr (10-cm) MACTM two-lumen central venous line inserted into the right subclavian vein.

  2. iSTAT (Abbott Laboratories, Princeton, NJ, USA) is a portable blood gas machine. MERT, medical emergency response team; FBC, full blood count; ED, emergency department.

Primary survey <C> ABC
Cervical spine mobilisation (if not already performed)
Rapid sequence induction (if not delivered by MERT)
 Ketamine 1–2 mg.kg−1
 Suxamethonium 1–2 mg.kg−1
Insertion of a trauma line if indicated*
Blood samples for ROTEM, iSTAT†, FBC and group and save, clotting
Additional i.v. access
Focused assessment with sonography for trauma scan (FAST) (by consultant radiologist)
Connection of rapid infusion device
Chest and pelvic digital X-rays (reported by consultant radiologist and viewed by clinicians)
Antibiotics
Tetanus vaccination
Swapping C-A-T® for pneumatic tourniquets
Additional drugs
 Ketamine
 Fentanyl (up to 500 μg often given in ED)
 Neuromuscular blocking drug
 Tranexamic acid 1 g

The resuscitation of the severely injured trauma patient is a dynamic process and the physiology can change rapidly. The physiological data needed to assess and monitor the patient’s condition must be rapidly responsive and readily accessible to the managing clinical team [6]. Many laboratory-measured parameters require time to send, analyse and return data to the clinical area by which time the results are of historic interest only as the patient’s condition will have changed in the intervening interval. Point of care tests at, or close to, the patient in the treatment areas (emergency room, operating theatre or intensive care unit) minimise the time for the test result to be available to the clinicians.

What to monitor?

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

A driving principle of resuscitation of the severely injured trauma patient is restoration of adequate tissue perfusion and oxygenation in order to maintain cellular homeostasis. Tissue hypoperfusion may drive the ATC as described above, shown by an ongoing coagulopathy in spite of seemingly adequate product replacement. Routine anaesthetic practice includes measuring blood pressure, heart rate, respiratory rate, capillary refill time and urine output. These physical signs poorly reflect the rate and degree of haemorrhage in the fit young trauma population whose physiological reserve can maintains apparently normal values until there is significant intravascular blood volume loss [31, 32].

The use of viscoelastic measurement techniques such as TEG® Thromboelastopgraphy (Haemoscope Corp.Niles, IL, USA) and ROTEM are increasing in trauma. These allow for a real-time dynamic interpretation of whole blood coagulation, with both cellular and factor components, and provide a quicker result than sending a standard clotting screen to the laboratory. Time is crucial in an evolving clinical situation, and ROTEM has been shown to provide an effective, early assessment of clotting in under 15 min from drawing a blood sample [33, 34]. These methods not only give a rapid assessment of coagulation but also allow the critical relative contribution of functional platelets and clotting factors to be analysed and used to guide specific component replacement therapy.

Onward patient pathway

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

The majority of patients (although severely injured) have a CT scan [35] pre-operatively as it is only continued haemodynamic instability that warrants transfer directly to the operating theatre. Patients are transported to radiology anaesthetised, with their lungs ventilated, with active patient warming and with a rapid infusion device running. A whole body CT (with contrast) is performed and reported by a consultant radiologist, with the key surgeons in attendance, whilst the patient is being transferred off the scanning trolley and into the operating theatre. This allows early planning of the surgical procedure, discussion concerning the viability of limbs and radiological clearance of the cervical and thoracolumbar spine.

On arrival in the operating theatre, the team dynamics now change, with the lead anaesthetist taking over the role as team leader following a formal handover from the emergency physician. Before starting surgery, there is a surgical briefing with the plan and any anticipated problems along the lines of the World Health Organization (WHO) surgical checklist [36]. For a patient with multiple amputations, there might be two surgeons per injury zone. The make-up of a typical surgical team is shown in Table 5.

Table 5. Typical surgical team for a complex trauma patient (consultants are in bold).
  1. ODP, operating department practitioner; FBC, full blood count; ED, emergency department.

Anaesthetist 1
Anaesthetist 2
ODP 1 – (perform ROTEM, FBC and iSTAT every 30 min)
ODP 2
Orthopaedic surgeon 1
Orthopaedic surgeon 2
Orthopaedic surgeon 3
Orthopaedic surgeon 4
General surgery 1
General surgery 2
Plastic surgeon
Scrub nurse 1
Circulating nurse 2
Theatre manager
ED nurse 1 rapid infuser
ED nurse 2 rapid infuser
Runner
Deployed medical director
Laboratory manager
Trauma nurse coordinator

Whilst short initial operating times remain important, a key goal now is to provide resuscitation seamlessly throughout surgery, so that patients leave the operating room with their physiology restored. Practically, this means that decision-making on the extent of initial surgery is now a dynamic process, involving both anaesthetic and surgical teams, with continuous re-assessment of the patient’s physiological status requiring constant communication [37]. Typical measureable physiological endpoints include systolic blood pressure > 90 mmHg, heart rate < 120 beats.min−1, SaO2 > 95% and normothermia. Regular blood samples are taken for arterial blood gas, full blood count (FBC) and ROTEM and ideally pH should be > 7.25, base excess should be decreasing and ionised calcium should be > 1.0 mmol.l-1 Blood products are administered to correspond with the clinical picture and the ROTEM trace and ideally a platelet count of 50,000–100,000 × 109.l-1 is desirable.

In some cases, this team approach to DCR may allow more extensive initial surgery, permitting limb salvage where this would not previously have been possible. In other cases, the patient’s condition may dictate that surgery must be focused on minimising the physiological insult and prioritising rapid control of haemorrhage. Good communication and planning is of particular importance at crucial moments during DCR-DCS, particularly when releasing pneumatic tourniquets. This allows the anaesthetist time to prepare for potential reperfusion injury and ensure that the rapid infuser is ready to deal with any blood loss.

Care in the UK

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

Following the primary surgery, the patient is transferred to critical care and will then be transported by the Royal Air Force Critical Care Air Support Team (CCAST) to the Queen Elizabeth Hospital in Birmingham, where casualties are admitted within 24–36 h of injury. At this time, the extensive nature of most IED wounds means that the patient is still in a damage control phase and within 24 h, a significant systemic inflammatory response syndrome (SIRS) inevitably complicates this acute situation. This is characterised by sustained tachycardia and hyperpyrexia that can persist for weeks. Within 4 h of arrival, most CCAST patients will undergo surgery to further extend the damage control procedures carried out in Camp Bastion. For many patients, this will be only the ‘second look’ since their original resuscitative surgery. The anaesthetic management is determined by their physiology (Table 6) [38].

Table 6. Anaesthetic principles for Critical Care Air Support Team patients during ‘first look’ at the Queen Elizabeth Hospital, Birmingham, UK.
  1. ATC, acute traumatic coagulopathy; DCR, damage control resuscitation; SIRS, systemic inflammatory response syndrome.

Damage control principles continue
Anaesthesia aims to maintain tissue perfusion and prevent ATC
Haemostatic resuscitation as per DCR principles
Hypotension from blood loss requires blood replacement not inotropes
Inotropes may be needed in the presence of ongoing SIRS
Blood loss requires blood and blood products not crystalloid
Designated transfusion line and rapid fluid infuser essential
Attention to patient warming (including warm theatre, warmed i.v. fluids and active patient warming with mattress and forced air convection)
Management of biochemistry with particular emphasis on K+ and Ca2+
Frequent point-of-care monitoring including arterial blood gases (for lactate and base excess) and thromboelastography to assess coagulation and targeted use of blood products
Bastion resuscitative trauma lines are changed
Frequent communication with surgical/scrub teams to update on the patient’s physiology

Ongoing critical care is aimed at supportive treatment for the SIRS and repeated visits to the operating theatre for further surgery to the evolving wounds [39]. Operative planning is punctuated by the need to exclude or treat sepsis by clinical examination, investigative radiology and emergent surgery. Following discharge from critical care, the patient progresses into the restorative part of their treatment where staged surgical procedures are often required.

Regional analgesia

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

Regional analgesia has a substantial profile in this patient group including assisting weaning from ventilation and subsequent tracheal extubation in critical care. Continuous peripheral nerve block catheters (typically supraclavicular, femoral and popliteal) may be in situ for a week or more. Careful consideration is given to ensure that guidelines in respect of concurrent thromboprophylaxis are respected [40].

The future

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

The UK-DMS have been very successful in the initial resuscitation, anaesthesia and surgery for these complex trauma patients but weapon systems and injury patterns change with different conflicts. Current Defence Medical Services research priorities include tailoring resuscitation to individual patient needs, developing transfusion capability without the need for frozen [3] or short shelf-life products and further developing trauma team training for complex decision-making.

Summary

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References

This article outlines the processes and logistical issues faced by the UK-DMS in managing haemorrhage and coagulation in severely injured casualties. The initial actions of the trauma team have been described with a focus on the principles of DCR-DCS, the predetermined ratio of blood and blood products and the early administration of tranexamic acid. The use of near-patient testing for coagulation and subsequent patient transfer from Bastion to the UK are also described. An anaesthetic trauma overview is summarised in Table 7.

Table 7. Trauma anaesthesia overview (adapted from Tarmey N, Park C. Trauma Anaesthesia Overview. Clinical Guidelines for Operations 2012).
  1. ODP, operating department practitioner; RSI, rapid sequence induction of anaesthesia; IPPV, intermittent positive pressure ventilation; PEEP, positive end-expiratory pressure; OR, operating room; CT, computerised tomography scan; ED, emergency department; MTP, massive transfusion protocol; ICU, intensive care unit; DMD, deployed medical director; CCAST, critical care air support team.

Before casualty arrives
 Assess pre-hospital informationa. Number and severity of casualties b. Information using AT-MIST acronym c. Airway at risk/already secured d. Requirement for massive transfusion
 Prepare anaesthetic teama. Briefing ODP(s) b. Checking availability of second anaesthetist c. Determining need to split anaesthetic team between multiple casualties
 Check anaesthetic equipmenta. Airway equipment and ventilator. Anaesthetic drugs. Large bore central access
Initial resuscitation in emergency department
 Remember team working and two-way communication with trauma team at every stage. Keep trauma team leader updated with casualty’s physiological status
 Priorities includea. Airway. Assess and treat, with RSI if indicated b. Breathing. In severe hypovolaemic shock, aim to minimise intrathoracic pressure during IPPV with low resp rate (e.g. 6.min−1) and zero PEEP c. Circulation. Gain large bore central access if indicated d. Analgesia. Manage acute pain in accordance with acute pain guideline e. Anaesthesia. Maintain anaesthesia with i.v. agent ready for transfer to OR/CT
 Plan for next stage of carea. Provide guidance to team leader on physiology and anaesthetic issues to decide:   i. Immediate surgery or CT first?   ii. If surgery, which body cavity first?   iii. RSI before transfer to CT/OR?
Transfer to and from CT scanner
 Anaesthetist has primary responsibility for safe and timely transfer to and from CT
 Check before transfera. Tourniquets tight and effective b. Airway secure c. Working ventilator and sufficient oxygen supply d. Venous access working and secure e. Sufficient blood products available f. Rapid infuser and ED transfusion team able to move with patient g. Effective analgesia, sedation and neuromuscular blockade h. Protection from hypothermia
 Plan for next stage of care. When CT in progress, confirm readiness and plans for next destination (e.g. OR)
Operating room
 Positioning on arrivala. The default patient position is supine with both arms abducted on boards b. Apply forced air warmer and commence warming as soon as possible c. Don’t attempt arterial line placement until a strong radial pulse is palpable
 Handover from ED team leadera. Handover does not begin until the patient is properly positioned and established on the anaesthetic machine b. Information handed over should include:  i. List of injuries found  ii. Treatment given so far  iii. Transfusion running totals  iv. Outstanding issues  v. Provisional plan
 Maintenance of anaesthesiaa. During hypovolaemic shock, titrate fentanyl and volatile anaesthetic carefully to physiology b. When bleeding is controlled, carefully titrate in further analgesia (e.g. fentanyl up to 15 μg.kg−1) to improve analgesia, prevent excessive vasoconstriction and permit further volume resuscitation with blood and blood products
 Haemostatic resuscitationa. Before surgical control of haemorrhage:   i. Keep ED transfusion team in OR   ii. Maintain circulating volume with empirical blood and products according  to MTP b. After effective surgical control of haemorrhage:   i. Take handover of transfusion from ED team   ii. Beware overtransfusion and hypervolaemia   iii. Move to tailored transfusion, guided by physiology, ROTEM and lab tests c. Remember:   i. Don’t treat hypovolaemic shock with vasopressors   ii. Don’t replace acute blood loss with crystalloid/colloid   iii. Warm aggressively to achieve normothermia   iv. Check blood gas and treat hyperkalaemia/hypocalcaemia   v. Use ROTEM to guide clotting product transfusion
 Communication and team workinga. Maintain effective two-way communication with Surgery, Radiology, ICU and DMD b. Ensure surgeons aware of:   i. current physiological status   ii. coagulopathy on ROTEM/laboratory tests   iii. plans for onward transfer, time constraints and resource limitations c. Ensure passage of information from surgeons, especially:   i. tourniquets and vascular clamps being released or applied   ii. difficult surgical control of haemorrhage   iii. surgical evidence of coagulopathy d. Check CT report (verbal or written) for:   i. radiological cervical spine clearance   ii. list of injuries found e. Remember DMD for:   i. activation of emergency donor panel   ii. referral for extrahospital transfer   iii. difficult futility decisions   iv. resolution of areas of disagreement
 Preparation for postoperative carea. Agree next destination (CT/ICU/CCAST) b. Ensure effective postoperative analgesia (systemic ± regional) c. Handover to next team (in theatre if possible)

References

  1. Top of page
  2. Summary
  3. The trauma team
  4. Patient journey
  5. Acute traumatic coagulopathy
  6. Trauma team activation
  7. Haemostatic resuscitation
  8. The trauma handover
  9. Primary survey and damage control resuscitation
  10. What to monitor?
  11. Onward patient pathway
  12. Care in the UK
  13. Regional analgesia
  14. The future
  15. Summary
  16. Competing interests
  17. References
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