OBJECTIVES:Management of blunt splenic injury (BSI) in battlefield casualties is controversial. Splenectomy is the traditional treatment, as setting the conditions for selective non-operative management (SNOM) is difficult in the operational environment. On mature operations, it may be feasible to adopt a more conservative approach and manage the patient according to civilian protocols. The aim of this study was to document the contemporary practice of deployed military surgeons when dealing with BSI and to compare this against a matched cohort of civilian BSI patients.METHOD:The Joint Theatre Trauma Registry held at the Royal Centre for Defence Medicine, Birmingham, was thoroughly examined to yield patients with BSI. The study encompassed a 55-month period ending September 2009. Data abstracted included patient demographics, injury epidemiology, grade of splenic injury, treatment and outcome. These data were compared with a registry database from a UK civilian major trauma centre.RESULT:Of 1516 military trauma patients, 16 (1%) had a splenic injury, of which five were excluded either because of fatalities due to overwhelming injury or penetrating trauma. The remaining 11 had a blunt component. Median (IQR) injury severity score (ISS) was 17 (15-21). Nine underwent a splenectomy with median (IQR) ISS of 17 (12-18). Of this group, organ injury grades were documented in 10 patients (four Grade V injuries, three Grade IV and three Grade II). All patients survived surgery. There were no complications in survivors as a result of splenic conservation in the military group. Data from the civilian major trauma centre database showed 160 (2%) patients sustained a splenic injury, of which 131 (82%) had a blunt mechanism, 43/160 (27%) and 9/160 (6%) patients underwent splenectomy and angio-embolisation, respectively.CONCLUSIONS:Patients with BSI, an uncommon finding in combat casualties, are occasionally selected for conservative management, contrary to previous military surgical paradigms but in keeping with the civilian shift to SNOM. Guidelines to clarify the place of SNOM are required to assist surgical decision making on deployed operations.

Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to "get it right, first time and every time" when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.

Background: Fluid resuscitation of trauma victims currently differs, depending on whether the Advanced Trauma Life Support (ATLS), Prehospital Trauma Life Support (PHTLS) or Battlefield Advanced Trauma Life Support (BATLS) algorithm is utilised. Resuscitation protocol depends on the situation of the patient before definitive surgical control of the haemorrhage can be achieved, that is, in the prehospital phase (the urban, rural or battlefield setting) or in the emergency room. The principle difference is between hypotensive (PHTLS and BATLS, in the prehospital phase) and normotensive (ATLS, in the emergency room) resuscitation. The aim of this review was to determine if there is sufficient evidence to consider altering the ATLS resuscitation algorithm to a hypotensive model prior to definitive surgical control of haemorrhage. Method: A literature review was conducted of the experimental and clinical evidence for hypotensive resuscitation. Results: Uncontrolled haemorrhage models are too severe. They do not realistically mimic — And their results cannot easily be extrapolated into — Clinical scenarios. One important clinical trial, inspired by these experimental models, has rightly influenced resuscitation of shocked prehospital patients towards a ‘scoop and run’ approach and permissive hypotension but it is specific to patients with penetrating trauma alone. Conclusion: There is insufficient evidence to alter the current ATLS algorithm in the emergency room in favour of hypotensive resuscitation. The future of resuscitation is considered.

It is possible that recombinant activated factor VII (rFVIIa) could revolutionise the medical and surgical management of haemorrhage following trauma and surgery due to its ease of administration and mechanism of action. This article reviews the evidence for the use of rFVIIa as a pro-coagulant, its mechanism of action, safety and recent research into its use in blunt and penetrating trauma and haemorrhage. The potential role of rFVIIa, both in the pre-hospital environment and in the emergency room or operating theatre, is discussed. Administration of rFVIIa at the roadside, on the battlefield or in a trauma centre may have significant potential implications, especially for the paramedical and surgical teams and even for strategic planners. Finally, the areas where further research is needed to provide objective evidence of its efficacy are elaborated. The potential thromboembolic complications of systemic administration of rFVIIa need to be carefully monitored but the high cost of this drug is likely to be the limiting factor in its widespread use.

The crystalloid – colloid debate regarding the most effective intravenous fluid for resuscitation from haemorrhagic shock has been raging over the past 60 years, and still continues without a satisfactory resolution (1). Crystalloid solutions are essentially isotonic salt solutions (270-310 mOsm/L) and have been in use since the 1800s but their use became widespread during World War I. Normal saline or Ringer’s lactate solutions currently predominate over all other fluids for intravenous volume support. Colloids, on the other hand, are large macromolecules that remain in the circulation and exert a colloid osmotic or oncotic pressure due to their molecular weight. Their size also determines how long they remain osmotically active in the circulation. Albumen, separated from plasma by Cohn in 1942, was introduced as a colloid and was used extensively in World War II. Today macromolecular solutions of albumin, dextran, hetastarch and gelatin are used, with preferences determined more by cost and marketing than for clinical indications or efficacy. Colloid solutions are normally 3-10% macromolecules in an isotonic crystalloid to prevent haemolysis. Most colloid solutions have a colloid osmotic (oncotic) pressure similar to plasma (20-30 mmHg). A 6% solution of albumin is isooncotic and expands plasma volume by 80% of infused volume; 6% hetastarch is slightly hyperoncotic and 6% dextran 70 is markedly hyperoncotic (60-75 mmHg) and expands plasma volume by 20-50% more than the infused volume (2-4). The ensuing debate revolved around the physiological response to hypovolaemia. The advantage of colloids is that they are more efficient plasma expanders and cause less oedema in hypovolaemic shock, compared to crystalloids that distribute rapidly throughout the entire extracellular space with no preference for the vascular compartment. Since the extracellular space is 4-5 times larger than the plasma volume, only 10-20% of infused crystalloid remains in the circulation, requiring at least three units of crystalloid to replace each unit of shed blood – the “3:1 rule” (2,5). The two major disadvantages of colloids are cost and their potential complications (Table 1). While blood and blood products have remained the mainstays of massive transfusions, they are only available in the hospital environment and there is always the risk of infection and immunological reactions. Blood substitutes, such as haemoglobin solutions, liposome encapsulated haemoglobins and perfluorocarbons are still in development and remain some years away from routine use. Thus, in recent years, attention has turned to the potential benefits of other fluids for resuscitation, in particular, hypertonic saline solutions, alone or combined with a colloid for the treatment of haemorrhagic shock. At the same time, research has questioned the traditional management of haemorrhagic shock with aggressive fluid resuscitation (based on the Wiggers (6) and Shires (7) models of controlled haemorrhage) as set out in the Advanced Trauma Life Support manual (8). The introduction of an animal model of uncontrolled haemorrhage that more closely mimics the pre-hospital clinical scenario favours hypotensive resuscitation regimen prior to the definitive control of haemorrhage in the operating theatre (9). The concept of hypotensive resuscitation was subsequently examined in Bickell’s seminal clinical trial where delayed fluid resuscitation in hypotensive patients with penetrating torso injuries was found to improve outcome (10) This review will concentrate on the resuscitation of haemorrhagic shock with one such fluid, a combination of hypertonic saline (7.5%) and the hyperoncotic colloid dextran 70 (6%), called hypertonic saline dextran or HSD. This review aims to

One of the primary goals of the military scientist addressing the prevention of trauma, is to develop new concepts for attenuating energy transfer to the body from either penetrating, non-penetrating or blast impacts. Personal armours have deficiencies, both in the body coverage achievable without degrading military performance, and in the inherent ability of the materials to attenuate high energy impacts, particularly from high energy bullets and anti-personnel fragments. Protection of the head from these types of projectiles is a difficult task – personal armour materials are available to stop very high energy projectiles (even up to 12.7 mm bullets), but the weight of these technologies precludes them from use on helmets. It is inevitable, therefore, that practical military helmets cannot stop high energy penetrating projectile impacts; they are remarkably effective however, against the principal threat in war – low energy antipersonnel fragments. The development of practical helmets capable of stopping high energy bullets is constrained by the limitations of currently available materials. Penetrating wounds to the brain continue to be a feature of military conflict. There are two types of traumatic brain injury (TBI), blunt and penetrating. The mechanisms are very different. Blunt injury involves the coupling of linear and rotational acceleration and deceleration forces into the brain tissue. The resultant impacts of brain tissue within the skull, and the tortional forces in particular, lead to primary brain injury, complicated by secondary damage as a result of subsequent pathological processes. Penetrating brain injury (PBI) involves local forces and stress waves that radiate out from the injury track, especially in the case of high available energy bullet and fragment injury. What is the status of research into the medical management of brain trauma – penetrating and non-penetrating, civil and military? Experimental research to enhance management (and indeed protection) requires models – tools to develop principles.There are several different models of TBI, both penetrating and blunt; using techniques such as fluid percussion, cortical contusion, single artery occlusion, forebrain ischaemia and stab wounds, but few address the issues relevant to PBI in the military environment. The established experimental models of TBI understandably focus on severe blunt head injury; this is much more frequent than PBI in a civilian setting. Furthermore, PBI in a civilian environment is different both in the characteristics of injury and outcome to that seen on the battlefield when helmets are frequently worn. Militarily relevant PBI is an underinvestigated field and receives little attention in research laboratories. Indeed, previous models of PBI involving the use of projectiles fired into the brain have succumbed to political pressure following animal rights activism (1). The aims of this article are to: • examine the nature and extent of the problem of PBI in the military environment; • identify the key clinical issues wherein the military scientist may profitably focus research to result in more effective treatment of the brain-injured casualty, particularly in the early stages of the injury; • provide a clinical basis for new approaches to the protection of the head from high energy penetrating projectiles; specifically, recognising the current inability to stop high energy projectiles and the merit in transforming a high energy transfer penetrating wound to the brain into a low energy transfer wound using lightweight materials.

It is possible that recombinant activated factor VII (rFVIIa) could revolutionize the medical and surgical management of haemorrhage following trauma due to its ease of administration and mechanism of action. This article reviews the evidence for the use of rFVIIa as a procoagulant, its mechanism of action and its potential role in blunt and penetrating trauma. The role of rFVIIa in the emergency room or operating theatre and in the pre-hospital environment is discussed. Administration of rFVIIa `at the roadside’ may have signifi cant potential implications, especially for the trauma surgeon and even for strategic planners. Finally, the areas where further research is needed to provide objective evidence of its effi cacy are elaborated.

It is generally accepted that there are no absolute contraindications to the movement of patients by air (1, 2). However, there are special physical and physiological factors that must be considered before subjecting a patient to the potentially hostile flight environment. The major considerations are altitude and airframe whilst minor considerations include space, noise, vibration, turbulence, G forces, temperature, humidity, fatigue, anxiety, time zone changes and airsickness. The purpose of this review is to consider when, following abdominal surgery, a patient can be considered for aeromedical evacuation. This review will consider only fixed wing aeromedical evacuation (AE) in pressurised aircraft capable of maintaining a cabin altitude of 8000 feet or better, which depends primarily on the airframe and secondarily on the altitude flown but includes all fixed wing aircraft deployed on aeromedical evacuation missions in the RAF. Furthermore, this review will concentrate on patients following abdominal surgery. Each aeromedical evacuation must be judged on its merits and in each case the anticipated benefits must outweigh the associated risks. In order to achieve this, the destination medical facility should be of a higher standard of medical care than the originating facility and the standard of care during aeromedical transfer should be at least equal to that of the originating facility.