The modified 'Jo'burg' technique for securing intercostal chest drains.

Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel as an emergency procedure during the initial resuscitation period and often within a stressful environment. Approximately one-fifth of all ICD insertions are associated with complications. In a retrospective review of over 1000 ICD insertions, 7% of the complications observed were due to inadequate fixation, resulting in dislodgement. The risk of dislodgement is greatest during transit or transfer of a casualty. In a military setting, this may involve movement of a casualty in a non-permissive environment and includes transfer on and off rotary wing, fixed wing, road vehicle and maritime transport platforms as well as between stretchers and hospital beds. While ICD insertion follows a standard technique in accordance with the Advanced Trauma Life Support guidelines, the method of securing ICDs has not been standardised across the Defence Medical Services (DMS). The aim of this paper is to first propose a modified version of a tried and tested technique of securing ICDs with alternative steps described for medical staff unfamiliar with surgical knot tying by hand. Second, we present the results from a pilot validation study of this technique when introduced to candidates on a trauma surgical skills course. We describe and demonstrate a robust, easily teachable and reproducible technique for securing ICDs. We would advocate the use of this technique among both surgically and non-surgically trained medical personnel and suggest that this should become the standardised technique for securing ICDs across the DMS. This could be easily implemented by introducing this technique into the various military trauma courses, for example the Military Operational Surgical Training, Medical Emergency Response Team and Critical Care Air Support Team courses.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma.

BACKGROUND: Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT. METHODS: A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor. RESULTS: Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation. CONCLUSION: A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.

A survey of major trauma centre staffing in England.

INTRODUCTION: Trauma care delivery in England has been transformed by the development of trauma networks, and the designation of trauma centres. A specialist trauma service is a key component of such centres. The aim of this survey was to determine to which extent, and how, the new major trauma centres (MTCs) have been able to implement such services. METHODS: Electronic questionnaire survey of MTCs in England. RESULTS: All 22 MTCs submitted responses. Thirteen centres have a dedicated major trauma service or trauma surgery service, and a further four are currently developing such a service. In 7 of these 17 centres, the service is or will be provided by orthopaedic surgeons, in 2 by emergency medicine departments, in another 2 by general or vascular surgeons, and in 6 by a multidisciplinary group of consultants. DISCUSSION: A large proportion of MTCs still do not have a dedicated major trauma service. Furthermore, the models which are emerging differ from other countries. The relative lack of involvement of surgeons in MTC trauma service provision is particularly noteworthy, and a potential concern. The impact of these different models of service delivery is not known, and warrants further study.

Factors affecting outcome after traumatic limb amputation.

BACKGROUND: Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation. METHODS: A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included. RESULTS: Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction. CONCLUSION: Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Epidemiology and outcome of vascular trauma at a British Major Trauma Centre.

OBJECTIVES: In the United Kingdom, the epidemiology, management strategies and outcomes from vascular trauma are unknown. The aim of this study was to describe the vascular trauma experience of a British Trauma Centre. METHODS: A retrospective observational study of all patients admitted to hospital with traumatic vascular injury between 2005 and 2010. RESULTS: Vascular injuries were present in 256 patients (4.4%) of the 5823 total trauma admissions. Penetrating trauma caused 135 (53%) vascular injuries whilst the remainder resulted from blunt trauma. Compared to penetrating vascular trauma, patients with blunt trauma were more severely injured (median ISS 29 [18-38] vs. ISS 11 [9-17], p < 0.0001), had greater mortality (26% vs. 10%; OR 3.0, 95% CI 1.5-5.9; p < 0.01) and higher limb amputation rates (12% vs. 0%; p < 0.0001). Blunt vascular trauma patients were also twice as likely to require a massive blood transfusion (48% vs. 25%; p = 0.0002) and had a five-fold longer hospital length of stay (median 35 days (15-58) vs. 7 (4-13), p<0.0001) and critical care stay (median 5 days (0-11) vs. 0 (0-2), p < 0.0001) compared to patients with penetrating trauma. Multivariate regression analysis showed that age, ISS, shock and zone of injury were independent predictors of death following vascular trauma. CONCLUSION: Traumatic vascular injury accounts for 4% of admissions to a British Trauma Centre. These patients are severely injured with high mortality and morbidity, and place a significant demand on hospital resources. Integration of vascular services with regional trauma systems will be an essential part of current efforts to improve trauma care in the UK.

Right turn resuscitation: frequently asked questions.

In this article the process of operating room resuscitation - commonly known as Right Turn Resuscitation (RTR) when conducted in the medical treatment facility at Camp Bastion - is described. The place of RTR within the concepts of damage control resuscitation and surgery is discussed along with activation criteria and protocols. The medical leadership, team roles, advantages and disadvantages are reviewed. Finally, studies describing the impact of RTR and operating room resuscitation are briefly described.

Difficult decisions in the surgical care of military casualties with major torso trauma.

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.

Management of intestinal injury in deployed UK hospitals.

INTRODUCTION: Definitive laparotomy (DL), with completion of all surgical tasks at first laparotomy has traditionally been the basis of surgical care of severe abdominal trauma. Damage control surgery (DCS) with a goal of physiological normalisation achieved with termination of operation before completion of anatomical reconstruction, has recently found favour in management of civilian trauma. This study aims to characterise the contemporary UK military surgeon's approach to abdominal injury. PATIENTS AND METHODS: A retrospective analysis was performed on British service personnel who underwent a laparotomy for intestinal injury at UK forward hospitals from November 2003 to March 2008 as identified from the Joint Theatre Trauma Registry. Patient demographics, mechanism and pattern of injury and clinical outcomes were recorded. Surgical procedures at first and subsequent laparotomy were evaluated by an expert panel. RESULTS: 22 patients with intestinal injury underwent laparotomy and survived to be repatriated; all patients subsequently survived to hospital discharge. Mechanism of injury was GSW in seven and blast in 13. At primary laparotomy, as defined by the operating surgeon, 15/22 underwent DL and 7/22 underwent DCS. Mean Injury Severity Score (ISS) was 19 for DL patients compared to 29 for DCS patients (p = 0.021). Of the 15 patients undergoing DL nine had primary repair (suture or resection/ anastomosis), one of which subsequently leaked. Unplanned re-look was required in 4/15 of the DL cases. CONCLUSION: This review examines the activity of British military surgeons over a time period where damage control laparotomy has been introduced into regular practice. It is performed at a ratio of approximately 1:2 to DL and appears to be reserved, in accordance with military surgical doctrine, for the more severely injured patients. There is a high rate of unplanned relook procedures for DL suggesting DCS may still be underused by military surgeons. Optimal methods of selection and implementation of DCS after battle injury to the abdomen remain unclear.

Optimal clinical timelines--a consensus from the academic department of military surgery and trauma.

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.

Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture.

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Knee versus thigh length graduated compression stockings for prevention of deep venous thrombosis: a systematic review.

OBJECTIVE: Graduated compression stockings are a valuable means of thrombo-prophylaxis but it is unclear whether knee-length (KL) or thigh length (TL) stockings are more effective. The aim of this review was to systematically analyse randomised controlled trials that have evaluated stocking length and efficacy of thromboprophylaxis. METHOD: A systematic review of the literature was undertaken. Clinical trials on hospitalised populations and passengers on long haul flights were selected according to specific criteria and analysed to generate summated data. RESULTS: 14 randomized control trials were analysed. Thirty six of 1568 (2.3%) participants randomised to KL stockings developed a deep venous thrombosis, compared with 79 of 1696 (5%) in the TL control/thigh length group. Substantial heterogeneity was observed amongst trials. KL stockings had a significant effect to reduce the incidence of DVT in long haul flight passengers, odds ration 0.08 (95%CI 0.03-0.22). In hospitalised patients KL stockings did not appear to be far worse than TL stockings, odds ratio 1.01 (95%CI 0.35-2.90). For combined passengers and patients, there was a benefit in favour of KL stockings, weighted odds ratio 0.45 (95% CI 0.30-0.68). CONCLUSION: KL graduated stockings can be as effective as TL stockings for the prevention of DVT, whilst offering advantages in terms of patient compliance and cost.