Meningoencephalitis in a Royal Marine after skinning reindeer in Norway.

Meningoencephalitis presenting in service personnel overseas may present a diagnostic challenge due to the broad range of potential differential diagnosis as well as the requirement for rapid assessment and treatment. A 25-year-old Royal Marine was evacuated to the Royal Centre for Defence Medicine in Birmingham, UK, with a history of rash consistent with erythema chronicum migrans, a seizure, and lymphocytic pleocytosis after skinning reindeer in Norway. Neuroborreliosis was suspected and empirical antibiotics were administered. Despite subsequent negative serology for Borrelia burgdorferi, given the clinical features and lymphocytic pleocytosis, an atypical presentation of neuroborreliosis remains a possible diagnosis in this scenario. This case serves to illustrate that British military personnel on exercise are potentially at risk of contracting borreliosis both in the UK and abroad, serological tests can be unreliable, and the differential diagnosis of meningoencephalitis can be broad with specialist input often required.

Upper extremity deep vein thrombosis in a military patient.

We describe the case of a 23-year-old serviceman on overseas deployment who presented with a painful, swollen arm. Investigations showed an upper extremity deep vein thrombosis (UEDVT) of the right arm with an associated asymptomatic pulmonary embolism, which was treated with warfarin anticoagulation. Further investigation identified positional obstruction at the thoracic outlet, and the patient was diagnosed with Paget-Schroetter syndrome. He underwent elective resection of the first rib, and has now returned to normal duties. After review of the literature on UEDVT, it is suggested that in this military patient, the occurrence of an anatomical variant put him at risk of upper limb venous thrombosis, which was probably potentiated by the occupational factor of carrying a rifle. The external compression of the subclavian vein from the rifle butt and hypertrophied muscles, in addition to the anatomical variation, caused repetitive microtrauma of the vessel intima, which precipitated venous thrombosis.

Post-operative negative pressure pulmonary oedema in an athletic male.

A case of post-operative negative pressure pulmonary oedema in a young, athletic male is reported. We discuss this rare but life-threatening condition and its aetiology, and review the published literature. Military health care providers need to be aware of this condition as young fit personnel may be at increased risk of developing negative pressure pulmonary oedema in the post-operative period.

Nutritional management of critically ill trauma patients in the deployed military setting.

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.

Focus on sepsis and intensive care.

The Surviving Sepsis Campaign (SSC) Guidelines collate the evidence for managing sepsis. Most of the interventions suggested by the SSC guidelines are very relevant to military critical care, including rapid microbiologic investigation, early antibiotic administration and many aspects of early goal directed therapy. Other interventions may be more difficult to provide in remote theatres of operation where resources may be limited. This article discusses the application of the SSC guidelines to deployed military hospitals, with suggestions as to which interventions are feasible, and which may not be indicated.

Medical conditions requiring intensive care.

Patients who require critical care for internal medical conditions make up a small but significant proportion of those requiring evacuation to the Royal Centre for Defence Medicine in Birmingham, UK. Infectious, autoimmune, neurologic, cardiac and respiratory conditions are all represented. Conditions which preclude military service and which one would not necessarily expect to see in a military hospital are still prevalent in civilian contractors and host nation personnel. With some 250,000 British military personnel based in the UK and overseas individual presentations of rare conditions occur regularly. This article discusses the ITU management of some key conditions. Whilst trauma makes up the majority of the workload in a field Intensive Care Unit, medical admissions happen not infrequently. This article describes some of the most common medical causes for admission and treatment is considered.

Statins and sepsis.

Severe sepsis and septic shock is common and frequently fatal. Over the last few years, the primary treatments demonstrated to improve outcome from several major clinical trials have finally emerged. However, translating these recent therapeutic advances to routine clinical practice has proven controversial, and new approaches of additional strategies are continued to be developed. Given their pleiotropic effects related to many pathophysiological determinants of sepsis, statin therapy could be the next step in the search for adjuvant therapy. A future challenge may be to test both the efficacy and the safety by large randomized controlled clinical trials ascertaining the effects of statins administered at the onset of sepsis and in patients with severe sepsis or septic shock admitted into intensive care units.

Pulmonary effects of combined blast injury and radiation poisoning.

In situations with relatively small numbers of patients with pulmonary blast injury aggressive modern intensive care treatment may allow a return to normal function. The additional effects of radiation poisoning are more difficult to factor in, but new treatments such as colony stimulating factors may improve the outlook for a group with moderate to severe radiation exposure who would previously have died of infection or haemorrhage.