Massive transfusion.

Massive Transfusion is a part of Damage Control Resuscitation. The aim of transfusion therapy is to restore oxygen delivery to poorly perfused tissues and to treat the acute coagulopathy of trauma. The severity and complexity of modern injuries have led to the use of swift, protocol-driven care with the use of'Shock Packs' and management of metabolic complications. The proactive treatment of the coagulopathy has been termed Haemostatic Resuscitation. The delivery of this transfusion capability has required an increasingly sophisticated logistic and laboratory response. New operational capabilities have included cold chain solutions; laboratory management information systems; platelet apheresis and ROTEM. This investment in the massive transfusion capability has delivered rapid resuscitation. It has also enabled clinicians to direct individualised transfusion support following initial resuscitation i.e. goal directed therapy. Future technical solutions should further support the prehospital delivery of transfusion while addressing the logistic tail. However, the key to success is the knowledge and skills of frontline staff to deliver safe and appropriate blood transfusion.

A pre-hospital technique for controlling haemorrhage from traumatic perineal and high amputation injuries.

Perineal trauma resulting from the adaptive use of improvised explosive devices (IEDs) has become an increasingly common problem during current operational conflicts in Afghanistan. Control of haemorrhage from the perineum and high amputations is a particular challenge due to the bony anatomy, rich pelvic vascular supply and the difficulty in achieving haemostasis by direct pressure. In this article, the authors describe a potential pre-hospital solution for controlling haemorrhage from perineal and high amputation injuries.

Vascular access on the 21st century military battlefield.

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of blood volume. Methods used to gain access can include; the cannulation of peripheral and central veins, venous cut-down and intraosseus devices. This article reviews the current literature on the benefits and complications of each vascular access method. We conclude that intraosseus devices are best for quick access to the circulation, with central venous access via the subclavian route for large volume resuscitation and low complication rates. Military clinicians involved with the care of trauma patients either in Role 2 and 3 or as part of the medical emergency response team (MERT), must have the skill set to use these vascular access techniques by incorporating them into their core medical training.

First military use of activated Factor VII in an APC-III pelvic fracture.

A male soldier in shock with an APC-III pelvic fracture was flown to an Air Assault Surgical Group (AASG) of 16 Close Support Medical Regiment at Al Amarah in Iraq. A pelvic external fixator was applied and his condition stabilized. Ultrasound scanning (FAST) showed an absent bladder, and a spreading retroperitoneal haematoma combined with intra-abdominal, free blood. Unfortunately he continued to bleed and required transfusion with the unit's entire stock of type-specific blood. At emergency laparotomy, uncontrollable pelvic bleeding was encountered and the abdominal aorta required clamping above the iliac bifurcation. Branches of the right internal iliac artery were the source and this was ligated. Some bleeding continued post-operatively: administration of activated Factor VII was associated with a marked reduction in the oozing from his fixator pin-sites and an improvement in his pH from 7.1 to 7.3. In total, 25 units of blood were transfused, 8 of which were fresh whole blood donated by individual members of the AASG. The patient survived, returned to the UK, had his injuries reconstructed, and is currently undergoing rehabilitation. This case illustrates the benefits of forward resuscitation surgery in wartime and the need for a multidisciplinary approach to trauma care.