Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement.

INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

Operative treatment of paediatric penetrating head injuries in southern Afghanistan.

The operative management and early post-operative outcome of 16 consecutive cases of paediatric penetrating head injury treated by a single surgeon at a military trauma centre in Southern Afghanistan are retrospectively analysed. The majority of cases of injury were caused by fragments from exploding munitions. The aim of neurosurgical intervention in penetrating head injury is the prevention of wound infection and treatment or prevention of a critical rise in intracranial pressure. In 14 cases in this study, these aims were fulfilled without resort to brain resection, although a delayed cranioplasty procedure was required in 6 patients. Despite the ongoing conflict, families, local communities and coalition forces transport teams combine to make the latter a viable option in Southern Afghanistan, with an excellent short-term outcome.

Lessons learned in oral and maxillofacial surgery from British military deployments in Afghanistan.

This article describes the combined lessons learned from two deployments of a cadre of British Oral and Maxillofacial surgeons to Kandahar between July 2006 to April 2007, and September 2008 to April 2009.

Five months of surgery in the multinational field hospital in Afghanistan with an emphasis on oral and maxillofacial injuries.

The aim of this review was to assess the workload of theatres in the role 3 Multinational Field Hospital in Kandahar, Afghanistan and to identify what period of day most emergency admissions arrived. During the period 05 August 2006 to 21 December 2006, 288 operations were performed on 259 patients and comprised 393 individually quantifiable procedures. 98% of these operations were to treat acute injuries. Oral and Maxillofacial surgeons were involved in 24% of operations. 63% of procedures done at these operations involved upper or lower limbs, 19% the head and neck and 18% involved the torso. An analysis of emergency admissions in November 2006 showed that most occurred between 18.00 and midnight. Although theatre timetabling made provision for this, whenever possible, elective surgery was scheduled for the following morning when emergency injury admissions were at their lowest.

Developing a craniomaxillofacial and cervical equipment module for surgeons in the austere environment: a systematic review.

The treatment of craniomaxillofacial and cervical wounds in a disaster relief setting is done by clinicians from local medical treatment facilities, non-governmental organisations (NGO), or the military. Although each group and individual surgeon will need specific equipment, this will be restricted by weight, portability and interoperability. We systematically reviewed scientific and commercial publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The papers we identified described the portable equipment that is required to treat patients who need damage-control surgery (decompressive craniectomy, temporary stabilisation, and internal and external fixation of the facial bones) for craniomaxillofacial and cervical injuries in austere or military settings. Austere settings are those in which there is an inherent lack of infrastructure, such as facilities, roads, and power. A total of 35 papers or scientific articles recommended the equipment that is needed to manage these injuries, but we could find no module that was specifically designed for use in these environments. Multiple modules are currently required to provide comprehensive surgical care and many of the items in the existing maxillofacial and neurosurgical kits are rarely used, which increases the cost of initial procurement and resupply. Duplications in equipment between modules also increase the size, weight, and financial cost. We suggest the equipment that is required to make up a rationalised, lightweight, and compact module that can be used for all craniomaxillofacial and cervical operations in austere settings.

Use of a Therabite appliance in the management of bilateral mandibular coronoid hyperplasia.

Persistent restriction of mouth opening after coronoidectomy to treat bilateral coronoid hyperplasia, may be the result of soft tissue fibrosis. We present the use of a mouth-opening appliance that helps to overcome this problem and improves long-term results.

Use of mini-implants in orthognathic surgery.

We report a case in which mini-implants were used for intraoperative maxillomandibular fixation and for postoperative elastic traction in the treatment of a 20-year-old woman with mandibular prognathism.

Are soldiers at increased risk of third molar symptoms when on operational tour in Iraq? A prospective cohort study.

OBJECTIVE: Pain associated with third molar (wisdom) teeth is a common cause of morbidity for soldiers in the United Kingdom and on operational deployments. This study compared the incidence of third molar symptoms between soldiers serving in Iraq and soldiers stationed in barracks in Northern Ireland and assessed if pre-deployment screening could be improved. METHOD: Data was collected in a prospective cohort study over five consecutive months. Dental officers recorded each time an Army soldier presented with third molar related symptoms. RESULTS: 1% of soldiers in Iraq had third molar related symptoms in this time compared to 1.4% of those stationed in Northern Ireland. The range of pathologies and teeth affected were similar between locations. In both locations approximately 40% of teeth that caused problems had been symptomatic before and 13 -16% had untreated decay. CONCLUSIONS: This study suggests that soldiers experience a lower incidence of symptoms related to third molars when in Iraq compared to Northern Ireland (P < 0.033) possibly due to pre-deployment treatment. If ideal pre-deployment screening of third molars was carried out and National Institute of Clinical Excellence guidelines applied 38% of the Operation Telic group of patient's problems could have been prevented.

Optimising ballistic facial coverage from military fragmenting munitions: a consensus statement.

VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.

Results of the centralisation of adult emergency oral and maxillofacial surgical services at the University Hospital, Birmingham.

In 2001, the oral and maxillofacial surgical (OMFS) services for adults in Birmingham were centralised at the Selly Oak site of the University Hospital and the OMFS department was given access to the emergency operating theatre every day. We examined the effects of this on the emergency workload during the 6 months after centralisation and compared it with the emergency workload at the University Hospital during the 6 months before centralisation. The number of adult patients who attended the University Hospital as emergencies increased from 242 in the 6 months before centralisation to 545 in the subsequent 6 months (an increase of 127%). Of the latter 164 (30%) were admitted and operated on, 138 (84%) within 24h of admission. Despite the large increase in the number of patients, 102 (74%) were operated on during normal working hours. After centralisation, all operations were done on multidisciplinary emergency lists compared with only 55% before centralisation. Centralisation did not reduce the access of patients to the emergency service and conformed with the guidelines of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

Advice given in community pharmacies to patients with possible oral carcinoma.

We compared advice given by community pharmacy staff in Worcestershire to a proxy consulter on behalf of a patient with a longstanding oral ulcer, presumed to be an oral cancer. If patients seek advice in this way the quality of the advice given is dependent on whether the respondent is a pharmacist or a community pharmacy assistant.

The use of the laryngeal mask in surgical tracheostomy.

The laryngeal mask may be used as an airway during surgical tracheostomy. This techniques has several advantages over conventional oral endotracheal intubation.

beta-D-Arabinofuran[1',2':4,5]oxazolo-1,3,5-triazine-5-N-methyl-4,6-dione and analogues, unusually specific immunosuppressive agents.

Sequential treatment of the protected beta-D-arabinofuran[1',2':4,5]-2-aminooxazoline (2) with methyl isocyanate and diimidazole carbonyl afforded the 2,2'-anhydro-beta-D-arabinofuranosyl nucleoside, 6. Deprotection and hydrolysis yielded the corresponding arabinoside. Although the anhydronucleoside exhibited in vitro antiviral activity against herpes simplex type 1, it exacerbated the infection in vivo. Further examination uncovered an in vitro inhibition of the induction of a cell-mediated immune response without cytotoxicity.

Nucleic acids. 16. Orally active derivatives of ara-cytidine.

Water-soluble derivatives of ara-cytidine (cytarabine, Cytosar) were prepared and tested for antitumor, immunosuppressive, and antiarthritic activities in animals after oral administration. The compounds tested included the 5'-palmitate, 5'-benzoate, and 5'-adamantoate esters of ara-cytidine, made water soluble by use of their hydrochloride salts of peptidyl derivatives, and two basic 5' esters (5'-nicotinoate and 5'-quinuclidinate) as their hydrochloride salts. Five of the compounds had antitumor activity superior to that found with ara-cytidine itself after oral administration in the L1210 leukemic mouse assay. One of these, 5'-adamantoyl-ara-cytidine hydrochloride, had antitumor activity after oral administration approaching that achieved with parenterally administered ara-cytidine.

Case report: computed tomography in the investigation of bilateral mandibular coronoid hyperplasia.

Bilateral mandibular coronoid hyperplasia is characterized by restricted mouth opening due to impingement of the coronoid processes on the zygomatic arches. The condition is unfamiliar to many clinicians and may be significantly under-reported. The presented case highlights the benefits of computed tomography (CT) in the diagnosis and surgical evaluation of this disorder.

The CRABEL score--setting standards in maxillofacial medical note-keeping.

The CRABEL score (developed by Crawford, Beresford and Lafferty) was introduced for auditing medical note-keeping at Morriston Hospital in June 2001. Guidelines detailing the scoring system were issued to all clinicians in the maxillofacial unit. An auditor selected two sets of medical notes from each consultant's firm, giving an initial allocation of 100points/firm (50 points for each set of notes). The notes of the most recent in-patient admission were analysed using the CRABEL marking sheet to give a score out of 100 for each firm. The audit was repeated at 3-month-intervals. CRABEL scores within the maxillofacial unit improved from 70 to 97. The CRABEL score is simple, reliable and repeatable. It is a successful and objective measure for audit and for improvement in the quality of note-keeping. We propose that it be adopted in maxillofacial units throughout the United Kingdom.

Can warfarin be continued during dental extraction? Results of a randomized controlled trial.

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.

Blood transfusion requirements in bimaxillary osteotomies.

The over-ordering of cross-matched blood to cover operations can result in blood shortages and is costly; it can never be free of risk. Current published guidelines recommend cross-matching 2 units of blood for bimaxillary orthognathic procedures with an additional 2 units if combined with a genioplasty. We reviewed the records of 115 consecutive cases of simultaneous bimaxillary osteotomies at Morriston Hospital over a 5-year period (January 1996 to December 2000). Ordering and use of blood were investigated and the cost analysed. Blood loss was minimised using a strategy of controlled moderate hypotension and meticulous haemostasis. Nine patients were given transfusions of blood but five of these were deemed inappropriate. No predisposing factors for transfusion were identified. We recommend that the tariff for ordering blood for bimaxillary osteotomies should be revised to a "group and save" with antibody screen, providing that a 30-min indirect antibody cross-match is available.