Combat Application Tourniquet fares well in a chemical, biological, radiological or nuclear dress state.

INTRODUCTION: There is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE). METHODS: 12 volunteers from the counter CBRN instructors' course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1-10). RESULTS: There were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0-3.5). The median control pain score was 4.0 (IQR 3-6). This was a statistically significant difference (p=0.002). CONCLUSION: C-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state.

Depiction of personal protective equipment in popular war films.

Background. Personal protective equipment (PPE) is worn by military personnel to protect from combat trauma. War films may not represent PPE accurately, even when considered realistic. There is a risk that the subtle influence of films may subvert the understanding of PPE amongst military personnel and civilians. Methods. An observational study compared the depiction of PPE within popular war films to real-life. Films were included if they depicted land-based warfare. Depiction of helmets, body armour, eye protection, gloves, combat boots and hearing protection was compared to benchmarks. Trends in PPE over time were analysed using linear regression. Results. There were 73 combat scenes viewed from 16 films. Combat boots were the most depicted (72 scenes; 99%); hearing protection was the least (two scenes; 3%). There were statistically significant differences in PPE adherence between real life and films for all items of PPE (p < 0.05), except for combat boots (p = 0.621). There were improvements over time for all PPE except for hearing protection. Conclusions. PPE adherence in modern war films is poor, but has improved over time. There is a hypothetical risk that this has a negative impact on perceptions by both civilians and military personnel.

Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures?

AIM: The aim of this study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved the radiological outcome and prevented a loss of fracture alignment. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing. METHODS: We searched computerized records at a UK level 1 major trauma center. The joint alignment was measured on the immediate postoperative radiograph and compared to the most recent radiograph. We used a difference of 2° to indicate a progressive deformity. RESULTS: Thirty patients were included. Twenty patients had no blocking screw and 10 patients had a blocking screw. Six patients had a difference in their coronal plane alignment of 2° or more (3/6 had no blocking screw). The results were analyzed and found to be not statistically significant (p = 0.82). The addition of a blocking screw has also been shown not to have an effect on the time to radiological union (RUST score greater or equal to 10). CONCLUSION: We use a 2.5-mm blocking wire to aid in fracture reduction prior to reaming or nail insertion and then remove the wire when the nail has been adequately locked. We no longer routinely replace the wire with a blocking screw and this could lead to a decrease in procedure time, cost, and radiation exposure. HOW TO CITE THIS ARTICLE: Fawdington RA, Lotfi N, Beaven A, et al. Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures? Strategies Trauma Limb Reconstr 2019;14(1):11-14.

Magnetically Controlled Growing Rods: The Experience of Mechanical Failure from a Single Center Consecutive Series of 28 Children with a Minimum Follow-up of 2 Years.

STUDY DESIGN: Retrospective observational study of a continuous series of 28 children. PURPOSE: To determine the mechanical failure rate in our cohort of children treated with magnetically controlled growth rods (MCGRs). OVERVIEW OF LITERATURE: Previous studies report a MCGR mechanical failure rate of 0%-75%. METHODS: All patients with MCGR implantation between 2012 and 2015 were examined and followed up for a minimum of 2 years. A retrospective evaluation of contemporaneously documented clinical findings was conducted, and radiographs were retrospectively examined for mechanical failure. The external remote controller (ERC)-specified length achieved in the clinic was compared to the length measured on subsequent radiographs. RESULTS: Fourteen mechanical failures were identified in 28 children (50%) across a total of 52 rods (24 pairs and four single constructs). Mechanical failures were due to: failure to lengthen under general anesthesia (seven children), actuator pin fracture (four), rod fracture (one), foundation screw failure (one), and ran out of rod length (one). Of the 14 mechanical failures, six were treated with final fusion operations (reflecting limited further growth potential), and eight patients were treated with the intention for further lengthening. We therefore consider these eight patients to represent the true incidence of mechanical failure in our cohort (29%). The difference between the ERC length and radiographic length was found to be identical in 11% cases; 35% were overestimates, and 54% were underestimates. The median underestimate was 2.45 mm whereas the median overestimate was 3.1 mm per distraction episode. In total, 95% of all ERC distractions were within ±10 mm of the radiographic length achieved over a median of nine distraction episodes. CONCLUSIONS: Our series is the most comprehensive MCGR series published to date, and we present a mechanical failure rate of 29%. Clinicians should be mindful of the discrepancies between ERC length and radiographic measurements of rod length; other modalities may be more helpful in this regard.

Two New Effective Tourniquets for Potential Use in the Military Environment: A Serving Soldier Study.

BACKGROUND: Limb tourniquets have been used extensively during modern Middle Eastern conflicts. Despite its undeniable successes, the combat applied tourniquet (C-A-T) has some shortfalls, principally its inability to reliably control lower limb bleeding when applied to the mid-thigh. We tested two tourniquets which may represent an improvement to the combat applied tourniquet; the tactical mechanical tourniquet and the tactical pneumatic tourniquet. METHODS: We recruited 12 healthy service personnel and applied the tactical mechanical tourniquet and tactical pneumatic tourniquet to both lower limbs in a randomly generated sequence. Tourniquets were tightened until popliteal artery occlusion. This was measured via a SonoSite portable ultrasound machine by a single consultant vascular radiologist familiar with its use. A longitudinal view of the popliteal artery was obtained, and Doppler waveform monitored. The tourniquets were tightened around volunteers' mid-thigh by a second researcher accustomed with their use. Time to complete occlusion, number of windlass revolutions, and pain scores were collected by a third researcher. Non-normally distributed data are present as median (interquartile range). Ordinal nonparametric data are analysed by Mann-Whitney U testing. RESULTS: Participants had a median age of 32.5 (28-35). Both tourniquets demonstrated complete occlusion of the popliteal artery in all limbs (n = 24). The mechanical tourniquet achieved arterial occlusion after a median of 3.8 (3-4) turns, and 16 (12-20) seconds. No participants dropped out of the study because of intolerable pain, or any cause. Median pain scores for the mechanical tourniquets were 4.5 (3-7) (maximum pain) and 4.0 (2-7) (pain when locked). Median pain scores for the pneumatic tourniquet were 5 (2-6) (maximum pain) and 5 (2-6) (pain when fully applied). There was no statistical difference in maximum pain scores between the tactical mechanical tourniquet and the tactical pneumatic tourniquet (p = 0.75). No participant had any tourniquet applied for longer than 80 seconds. CONCLUSION: Both tourniquets completely occluded the popliteal artery in all participants within an acceptable pain threshold. Further testing is required before the presented tourniquets can be taken to the battlefield; particularly measures of self-application, and use on other anatomical areas.

An adapted Clavien-Dindo scoring system in trauma as a clinically meaningful nonmortality endpoint.

BACKGROUND: There is no consensus on reporting nonmortality trauma complications in a graded manner. The Clavien-Dindo scale of complications was originally for elective surgery and requires adaptation to provide meaningful data for trauma patients. In particular, the original score does not account for those treated without surgery. We report an adapted Clavien-Dindo in trauma (ACDiT) scale and apply it to patients managed operatively and nonoperatively. METHODS: A combined prospective and retrospective international multicenter observational study was undertaken to apply the ACDiT scale to 484 trauma patients at three university teaching hospitals (Birmingham, England (n = 303); Houston, Texas (n = 113); and Glasgow, Scotland (n = 68)). These included both intensive care unit (ICU) and non-ICU-managed patients. The Clavien-Dindo scoring system was adapted for trauma patients based on consensus amongst an international collaboration of trauma specialists at these sites. Data included whether initial patients were managed operatively or nonoperatively. Complication grades were compared with hospital-free and ICU-free days as other outcome measures of patient morbidity. RESULTS: Two hundred seventeen (44.8%) of 484 patients experienced complications, of whom 61 (28.1%) of 217 died (grade V). The remainder consisted of grades I (n = 20), II (n = 60), III (n = 24), and IV (n = 52). There was a strong association between higher ACDiT grade category and lower number of hospital-free and ICU-free days (p < 0.01). Eighty-eight patients with complications did not require surgery, validating the score's usefulness in patients managed nonoperatively. CONCLUSION: The ACDiT scale can be used to grade the severity of posttrauma complications in patients managed both operatively and nonoperatively. It provides clinically meaningful data for morbidity and mortality meetings and other quality improvement exercises. LEVEL OF EVIDENCE: Prognostic, level IV.

Searching For the Optimal Fluid to Restore Microcirculatory Flow Dynamics After Haemorrhagic Shock: A Systematic Review of Preclinical Studies.

BACKGROUND: Increased microcirculatory flow and perfusion has been reported to improve clinical outcomes following shock. The optimal resuscitation fluid to restore the flow dynamics of the microcirculation is unknown. This review summarizes the preclinical literature to inform the direction and most important hypotheses for future clinical interventional studies. METHODS: Standard systematic review methodology was utilized, and registered with the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES). Medline and Embase (via OVID SP) and SCOPUS were searched for all preclinical studies of haemorrhagic shock that compared fluid resuscitation of any kind (e.g., blood products, crystalloids, colloids, or haemoglobin based oxygen carriers) to another fluid or haemorrhage only, and reported at least one microcirculatory physical endpoint (such as flow rate, velocity, vessel diameter, functional capillary density, or glycocalyx thickness). Risk of bias was assessed using the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE) tool. Translatability was also assessed for each study based on the most common recommendations. RESULTS: There were 3,103 potential studies of interest, of which 71 studies fulfilled all eligibility criteria. There were 62 rodent, 5 canine, and 4 porcine studies. Flow rate, velocity, and vessel diameter were the most commonly reported endpoints. Studies reported the importance of the presence of haemoglobin, as well as osmotic potential and viscosity in providing optimal restoration of microcirculatory flow dynamics. Others reported the restoration of the endothelial glycocalyx and attenuation of inflammation as important properties for the choice of fluid. All studies were at potential risk of bias due to unclear randomization, concealment, and blinding. There were important threats to translatability for all studies. CONCLUSION: The ideal resuscitation fluid for restoration of the microcirculation following haemorrhagic shock is likely to contain a preparation of haemoglobin, favor higher oncotic potential, and viscosity, protect and reconstitute the endothelium, and attenuate inflammation. These hypotheses that are derived from preclinical research warrant further exploration in the clinical context.

Ovarian vein thrombosis in a polytrauma patient.

A young mother presented to a major trauma centre following a road traffic collision. Her admission CT traumagram demonstrated liver and renal lacerations, spinal and pelvic fractures with no abnormalities of the ovarian veins. Her inpatient course was uncomplicated other than a sustained, isolated raised C reactive protein. CT of the abdomen 1 week after injury demonstrated stable solid organ injuries and the additional, unexpected finding of a right ovarian vein thrombosis (OVT). A pragmatic approach was taken towards the management of the OVT given the haemorrhagic risk from her traumatic injuries. A multidisciplinary, consultant-led plan was made to slowly increase enoxaparin to a therapeutic dose under close surveillance and to then switch to warfarin following an outpatient consultation with a consultant haematologist. A MR venogram was performed after 3 months of anticoagulation, and this demonstrated complete resolution of the OVT and normal appearances of the ovary.

Preoperative warfarin reversal for early hip fracture surgery.

PURPOSE: To evaluate our hospital protocol of low-dose vitamin K titration for preoperative warfarin reversal for early hip fracture surgery. METHODS: Records of 16 men and 33 women aged 63 to 93 (mean, 81) years who were taking warfarin for atrial fibrillation (n=40), venous thromboembolism (n=9), cerebrovascular accident (n=3), and prosthetic heart valve (n=3) and underwent surgery for hip fractures were reviewed. The 3 patients with a prosthetic heart valve were deemed high risk for thromboembolism and the remainder low-risk. The international normalised ratio (INR) of patients was checked on admission and 6 hours after administration of vitamin K; an INR of <1.7 was considered safe for surgery. RESULTS: No patient developed venous thromboembolism within one year. The 30-day and one-year mortality was 8.2% and 32.6%, respectively. For the 46 low-risk patients, the mean INR on admission was 2.6 (range, 1.1-4.6) and decreased to <1.7 after a mean of 2.2 (range, 0-4) administrations of 2 mg of vitamin K. Their INR was <1.7 within 18 hours (mean, 14 hours). 78% of patients underwent surgery within 36 hours. In the 22% of patients who did not undergo surgery within 36 hours, the delay was due to insufficient operative time or the patient being medically unfit for surgery. The 3 high-risk patients underwent bridging therapy of low-molecular-weight heparin and received no vitamin K; their mean INR on admission was 3.2 (range, 3.1-3.3) and the mean time to surgery was 5.3 (range, 3-8) days. Two low-risk patients and one high-risk patient died within 5 days of surgery. CONCLUSION: The low-dose intravenous vitamin K protocol is safe and effective in reversing warfarin within 18 hours. Hip fracture surgery within 36 to 48 hours of admission improves morbidity and mortality.