Journal of the Royal Army Medical Corps
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The signature injury of the Afghanistan campaign has, amongst other things, included an increased incidence of destructive anorectal injury. There is no significant body of evidence about this type of injury on which to base management strategies. This review examines the historical military data, later civilian reports, many of which have challenged the military dogmas of Vietnam, and the spartan contemporaneous military data which does not particularly address pelviperineal blast injury. There is no evidence to support a move away from the doctrine of the four D's (diversion, distal washout, drainage and direct repair), but sound surgical judgement remains the mainstay of managing these challenging and highly morbid injuries.
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Improvised explosive device (IED) yields in Afghanistan have increased resulting in more proximal injuries. The injury severity score (ISS) is an anatomic aggregate score of the three most severely injured anatomical areas but does not accurately predict severity in IED related pelvi-perineal trauma patients. A scoring system based on abbreviated injury score (AIS) was developed to reflect the severity of these injuries in order to better understand risk factors, develop a tool for future audit and improve performance. ⋯ This scoring system is the initial part of a more complex logistic regression model that will contribute towards a unique trauma scoring system to aid surgical teams in predicting fluid requirements and operative timelines. In austere environments, it may also help to prevent futile resuscitations. Better correlation between measurement of severity and outcome would aid performance improvement monitoring. In the longer term it will also allow benchmarking of current survival rates and comparisons in the future.
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Haemorrhage from severe pelvic fractures can be associated with significant mortality. Modern civilian trauma centres may manage these injuries with a combination of external pelvic fixation, extra-peritoneal packing and/or selective angiography; however, military patterns of wounding are different and deployed medical facilities may be resource constrained. ⋯ We conclude that pelvic packing should be considered early in patients with military pelvic trauma and major haemorrhage, as part of damage control surgery and that Celox gauze may be a useful adjunct. In our cases, the Celox gauze was easily removed after 24-48 hours without significant bowel adhesions and did not leave a residual phelgmon (of exudate or gel) that may predispose to infection.
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A satellite compound of an International Security Assistance Force Patrol Base came under assault during OP HERRICK 12 resulting in eight casualties. Multiple fragmentation type injuries were sustained over a short period of time which tested the locations medical capacity. This account describes the events that occurred in extracting and treating those injured.