Journal of the Royal Army Medical Corps
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Haemorrhagic shock from traumatic injuries is now often treated using a damage control resuscitation strategy that transfuses packed red blood cells, plasma and platelets in a 1:1:1 ratio, early use of activated recombinant factor VII and transfusion of fresh whole blood. These therapies are aimed at promoting thrombosis in injured vessels. Such patients are at high risk for thrombotic complications and thromboprophylaxis is necessary, but frequently impossible to use in the early phase of care. ⋯ Care providers and policy makers must recognize that the increased use of prothrombotic strategies of resuscitation will likely increase the incidence of thrombotic complications in the high risk population of severely injured patients in combat support hospitals. Monitoring the incidence of these complications and development of strategies for prevention and treatment are required to avoid undermining the positive outcomes of damage control resuscitation. These strategies could include supplying combat support hospitals with the equipment and training necessary for placement of temporary IVC filters under fluoroscopic guidance.
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A Delphi study was carried out to investigate recent changes in the fluid resuscitation of patients. A thirty member panel was selected primarily from the UK Defence Medical Services but also included contributors from other NATO members and civilian practice. The study was carried out in two rounds and achieved consensus on a range of statements relating to fluid resuscitation. ⋯ Statements reaching consensus included the use of adult intraosseous access, limited hypotensive resuscitation and goal directed therapy in trauma patients. Consensus was not achieved with respect to the selection of non-oxygen carrying synthetic colloids. The study provides a broad review of current practice and adds to previous consensus publications on fluid resuscitation.
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Review Case Reports
Operational critical care. Intensive care and trauma.
Trauma management involves good prehospital, emergency, surgical, anaesthetic and intensive care decision-making. Optimal outcome depends on keeping abreast of the latest thinking in an ever-changing and increasingly technology-rich environment. The intensive care unit needs to represented as early as possible in the damage-control resuscitation phase. ⋯ Attention to detail is important, preservation of organ function, infection control and nutrition to maintain muscle strength allowing normal metabolic function to return. Multiply injured patients often require lengthy periods of mechanical ventilation and a variety of therapeutic interventions may have to be considered during management of the disease process. As we are now seeing more survivors in the military trauma system the focus now needs to be morbidity reduction in order for these survivors to be best prepared for their rehabilitation phase of care.
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The limited capacity and resources of a Field Hospital Intensive Care Unit may necessitate the triage or prioritisation of critically ill patients requiring admission. The use of critical care resources by members of the local population in certain Areas of Operation, who can not be discharged or transferred to equivalent care in their local health service, impacts significantly on bed occupancy. ⋯ Discriminating between seriously ill patients before admission and decision making regarding withdrawal of care is very difficult. Senior clinicians working regularly in a critical care setting demonstrate a better level of discrimination in assessing outcome of seriously ill patients and are best placed to make decisions regarding admission, continuation and withdrawal of treatment.
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Intraosseous needles provide an important alternative to intravenous access for administration of drugs, fluids and blood products in the emergency management of trauma patients. This case report highlights one potential complication of the use of one brand of IO needle.