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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The Surviving Sepsis Campaign (SSC) Guidelines collate the evidence for managing sepsis. Most of the interventions suggested by the SSC guidelines are very relevant to military critical care, including rapid microbiologic investigation, early antibiotic administration and many aspects of early goal directed therapy. Other interventions may be more difficult to provide in remote theatres of operation where resources may be limited. This article discusses the application of the SSC guidelines to deployed military hospitals, with suggestions as to which interventions are feasible, and which may not be indicated.
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Scoring systems for both trauma and intensive care patients have been widely used since the 1960's. This article will introduce several scoring systems currently in use and discuss their potential use for military ICU patients.
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Emergency thoracotomy is a dramatic and controversial intervention which may be life saving after major torso trauma. Success rates are variable and differ widely according to mechanism of injury. This article outlines the current indications and contraindications to emergency thoracotomy and examines the evidence to support it accumulated over 40 years.
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The mechanism of injury on the modern battlefield results in a pattern of wounding which is associated with both nociceptive and neuropathic pain. Nociceptive pain is managed using the WHO Analgesic Ladder but neuropathic pain requires the use of co-analgesic drugs, e.g. antidepressants and anticonvulsants. ⋯ During the first week post injury, 30% of casualties had a LANSS pain score > 12, suggesting a neuropathic element to their pain. The early detection (using LANSS) and management of neuropathic pain using robust protocols represent the most effective strategy to address this significant problem.