Journal of the Royal Army Medical Corps
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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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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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The majority of neurological admissions to military Intensive Care will be for Traumatic Brain Injury (TBI). These injuries will be either penetrating from fragmentation or missiles or blunt due to blast or impact. ⋯ This management is based largely on comprehensive evidence based guidelines produced by the Brain Trauma Foundation. The most significant dilemma faced by UK military intensivists is whether we should be measuring Intracranial Pressure in patient with severe TBI in the deployed setting; and if so what technique should be used.
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Burn casualties will inevitably occur in the military environment during both conflict and peacetime. The number and type of casualties will vary on the nature of warfare and the type of troops deployed. New preventative measures have decreased the number and severity of burns found on the battlefield however with new weapon systems casualties suffering from thermal injuries are still to be expected in modern warfare. ⋯ These advances are reviewed here with emphasis on those that can be accomplished in the Role 3 facility by non-specialist clinicians. It is beyond the scope of this review to produce didactic treatment protocols but it is hoped that in the near future Clinical Guidelines for Operations will soon reflect these. Where advances have occurred that can not be mirrored in the field hospital early evacuation to specialist facilities back at Role 4 facilities should be a priority.
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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.