Abdominal aortic junctional tourniquet (AAJT-S): a systematic review of utility in military practice.

INTRODUCTION: Haemorrhage is the leading cause of potentially survivable death on the battlefield. Despite overall improvement in battlefield mortality, there has been no improvement in survival following non-compressible torso haemorrhage (NCTH). The abdominal aortic junctional tourniquet-stabilised (AAJT-S) is a potential solution that may address this gap in improving combat mortality. This systematic review examines the evidence base for the safety and utility of the AAJT-S for prehospital haemorrhage control in the combat setting. METHODS: A systematic search of MEDLINE, Cumulated Index to Nursing and Allied Health Literature and Embase (inception to February 2022) was performed using exhaustive terms, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The search was limited to English-language publications in peer-reviewed journals; grey literature was not included. Human, animal and experimental studies were included. Papers were reviewed by all authors to determine inclusion. Each study was assessed for level of evidence and bias. RESULTS: 14 studies met the inclusion criteria: 7 controlled swine studies (total n=166), 5 healthy human volunteer cases series (total n=251), 1 human case report and 1 mannikin study. The AAJT-S was demonstrated to be effective at cessation of blood flow when tolerated in healthy human and animal studies. It was easy to apply by minimally trained individuals. Complications were observed in animal studies, most frequently ischaemia-reperfusion injury, which was dependent on application duration. There were no randomised controlled trials, and the overall evidence base supporting the AAJT-S was low. CONCLUSIONS: There are limited data of safety and effectiveness of the AAJT-S. However, there is a requirement for a far-forward solution to improve NCTH outcomes, the AAJT-S is an attractive option and high-quality evidence is unlikely to be reported in the near future. Therefore, if this is implemented into clinical practice without a solid evidence base it will need a robust governance and surveillance process, similar to resuscitative endovascular balloon occlusion of the aorta, with regular audit of use.

Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014).

INTRODUCTION: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.

Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study.

BACKGROUND: Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI). OBJECTIVE: We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study. METHODS: A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy. RESULTS: 34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients. CONCLUSIONS: In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route. TRIAL REGISTRATION NUMBER: RCDM/Res/Audit/1036/12/0162.

Anterior chamber gas bubbles in open globe injury.

We present a case of a 40-year-old soldier who was in close proximity to the detonation of an improvised explosive device (IED). Bubbles of gas were visible within the anterior chamber of his left eye. The authors propose that intraocular gas, present acutely after trauma, is diagnostic of open globe injury and is of particular importance in remote military environments.