Understanding the burden of injury in children from conflict: an analysis of radiological imaging from a Role 3 hospital in Afghanistan in 2011.

INTRODUCTION: There is a need for quality medical care for children injured in conflict, but a description of injuries and injury burden from blast and ballistic mechanisms is lacking. The radiology records of children imaged during the war in Afghanistan represent a valuable source of information about the patterns of paediatric conflict injuries. METHODS: The UK military radiological database was searched for all paediatric presentations to Camp Bastion during 2011. Reports and original images were reviewed to determine location and severity of injuries sustained. Additional information was obtained from imaging request forms and the Joint Theatre Trauma Register, a database of those treated at UK medical facilities in Iraq and Afghanistan. RESULTS: Radiology was available for 219 children. 71% underwent CT scanning. 46% suffered blast injury, 22% gunshot wounds (GSWs), and 32% disease and non-battle injuries (DNBIs). 3% had penetrating head injury, 11% penetrating abdominal trauma and 8% lower limb amputation, rates far exceeding those found in civilian practice. Compared with those with DNBI, those with blast or GSW were more likely to have serious (Abbreviated Injury Score, AIS, ≥3) injuries (median no. AIS ≥3 injuries were 1 for blast, 1 for GSW and 0 for DNBI, p<0.05) and children exposed to blast were more likely to have multiple body regions with serious injuries (OR for multiple AIS ≥3 injuries for blast vs DNBI=5.811 CI [1.877 to 17.993], p<0.05). CONCLUSIONS: Paediatric conflict injuries are severe, and clinicians used only to civilian practice may be unprepared for the nature and severity of injuries inflicted on children in conflict. Whole-body CT for those with conflict-related injuries, especially blast, is hugely valuable. We recommend that CT is used for paediatric assessment in blast and ballistic incidents and that national imaging guidelines amend the threshold for doing so.

Fluorescence and thermal imaging of non-melanoma skin cancers before and during photodynamic therapy.

BACKGROUND: Photodynamic therapy (PDT) has been shown to be less effective on the extremities. Protoporphyrin-IX (PpIX) fluorescence and skin surface temperature are variables that have been implicated in the differences in efficacy with body site, but objective studies have not been undertaken. OBJECTIVES: To further investigate observations from our previous study that temperature and fluorescence during pro-drug incubation are correlated, through a prospective objective investigation of the relationships between fluorescence and skin surface temperature before and during PDT and relationships with body site and efficacy. METHODS: Eighteen patients with Bowen's disease or basal cell carcinoma, who had been referred for PDT, were recruited to this study. PpIX fluorescence and thermal measurements were recorded at intervals during the pro-drug incubation and irradiation phases of PDT. Pain immediately after irradiation, and outcome at 3- and 12-months were recorded. RESULTS: Temperature and PpIX fluorescence were higher on the trunk than lower leg immediately before treatment (median temperature 32.7 °C vs. 27.8 °C, p < 0.05 and median fluorescence 16.5 vs. 6.7, p < 0.05). Higher pain levels were reported during PDT on the extremities (median 5.7 vs. 2.2, p < 0.05). Clearance rates at 12-months were 80 %. CONCLUSIONS: The study supports a correlation between temperature and PpIX fluorescence during PDT, providing robust objective data to support our previous hypothesis and observations. The higher pain levels, lower PpIX fluorescence on the lower leg, and the high efficacy rates at all body sites irrespective of temperature and fluorescence indicates that relationships between PDT treatment conditions and parameters is likely to be multifactorial.

Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement.

INTRODUCTION: Future conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions. METHODS: A three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities. RESULTS: Consensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement. CONCLUSIONS: Retaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

Minimum depths to essential structures in a UK military population using computed tomography: application to stab-resistant body armour.

INTRODUCTION: Edged weapons are a known domestic threat to the police forces of the UK. This threat is mitigated by wearing stab-resistant body armour that is either worn overtly or covertly depending on role. Although the UK military have traditionally focused their body armour design upon ballistic and fragmentation threats, future roles may require protection against an edged weapon threat. Since 2017, UK police body armour requirements for anatomical coverage for both edged weapon and ballistic threats are now based upon the requirements of UK military. This revised coverage may need additional research to determine minimum distances to essential structures. METHOD: Three entry locations and penetration vectors were chosen using the limited available information in the literature, in combination with a specialist in edged weapons defence. One hundred twenty CT trauma scans of male military service personnel were subsequently analysed to ascertain minimum distances from skin surface to the first structure encountered that is included in essential coverage (heart, aorta, vena cava, liver and spleen) at 3 specific entry points. RESULTS: Individuals ranged between 18 and 46 years, with a mean body mass index of 24.8. The absolute minimum depth from skin surface to a structure within the auspice of essential coverage was 17 mm to the liver in entry point 3 and 19 mm to the heart in entry point 2. CONCLUSIONS: Minimum distances to critical structures were significantly larger than those described in previous studies on civilians. This study will be used to supplement existing evidence to support existing UK police requirements for stab-resistant body armour. Using the weapon entry sites and vectors described in this study, overmatching to a behind armour depth of 17 mm would cover all of this population in this study.

Perioperative and early rehabilitation outcomes following osseointegration in UK military amputees.

INTRODUCTION: This paper examines the pain management, from surgery to specialist rehabilitation, of the first seven military transfemoral amputee patients treated in the UK with femoral osseointegration. All the patients had sustained complex ballistic injuries on the battlefield. The patients were characterised by long-standing problems with functional rehabilitation due to limitations with conventional prostheses, including stump soft tissue issues and impaired biomechanics. METHODS: A prospective service investigation was undertaken to evaluate the effectiveness of the pain management of patients undergoing osseointegration. Data were collected by daily direct patient contact, supplemented by a focused review of perioperative and rehabilitation case notes. Physiological and medication details were recorded with specific reference to systemic and regional analgesia and the impact of postoperative complications, including infection and accidental injury. RESULTS: Seven patients underwent femoral osseointegration and were followed up for a period of up to 3 years following surgery. The perioperative recovery was associated with significant escalation of analgesic requirements. Postoperative systemic inflammatory response syndrome was identified in six patients, with wound infection persisting in some cases into the rehabilitation phase. Three patients suffered femoral fractures following accidental injuries secondary to increased mobilisation following surgery. CONCLUSIONS: Successful surgical outcomes were achieved in a difficult patient cohort disadvantaged by previously restricted functional recovery from complex injuries. The importance of supporting the operative and recovery phases with a multidisciplinary pain service is emphasised. We offer this data and the lessons learnt to assist clinicians contemplating the establishment and service development of osseointegration services.

UK military helmet design and test methods.

The aim of this paper was to provide the military medical community with an expert summary of military helmets used by HM Armed Forces. The design of military helmets and test methods used to determine the fragmentation and non-ballistic impact protection are discussed. The helmets considered are Parachutist, Combat Vehicle Crewman, Mk6, Mk6A, Mk7 and VIRTUS. The helmets considered provide different levels of fragmentation and non-ballistic impact protection dictated by the materials available at the time of the helmet design and the end-user requirement. The UK Ministry of Defence defines the area of coverage of military helmets by considering external anatomical features to provide protection to the brain and the majority of the brainstem. Established test methods exist to assess the performance of the helmet with respect to the threats; however, these test methods do not typically consider anatomical vulnerability.

Additive manufacturing titanium components with isotropic or graded properties by hybrid electron beam melting/hot isostatic pressing powder processing.

A methodology has been demonstrated to consolidate Ti-6Al-4V powder without taking it to the liquid state by novel combination of the electron beam melting additive manufacture and hot isostatic pressing processes. This results in improved static mechanical properties (both strength and yield) in comparison to standard EBM processed material. In addition, the ability to generate microstructurally graded components has been demonstrated by generating a component with a significant change in both microstructure and mechanical properties. This is revealed by the use of electron backscattered diffraction and micro hardness testing to produce maps showing a clear distinction between materials consolidated in different ways. The variation in microstructure and mechanical properties is attributed to the different thermal history experienced by the material at different locations. In particular, it is found that the rapid cooling experienced during EBM leads to a typical fine α lath structure, whereas a more equiaxed α grains generated by diffusion is found in HIP consolidated powder.

Edged weapons awareness.

Edged weapons (sometimes referred to as sharp weapons or blades) are an increasing threat to military personnel, the blue light community (police, ambulance, firefighters, other first responders) and the general public worldwide. The use of edged weapons in criminal and terrorist incidents internationally means the forensic community needs an awareness of the technology of edged weapons, how they are used, the damage (clothing and wounding) that might be caused and any other forensic implications. In this paper, the magnitude of the problem is presented, prior research summarised and implications for forensic investigations discussed.

The use of gelatine in wound ballistics research.

Blocks of gelatine are used in both lethality and survivability studies for broadly the same reason, i.e. comparison of ammunition effects using a material that it is assumed represents (some part of) the human body. The gelatine is used to visualise the temporary and permanent wound profiles; elements of which are recognised as providing a reasonable approximation to wounding in humans. One set of researchers aim to improve the lethality of the projectile, and the other to understand the effects of the projectile on the body to improve survivability. Research areas that use gelatine blocks are diverse and include ammunition designers, the medical and forensics communities and designers of ballistic protective equipment (including body armour). This paper aims to provide an overarching review of the use of gelatine for wound ballistics studies; it is not intended to provide an extensive review of wound ballistics as that already exists, e.g. Legal Med 23:21-29, 2016. Key messages are that test variables, projectile type (bullet, fragmentation), impact site on the body and intermediate layers (e.g. clothing, personal protective equipment (PPE)) can affect the resulting wound profiles.

Neuropathic pain treatment and research: experiences from the United Kingdom mission to Afghanistan and future prospects.

The Defence Medical Services (DMS) of the United Kingdom (UK) assumed command of the Role 3 Medical Treatment Facility field hospital during Operation HERRICK in Afghanistan from April 2006 until the final drawdown in November 2014. The signature injury sustained by coalition personnel during this period was traumatic amputation from improvised explosive devices. Many patients who had suffered extensive tissue damage experienced both nociceptive and neuropathic pain (NeuP). This presented as a heterogeneous collection of symptoms that are resistant to treatment. This paper discusses the relationship of NeuP in the context of ballistic injury, drawing in particular on clinical experience from the UK mission to Afghanistan, Operation HERRICK. The role of this paper is to describe the difficulties of assessment, treatment and research of NeuP and make recommendations for future progress within the DMS.

Does preliminary optimisation of an anatomically correct skull-brain model using simple simulants produce clinically realistic ballistic injury fracture patterns?

Ballistic head injury remains a significant threat to military personnel. Studying such injuries requires a model that can be used with a military helmet. This paper describes further work on a skull-brain model using skulls made from three different polyurethane plastics and a series of skull 'fills' to simulate brain (3, 5, 7 and 10% gelatine by mass and PermaGel™). The models were subjected to ballistic impact from 7.62 × 39 mm mild steel core bullets. The first part of the work compares the different polyurethanes (mean bullet muzzle velocity of 708 m/s), and the second part compares the different fills (mean bullet muzzle velocity of 680 m/s). The impact events were filmed using high speed cameras. The resulting fracture patterns in the skulls were reviewed and scored by five clinicians experienced in assessing penetrating head injury. In over half of the models, one or more assessors felt aspects of the fracture pattern were close to real injury. Limitations of the model include the skull being manufactured in two parts and the lack of a realistic skin layer. Further work is ongoing to address these.

Primary blast lung injury - a review.

Bomb or explosion-blast injuries are likely to be increasingly encountered as terrorist activity increases and pre-hospital medical care improves. We therefore reviewed the epidemiology, pathophysiology and treatment of primary blast lung injury. In addition to contemporary military publications and expert recommendation, an EMBASE and MEDLINE search of English speaking journals was undertaken using the medical subject headings (MeSHs) 'blast injury' and 'lung injury'. Review articles, retrospective case series, and controlled animal modelling studies published since 2000 were evaluated. 6-11% of military casualties in recent conflicts have suffered primary blast lung injury but the incidence increases to more than 90% in terrorist attacks occurring in enclosed spaces such as trains. The majority of victims require mechanical ventilation and intensive care management. Specific therapies do not exist and treatment is supportive utilizing current best practice. Understanding the consequences and supportive therapies available to treat primary blast lung injury are important for anaesthetists.

A 'mixed reality' simulator concept for future Medical Emergency Response Team training.

The UK Defence Medical Service's Pre-Hospital Emergency Care (PHEC) capability includes rapid-deployment Medical Emergency Response Teams (MERTs) comprising tri-service trauma consultants, paramedics and specialised nurses, all of whom are qualified to administer emergency care under extreme conditions to improve the survival prospects of combat casualties. The pre-deployment training of MERT personnel is designed to foster individual knowledge, skills and abilities in PHEC and in small team performance and cohesion in 'mission-specific' contexts. Until now, the provision of airborne pre-deployment MERT training had been dependent on either the availability of an operational aircraft (eg, the CH-47 Chinook helicopter) or access to one of only two ground-based facsimiles of the Chinook's rear cargo/passenger cabin. Although MERT training has high priority, there will always be competition with other military taskings for access to helicopter assets (and for other platforms in other branches of the Armed Forces). This paper describes the development of an inexpensive, reconfigurable and transportable MERT training concept based on 'mixed reality' technologies-in effect the 'blending' of real-world objects of training relevance with virtual reality reconstructions of operational contexts.

AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.

Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Modelling primary blast lung injury: current capability and future direction.

Primary blast lung injury frequently complicates military conflict and terrorist attacks on civilian populations. The fact that it occurs in areas of conflict or unpredictable mass casualty events makes clinical study in human casualties implausible. Research in this field is therefore reliant on the use of some form of biological or non-biological surrogate model. This article briefly reviews the modelling work undertaken in this field until now and describes the rationale behind the generation of an in silico physiological model.

Use of illuminance as a guide to effective light delivery during daylight photodynamic therapy in the U.K.

BACKGROUND: Daylight PDT (dPDT) is an effective and nearly painless treatment for field-change actinic keratosis. Measuring the protoporphyrin-IX (PpIX)-weighted exposure dose can give an indication of when conditions are most viable for effective dPDT. It would be advantageous for practitioners if more detailed information of exposure dose and appropriate treatment conditions were available. Where sophisticated measurement equipment is unavailable, simpler and more cost-effective methods of dose measurement are desirable. OBJECTIVES: To devise a model whereby illuminance data can be converted into PpIX-weighted exposure dose, and to use this model to estimate appropriate times for dPDT across the U.K. and Ireland. METHODS: Spectral irradiance data were analysed to obtain a conversion model for illuminance to PpIX-weighted dose. This model was applied to historic illuminance data from nine sites to obtain PpIX-weighted dose across the U.K. and Ireland. Temperature data and an analysis of conservatory-based dPDT were also considered. RESULTS: Distribution of the expected PpIX-weighted dose across the nine locations is presented. Temperature data showed that it could be too cold for dPDT, even when there is sufficient light exposure. Conservatory-based dPDT could extend the times in the year for possible treatment. CONCLUSIONS: This proposed conversion model provides a means of using an illuminance reading to calculate the PpIX-weighted exposure dose. Dosimetry of dPDT may be carried out simply and at low cost using the presented method; however, the results presented may be used as a guide for those considering dPDT, without the need to conduct measurements themselves.