Management of children in the deployed intensive care unit at Camp Bastion, Afghanistan

A narrative review of damage control resuscitation for paediatric trauma patients in Iraq and Afghanistan from 2001 to 2016

Introduction

Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments.

Methodology

A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included.

Results

Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA.

Conclusion

The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.

Strengthening the emergency health response to children wounded by explosive weapons in conflict

The 2022 war in Ukraine has highlighted the unacceptable consequences wrought on civilians and health infrastructure by conflict. Children are among the most vulnerable of those affected and constitute an increasing percentage of non-combatants injured in conflicts globally. A disproportionate number of these injuries are caused by blast mechanisms from munitions including ‘conventional’ landmines and indiscriminate explosive weapons such as barrel bombs and improvised explosive devices. In 21st century conflict, children are no longer only accidental casualties of war, but are increasingly targeted by parties through acts such as bombing of school buses and playgrounds, conscription as child soldiers, and use as human shields. In the present viewpoint article, we review the state of pediatric blast injury studies, synthesizing current understandings of injury epidemiology and identifying gaps in research to advance the field towards a concrete agenda to improve care for this vulnerable population.

Characterization of Humanitarian Trauma Care by US Military Facilities During Combat Operations in Afghanistan and Iraq

OBJECTIVE

To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations.

BACKGROUND

International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949 these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements and outcomes of civilian trauma in combat zones has not been previously characterized.

METHODS

Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005-2019. Inclusion criteria were civilians and non-NATO coalition personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.

RESULTS

A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age >13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median injury severity score (ISS) was 9 in each cohort with ISS scores ≥ 25 in 2,236 (13.4%) civilians and 1,398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5,850 civilians received a transfusion with 2,118 (12.6%) of them receiving ≥10 units; 4,590 NNCPs received a transfusion with 1,669 (12.6%) receiving ≥ 10 units. MTF mortality rates were civilians 1,263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and non-operative, were similar between both groups.

CONCLUSIONS

In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as non-NATO Coalition Personnel. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.

Pediatric Blast Trauma: A Systematic Review and Meta-Analysis of Factors Associated with Mortality and Description of Injury Profiles

Introduction:

Blast polytrauma is among the most serious mechanisms of injury confronted by medical providers. There are currently no specific studies or guidelines that define risk factors for mortality in the context of pediatric blast injuries or describe pediatric blast injury profiles.

Objective:

The objectives of this study were to evaluate risk factors for pediatric mortality and to describe differences in injury profiles between explosions related to terrorism versus unrelated to terrorism within the pediatric population.

Methods:

A PRISMA systematic review and meta-analysis was performed where articles published from the years 2000-2021 were extracted from PubMed. Mortality and injury profile data were extracted from articles that met inclusion criteria. A bivariant unadjusted odds ratio (OR) analysis was performed to establish protective and harmful factors associated with mortality and to describe the injury profiles of blasts related to terrorism. Statistical significance was established at P < .05.

Results:

Thirty-eight articles were included and described a total of 222,638 unique injuries. Factors associated with increased mortality included if the explosion was related to terrorism (OR = 32.73; 95% CI, 28.80-37.21; P < .05) and if the explosion involved high-grade explosives utilized in the Global War on Terror ([GWOT] OR = 1.28; 95% CI, 1.04-1.44; P < .05). Factors associated with decreased mortality included if the patient was resuscitated in a North Atlantic Treaty Organization (NATO)-affiliated combat trauma hospital (OR = 0.48; 95% CI, 0.37-0.62; P < .05); if the explosive was fireworks (OR = 3.20×10-5; 95% CI, 2.00×10-6-5.16×10-4; P < .05); and if the explosion occurred in the United States (OR = 2.40×10-5; 95% CI, 1.51×10-6-3.87×10-4; P < .05). On average, victims of explosions related to terrorism were 10.30 years old (SD = 2.73) with 68.96% (SD = 17.58%) of victims reported as male. Comparison of victims of explosions related to terrorism revealed a higher incidence of thoracoabdominal trauma (30.2% versus 8.6%), similar incidence of craniocerebral trauma (39.5% versus 43.1%), and lower incidence of extremity trauma (31.8% versus 48.3%) compared to victims of explosions unrelated to terrorism.

Conclusion:

Explosions related to terrorism are associated with increased mortality and unique injury profiles compared to explosions unrelated to terrorism in the pediatric population. Such findings are important for optimizing disaster medical education of pediatric providers in preparation for and management of acute sequelae of blast injuries—terror-related and otherwise.

Pediatric casualties in contemporary armed conflict: A systematic review to inform standardized reporting

BACKGROUND

Children represent a significant percentage of casualties in modern conflict. Yet, the epidemiology of conflict-related injury among children is poorly understood. A comprehensive analysis of injuries sustained by children in 21^st-century armed conflict is necessary to inform planning of local, military, and humanitarian health responses.

METHODS

We conducted a systematic search of databases including PubMed, Embase, Web of Science, World Health Organization Catalog, and Google Scholar to identify records that described conflict-related injuries sustained by children since 2001.

RESULTS

The search returned 5,264 records. 9 eligible reports without potentially duplicative data were included in analysis, representing 5,100 pediatric patients injured in 5 conflicts. Blast injury was the most frequent mechanism (57%), compared to 24.8% in adults. Mortality was only slightly higher among children (11.0% compared to 9.8% among adults; p <0.05). Non-uniform reporting prevented pooled analysis and limited the conclusions that could be drawn.

CONCLUSIONS

Children sustain a higher proportion of blast injury than adults in conflict. Existing data do support the conclusion that child casualties have higher mortality than adults overall; however, this difference is slighter than has been previously reported. Specific subpopulations of children appear to have worse outcomes. Overall, non-uniform reporting renders currently available data insufficient to understand the needs of children injured in modern conflict.

Blast injuries in children: a mixed-methods narrative review

BACKGROUND AND SIGNIFICANCE

Blast injuries arising from high explosive weaponry is common in conflict areas. While blast injury characteristics are well recognised in the adults, there is a lack of consensus as to whether these characteristics translate to the paediatric population. Understanding blast injury patterns in this cohort is essential for providing appropriate provision of services and care for this vulnerable cohort.

METHODS

In this mixed-methods review, original papers were screened for data pertaining to paediatric injuries following blasts. Information on demographics, morbidity and mortality, and service requirements were evaluated. The papers were written and published in English from a range of international specialists in the field.

RESULTS

Children affected by blast injuries are predominantly male and their injuries arise from explosive remnants of war, particularly unexploded ordinance. Blasts show increased morbidity and mortality in younger children, while older children have injury patterns similar to adults. Head and burn injuries represent a significant cause of mortality in young children, while lower limb morbidity is reduced compared with adults. Children have a disproportionate requirement for both operative and non-operative service resources, and provisions for this burden are essential.

CONCLUSIONS

Certain characteristics of paediatric injuries arising from blasts are distinct from that of the adult cohort, while the intensive demands on services highlight the importance of understanding the diverse injury patterns in order to optimise future service provisions in caring for this child blast survivor.

Effects of armed conflict on child health and development: A systematic review

BACKGROUND

Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development.

METHODS

A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425.

FINDINGS

Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce.

INTERPRETATION

The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.

Violence against children in Afghanistan: Concerns and opportunities for positive change

Violence against children (VAC) in Afghanistan is a serious issue in the context of many decades of conflict and poverty. To date, limited studies have explored the extent of VAC in Afghanistan and the settings where VAC takes place. To understand (i) the extent of VAC, (ii) settings where VAC takes place, (iii) parental forms of VAC and (iv) regional differences, an interview administered cross-sectional survey was employed among a community sample of 145 children and 104 parents living within Kabul, Torkham, and Jalalabad. Demographic information was collected as well as items from the International Child Abuse Screening Tool (ICAST-CH). In this study, 71% of children reported experiencing physical violence is some form in the past year. Home was the most likely location of violence. The overwhelming majority of parents reported using physical violence as a discipline method. Parents who attained higher levels of education and had more skilled occupations used violence less as a discipline method. However, consistent with international research, children cited their parents as their preferred source of support in situations of violence. Interestingly, parents did not see violent forms of discipline as more effective than non-violent strategies. The results offer a disturbing yet 'on the ground' insight into VAC in Afghanistan from the experience of children and parents. The results have important implications for programming design and provide a focus for stopping and preventing VAC in Afghanistan and similar contexts.

[And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]

In light of the recent terrorist attacks in Europe, we need to reconsider the organization of rescue and medical management and plan for an attack involving multiple pediatric victims. To ensure quick surgical management, but also to minimize risk for on-site teams (direct threats from secondary terrorist attacks targeting deployed emergency services), it is crucial to evacuate patients in a swift but orderly fashion. Children are vulnerable targets in terrorist attacks. Their anatomical and physiological characteristics make it likely that pediatric victims will suffer more brain injuries and require more, often advanced, airway management. Care of multiple pediatric victims would also prove to be a difficult emotional challenge. Civilian medical teams have adapted the military-medicine principles of damage control in their medical practice using the MARCHE algorithm (Massive hemorrhage, Airway, Respiration [breathing], Circulation, Head/Hypothermia, Evacuation). They have also learned to adapt the level of care to the level of safety at the scene. Prehospital damage control principles should now be tailored to the treatment of pediatric patients in extraordinary circumstances. Priorities are given to hemorrhage control and preventing the lethal triad (coagulopathy, hypothermia, and acidosis). Managing hemorrhagic shock involves quickly controlling external bleeding (tourniquets, hemostatic dressing), using small volumes for fluid resuscitation (10-20ml/kg of normal saline), quickly introducing a vasopressor (noradrenaline 0.1μg/kg/min then titrate) after one or two fluid boluses, and using tranexamic acid (15mg/kg over 10min for loading dose, maximum 1g over 10min). Prehospital resources specifically dedicated to children are limited, and it is therefore important that everyone be trained and prepared for a scene with multiple pediatric patients.

Lessons from the organisation of the UK medical services deployed in support of Operation TELIC (Iraq) and Operation HERRICK (Afghanistan)

This paper provides the definitive record of the UK Defence Medical Services (DMS) lessons from the organisation of medical services in support of Operation (Op) TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis involved a detailed review of the published academic literature, internal post-operational tour reports and post-tour interviews. The list of lessons was reviewed through three Military Judgement Panel cycles producing the single synthesis 'the golden thread' and eight 'silver bullets' as themes to institutionalise the learning to deliver the golden thread. One additional theme, mentoring indigenous healthcare systems and providers, emerged as a completely new capability requirement. The DMS has established a programme of work to implement these lessons.

'A band of brothers'-an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study

AIMS

To identify and explore features of ethical issues that senior clinicians faced as deployed medical directors (DMDs) to the British Field Hospital in Afghanistan as well as to determine the ethical training requirements for future deployments.

METHOD

A qualitative study in two phases conducted from November 2014 to June 2015. Phase 1 analysed 60 vignettes of cases that had generated ethical dilemmas for DMDs. Phase 2 included focus groups and an interview with 13 DMDs.

FINDINGS

Phase 1 identified working with limited resources, dual conflict of meeting both clinical and military obligations and consent of children as the most prevalent ethical challenges. Themes found in Phase 2 included sharing clinical responsibilities with clinicians from other countries and not knowing team members' ways of working, in addition to the themes from Phase 1.

DISCUSSION

This study has drawn together examples of scenarios to form a repository that will aid future training. Recommendations included undertaking ethics training together as a team before, during and after deployment which must include all nationalities who are assigned to the same operational tour, so that different ethical views can be explored beforehand.

Characteristics and values of a British military nurse. International implications of War Zone qualitative research

BACKGROUND

Between 2001 and 2014, British military nurses served in Afghanistan caring for both Service personnel and local nationals of all ages. However, there have been few research studies assessing the effectiveness of the military nurses' operational role and no papers naming the core values and characteristics. This paper is from the only qualitative nursing study completed during this period where data was collected in the War Zone.

OBJECTIVE

To explore the characteristics and values that are intrinsic to military nurses in undertaking their operational role.

DESIGN

A constructivist grounded theory was utilised. The authors designed the interview schedule, and then following a pilot study, conducted and transcribed the discussions. Informed consent and UK Ministry of Defence Research Ethical Committee approval was obtained.

SETTING

Camp Bastion Hospital, Afghanistan, in 2013.

METHOD

Semi-structured interviews were conducted with 18 British Armed Forces nurses.

RESULTS

A theoretical model was developed that identifies the intrinsic characteristics and values required to be a military nurse. Nursing care delivered within the operational environment was perceived as outstanding. Nurses consciously detached themselves from any legal processes and treated each casualty as a vulnerable patient, resulting in care, compassion and dignity being provided for all patients, irrespective of their background, beliefs or affiliations.

CONCLUSION

The study findings provide military nurses with a framework for a realistic personal development plan that will allow them to build upon their strengths as well as to identify and ameliorate potential areas of weakness. Placing nurses first, with a model that focusses on the requirements of a good nurse has the potential to lead to better patient care, and improve the quality of the tour for defence nurses. These findings have international implications and have the potential for transferability to any level of military or civilian nursing practice.