Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury

Neuro damage control: current concept and civilian applications

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the 'bloody vicious circle' of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.). DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.

Injury scoring systems for blast injuries: a narrative review

Injury scoring systems can be used for triaging, predicting morbidity and mortality, and prognosis in mass casualty incidents. Recent conflicts and civilian incidents have highlighted the unique nature of blast injuries, exposing deficiencies in current scoring systems. Here, we classify and describe deficiencies with current systems used for blast injury. Although current scoring systems highlight survival trends for populations, there are several major limitations. The reliable prediction of mortality on an individual basis is inaccurate. Other limitations include the saturation effect (where scoring systems are unable to discriminate between high injury score individuals), the effect of the overall injury burden, lack of precision in discriminating between mechanisms of injury, and a lack of data underpinning scoring system coefficients. Other factors influence outcomes, including the level of healthcare and the delay between injury and presentation. We recommend that a new score incorporates the severity of injuries with the mechanism of blast injury. This may include refined or additional codes, severity scores, or both, being added to the Abbreviated Injury Scale for high-frequency, blast-specific injuries; weighting for body regions associated with a higher risk for death; and blast-specific trauma coefficients. Finally, the saturation effect (maximum value) should be removed, which would enable the classification of more severe constellations of injury. An early accurate assessment of blast injury may improve management of mass casualty incidents.

Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts

INTRODUCTION

Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes.

METHODS

The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables.

RESULTS

15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×10⁴, 95% CI 1.61×10⁴ to 110.6×10⁴, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001).

CONCLUSIONS

Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.

Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People's Liberation Army

The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army (PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia (MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level II facilities. In level III facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.