Lessons learned from early rehabilitation of complex trauma at the Royal Centre for Defence Medicine

Torso hemorrhage: noncompressible? never say never

Since limb bleeding has been well managed by extremity tourniquets, the management of exsanguinating torso hemorrhage (TH) has become a hot issue both in military and civilian medicine. Conventional hemostatic techniques are ineffective for managing traumatic bleeding of organs and vessels within the torso due to the anatomical features. The designation of noncompressible torso hemorrhage (NCTH) marks a significant step in investigating the injury mechanisms and developing effective methods for bleeding control. Special tourniquets such as abdominal aortic and junctional tourniquet and SAM junctional tourniquet designed for NCTH have been approved by FDA for clinical use. Combat ready clamp and junctional emergency treatment tool also exhibit potential for external NCTH control. In addition, resuscitative endovascular balloon occlusion of the aorta (REBOA) further provides an endovascular solution to alleviate the challenges of NCTH treatment. Notably, NCTH cognitive surveys have revealed that medical staff have deficiencies in understanding relevant concepts and treatment abilities. The stereotypical interpretation of NCTH naming, particularly the term noncompressible, is the root cause of this issue. This review discusses the dynamic relationship between TH and NCTH by tracing the development of external NCTH control techniques. The authors propose to further subdivide the existing NCTH into compressible torso hemorrhage and NCTH' (noncompressible but REBOA controllable) based on whether hemostasis is available via external compression. Finally, due to the irreplaceability of special tourniquets during the prehospital stage, the authors emphasize the importance of a package program to improve the efficacy and safety of external NCTH control. This program includes the promotion of tourniquet redesign and hemostatic strategies, personnel reeducation, and complications prevention.

Effect of one session of mirror therapy on phantom limb pain and recognition of limb laterality in military traumatic lower limb amputees: a pilot study

Up to 70 % of military amputees suffer phantom limb pain (PLP), which is difficult to treat. PLP has been attributed to cortical reorganisation and associated with impaired laterality. Repeated sessions of mirror therapy (MT) can benefit PLP; however, anecdotal evidence suggests one MT session could be effective. In a one-group pretest and post-test design, 16 UK military unilateral lower limb amputees (median age: 31.0, 95% CI 25.0 to 36.8 years) undertook one 10 min MT session. Visual analogue scale (VAS) pain and laterality (accuracy and reaction time) measurements were taken pre-MT and post-MT. Median VAS PLP did not differ significantly between pre-MT 15 mm (2-53 mm) and post-MT 12 mm (1-31) (p=0.875) scores. For the amputated limb, there were no significant differences between pre-MT and post-MT scores for laterality accuracy, 95.3%, 95% CI 90.5% to 97.6% and 96.7%, 95% CI 90.0% to 99.4%, respectively (p=0.778), or reaction time, 1.42 s, 95% CI 1.11 to 2.11 s and 1.42 s, 95% CI 1.08 to 2.02 s, respectively (p=0.629). Laterality was also not different between limbs for accuracy, p=0.484, or reaction time, p=0.716, and did not correlate with PLP severity. No confounding variables predicted individual responses to MT. Therefore, one 10 min MT session does not affect laterality and is not effective as standard treatment for PLP in military lower limb amputees. However, substantial PLP improvement for one individual and resolution of a stuck phantom limb for another infers that MT may benefit specific patients. No correlation found between PLP and laterality implies associated cortical reorganisation may not be the main driver for PLP. Further research, including neuroimaging, is needed to help clinicians effectively target PLP.