Understanding occipital pressure sores in UK military casualties: a pilot study in healthy military personnel

INTRODUCTION

The high prevalence of occipital ulcers in UK military casualties observed during the conflict in Afghanistan is a multifactorial phenomenon. However, the consensus is that ulceration is triggered by excessive pressure that is maintained for too long during the use of the general service military stretcher. Thresholds for capillary occlusion are accepted benchmarks to define excessive pressure, but similar thresholds for safe/excessive duration of pressure application do not exist. To address this gap in knowledge, we propose to use the time it takes for a healthy person to feel pain at the back of the head as an initial indication of safe exposure to pressure.

METHODS

Healthy military personnel (16 male/10 female) were asked to lie motionless on a typical general service stretcher until they felt pain. Time-to-pain and the location of pain were recorded. To support the interpretation of results, baseline sensitivity to pain and pressure distribution at the back of the head were also measured. Independent samples t-test was used to assess differences between genders.

RESULTS

Twenty participants felt pressure-induced soft-tissue pain at the back of the head. The remaining six participants terminated the test due to musculoskeletal pain caused by poor ergonomic positioning. On average, pain at the occiput developed after 31 min (±14 min). Female participants were significantly more sensitive to pain (t(24)=3.038,p=0.006), but time-to-pain did not differ significantly between genders (p>0.05).

CONCLUSIONS

When people lie motionless on a typical military stretcher, the back of the head is the first area of the body that becomes painful due to pressure. The fact that pain develops in ≈30 min can help healthcare providers decide how frequently to reposition their patients who are unable to do this on their own. More research is still needed to directly link time-to-pain with time-to-injury.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

Delirium in critically ill military patients following trauma: A cohort analysis

Critically ill military trauma patients have been found to have a high incidence of psychological morbidity following their Intensive Care Unit (ICU) experience, including recall of significant auditory and visual hallucinations. It follows that this may be attributable to delirium, which has not been previously described in a young, previously fit population following trauma. The case-notes of 85 male patients (mean age 26 years), admitted to a single UK ICU following military trauma, were retrospectively assessed for delirium using DSM-IV criteria. Of the 993 ICU days assessed, 13.4% were delirium-positive, with just over half of patients (51.8%) experiencing at least one day of delirium. On delirium-positive days, 69.2% received a documented intervention, with the majority of interventions (66.4%) being pharmacological, commonly with a sedative or anti-psychotic. Presence of delirium was significantly associated with severity of injury, assessed by Injury Severity Score (OR 1.037, 95% CI 1.003-1.072, p = 0.031). Duration of ICU stay was significantly increased, from 4 to 8 days (p < 0.005), as was the duration of mechanical ventilation (for the 84.7% of patients who were ventilated) from 7 to 13 days (p < 0.005). Delirium is common in military trauma patients, despite their young age and premorbid fitness. A review of longer-term psychological outcomes should be considered.