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Whole body computed tomography has become standard practice in many centres in the management of severely injured trauma patients, however, the evidence for it's diagnostic accuracy is limited.To assess the sensitivity of whole body CT in major trauma.Retrospective review of all patients with injury severity score (ISS) 15 presenting with blunt trauma to a UK Major Trauma Centre between May 2012 and April 2014. Injuries were classified as per ISS score-1 = head and neck 2 = face 3 = chest 4 = abdomen. The authors reviewed patient's electronic charts, radiological results; interventional procedure records, discharge letters and outpatient follow up documentation and referenced this with Trauma Audit and Research Network data.407 patients with ISS 15 presented to the Trauma centre during May 2012 and April 2014. Of these, 337 (82.8%) had a whole body CT scan. 246 pts were male, 91 were female. 74 (21.9%) were due to a fall from 2 m, 41 (12.2%) due to a fall from 2 m, 208 (61.7%) were due to motor vehicle crashes, 1 (0.3%) due to a blast injury, 5 (1.5%) due to blows, and 8 (2.4%) due to crush injuries. Sensitivity for Region 1 was 0.98, Region 2 = 0.98, Region 3 = 0.98 and Region 4 was 0.95. Overall sensitivity was 0.98. 15 injuries (2.4%) were not identified on initial CT (false -ve). These injuries were: colonic perforation = 1, splenic contusion = 1, pneumothorax = 1, liver laceration = 1, intracranial haemorrhage = 1, cerebral contusions = 1, spinal injuries = 7, canal haemorrhage = 1, maxilla fracture = 1.These results show that whole body CT in trauma has a high sensitivity and a low rate of missed injuries (2.4%). However, our study only evaluated a subgroup of patients with ISS 15 and further work is required to assess the use of this investigation for all major trauma patients.

The third stage ofdamage control (DC III) is a critical phase of thepatient’s care. Following unpacking and restorationof gastrointestinal continuity, the final step of DC IIIis closure of the abdominal wall. Frequently, this isnotpossibleasaresultofcontinuedboweledemaorretroperitoneal hematoma. In these patients theabdomen has to be managed open, eventually fol-lowedbyeitherdelayedclosureortheplacementofan absorbable mesh and subsequent delayed skingrafting. Even with meticulous care and dailyabdominal washouts, the incidence of fistula forma-tion during this process is significant.

Twenty-three thousand doctors in the UK have undertaken The Advanced Trauma Life Support Course for doctors over the past 12 years. The course was never designed to provide anything more than a framework within which inexperienced doctors could safely manage multiple injured patients until expert help arrived. Its critics will say that the course is didactic and its treatment protocols are not always up to date. Since its inception in 1976 in Nebraska it has undergone constant revision and the seventh edition of the course will appear in 2002. With each revision, evidence for new methods of management for the trauma victims are reviewed; some of these are discussed in this paper.

There has been a rapid increase in the use of laparoscopy in general surgery over recent years. However in the field of trauma its role has not been defined and its regular use remains limited to a select group of enthusiasts. We present a review of the current literature on laparoscopic surgery in trauma including therapeutic procedures and a brief synopsis of the alternative methods of investigation for abdominal injury, and our interpretation of the current role of laparoscopic surgery in trauma today.

In year 2000, there were approximately 4600 reported firearm injuries in the UK. Most large urban Accident & Emergency Departments can expect to manage at least 5-10 gunshot injuries per year. In the UK, these injuries tend to involve handguns or shotguns (rather than military-style weapons) and occur in inner-city areas, often being gang- or drug-related. The steady increase in the incidence of gun-associated violence in the UK has occurred despite the alteration in gun legislation that was introduced following a multiple shooting incident in Dunblane, UK, in 1996. The UK, however, remains towards the bottom of the ‘league’ of firearm deaths, with a rate of 0.3 per 100,000 population. In comparison, South Africa, with an estimated 8 million weapons in circulation, has a murder rate of 56 per 100,000, and the USA has a value of 10.6. Explosives cause unique injury patterns, devastating multiple wounds, and trauma to many body systems. The recognition, resuscitation and appropriate management of these injuries is vital. A wide range of weapons can be responsible for ballistic-type injuries, including handguns, automatic assault rifles, bombs, mines and fragments. Whilst it is important to ‘treat the wound and not the weapon’, an understanding of ballistics and injury patterns is valuable, as these wounds can be complex and involve multiple body systems.

Damage Control Surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma of the injury and surgery. In the past this has been very much focussed on abdominal trauma and the idea of performing an “abbreviated laparotomy.” However the concepts outlined here are applicable to injury beyond the abdomen.1-3

There are no published studies directly addressing the issue of what is an acceptable timeline from point of wounding to surgical intervention within the military context. The proximal threshold has previously been determined by personal opinion, tactical, logistic and practical imperatives rather than by clinical demands. The aimof this paper is to review all relevantmilitary and civilian studies where timelines have been quoted and to reach a number of unambiguous consensus statements to state the perceived ideal upper limits from point of wounding to holistic and realistic surgical care in modern war. An injured casualty should be transferred to an appropriate surgeon in an appropriate facility in as short a time from wounding as practical. It is clear that the best trauma surgery is performed in large, well resourced, well-supplied, airconditioned hospitals. Current advances aimed to stretch timelines from wounding to surgical intervention are exciting and hold potential but remain scientifically unproven and are currently without any firm evidence base. Further critical research is therefore necessary. The effect of pre-hospital haemostatic resuscitation, provided by the enhanced Medical Emergency Response Team (MERTe) on patient outcome and effective timelines is currently unknown and unproven: it does have intuitive medical merit. There is also a very significant moral and morale component. MERTe serves two main functions; reduction in time from point of wounding to advanced / haemostatic resuscitation and provision of in-flight diagnostics. Continuation of in-flight resuscitation then allows physician-led decision making on critically unstable casualties. This allows either an expedited straight move from the HLS direct to the operating theatre or direct transfer to a regional neurosurgical centre. To prevent avoidable death, our unequivocal conclusion is that there must be an upper limit of 2 hours from wounding to surgical intervention (surgical haemorrhage control) for all casualties.

Radio-opaque markers placed over entry and exit wounds, have been used to help evaluate penetrating injuries and provide a permanent record of wound location on plain radiographs. To date there are no published reports of the application of improvised bullet markers in the evaluation of penetrating injuries using computed tomography (CT). We report a series of 4 cases where bullet markers were used in combination with three-dimensional (3D) computerised tomography (CT) to ascertain the path of the bullets and to assess damage to vital structures. We believe that the use of bullet markers in penetrating trauma casualties undergoing CT is valuable in the surgical decision making process and allows planning of surgical approaches.

A 12-year-old boy presented to the field hospital in Afghanistan following a gunshot wound to his right buttock. He was cardiovascularly stable with no abdominal tenderness. Examination revealed a single wound on his right …

This text is part of a set (now in its second edition), providing an illustrated review of normal anatomy and its common variants, examination techniques and practical clinical considerations. This volume concentrates on the abdomen.

Medical facilities in all locations—urban, rural, or austere—need to prepare to receive casualties well before they arrive. In a civilian hospital, this is likely to involve activating the trauma team and notifying other key personnel. In a military field hospital, this preparation will include putting a system in place to remove safely the casualty’s weapons and ammunition (Figure 8-1). Casualties exposed to chemicals or other noxious agents will need decontamination before entering the hospital.

Summary Objective: To determine opportunities for improvement (OI) in the critical care management of severely injured patients in a general adult intensive care unit through a performance improvement (PI) process. Methods: Retrospective review of patient records from intensive care patients who had sustained traumatic injuries, except isolated head injury, over a 1-year period. Three assessors independently audited the notes using performance improvement methodology to determine complications, errors in management and preventability. Complications were included when two or more assessors independently detected the complication. Measurements and results: Records from 90 patients with a diagnosis of ‘trauma’ were reviewed, 14 patients with isolated head injury were excluded. The mean injury severity score was 23 (range 4–43). No complications or errors of management were identified from 41 patients, including ten patients who died. Seventy-two complications were identified in 35 patients including 15 pneumonias, 6 cases of peri-operative hypothermia and 5 recurrent pneumothoraces. Fourteen preventable complications were identified. Conclusions: The PI OI process highlighted specific opportunities for the improvement of critical care management of trauma patients in our unit. These will be addressed through the introduction of formal tertiary surveys and clinical management guidelines addressing hypothermia and management of coagulopathy.