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Military surgeons have gained familiarity and experience with mass casualty events (MCEs) as a matter of routine over the course of the last two conflicts in Afghanistan and Iraq. Over the same period of time, civilian surgeons have increasingly faced complex MCEs on the home front. Our objective is to summarize and adapt these combat surgery lessons to enhance civilian surgeon preparedness for complex MCEs on the home front. The authors describe the unique lessons learned from combat surgery over the course of the wars in Afghanistan and Iraq and adapt these lessons to enhance civilian surgical readiness for a MCE on the home front. Military Damage Control Surgery (mDCS) combines the established concept of clinical DCS (cDCS) with key combat situational awareness factors that enable surgeons to optimally care for multiple, complex patients, from multiple simultaneous events, with limited resources. These additional considerations involve the surgeon's role of care within the deployed trauma system and the battlefield effects. The proposed new concept of mass casualty DCS (mcDCS) similarly combines cDCS decisions with key factors of situational awareness for civilian surgeons faced with complex MCEs to optimize outcomes. The additional considerations for a civilian MCE include the surgeon's role of care within the regional trauma system and the incident effects. Adapting institutionalized lessons from combat surgery to civilian surgical colleagues will enhance national preparedness for complex MCEs on the home front.

Background: Posttraumatic pulmonary embolism is historically diagnosed after clinical deterioration within the first week after injury. An increasing prevalence of immediate and asymptomatic pulmonary embolism have been reported in civilian and military trauma, termed hereafter as acute peritraumatic pulmonary thrombus (APPT). The objective of this study was to define the frequency of APPT diagnosed by computed tomographic (CT) imaging in wartime casualties. An additional objective was to identify factors, which may be associated with this radiographic finding, Methods: A 1-year retrospective cohort analysis conducted using the US and UK Joint Theater Trauma Registries performed to determine the prevalence of and risk factors for the diagnosis of APPT in casualties admitted to Bastion Hospital, Afghanistan. APPT imaging characteristics were collected, and demographics, injury severity and mechanism, and risk factors were included in the analysis. Logistic regression was used to identify factors independently associated with APPT., Results: APPT was found in 66 (9.3%) of 708 consecutive trauma admissions, which received a CT chest with intravenous contrast as part of their initial evaluation. Diagnosis of APPT at the time of injury was made in 23 patients (3.2%), while thrombus was detected in 43 additional patients (6.1%) at the time of reexamination of CT images. Of the APPTs, 47% (n = 31) were central, 38% (n = 25) were segmental, and 15% (n = 10) were subsegmental. Forty-seven percent (n = 31) had bilateral APPT. Logistic regression found presence of deep venous thrombosis on admission (odds ratio, 5.75; 95% confidence interval, 2.44-13.58; p < 0.0001) and traumatic amputation (odds ratio, 2.53; 95% confidence interval, 1.10-5.85; p = 0.030) to be independently associated with APPT. All APPTs were felt to be incidental and likely would not have required interventions such as anticoagulation or vena caval interruption., Conclusion: This report is the first to characterize acute, peritraumatic pulmonary thrombus in combat injured. Nearly 1 in 10 patients with severe wartime injury has findings of pulmonary thrombus on CT imaging, although many instances require repeat examination of initial images to identify the clot. APPT is a phenomenon of severe injury and associated with deep venous thrombosis and lower-extremity traumatic amputation. Additional study is needed to characterize the natural history of peritraumatic pulmonary thrombus and the indications for anticoagulation or vena cava filter devices.

Introduction: Pedal cycling in cities has the potential to deliver significant health and economic benefits for individuals and society. Safety is the main concern for potential cyclists although the statistical risk of death is low. Little is known about the severity of injuries sustained by city cyclists and their outcome., Aim: The aim of this study was to characterise the physiological status and injury profile of cyclists admitted to our urban major trauma centre (MTC)., Methods: Database analysis of cyclist casualties between 2004 and 2009. The physiological parameters examined were admission systolic blood pressure (SBP), admission base deficit and prehospital Glasgow Coma Scale., Results: 265 cyclists required full trauma-team activation. 82% were injured during a collision with a motorised vehicle. The majority (73%) had collided with a car or a heavy goods vehicle (HGV). These casualties formed the cohort for further analysis. Cyclists who collided with an HGV were more severely injured and had a higher mortality rate. Low SBP and high base deficit indicate that haemorrhagic shock is a key feature of HGV casualties., Conclusion: Collision with any vehicle can result in death or serious injury to a cyclist. Injury patterns vary with the type of vehicle involved. HGVs were associated with severe injuries and death as a result of uncontrollable haemorrhage. Awareness of this injury profile may aid prehospital management and expedite transfer to MTC care. Rapid haemorrhage control may salvage some, but not all, of these casualties. The need for continued collision prevention strategies and long-term outcome data collection in trauma patients is highlighted.

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 aim of this paper is to review all relevant military 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, air-conditioned 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.

Background: Key performance indicators (KPI) are tools for assessing process and outcome in systems of health care provision and are an essential component in performance improvement. Although KPI have been used in British military trauma for 10 years, they remain poorly defined and are derived from civilian metrics that do not adjust for the realities of field trauma care. Our aim was to modify current trauma KPI to ensure they more faithfully reflect both the military setting and contemporary evidence in order to both aid accurate calibration of the performance of the British Defence Medical Services and act as a driver for performance improvement., Method: A workshop was convened that was attended by senior, experienced doctors and nurses from all disciplines of trauma care in the British military. "Speciality-specific" KPI were developed by interest groups using evidence-based data where available and collective experience where this was lacking. In a final discussion these were streamlined into 60 KPI covering each phase of trauma management., Conclusion: The introduction of these KPI sets a number of important benchmarks by which British military trauma can be measured. As part of a performance improvement programme, these will allow closer monitoring of our performance and assist efforts to develop, train, and resource British military trauma providers.