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BackgroundCOVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template.MethodsAn 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1–9 (where 1–3 is inappropriate, 4–6 is uncertain and 7–9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again.ResultsDisagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease.ConclusionThe expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.

We report the case of a 69-year-old man admitted to the emergency department of a UK district general hospital with an extradural haematoma following closed head injury. He deteriorated rapidly before transfer to the regional neurosurgical centre and was treated with decompression of the extradural haematoma through an EZ-IO™ intraosseous needle in our department, with telephone guidance from the neurosurgeon. We believe this to be the first reported use of this technique in a district general hospital.

War and conflict have long been associated with improvements in medical care. The recent conflicts in Afghanistan and Iraq have been no exception. The high tempo of operations has presented the United Kingdom’s Defence Medical Services (DMS) with the need to care for injured service personnel and local nationals with highly complex patterns of injury. Patients have presented to the DMS with injuries not commonly encountered in civilian practice—typically the result of blast and ballistic mechanisms. The deployed anaesthetist is involved in all stages of the patient pathway from point of wounding to the emergency department, through the resuscitative period encompassed by the damage control construct; to the critical care delivered on the ground and in the air and finally back in the United Kingdom at the interface with the civilian National Health Service. The high quality of care delivered in association with rigorous clinical audit and research including laboratory physical science, has produced developments that not only impact on military outcomes, but which are being introduced in wider civilian practice. This chapter covers all these areas from first principles to the management of pain and advances in the understanding of coagulopathy.

Military trauma victims are injured often more severely and by mechanisms different from civilian equivalents,1 with major hemorrhage being the principal cause of preventable death.2 The military environment presents special challenges to medical teams, often with difficult evacuation from the battlefield to the field hospital and definitive care and constrained resources, including the supply of blood and clotting products.The past decade has seen a revolution in the military approach to the management of major trauma, based on new insights into the pathophysiology of coagulopathy and hemorrhage. In the United Kingdom Defence Medical Services (UK-DMS), advances have been achieved in a number of complementary areas

Blast injury results in a complex pattern of tissue injury, inflammation and coagulopathy, presenting great challenges in clinical management. The pathophysiology of blast-associated inflammation and coagulopathy is only partially understood and there remains a great deal of uncertainty over management strategies.

When traditional vascular access methods fail, emergency access through the intraosseous (IO) route can be lifesaving. Fluids, medications, and blood components have all been delivered through these devices. We sought to compare the performance of IO devices placed in the sternum, humeral head, and proximal tibia using a fresh human cadaver model.Commercially available IO infusion devices were placed into fresh human cadavers: sternum (FAST-1), humeral head (EZ-IO), and proximal tibia (EZ-IO). Sequentially, the volume of 0.9% saline infused into each site under 300 mm Hg pressure over 5 minutes was measured. Rates of successful initial IO device placement and subjective observations related to the devices were also recorded.For 16 cadavers over a 5-minute bolus infusion, the total volume of fluid infused at the three IO access sites was 469 (190) mL for the sternum, 286 (218) mL for the humerus, and 154 (94) mL for the tibia. Thus, the mean (SD) flow rate infused at each site was as follows: (1) sternum, 93.7 (37.9) mL/min; (2) humerus, 57.1 (43.5) mL/min; and (3) tibia, 30.7 (18.7) mL/min. The tibial site had the greatest number of insertion difficulties.This is the first study comparing the rate of flow at the three most clinically used adult IO infusion sites in an adult human cadaver model. Our results showed that the sternal site for IO access provided the most consistent and highest flow rate compared with the humeral and tibial insertion sites. The average flow rate in the sternum was 1.6 times greater than in the humerus and 3.1 times greater than in the tibia.

Aim To determine the characteristics of military traumatic cardiorespiratory arrest (TCRA), and to identify factors associated with successful resuscitation. Methods Data was collected prospectively for adult casualties suffering TCRA presenting to a military field hospital in Helmand Province, Afghanistan between 29 November 2009 and 13 June 2010. Results Data was available for 52 patients meeting the inclusion criteria. The mean age (range) was 25 (18–36) years. The principal mechanism of injury was improvised explosive device (IED) explosion, the lower limbs were the most common sites of injury and exsanguination was the most common cause of arrest. Fourteen (27%) patients exhibited ROSC and four (8%) survived to discharge. All survivors achieved a good neurological recovery by Glasgow Outcome Scale. Three survivors had arrested due to exsanguination and one had arrested due to pericardial tamponade. All survivors had arrested after commencing transport to hospital and the longest duration of arrest associated with survival was 24min. All survivors demonstrated PEA rhythms on ECG during arrest. When performed, 6/24 patients had ultrasound evidence of cardiac activity during arrest; all six with cardiac activity subsequently exhibited ROSC and two survived to hospital discharge. Conclusion Overall rates of survival from military TCRA were similar to published civilian data, despite military TCRA victims presenting with high Injury Severity Scores and exsanguination due to blast and fragmentation injuries. Factors associated with successful resuscitation included arrest beginning after transport to hospital, the presence of electrical activity on ECG, and the presence of cardiac movement on ultrasound examination.

We thank the correspondents for their interest in our research nd we read with interest their comments on the appropriateness f attempting resuscitation from traumatic cardiorespiratory arrest TCRA) in the military prehospital environment. Our first comment ould be that, as with US military doctrine, current UK military proocol is not to attempt resuscitation from cardiorespiratory arrest n the presence of “effective enemy fire” on the battlefield.1 The esults of our study, where TCRA on the battlefield was universally atal despite attempted resuscitation, would seem to support this pproach.2 Recognising the difficulties of making absolute predictions of utility, it is however considered acceptable to attempt resuscitaion in a more permissive military prehospital environment.1 This s the situation frequently encountered during the current conflict n Afghanistan where the majority of fatal injuries are caused by mprovised explosive device (IED) explosions, often in the absence f additional enemy fire. It is perhaps not surprising, therefore, that ttempts were sometimes made by both UK and US first responers in our study to resuscitate these victims on the battlefield. lthough these attempts did ultimately prove futile, we are not ware of any additional injuries that were incurred as a result of hese actions. Finally, we would like to highlight the distinction between ttempting resuscitation on the battlefield and beginning resusitation on the UK helicopter-based Medical Emergency Response eam (MERT). This physician-delivered service is able to offer a umber of important interventions for these patients including aemorrhage control, advanced airway management, chest decomression and rapid volume resuscitation with uncrossmatched lood and fresh frozen plasma. This ability to bring emerency department-level therapies to the pre-hospital environment ppeared to contribute to the neurologically intact survival of one atient from our study, despite over 20 min of pre-hospital cariorespiratory arrest.