JJK McNicholas, JD Henning. Major Military Trauma: Decision ...

Major Military Trauma: Decision Making in the
ICU
JJK McNicholas 1 , JD Henning 2
1 Consultant in Critical Care and Anaesthetics, MDHU Portsmouth, Queen Alexandra Hospital, Cosham, Portsmouth;
2 Consultant in Anaesthetics and Intensive Care, James Cook University Hospital, Middlesborough.
Abstract
The management of trauma in the field intensive care unit has evolved in recent years. Key issues in current practice and
organisation are discussed, with particular attention to areas where civilian and military practice differs. Possible future
improvements are explored.
Introduction
The development of modern trauma medicine and surgery has
been closely linked with warfare throughout recent history. This
is evident in critical care, as much as surgery and anaesthesia.
From the shock wards of the Great War, through the introduction
of positive pressure ventilation during the Vietnam War and
more recently the provision of sophisticated multi-organ
support [1], advances in civilian and military practice have been
complementary.
The modern field intensive care unit (ICU) is principally
required to provide early critical care to battle casualties. The aim
is to stabilise and provide organ support for up to 48 hours after
surgery, in preparation for repatriation to the casualty’s home
nation medical service. In addition, the facility must be ready
to provide more protracted critical care to all eligible casualties,
where no rearward evacuation is possible. It is also expected that
critical care be offered to eligible patients with disease and nonbattle
injuries (DNBI), and a wide variety of medical critical care
admissions have been described [2].
A number of important differences exist between military and
civilian critical care; the physical environment of the field hospital
is very different, with implications for manpower and logistics; the
hospital is more likely to be remote from other medical facilities;
the case mix differs from civilian practice, with more trauma and
different co-morbid diseases; and there is not necessarily any
separation of general and sub-specialty critical care.
Critical care medicine is a young specialty, which is rapidly
evolving. Military critical care must also evolve in response both
to changes in civilian practice, and to the rapidly changing nature
of warfare. Areas in which civilian and military critical care differ,
will be explored.
Manpower
The field intensive care unit is manned by nurses, health care
support workers, doctors and physiotherapists. Military personnel
from all three services are eligible. Medical staff are drawn from
a cadre of military consultants, both regular and reservist. This
Corresponding Author: Lt Col James McNicholas,
Consultant in Critical Care and Anaesthetics, Department
of Critical Care, Queen Alexandra Hospital, Cosham,
Portsmouth PO6 3LY.
Tel: 02392 286000 ext 5756. Fax 02392 286844.
Email: james.mcnicholas@porthosp.nhs.uk
group are generally specialists in adult intensive care medicine
in their UK practice, with base specialty background in either
anaesthetics or medicine. In smaller facilities with 4-6 ICU beds,
there will generally only be one such specialist for the hospital, so
they must be able to work in a single handed role. It is expected
that training will have involved some paediatric intensive care
medicine, and sub-specialty critical care for neurosurgery and
cardiothoracic surgery. The deployed intensive care unit has no
junior medical staff, so consultants must be ready to undertake
both junior and senior roles concurrently, and be able to prioritise
effectively at periods of high demand.
Nursing staff are drawn from different groups. The majority are
uniformed military nurses with a UK practice in adult intensive
care medicine. Some have been drawn from a broader pool of
critical care background, including neonatal intensive care and
coronary care. With an appropriate balance of skills in a given
team, this has worked well. In mature operations, military nurses
have been reinforced in recent years by civilian colleagues. This
has allowed military nurses to be available for service which
requires military training and skills. Staff are usually arranged in
three rotating teams. In the event of high capacity pressure, this
can be altered to two larger teams for a short period to permit
emergency beds to open.
Local clinical policy in UK intensive care practice is usually
formulated by a group of critical care consultants with different
interests and time is dedicated within job plans to permit this.
The single handed intensive care consultant in the field hospital
cannot draw on these resources when deployed. Clinical policies
are determined by uniformed clinicians in the UK. The Critical
Care Special Interest Group (CCSIG) is a committee within the
Department of Military Anaesthesia, Pain and Critical Care of
UK Joint Medical Command. The function of CCSIG is to act
as a senior staff group providing advice to the medical chain of
command on critical care matters. Membership is drawn from
UK military intensive care doctors, nurses and physiotherapists.
Military operations are increasingly multi-national. Defence
Medical Services have adapted organisational structures to reflect
this, with deployed UK facilities including both European and
US service personnel. Multi-national working requires careful
management of integration, because clinical roles, working
practices and clinical guidelines sometimes differ. In intensive care
this has been managed by experienced clinical leadership, both
medical and nursing. Forthcoming critical care clinical guidelines
for operations will also help.
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Intensive Care Decisions JJK McNicholas, JD Henning
Logistics
Despite improved logistics in recent years, the isolated nature
of the hospital means that the ICU needs to be able to support
itself as much as possible. It may not be possible to mount
a substantial resupply chain in the early phases of an entry
operation and even on mature campaigns the air bridge may be
interrupted at intervals. Equipment must therefore have certain
specific attributes to ensure it will meet the requirements of the
operational environment (Box 1). The potential conflict between
these constraints means that risk assessment will also need to be
robust. Examples of items which increase self sufficiency include
electrical items which can accept multiple power inputs should
generators fail, and ventilators which accept oxygen from low
pressure oxygen concentrators to minimise the use of cylinders.
The possibility of a surge requirement means that there must also
be redundancy in the unit equipment scale.
Robust
Dependable at extremes of temperature
Able to provide therapy to the best practice standard
Substantial battery backup
Physically small
Tactically packed
Intuitive to use
Box 1 Generic attributes of deployed intensive care equipment
As in civilian practice there is a requirement for a temperature
controlled logistic chain. If this should fail some drugs will lose
efficacy, and some become dangerous. A thorough knowledge of
how temperature can affect drugs is required.
Finally, it should be noted that personnel are in short supply
in the field environment, so all staff need to be able to carry out
user equipment checks and repairs, as well as having a good
understanding of resupply.
Admission and Discharge
The Intensive Care is described as ‘the degree of care of care,
which is extensive, highly technical and required because of the
patient’s actual or threatened inability to maintain function’ [3]. In
principle therefore, any patient who is too sick to be cared for on
an intermediate care bed, should be looked after in ICU until
they are well enough to be discharged, or transferred to another
Medical Treatment Facility (MTF). Operational ICUs however
have limited capacity, and can only remain open to admissions
by evacuating their patients early, preferably within 48 hours.
Many admissions are therefore of short duration. The ethics of
this are discussed elsewhere in this article, but the mechanics are
also important.
For the severely sick patient, the field ICU phase is often the first
occasion that there is time to review thoroughly what has happened.
A total review of the notes must be made and a tertiary survey
undertaken, with careful documentation of all injuries. There is
evidence from civilian literature that 40% of minor orthopaedic
injuries are missed in the emergency department (ED) [4].
Equally important is the preparation for discharge of the
ICU patient; by the time a patient gets to the home nation
ICU, they may have had nine handovers of care (Box 2). Robust
documentation is essential as is a contemporaneous copy of the
observations, because what may seem unimportant in the acute
event maybe of note later.
Buddy Aid to Team Medic
Team Medic to BATLS Medic
BATLS Medic to Role 1 Doctor
Role 1 to MERT
MERT to ED
ED to Theatre
Theatre to ICU
ICU to CCAST
CCAST to home nation ICU
Box 2 Sequential handovers in the route to home nation ICU. BATLS
– Battlefield Advanced Life Support; MERT – Medical Emergency
Response Team; ED – Emergency Department; ICU – Intensive Care
Unit; CCAST – Critical Care Air Support Team
Organ Support
The essential role of an ICU (on operations or not) is to support
failing organ systems in the critically sick patient. A broad range
of organ support is offered, commensurate with the requirements
of the particular case mix.
Respiratory Support
The ideal field ventilator should be able to support any manner of
lung injury. The recently introduced Vela Ventilator [5] provides
all modern modes of conventional invasive ventilation and permits
non-invasive ventilation. It represents a significant improvement
in the available range of respiratory support. This is timely
because soldiers are now surviving ever more profound injuries,
and the boundaries of conventional ventilation are being tested.
Severe blast lung responds well to high positive end expiratory
pressure (PEEP), but this can impair venous return, leading to
hypotension. This is more marked where there is concomitant
hypovolaemia, but also occurs in the volume-replete casualty.
Marked bronchopleural leaks can require asymmetric ventilation
with two ventilators via a double lumen endotracheal tube.
This strategy has also been used recently by one of the authors
for a devastating unilateral blast lung injury without thoracic
penetration, and led to a significant improvement in oxygenation.
Cardiovascular Support
Cardiovascular support in the multiply injured military patient
differs from usual civilian practice. The trained soldier maintains
a very high level of physical fitness and resting cardiovascular
parameters will not be normal. Resting blood pressure and heart
rate are likely to be lower than the civilian population and skeletal
muscle mass may be greater. Vasoactive drugs are not frequently
used in the early phase and indeed may be detrimental [6], as oxygen
delivery and organ perfusion can usually be maintained with
volume resuscitation. Subsequently, in some but not all casualties,
there may be a phase of profound inflammatory response, with
vasodilatation secondary to release of cytokines. This group may
develop a vasoactive drug requirement. Complicating this may be
the effect of blast on the heart, which is poorly understood. There
is a clear need to understand the mechanics of the circulatory
system in this group of patients, and to define resuscitation end
points which confer outcome benefit.
Gastrointestinal Support
Early enteral feeding of critically ill patients has been shown to
decrease the incidence of ventilator acquired pneumonia, and
possibly decrease length of stay (LOS) on ICU [7]. However, many
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Intensive Care Decisions
of the patients admitted to field ICUs will be transported by air
within 48 hours of admission. It is possible that the accelerations
and pressure changes of air transport may predispose to aspiration
if the stomach is full. Early feeding may therefore be detrimental,
if transport is imminent. This is the subject of current research.
Trauma patients also have a high metabolic load, and may need
a higher calorie intake than other ICU patients for the benefits of
decreased LOS and morbidity to occur. Delayed feeding may lead
to a marked calorie deficit early in their stay, which may never be
made up [8].
It is also established that this group of patients has a high
incidence of Abdominal Compartment Syndrome. This can impair
ventilation and renal function and potentially cause circulatory
collapse. It is therefore essential that abdominal pressure is
measured routinely. In order to avoid this complication, delayed
primary closure for abdominal wounds is now well accepted.
Renal Support
Renal support in ICU is traditionally with Continuous Venovenous
Haemofiltration (CVVHF), but this is usually not available in the
field hospital as it is resource intensive (CVVHF may use 60 litres
of fluid per day) and may increase ICU length of stay [9]. Some
authors have advocated the use of peritoneal dialysis instead of
CVVHF, or a furosemide diuresis to permit regulation of fluid
balance. This does not however answer the problem of increased
ICU stay. It is the authors’ view, that if renal replacement therapy
is to be attempted in the field hospital, then CVVHF should be
provided, if not the patient should be evacuated. The RAF Critical
Care Air Support Teams (CCAST) maintain CVVHF capability.
This is used in the field hospital prior to transport, for the casualty
in whom delay would be detrimental.
Sedation and Analgesia
A full range of sedative and analgesic medications are available,
and the principle of balanced analgesia is used. All patients with
painful conditions receive regular paracetamol and consideration
of a non-steroidal anti-inflammatory. For ventilated casualties,
where emergence is considered likely within 48 hours, the choice
of propofol for sedation and alfentanil for analgesia is usual.
Where emergence is likely to be more protracted midazolam may
be chosen for sedation and morphine for analgesia. Tramadol and
clonidine are available as adjuncts. Amitriptyline is routinely given
to limb amputees, with the intention of preventing neuropathic
pain, notwithstanding the fact that preventive benefit remains
unproven [10].
Local anaesthetic techniques are popular, particularly for
amputees and abdominal injuries. Neuraxial blocks and peripheral
nerve blocks, both with indwelling catheters, are now regularly
used and ultrasound guidance is available to assist placement of
peripheral blocks. Whilst these techniques can be very effective,
caution must be exercised to ensure that there is no coagulopathy
where neuraxial block is considered, and that the skin surface is
not contaminated by debris from the initial injury. In the event of
an epidural haematoma, diagnosis would be difficult as MRI is not
available. Local anaesthetic infusions, usually 0.2% ropivacaine,
are delivered from either syringe drivers or elastomeric pumps.
Epidural and peripheral nerve catheters are clearly labelled as such
and extension tubing includes a high visibility yellow stripe for
easy identification.
Sedation scoring is undertaken every hour for every patient,
with appropriate titration of sedative medication. Unless
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JJK McNicholas, JD Henning
specifically contra-indicated a lightly sedated state is sought. A
daily sedation hold is routine and the consultant should indicate
exceptions to this practice, rather than requesting it.
Coagulopathy
The Acute Coagulopathy of Trauma Syndrome (ACoTS) is
achieving wider recognition as the explanation of coagulopathy
in trauma [11]. It is complex and differs from conventional
explanations of trauma coagulopathy. A better understanding
of trauma coagulopathy has led to an aggressive approach to
correction during the phase of resuscitation and surgery. Empirical
transfusion of a higher ratio of fresh frozen plasma to packed
red blood cells, usually a 1:1 ratio, in the context of massive
transfusion, is now recognised as best practice in military units.
This has almost certainly saved lives, and is felt to have prevented
many ICU admissions.
The more normal response to trauma is a hypercoagulable state.
Even those with impaired coagulation on admission to hospital
may swiftly become prone to thrombosis, certainly within 48
hours [12], and particularly where older blood products are
given or recombinant factor VII has been used [13]. This field
is developing rapidly and further research is needed to quantify
the risks.
One practical difficulty in the field ICU environment is when
to make the decision to stop aggressive blood product transfusion
with the 1:1 ratio of fresh frozen plasma and packed red blood cells
and revert to a conventional transfusion approach. This decision
may be assisted by point of care testing - haemoglobin is measured
using i-Stat ® and clotting using ROTEM ® - with conventional
transfusion being adopted as ROTEM ® normalises. In essence
however the decision remains one of clinical judgement. A further
difficulty is when to start chemical thromboprophylaxis; trauma
patients have a 10-fold increase in the incidence of thrombotic
events, therefore active prophylaxis should be started as soon as
possible and certainly as soon as the ROTEM ® starts to return to
normal [14].
There is also now a group of patients, who may need ongoing
resuscitation, continued during CCAST evacuation. Examples
include those with multiple fasciotomies or devastating pelvic soft
tissue injuries.
Preparation for Evacuation
The concept of field intensive care medicine depends upon
aggressive early stabilisation after surgery and early rearward
evacuation. Early evacuation is important for two reasons; the
facility must be able to accommodate a high volume of admissions,
with a relatively small capacity; complex and protracted critical
care, where this is required, is better managed in a UK facility
with access to the full range of clinical resources.
Among the most difficult decisions is when to effect evacuation
in the unstable patient. There is a balance of risks. To retain the
patient in the field ICU, permits surgical intervention, maintains
access to laboratory and imaging resources and delays the effects
of transport. To transfer allows earlier access to the full range of
clinical resources in the UK (or other home nation).
There are no definitive criteria upon which to base a decision
and the judgement of experienced clinicians is required. If life
or limb saving surgical intervention is judged to be likely before
transfer can be completed, then the patient should be retained. If
it is judged that there are critical care interventions, which can be
accomplished prior to transport, which cannot be undertaken in
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Intensive Care Decisions JJK McNicholas, JD Henning
flight by the CCAST, and which will permit safer transport, then
the patient should be retained.
Future Developments
The resuscitation of military polytrauma has changed during the
past decade, with the introduction of topical haemostatics and
tourniquets, empirical transfusion of fresh frozen plasma and
platelets, and the description of damage control resuscitation
[15]. This is likely to continue, and there are several critical care
therapies which may find a place.
High Frequency Oscillatory Ventilation
High Frequency Oscillatory Ventilation (HFOV) has been
investigated for the treatment of Adult Respiratory Distress
Symdrome (ARDS), with a large randomised controlled trial
(RCT) showing early improvement in oxygenation but no overall
mortality benefit [16]. Meta-analysis of six RCTs did show
mortality benefit, and concluded that HFOV might improve
survival [17], though the results must be treated with caution as
not all controls received low tidal volume ventilation [18]. Best
practice in ARDS now requires low tidal volume ventilation,
so it remains unclear whether HFOV is likely to lead to better
outcomes than low tidal volume conventional ventilation. The
High Frequency Oscillation in ARDS (OSCAR) trial is currently
investigating the use of oscillatory ventilation as an alternative
to low tidal volume conventional ventilation in ARDS. Military
critical care admissions often suffer from ARDS either as a result
of chest trauma, or secondary to the inflammatory process
accompanying trauma elsewhere. If HFOV is shown to have
outcome benefit in the civilian context, this may be transferable
to the field environment.
Extra-corporeal CO 2 Removal
Extra-corporeal CO 2 removal ( ECCO 2 R) may be of advantage in
patients who are difficult to ventilate with poor lung compliance.
There are well developed technologies now available for extracorporeal
CO 2 removal. The principle involves diversion of a
proportion of cardiac output through an extra-corporeal filter,
across which CO 2 is removed into a fresh gas supply. Cannulation
of a femoral artery and vein are required and flow is generated by
the patient’s arterial blood pressure. The main benefit is that tidal
ventilation may be reduced to very low levels, whilst maintaining
physiological pH. This has been called ultra-protective lung
ventilation and seeks to avoid regional hyperinflation of the lung.
There is evidence of regional lung hyperinflation, even with a low
tidal volume ventilation strategy [19].
ECCO 2 R has been used for transportation of severe ARDS
and in trauma where ventilation is difficult [20, 21]. It has also
been used for other causes of ventilatory failure or hypoxaemic
respiratory failure in which permissive hypercapnoea is chosen
[22, 23]. This technology is of limited benefit in providing
oxygenation to the patient who is difficult to oxygenate. At present
there are no established criteria upon which to select patients for
ECCO 2 R, in the context of trauma.
Introduction of ECCO 2 R into the field would be challenging.
Both the CCAST and intensive care consultant cadres would need
to be trained and experienced in its use, and cannula placement
would need to be learned. Iatrogenic complications are described,
such as haemorrhage, ischaemia and inadvertent displacement,
and are difficult to quantify as the published series are small. Risks
may be mitigated in the future; the cannulae now used are smaller
than previously and the membrane technology has improved in
recent years, permitting lower flow resistance and enabling devices
to perform for protracted periods.
Ethical Issues
The principles of medical ethics must inform all medical
practice; their application must evolve as medicine changes.
Critical care medicine is a relatively new field and one in which
rapid technological advance has greatly influenced treatment
possibilities. Ethical dilemmas have arisen in the wake of these
developments, which are unique to critical care practice. One
example among many is the advent of brain stem death and the
potential for organ donation in these circumstances, which is a
direct consequence of the possibility of mechanical ventilation.
Military critical care is also evolving swiftly and the clinical
scenarios are unique to the environment. The juxtaposition of
high technology critical care capability and a high volume of
military penetrating trauma is found only in the military field
hospital. It is not surprising therefore that clinical dilemmas arise,
for which there is little precedent elsewhere.
Among the particular areas, which require the clinician to
give careful consideration to the principles of medical ethics are:
prolonged critical care admission for local casualties in a facility
originally intended for 48 hour holding; evolving boundaries of
survivability in extreme polytrauma; resource allocation without
the flexibility of a comprehensive local critical care system; the
provision of a critical care service to different demographic
groups, with different lines of evacuation and rehabilitation
services; communication and the use of interpreters; paediatric
critical care provided by predominantly adult specialists; creation
of the expectation of critical care in the location, followed
by inevitable withdrawal from the area in time; reluctance to
undermine the development of local critical care capability;
the decision to repatriate where death is expected; continuity
of clinical practice in a remote environment with a rapidly
changing staff.
Decisions of this kind are difficult and likely to be unfamiliar
to many clinicians. At present decision making is strengthened
by several means: the deployed medical director is an experienced
military clinician, who will have undertaken operational tours in
recent years and will be involved in the most difficult decisions;
all unfamiliar or difficult choices are made by more than one
consultant; the pace of operations in recent years has meant that
corporate expertise has accumulated within a relatively small
cadre of providers.
There is little clinical research, which specifically investigates
the ethics of military critical care. Military medical support to
civilians on operations was investigated recently, using Delphi
methodology [24]. This approach may provide a means by
which a more secure evidence base can be developed to assist the
deployed clinician.
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19. Terragni PP, Rosboch G, Tealdi A et al. Tidal hyperinflation during
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20. Zimmermann M, Philipp A, Schmid FX et al. From Baghdad to
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Lessons Learned . . . . on Operation TELIC (Iraq) in 2003 about Surgery at Role 2
Limb and abdominal surgery cannot be truly sorted unless there is an accurate and timely plan for casevac (the ‘back door’) at
all times. This means having tactical awareness before, during and after surgery. Too much surgery was done at Role (R)2 - but
such units were often unsure when they would be able to casevac their patients. There needed to be a more robust and close
liaison between surgical and casevac assets. Half of helicopter casevac requests in forward units were not fulfilled. Critical Care
Air Support Team assets should be embedded into all forward units as well as R3. Several Role 2 Field Surgical Teams (FSTs) were
not closed down when R3 facilities were available close by, in some cases leading to forward casevac from R2 FST to R3. This
led to inappropriate and potentially detrimental patient care, in that once the patient was in a ‘surgical facility’ , they were then
a lower priority for onward movement. R3 units became R4 units when the rearward evacuation of Prisoners of War (POWs)
became impossible for political reasons. Traction beams had to be fashioned from wooden pallets and POW long bone (femur,
tibia) fractures treated to union over many weeks. No provision was made initially for the care of local people especially pregnant
women and children. Anaesthetists often had to fashion ad-hoc paediatric anaesthetic equipment. Planning staffs should clearly
have foreseen this POW and refugee problem.
Parker PJ, Adams SA, Williams D, Shepherd A. Forward surgery on Operation Telic – Iraq 2003. J R Army Med Corps 2005;
151(3): 186-91
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