Defence Anaesthesia - Journal of the Royal Army Medical Corps

Defence Anaesthesia: 

Conflict Research and 

Clinical Delivery

From The Editors 

Welcome to this Defence Anaesthesia supplement to the Journal of the Royal Army Medical Corps. The supplement has a broad range 

of articles covering diverse aspects of our current practice and balances academic endeavour with pragmatic clinical advice. The guest 

editors are very grateful for the efforts of all the authors- both from DMS and our civilian colleagues in the NHS- and to the editor, 

Lt Col Jeff Garner for hosting us. 

Wg Cdr Simon Turner FRCA RAF 

Consultant in Anaesthesia and Intensive Care, Leeds General Infirmary; Research Lead, Department of Military Anaesthesia, Pain and 

Critical Care; Consultant, Critical Care Air Support Team, Royal Air Force 

Col Peter Mahoney OBE TD FRCA L/RAMC 

Defence Professor Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham 

Front Cover Illustration: ‘Resuscitation on the MERT’ reproduced by kind permission of the artist, David Rowlands. David Rowlands is a 

professional artist specialising in military paintings. He has worked with many Regiments and Corps of the British Army since his first military 

commission in 1983 and has deployed frequently to witness first hand soldiers in action in locations as diverse as South Armagh, Kuwait 

(Op GRANBY), Bosnia (Op GRAPPLE), Iraq (Op TELIC) and Afghanistan (Op HERRICK). In 2008, he flew with the Medical Emergency 

Response Team of Close Support Medical Regiment, 16 Air Assault Brigade in Helmand province which is when this sketch was made. Further 

details are available at www.davidrowlands.co.uk 

282 J R Army Med Corps 156 (4 Suppl 1): S282

Personal Views

Defence Anaesthesia - Look Back, Look Forward 

This supplement to the Journal of the Royal Army Medical Corps 

examining the Challenges in Defence Anaesthesia is the latest 

collection of articles that examine developments in the specialty 

of military anaesthesia in all its facets; previously the journal has 

Focused On… Pain Management (March 2009) and Intensive 

Care (June 2009). It is coincidentally being published close to the 

20-year anniversary of the 1990-1991 Gulf War. Looking back to 

this conflict allows us to examine how much has changed in UK 

Military Anaesthesia in the intervening two decades. 

32 Field Hospital was one of four UK military hospitals 

deployed to the Arabian Gulf in 1991. It was located in the 

desert in Northern Saudi Arabia and housed 200 beds, eight 

operating tables, eight resuscitation bays and a treatment 

department. The resuscitation teams comprised three people (a 

doctor, nurse and medic) with responsibility for two resuscitation 

bays each. Anaesthesia duties were to be shared with Dental 

officers and the McVicar operating tables were arranged in zig- 

zag fashion in the open tented area with the two head ends close 

together. This meant that, if required, one anaesthetist could 

look after two patients at once. Anaesthesia was given with 

the triservice kit using halothane and trilene. The ‘Cold War’ 

template of the hospital meant that critical care as such did not 

exist. The long tented corridors of the hospital were dark and in 

January 1991 the complex was very cold at night. Fortunately the 

anticipated casualty load did not arrive – and those patients who 

came through the hospital were given the best care the staff could 

offer with the materials and equipment to hand. I am grateful to 

the mentors who gave a good grounding in the resuscitation and 

anaesthesia of the ballistic casualty. 

The Camp Bastion hospital in Afghanistan, 20 years later, is 

a very different place. The workload is intense. The equipment 

within the hospital is first class. CT scanners and digital X Ray 

have revolutionised our ability to image the severely injured and 

plan their care. Joint training on the MOST course and HOSPEX 

mean that the deployed teams have a shared understanding of 

military damage control resuscitation concepts- and the role 

of anaesthesia within this. Our strong links with the Combat 

Casualty Care programme at DSTL Porton Down has meant that 

quality research is used to underpin our protocols- or where this 

is impractical give us a sound theoretical basis for what we want 

to achieve. The current state of development of the deployed 

hospital including intensive care and regional analgesia systems 

would not have been imagined by our teams in 1991. 

Getting to this point has not been straightforward. As a cadre 

we owe a great debt to a series of Defence Consultant Advisors 

and single service consultant advisers, supported by key members 

of the clinical cadres, who have pushed at the boundaries of 

deployed anaesthesia and worked with the Surgeon General’s 

Department and PJHQ to get new equipment and materials into 

service. 

The collection of articles in this supplement gives a flavour of 

the level of care that these efforts have facilitated. 

Not all deployed operations are, or will be, like Bastion. 

Everyone who has been on short notice entry operations will 

know the compromises that have to be made when working 

within a strict air cargo constraint. Defence Anaesthesia can be 

very proud of all the contributions made to the care of our combat 

casualties- but it is important as a cadre that we continually learn 

from our experiences, research emerging questions and contribute 

to ongoing operational training so the best of our practice can be 

adapted to whatever environments and situations we need to face 

in the future. 

This collection of articles is a very welcome contribution to 

this process and I am very grateful to the editor and the journal 

for supporting us. 

Col Peter F Mahoney 

Defence Professor of Anaesthesia 

The Future for Military Anaesthesia After 

Operations in Afghanistan 

Introduction 

The provision of military anaesthesia has evolved dramatically 

during the last few years and more specifically during Op 

HERRICK. The input from Defence Anaesthesia into casualty 

care is greater now than at any previous time. Anaesthesia as a 

whole provides medical capability throughout the casualty 

pathway almost from point of wounding through all echelons 

of care including Aero Medical evacuation both tactically and 

strategically to Role 4 and beyond with input at the Defence 

Medical Rehabilitation Centre at Headley Court and the Regional 

Rehabilitation Units. 

The foundation of deployed medical capability is rooted 

in three factors. Having the appropriately trained individual, 

equipped in the correct manner and commanded effectively 

to deliver the right care at the right time in the right place. The 

pace of change that has occurred during HERRICK has been 

frenetic. This has been in response to the demands placed upon 

us by the casualty load and complexity of injury. The fact that 

Defence Anaesthesia has been up to the challenge is in no small 

part due to the professionalism and leadership of every single 

deployed anaesthetist as well as the guidance and tenacity of 

various members of the cadre. As is inevitable at this time with 

the ramifications of the Strategic Defence and Security Review 

(SDSR) still to be fully absorbed, we must look to the future. 

What threats and challenges are likely to confront us in the future 

and how are we best to meet these challenges? 

There are many lessons to learn from HERRICK, however we 

should not just try and duplicate the model that is so successful 

in Afghanistan in the next conflict. The pace of change that has 

occurred in Afghanistan was required to meet the challenges that 

J R Army Med Corps 156 (4 Suppl 1): S285–286 285

occurred in that particular theatre of operations and has produced 

an almalgamation of medical capabilities, a hybrid - a highly 

evolved military medical system that functions extremely well. 

However, removed from that environment with its established 

support mechanisms it will potentially fail like any other organism 

that has evolved in isolation. It becomes our responsibility to 

examine what lessons can be learnt from HERRICK that are 

transferable to future deployments. 

Command and Control & the Medical Plan. 

The first lesson must be that the severely injured soldier is a time 

sensitive casualty. Rapid medical intervention carried out at the 

appropriate time saves life. This is reflected in the principle of 

simultaneous initiation of treatment with casualty evacuation to 

the next level of care. 

The next conflict may not be as asymmetric as Afghanistan; 

ground forces may not have the ability to switch priority from 

aggressive patrolling to casualty extraction. During contingency 

operations the number of airframes will be severely limited and 

the area of operations will likely to be smaller in geographical area. 

The use of other casualty extraction vehicles other than airframes 

is potentially more likely. All these factors are likely to delay 

casualty extraction to primary surgery or definitive care. How 

we as health care providers mitigate for this will be important 

if we intend to minimise mortality and morbidity. The concept 

of intelligent tasking will become more important to rationalise 

limited resources and requires flexible thinking and efficient 

decision making. 

Equipment 

The Role 3 facility at Camp Bastion operates above its designated 

deployed capability; the through put of casualties reflects the work 

load of a military Role 3 hospital with twice if not three times the 

50 established beds. This is achievable because in certain areas 

the hospital is equipped and manned as if it was established for 

100 beds. It has eight resuscitation bays, four operating tables and 

10 intensive care beds which is soon to be expanded to 12. The 

Operational Establishment Table (OET) also reflects this uplift in 

capability. The other important force multiplier is the exceptional 

Aero Medical evacuation system that is working at full capacity 

nearly every day to keep the hospital functioning. The reason that 

the hospital in Bastion has been able to evolve in this way is that it 

is a fixed establishment with medical equipment and life support 

systems for the hospital such as power and environmental control 

being employed that would be impractical in all but the most 

enduring operation in the future. 

It is not only medical planners that need to be aware of this 

paradox. The expectation of those forces that rely on our care 

needs to be tempered. The next operational area by definition 

will be an entry operation of some nature. The logistical support 

including the air bridge will therefore be much more fragile and as 

a result the medical infrastructure will likely be different. This will 

impact on the way we deliver care and potentially the morbidity 

and mortality of the forces that we support. 

The Trained Individual 

Of the three factors or foundations that produce operational 

medical capability on operations outlined earlier (equipment, 

Command and Control and the trained individual), I believe the 

most important is the appropriately trained individual. The most 

constant mitigating factor against the unpredictability of the future 

will be the clinician, be that the CMT, Nursing Officer, General 

Practioner or Secondary Health Care consultant. HERRICK has 

shown us that one way to increase capability, and thus success, is to 

increase the number of deployed consultants on the OET. When 

placed in multidisciplinary teams working together to produce 

horizontal resuscitation great results can be achieved. However 

these individuals must be trained for the environment that they 

are deployed to. Pre-deployment training has become the main 

priority in the training arena. This emphasis must continue but 

change to encompass the generic entry operation. Old lessons 

need to be revisited. The deployed clinician of tomorrow should 

not only be trained to survive but to function in the austere 

environment. The next war will not be HERRICK and the next 

hospital will not be Bastion. The one known factor is that the team 

should aim to deliver consultant delivered care, and be trained to 

work in more austere environments. Instead of using the term 

Field Surgical Team (FST) to describe a deployed capability the 

phrase Damage Control Resuscitation team (DCR) would be 

more appropriate. Such a phrase captures the multidisciplinary 

approach to the severely injured casualty including the specialities 

of Emergency and Intensive Care Medicine. 

Whatever challenges await, Defence Anaesthesia will play 

a significant part and this will mean more anaesthetists being 

held at high readiness not only as part of the deployed surgical 

team but covering the other capabilities of Pre-Hospital care, 

Intensive Care and Aero Medical evacuation at both tactical and 

strategic level. 

The appropriately trained individual is the greatest assets the 

DMS has and the training ethos of the future should be those that 

deploy together need to train together and this represents the true 

lesson from HERRICK that can be used in the future. 

Lt Col DA Parkhouse FRCA RAMC 

Consultant Anaesthetist 16 Medical Regiment; Consultant 

Adviser Anaesthetics (Army) to DGAMS; 

Defence Anaesthesia Operational Governance Lead and Defence 

Anaesthesia Lessons Management Lead 

286 J R Army Med Corps 156 (4 Suppl 1): S285–286

Clinical Practice

Pre-hospital Anaesthesia 

RJ Dawes 1 , A Mellor 2 

1 Specialist Registrar in Anaesthetics and Intensive Care, Wessex Rotation. 2 Consultant Anaesthetist, Dept of Academic 

Emergency Medicine, James Cook University Hospital, Middlesbrough 

Abstract 

This review presents the history of Pre-hospital anaesthesia, it’s evidence base, required training and examines current 

arguments focusing on best practice such as who should undertake the procedure and how identifying appropriate patients, 

utilizing new techniques and drugs may benefit the Pre-hospital practitioner in optimum delivery of this important procedure. 

Introduction 

Pre-hospital anaesthesia is used to rapidly secure and protect the 

airway, prevent secondary brain injury, for humanitarian reasons 

and to facilitate safe transfer when access to the patient may be 

less than ideal. Traditionally, the airway is secured by a technique 

known as Rapid Sequence Induction and Intubation (RSII). 

Securing the airway is second in importance only to the control 

of catastrophic haemorrhage, but pre-hospital anaesthesia is more 

than securing the airway, and intubation merely the first step . 

Once the airway is secured, supporting physiology, preventing 

secondary injury and safe transfer to an appropriate centre is the 

goal in the pre-hospital phase. 

Definition and History of Rapid Sequence 

Induction/Intubation 

RSII is defined by Walls in the Manual of Emergency Airway 

Management 3rd Edition (Lippincott Williams & Wilkins) as 

“the administration, after preoxygenation, of a potent induction agent 

followed immediately by a rapidly acting neuromuscular blocking 

agent to induce unconsciousness and motor paralysis for tracheal 

intubation” 

The preoxygenation phase permits a period of apnoea to 

occur between administrating drugs and intubating the trachea. 

RSII is used on the predicated assumption that the patient has 

a full stomach and may be at risk of pulmonary aspiration of 

gastric contents. This has long been recognized as a risk during 

anaesthesia. In 1950, the Association of Anaesthetists of Great 

Britain and Ireland (AAGBI) investigated deaths associated with 

anaesthesia and discovered 43 deaths caused by aspiration. Six 

years on, another 110 deaths due to aspiration of gastric contents 

were reported. 

In 1961, Brian Sellick first described a manoeuvre attempting 

to control and minimize regurgitation of gastric contents before 

intubation by compressing the cricoid cartilage against the bodies 

of the cervical vertebrae. Prior to this, anaesthesia was induced in 

an upright position to provide airway protection, but debate still 

reigns regarding cricoid pressure [1]. 

A ‘classical’ RSII incorporates Sodium Thiopentone (STP) 

as the induction agent and Suxamethonium for neuromuscular 

blockade (NMB) followed swiftly by tracheal intubation. Tracheal 

intubation was not routine until the 1940s when STP was used 

in WWII for military anaesthesia. Suxamethonium was first 

synthesised in 1949, Ketamine in 1961, etomidate in 1964 and 

Corresponding Author: Surg Cdr Adrian Mellor , Consultant 

Anaesthetist, Dept of Academic Emergency Medicine, James 

Cook University Hospital, Middlesbrough, TS3 4BW 

Propofol in 1980. Despite their age, STP and Suxamethonium 

remain the most widely used agents. What is now apparent 

however, is that there is no universal regime [2], and that RSII is 

evolving slowly as new drugs, equipment and knowledge emerge. 

Several induction agents as well as alternatives to Suxamethonium 

are used by both anaesthetists and non-anaesthetists. These 

include using the long acting non-depolarizing neuromuscular 

blocking agent Rocuronium, instead of Suxamethonium, as 

the ability now exists to rapidly reverse Rocuronium-induced 

paralysis with Sugammadex. 

Who should perform pre-hospital Rapid Sequence 

Induction/Intubation (PHRSII)? 

PHRSII brings with it its own unique challenges. It is an austere 

environment, often with little back up, with the capacity for failure 

higher than in hospital. These factors all undoubtedly contribute 

to why many studies looking for any benefit of pre-hospital 

intubation have been inconclusive. Note the deliberate use of the 

term pre-hospital intubation. Many of the studies involved did not 

use NMB, used inadequate or no clinical monitoring, personnel 

often had short and poor training, had differing skill sets, and 

poor study design and methods [3]. The majority of pre-hospital 

intubations were not RSII’s. The Joint Royal Colleges Ambulance 

Liaison Committee have recently stated that UK paramedics 

should no longer be routinely trained in intubation [4], as evidence 

of benefit to patients intubated without drugs is lacking. London 

Ambulance Service have recently ceased training paramedics in 

endotracheal intubation (June 2010). A criticism often leveled 

by hospital practitioners regarding interventions undertaken 

on scene relates to the extra time taken to undertake those 

procedures, thereby prolonging the on scene time. Critical care 

is a process, not a place, and the patient requires an intervention 

when they require it, not when they have been transported to 

hospital. Interventions such as RSII, blood transfusion and large 

bore central access are undertaken routinely in the emergency 

department (ED) for conditions such as traumatic brain injury 

(TBI) and polytrauma, and are seen as minimum standards of 

care. Hypoxia, hypotension and hypercapnia all increase mortality 

and morbidity in TBI. PHRSII allows control of oxygenation and 

ventilation early and safely in the pre-hospital phase. 

There is evidence that a well organised physician anaesthetist 

staffed pre-hospital organisation can deliver anaesthesia in the 

pre-hospital phase as safely as in hospital [5-7]. The data on other 

groups is conflicting. This may be in part due to training and skill 

levels but also due to the drug combinations with midazolam and 

etomidate all reported as agents used to achieve a drug assisted 

intubation but without muscle relaxants [8-11]. 



The two largest UK studies of ED RSII where ED staff were 

compared to anaesthetists showed that anaesthetists achieved 

significantly better views at laryngoscopy and more first time 

intubations [12-13]. A study of RSIIs performed by nonanaesthetists 

(critical care and ED staff) reported a significantly 

higher incidence of multiple attempts and unsuccessful 

intubation by the initial operator [14]. This finding is important 

as a large US study found that the incidence of complications 

increases significantly when more than one attempt at intubation 

is required [15]). Graham’s paper [13] reported almost three 

times as many oesophageal intubations (17 vs. 6), twice as many 

episodes of severe hypotension (17 vs. 8) and twice as many (6 

vs. 3) endobronchial intubations during RSII by ED staff. These 

numbers were not assessed for statistical significance and are small 

(in a series of 735 RSII) but may represent clinically significant 

harm. Reid’s study [14] showed a significantly higher incidence 

of multiple attempts and unsuccessful intubation when the initial 

intubator was not an anaesthetist; however overall (albeit selfreported) 

complications were similar. Similarly the Stevenson 

paper [12] reported overall comparable complication rates for ED 

vs. anaesthetic RSII. The choice of agent used is worthy of comment 

in that most anaesthetists choose to use propofol or thiopentone. 

One might speculate that the episodes of hypotension requiring 

treatment might have been significantly reduced for anaesthetists 

had they used etomidate (ED 72% Etomidate vs. anaes 19%). 

This is possibly because the majority of anaesthetists were junior 

trainees with little or no experience of using etomidate, whereas 

the majority of ED physicians were consultants. Despite using 

drugs more likely to produce hypotension, the anaesthetists had 

no more episodes of hypotension than the ED staff. Familiarity 

with the side effects and appropriate doses of induction agents, 

and the ability to minimize and manage adverse effects is as 

important as the ability to get the tube in with the best view. 

The AAGBI produced a set of guidelines for PHRSII in 

2009 [16]. A panel concluded that practitioners “should have 

the same level of training and competence that would enable them 

to perform RSII unsupervised in the emergency department”. 

This should include training through the acute care common 

stem (or equivalent). An expert panel in 2007 on behalf of 

The National Confidential Enquiry into Patient Outcome and 

Death (NCEPOD) produced the report “Trauma who cares” 

[17] and concluded: “Airway management in trauma patients is 

often challenging. The pre-hospital response for these patients should 

include someone with the skill to secure the airway, (including the use 

of rapid sequence intubation), and maintain adequate ventilation “ 

and furthermore “If pre-hospital intubation is to be part of the prehospital 

trauma management plan , it needs to be in the context of a 

physician based pre-hospital care system”. Once a satisfactory level of 

competency has been attained, this needs to be maintained, with 

at least one drug assisted intubation per month currently thought 

to be the absolute minimum required to maintain competency. 

These recent recommendations effectively limit the provision 

of PHRSII to those who regularly undertake RSII in the course 

of their job such as anaesthetists or occasionally emergency 

physicians and rarely to others who have the flexibility to attain 

the competencies and maintain regular sessions undertaking RSII 

in a supervised environment. 

Indications for PHRSII 

After arrival in the ED, RSII will usually be carried out early 

to secure the airway, to improve physiological variables, for 

290 

RJ Dawes, A Mellor 

humanitarian reasons, and to facilitate safe further investigation 

(e.g. CT). To carry this argument forward, should the patient 

require the intervention during the patient journey but in the 

pre-hospital phase, then there is logic to carrying out RSII in the 

pre-hospital environment if it can be done safely. The evidence 

above supports this, when undertaken by a well trained senior 

team under optimized conditions. However, the evidence to date 

does not support any survival benefit over non-RSII managed 

patients and if performed by those lacking experience or using 

sub-optimal techniques then this may be harmful. It may be 

reasonable to be more conservative with pre-hospital RSII than in 

the Emergency department. 

Indications for PHRSII include: 

• Airway problems that cannot be reliably managed by simple 

manoeuvres e.g. severe facial injury 

• Respiratory insufficiency (SpO 2 < 92%) despite 15L/min 

O 2 or impending respiratory collapse due to exhaustion or 

pathology 

• GCS rapidly falling or < 9. 

• Patients at risk of deterioration when access is difficult 

during transfer to definitive care e.g. facial burns 

• Patients requiring analgesia and/or sedation prior to 

transfer to hospital because they present a danger to themselves 

or attending staff or for humanitarian reasons e.g. provide 

complete pain relief without respiratory depression. 

Using published and accepted guidelines, any patients in pain 

or at risk of deterioration should be considered for PHRSII. 

This effectively means any patient with major illness or injury. 

Clearly not all patients can or should receive anaesthesia and it is 

probably more helpful to think in terms of contraindications to 

the procedure; 

• Lack of a suitably trained team 

• Conditions likely to make intubation difficult or impossible 

where other techniques only available in hospital may be 

required e.g. facial deformity, epiglottitis, lack of difficulty 

airway equipment 

There is currently no randomized controlled data showing 

clear benefit in mortality or morbidity following pre-hospital 

intubation. The only randomized controlled trial of pre-hospital 

intubation performed so far involved paramedics intubating 

children without drugs [18] and in addition to the lack of doctors 

and drugs (i.e. not PHRSII), the study had major flaws. There 

have been several retrospective studies conducted in this area, and 

overall these have not been conclusive. Some of the studies suggest 

survival advantage [19-20]. Others showed no improvement 

in neurological outcome or mortality [21] or even appeared to 

show an adverse outcome from pre-hospital intubation [22- 

23]. A recent review in the British Journal of Anaesthesia [24] 

reviewed the value of pre-hospital tracheal intubation in patients 

with traumatic brain injury and concluded there was no evidence 

to support pre-hospital intubation. Unfortunately this detailed 

systematic review made no attempt to distinguish those patients 

given drugs (or not) to facilitate intubation nor operator skill 

level. In the majority of cases the drugs used were not stated and 

in other studies paramedics were taught to perform intubation 

with six or eight hours training. Comparing anaesthesia 

delivered by consultant anaesthetists (to standard guidelines) in 

the pre-hospital environment is very different to intubation by 

a paramedic with six hours training without the use of drugs. 

J R Army Med Corps 156 (4 Suppl 1): S289–294

Pre-hospital Anaesthesia RJ Dawes, A Mellor 

Induction 

Agent 

Sodium 

Thiopentone 

(STP) 

General Info Dose Advantages for PHRSII 

Packaged as a yellow powder in 

a “multi-dose” glass bottle that 

requires reconstitution with 20mls 

of water to make up a 25mg/ml 

solution. Stable for days in this 

made up state. 

Induces sleep very quickly, 

but redistributed very quickly 

(5-10 mins) 

Is a dose dependant potent 

cardio-suppressant and venodilator 

Propofol Packaged as a ready made white 

emulsion in a break open glass 

bottle as 10mg/ml solution. 

Induces sleep quickly, redistributed 

quickly (5-10mins) 

Potent venodilator with no reflex 

tachycardia 

Ketamine Packaged in premixed multi-dose 

glass vial in three concentrations; 

10mg/ml (intravenous injection 

concentration), 50mg/ml and 

100mg/ml. 

Stable once drawn up for 24 

hours. There is a racaemic mixture 

(UK and USA) but the stereoselective 

S-isomer is available and 

is in widespread use in western 

Europe. 

Its pharmacodynamics are more 

favourable. 

Slower sleep onset time 30-60 secs. 

Anaesthesia for 10-20 mins 

Sympothomimetic: Excellent for 

hypotensive patients. Stabilises or 

increases MAP. Increase in MAP 

offsets increase in intracranial 

pressure and sustains cerebral 

perfusion pressure in TBI 

Etomidate Packaged in break open glass vials 

as a premixed 2mg/ml solution 

Fast sleep onset time 15-45 secs. 

Anaesthesia for 3-12 mins 

Cardiovascularly stable for 

hypotensive patients 

Normotensive dose: 

3-7mg/kg. 

70kg patient 

= 8-20 mls of 

standard solution 

Hypotensive dose: 

0.1-0.5 of normal dose. 

1.5-3.5mg/kg 

=4-10mls of 


Normotensive dose: 

1-3mg/kg. 

70kg patient 

= 7-21mls of 


Hypotensive dose: 

Not recommended 

for hypotensive 

patients unless very 

familiar with its use in 

hypotensive patients 

Dose is 

0.5-2mg/kg dependant 

on haemodynamic 

status. 

Always dilute to 

10mg/ml 

concentration 

for IV use. 

70kg patient 

3.5 – 14mls of 

10mg/kg solution. 

Dose is 0.3mg/kg 

70 kg patient requires 

~10mls of premixed 

drug 

Table 1: The four main induction agents used for pre-hospital rapid sequence induction 

Cerebral protective 

(if CPP maintained) 

Reduces cerebral 

metabolic rate of 

oxgygen (CMRO2) 

Will not mask 

hypovolaemia 

Raises seizure threshold 

Stable once drawn up 

Ready mixed 

Can be used to extend 

anaesthesia 

Useful as titrateable 

sedative 

Familiarity to many 

Ready mixed 

Maintains or increases 

MAP in hypotensive 

patients 

Bronchodilator, first 

choice for severely ill 

asthmatics 

Potent analgesic in subanaesthetic 

doses 

Avoids polypharmacy if 

also used as analgesic 

NMDA receptor 

antagonism in TBI 

theorectically useful 

Can be used IV, IN, IM 

and orally 

Premixed: 2 preparations 

– Clear (Hypnomidate) 

and Fat emulsion 

(Lipuro) both 2mg/ml 

Stable in hypotensive 

patients 

Disadvantages for 

PHRSII 

Needs mixing 

Will drop Mean 

Arterial Pressure 

(MAP) precipitously 

if not used cautiously 

Precipitous drop in 

MAP in hypotensive 

patients from whatever 

cause 

Cannot be pre 

drawn up 

Increases CMRO2 

Unfamiliarity 

Suppresses steroid axis 

(exact outcome from 

a single bolus dose 

unknown) 

Unfamiliarity 

Pain on injection 

particularly with 

clear solution 



Neuromuscular 

Blockers 

Suxamethonium 

(Short Acting) 

292 

General Information Dose Advantages Disadvantages 

Packaged as premixed solution 

in 2ml break open glass vials 

50mg/ml = 100mg per vial 

Induces paralysis very quickly, 

but redistributed very quickly 

dependant on metabolic rate 

and cardiac output. 3-7 mins 

Degrades once out of 

temperature range (2-7 Deg 

C) but will retain up to 90% 

efficacy for up to 3 months 

out of fridge (dependant on 

ambient temperature) 

Rocuronium Packaged as premixed solution 

in 5ml multi dose glass vials 


Only long acting NMB 

that induces paralysis as 

quickly as Suxamethonium 

at high doses (1.2mg/kg) and 

therefore an alternative to 

Suxamethonium for PHRSII, 

and maintains paralysis for 20- 

40 mins dependant on patient 

pharmokinetics 

Specific reversal agent available 

(Sugammadex Schering- 

Plough, Schering-Plough 

House, Shire Park, Welwyn 

Garden City, Hertfordshire 

AL7 1TW) 

Pancuronium Packaged as premixed solution 

in 2ml break open glass vials 


Longest acting paralytic with 

vagolytic properties that can 

help maintain MAP. 

Vecuronium Packaged as two vials. 5mls of 

sterile water in first break open 

glass vial and second glass vial 

containing vecuronium powder 

in glass vial. Vecuronium needs 

premixing before use. Once 

mixed solution is 2mg/ml = 

10mg per 5ml vial 

1.5-2mg/kg 

70kg patient 

= 105-140mg 

= 2-3 mls 

1.2mg/kg. 

70kg patient 

= 84mg 

= ~9mls 

0.1mg/kg. 

70kg patient 

= 7mg 

= 3.5mls 

0.1mg/kg. 

70kg patient 

= 7mg 

= ~4mls 

Quick onset 

Familiarity 

Can be used IV 

and IM 

Premixed 

Stable at ambient 

temperatures 

Reversible with 

Sugammadex 

Quick acting 

Long acting 

Negates need for 

second NMB post 

suxamethonium 

Premixed 

Helps maintain 

MAP 

Longest acting 

NMB >40 mins 

dependant 

on patient 

pharmokinetics 

Familiarity 

Predicticable 

phamodynamics 

Reversible with 

Sugammadex 

Table 2 The four Neuromuscular blocking agents used for pre-hospital rapid sequence induction 


Difficult storage (needs to be 

exchanged frequently in hot 

climes if not refrigerated) 

Nearly always require two vials 

Short duration of action 

Second doses can precipitate 

profound bradycardia 

especially in children 

Can cause cord spasm if not 

intubated before paralysis is 

extended leading to a 

“can’t intubate/can’t ventilate” 

scenario 

Some patients unable to 

metabolise drug leading to 

greatly lengthened paralysis 

time (hrs) 

Not compatible (in same 

IV line) with STP without 

flushing first 

Need two vials in 

most patients 

Needs premixing from 

two vials 

Very stable 


Pre-hospital Anaesthesia RJ Dawes, A Mellor 

Specific 

Reversal Agents 

General Information Dose Advantages Disadvantages 

Sugammadex First-in-class reversal agent 

that encapsulates and 

inactivates rocuronium or 

vecuronium 

Packaged as premixed 

multi dose glass vial 

in 1ml (100mg), 2ml 

(200mg) and 5ml 

(500mg) volumes. 

RSII reversal is 16mg/ml 

70kg patient dose is 

1120mg (11mls) 

Table 3 The properties of a specific neuromuscular blockade reversal agent 

Many of the studies in the literature focus on the process of 

intubation, rather than the process of anaesthesia to facilitate 

intubation. Drug use is important as both failed intubations and 

complications are reduced by the use of NMB drugs [25]. For 

this reason one should be extremely cautious using these studies 

to make conclusions about PHRSII. 

Importantly the published evidence does not show RSII to be 

detrimental and, when delivered as part of a well governed system, 

may be beneficial. Services such as the Whatcom Medic One 

(Washington state) have a relatively small number of well-trained 

paramedics using a recognized PHRSII technique and report very 

good results [26]. Improved outcome has been demonstrated for 

patients transferred by helicopter compared to land ambulance 

[27]. This may be due to speed of transfer to hospital, better 

trained staff or a combination of both. Together this leads to 

the conclusion that small teams of well-trained staff on board 

helicopters are likely to improve outcomes if they are able to 

perform PHRSII in certain patients. 

Attempting to tease out the exact benefits of PHRSII in the prehospital 

phase is difficult, but no more difficult than attempting 

to demonstrate the benefit of early intubation in the emergency 

department. Another facet to pre-hospital care is appropriate 

triage. Good evidence exists indicating that direct triage bypassing 

district general hospitals with TBI conditions such as extradural 

and subdural haematomas to regional neurological centres 

significantly reduces morbidity and mortality [28,29]. PHRSII 

is merely one component of a package of care provided by a prehospital 

critical care team. 

Drugs 

There are four main induction agents (Table 1) and four NMB 

drugs (Table 2) used in PHRSII. Table 3 lists the properties of a 

specific reversal agent for some NMB agents. 

Training and standards 

There is an obvious dichotomy between the fact that in hospital 

anaesthesia for a polytrauma patient would usually be carried 

out by the most senior available anaesthetist, whereas historically 

pre-hospital anaesthesia and intubation has been carried out by 

enthusiastic amateurs with little or no governance. This situation 

has recently been reviewed and a set of guidelines published by 

the AAGBI [16] with the support of the British Association of 

Immediate Care Schemes (BASICS), the Faculty of Pre-hospital 

Care at the Royal College of Surgeons of Edinburgh, the Royal 

College of Anaesthetists and the Military. 

Complete and fast reversal 

of Rocuronium paralysis 

Shelf life 3 years 

Expensive – RSII reversal 

costs approximately £350 

(June 2010) 

These guidelines state the accepted level of monitoring, operator 

experience and team composition for delivering anaesthesia. Not 

surprisingly the monitoring standards remain the same as those 

for in hospital anaesthesia and minimal standards being noninvasive 

blood pressure, oxygen saturation, heart rate monitoring 

and end tidal carbon dioxide. The guidelines suggest that those 

undertaking PHRSII should perform at least one intubation per 

month. Whether this should be simulated or “live” is not stated. 

The process of pre-hospital anaesthesia is a complex process 

requiring over 100 individual tasks There is merit in practicing 

the process of intubation first in the elective surgical setting then 

progressing to high fidelity simulation to practice crew resource 

management to successfully assess, anaesthetise, resuscitate and 

package a patient in this challenging environment. 

Courses do exist to train teams specifically to deliver PHRSII. 

These include the courses provided by the Great North Air 

Ambulance Service and the Mid Anglia General Practitioner 

Accident Service. They build team skills through realistic 

scenario training to familiarize providers with the procedures for 

anaesthesia, failed intubation drills, post intubation management 

and managing PHRSII as part of a complex pre-hospital scenario. 

Conclusions 

Taking anaesthesia to patients in the pre-hospital setting is 

a challenge in terms of individual skill and judgment and 

organization. The evidence base to support pre-hospital anaesthesia 

is by no means conclusive but what is clear is that outcomes are 

dependent upon the capabilities of the team delivering that care. 

PHRSII of anaesthesia should not just be seen as a treatment but 

merely one step in stabilizing a patient on a journey to definitive 

care. 

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7. Botker MT, Bakke SA, Christensen EF. A systematic review of 

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treatment? Scand J Trauma Resusc Emerg Med 2009; 17(1):12. 

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midazolam as a single pharmacologic agent to facilitate endotracheal 

intubation by paramedics. Prehosp Emerg Care 1999; 3(3):191-3. 

9. Bozeman WP, Young S. Etomidate as a sole agent for endotracheal 

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10. Warner KJ, Cuschieri J, Jurkovich GJ, Bulger EM. Single-dose 

etomidate for rapid sequence intubation may impact outcome after 

severe injury. J Trauma 2009; 67(1):45-50. 

11. Swanson ER, Fosnocht DE, Jensen SC. Comparison of etomidate 

and midazolam for pre-hospital rapid-sequence intubation. 

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12. Stevenson AG, Graham CA, Hall R, Korsah P, McGuffie AC. 

Tracheal intubation in the emergency department: the Scottish 

district hospital perspective. Emerg Med J 2007; 24(6):394-7. 

13. Graham CA, Beard D, Oglesby AJ et al. Rapid sequence intubation 

in Scottish urban emergency departments. Emerg Med J 2003; 

20(1):3-5. 

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sequence intubation: prospective observational study of emergency 

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with repeated laryngoscopic attempts. Anesth Analg 2004; 

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16. AAGBI. Pre-hospital Anaesthesia. 2009. 

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18. Gausche M, Lewis RJ, Stratton SJ et al. Effect of out-of-hospital 

pediatric endotracheal intubation on survival and neurological 

outcome: a controlled clinical trial. JAMA 2000; 283(6):783-90. 

19. Winchell RJ, Hoyt DB. Endotracheal intubation in the field 

improves survival in patients with severe head injury. Trauma 

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132(6):592-7. 

20. Arbabi S, Jurkovich GJ, Wahl WL et al. A comparison of prehospital 

and hospital data in trauma patients. J Trauma 2004; 

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21. Stockinger ZT, McSwain NE, Jr. Pre-hospital endotracheal 

intubation for trauma does not improve survival over bag-valvemask 

ventilation. J Trauma 2004; 56(3):531-6. 

22. Murray JA, Demetriades D, Berne TV et al. Pre-hospital intubation 

in patients with severe head injury. J Trauma 2000; 49(6):1065-70. 

23. Eckstein M, Chan L, Schneir A, Palmer R. Effect of pre-hospital 

advanced life support on outcomes of major trauma patients. J 

Trauma 2000; 48(4):643-8. 

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tracheal intubation in patients with traumatic brain 

injury: systematic review of current evidence. Br J Anaesth 2009; 

103(3):371-86. 

25. Bulger EM, Copass MK, Sabath DR, Maier RV, Jurkovich GJ. 

The use of neuromuscular blocking agents to facilitate pre-hospital 

intubation does not impair outcome after traumatic brain injury. J 

Trauma 2005; 58(4):718-23 

26. Wang HE, Davis DP, Wayne MA, Delbridge T. Pre-hospital rapidsequence 

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from the 2004 National Association of EMS Physicians annual 

meeting. Prehosp Emerg Care 2004; 8(4):366-77. 

27. Davis DP, Peay J, Serrano JA et al. The impact of aeromedical 

response to patients with moderate to severe traumatic brain injury. 

Ann Emerg Med 2005; 46(2):115-22. 

28. Tasker RC, Morris KP, Forsyth RJ, Hawley CA, Parslow RC. Severe 

head injury in children: emergency access to neurosurgery in the 

United Kingdom. Emerg Med J 2006; 23(7):519-22. 

29. London Severe Injuries Working Group. Modernising Major 

Trauma Centres in London. 2001. 


Prehospital Analgesia: Systematic Review of 

Evidence 

CL Park 1 , DE Roberts 2 , DJ Aldington 3 , RA Moore 4 

1 Specialist Registrar in Anaesthetics, 2 ST4 in Anaesthetics & Intensive Care Medicine, St Georges Hospital, London and 

Royal Air Force; 3 Consultant in Pain Relief, John Radcliffe Hospital, Oxford; 4 Senior Research Fellow, Pain Research, 

Nuffield Department of Anaesthetics, John Radcliffe Hospital Oxford 

Abstract 

The purpose of this systematic review is to investigate current evidence for analgesic use in the prehospital environment using 

expert military and civilian opinion to determine the important clinical questions. There was a high degree of agreement 

that pain should be no worse than mild, that pain relief be rapid (within 10 minutes), that patients should respond to verbal 

stimuli and not require ventilatory support, and that major adverse events should be avoided. Twenty-one studies provided 

information about 6,212 patients; the majority reported most of the outcomes of interest. With opioids 60-70% of patients 

still had pain levels above 30/100 mm on a Visual Analogue Scale after 10 minutes, falling to about 30% by 30-40 minutes. 

Fascia iliaca blocks demonstrated some efficacy for femoral fractures. No patient on opioids required ventilatory support; 

two required naloxone; sedation was rare. Cardiovascular instability was uncommon. Main adverse events were dizziness or 

giddiness, and pruritus with opioids. There was little evidence regarding the prehospital use of ketamine. 

Introduction 

That analgesia should be provided in the pre-hospital 

environment has not always been as widely agreed at it is 

today. As late as 1981 thinking about pre-hospital analgesia 

was different: ‘Any agent that interferes with the patient’s normal 

pain response may frustrate the physician attempting to make 

a diagnosis’ and ‘A suitable agent for use by paramedics in prehospital 

treatment should be quick-acting and short-lived in 

order to preserve the pain response for diagnostic purposes in the 

emergency department...‘ [1]. Many studies have shown inability 

to provide adequate pre-hospital analgesia [2-4]. Even as 

recently as 2000, only 1.8% of 1073 patients received any form 

of pre-hospital analgesia for extremity fractures [5]. 

Morphine has been used in the pre-hospital environment 

for many years. There are descriptions of its use in the midnineteenth 

century during the Crimean War [6], but the 

expansion in interest in pre-hospital analgesics came in the 1970s 

with the introduction of nitrous oxide and oxygen (Entonox), 

and then with nalbuphine in the 1980s. More opioid drugs have 

subsequently become available by more routes of administration. 

In the non-opioid category, ketamine is often suggested for use 

in the pre-hospital environment. 

No systematic review of the available evidence has been 

published previously, although reviews have summarised 

options available for pre-hospital analgesia [7-9]. Most notable 

was a literature search for all available evidence using levels of 

evidence [9]. Studies found at that time were limited and mainly 

descriptive, and the review described options available from the 

various studies, rather than extracting data on efficacy and harm. 

Providing pre-hospital analgesia is not a simple matter; there 

are a number of issues. These include the skills and knowledge of 

the analgesic provider; if the provider is well versed in pre-hospital 

care (including appropriate intravenous access and ventilatory 

Corresponding Author: Dr RA Moore, Pain Research, 

Nuffield Department of Anaesthetics, University of Oxford, 

Level 6, West Wing, John Radcliffe Hospital OX3 9DU, UK 

Tel: 01865 231512 Fax: 01865 234539 

Email: andrew.moore@nda.ox.ac.uk 

support) the options are very different from those where the 

provider has limited medical knowledge and skills. The location 

and type of other medical support may make a difference; if 

one is several days away from any medical help and specialised 

monitoring the options are different from those where these may 

be less than an hour away. The type of injury is important; an 

isolated closed limb injury will often require a different approach 

from multiple injuries associated with massive tissue disruption, 

hypovolaemia and hypothermia. 

All of these issues, and others not detailed here, will affect 

choice of pre-hospital analgesic. Practical considerations are 

likely to outweigh academic ideals, but consideration of evidence 

of effectiveness or harm is important in either case. One of the 

drivers for this is the increasing number of buccal, sublingual and 

nasal opiates available, notably fentanyl, as well as increasing use 

of ketamine. While most of these are usually licensed for cancer 

breakthrough pain they may appear attractive to the pre-hospital 

care provider. 

The purpose of this systematic review is to investigate current 

evidence for analgesics in the pre-hospital environment. 

Methods 

We searched Medline (PubMed) and EMBASE using free 

text terms of pre-hospital pain relief, pre-hospital analgesia, 

and wilderness analgesia, alone and with individual drug names 

(morphine, fentanyl, etc) and routes (intravenous, intramuscular, 

intranasal, lollipop, oral, transmucosal, regional techniques 

etc). Reference lists from reviews and papers retrieved were also 

examined for possible inclusion. No language exclusion applied 

and the date of last search was November 2009. 

Any study, of any design, providing efficacy or adverse 

event results concerning pre-hospital analgesia was included 

if it reported results in adults. Studies were excluded if they 

contained no numerical results, were not original studies, or 

were actually performed only in hospital. We also excluded 

studies involving nalbuphine [10 – 14] which is not now 

available in the UK, but did include a study on methoxyflurane 

[15] because it is used extensively by the Australasian military 

and civilian emergency services. 


Pre-hospital analgesia 

Data extraction was guided by a Delphi process, in which UK 

military emergency medicine and anaesthetic consultants were 

asked about criteria for an ideal pre-hospital analgesic, as well 

as civilian doctors involved with helicopter emergency services 

in southern England. Their comments were used to determine 

which patient outcomes would be sought from included studies, 

for both efficacy and adverse events. They were asked whether 

they agreed or disagreed with the following statements regarding 

adequacy of outcomes: 

1. Pain score of

Pre-hospital analgesia CL Park, DE Roberts, DJ Aldington et al 

Figure 1: Flow of references identified for the systematic review 

reviews (1,030 patients [36] and 2,129 patients [33]) both looking 

mainly at adverse events rather than pain scores and effectiveness. 

Delphi responses 

Forty of the military anaesthetic and emergency medicine 

consultants responded to the Delphi exercise, as well as 16 

civilian air ambulance doctors; there was good agreement (Table 

2). There was a high degree of agreement that analgesia pain 

should be no worse than mild [16], that pain relief should be 

rapid (within 10 minutes), that patients should respond to 

verbal stimuli, not require ventilation, and that major adverse 

events should be avoided. 

They were also given an opportunity to make additional 

comments about what they would find important in pre-hospital 

analgesia. These were concerned mainly with issues of adverse 

events, typically the severity of events like nausea and vomiting, 

and whether cardiovascular stability should also be a criterion 

for choosing pre-hospital analgesia. Civilian physicians were 

more accepting of possible adverse events in order to obtain high 

quality analgesia. 

Analgesic failure and timing 

The majority of included studies reported most of the outcomes 

of interest. Least often reported were the timing of analgesia 

(within 10-20 minutes; 10/21 studies) and the extent of analgesia 

(14/21). Need for ventilatory support, sedation, and adverse 

events were reported in 20/21 studies (Table 1). 

Many studies provided average pain scores, usually with a 

standard deviation. Initial average pain scores were above 60/100 

mm or equivalent, and typically 80/100 mm. After treatment, 

pain scores were usually lower, typically averaging 30-40/100 

mm, but with standard deviations almost as large as the average, 

indicating large disparity between individuals. These data were 

unhelpful in determining failure rate, but did indicate that 

analgesic failure was occurring. 

Some studies on opioids [17, 19 – 21, 23 – 27, 33 – 34] provided 

information on the proportion of patients achieving analgesic 

success and failure. Figure 2 shows the failure rates (pain ≥30/100 

mm) between 10 and 40 minutes after treatment with intravenous 

morphine, fentanyl, and tramadol, and transmucosal fentanyl. 

After 10 minutes, about 60-70% of patients still had pain levels 

above 30/100 mm, but by 30-40 minutes this had fallen to about 

30%. There was no obvious difference between opioid chosen in 

Military 

(n=40) 

Number Question Agree 

(%) 

1 Pain score of < 30/100 mm on 

VAS (or equivalent) achieved 

Civilian 

(n=16) 

this limited data set (Figure 2), and each study used different dose 

levels and dosing schedules. Failure rates on arrival at hospital were 

reported as 43% [17] and 17% [19], both involving battle injuries. 

J R Army Med Corps 156 (4 Suppl 1): S295–300 297 

Agree 

(%) 

68 56 

2 Rapid onset of action. Pain 

relief achieved within: 

5 minutes 72 100 

10 minutes 

23 

15 minutes 

3 

20 minutes 

3 

3 Patients should remain 

responsive to verbal stimuli 

100 75 

4 Patient should not require 

any airway manoeuvres 

or ventilatory support to 

be performed following 

administration 

5 Absence of any harmful 

adverse events following 

administration 

97 88 

92 88 

Table 2: Results of the Delphi exercise – replies from 40 military 

anaesthetic and emergency medicine consultants and 16 civilian 

helicopter emergency service doctors 

Figure 2: Failure rates (pain greater than 30mm) between 10 and 

40 minutes after treatment with intravenous morphine (white), 

fentanyl (light gray), and tramadol (dark gray), and transmucosal 

fentanyl (black); the larger the circle’s diameter the larger the 

number in the study.


298 

Drug 

and route 

Number 

of patients 

IV morphine 815 Hypoventilation 

(3);only 1 treated 

with naloxone 

IV fentanyl 2224 Reduced respiratory 

rate or saturation 

(3), 1 given 

naloxone but no 

ventilatory support 

Transmucosal 

fentanyl 

Intranasal 

fentanyl 

Ventilatory support Sedation Nausea (N) & 

vomiting (V) 

22 Hypoventilation (1) 

given naloxone 

127 Reduced respiratory 

rate or saturations 

(7), none needed 

ventilatory support 

Fascia iliaca blocks demonstrated some efficacy for femoral 

fractures. Though some pain relief was noted after 10 minutes, low 

levels of analgesic failure were noted at later times, with 26/27 with 

mild pain on arrival at hospital [28], and 30-minute pain scores 

averaging below 30/100 mm [29]. For inhalational analgesia, three 

studies with 1550 patients using Entonox reported 30% marked 

or complete pain relief on arrival at emergency department, with 

53% partial, and 8% with mild or no relief [30-32]. Pain returned 

when gas was stopped. Inhalational methoxyflurane produced 

mean scores of 35/100 mm after 20 minutes in 83 patients [15]. 

Table 3 shows the number of cases of need for ventilatory 

support, sedation, nausea and vomiting, and cardiovascular 

instability reported, as well as other adverse events recorded. 

Among opioids, the pattern of reporting was quite similar, though 

it was notable that no patient required ventilatory support and 

only two patients required naloxone. Sedation was rarely a problem 

3 Nausea (20), 

Vomiting (8), 

N & V (16) 

4 Nausea (6), 

vomiting (3) 

0 Nausea (3), 

vomiting (2) 

Cardiovascular 

instability 

↓ BP (9), no 

support given 

↓ BP (9), no 

support given 

0 Nausea (9) ↓ BP (8), no 

support given 

CL Park, DE Roberts, DJ Aldington et al 

Other 

Pruritus (4), dizziness (5), 

dysphoria (1), fatigue (1), 

rash (1) 

Dysphoria (1) 

None Pruritus (5), light headed 

(2) 

IV alfentanil 16 0 0 Nausea (1) 0 Dizzy (4) 

IV tramadol 154 0 0 Nausea (40), 

vomiting (6) 

0 Dizzy (8) 

IV ketamine 870 0 0 0 0 Dizzy (3) 

IV pentazocine 9 0 9 0 0 0 

Sleepy/dizzy(5), bad taste 

(5), irritated throat (2), 

watery eyes (2), congestion 

(2), chest tightness (1), 

dysphoria (1) 

Fascia iliaca 79 0 0 0 0 Rapid absorption of local 

anaesthetic leading to 

headache, tachycardia, and 

increased BP (1) 

Inhalational 

Entonox 

Inhalational 

methoxyflurane 

1555 0 3 Nausea (15), 

N&V (69) 

83 0 Increased 

sedation 

score (29) 

0 Dizzy/light headed (177), 

drowsy (123), excitement 

(44), giddy (16), amnesia, 

numbness and headache 

(16) 

Nausea (7) 0 Euphoria (3), dizzy (2), 

headache (1), hallucinations 

(1), sore throat and lip 

paraesthesia (1) 

Table 3: Adverse events recorded according to treatment used. The numbers quoted are the number of patients with each adverse event. 

with any opioid treatment at the doses used. Nausea and vomiting 

were more frequent with intravenous tramadol and inhalational 

Entonox, but the severity was not mentioned. Cardiovascular 

instability again was uncommon, with a few instances of reduced 

blood pressure without necessity of intervention. Other adverse 

events were mainly dizziness or giddiness, with the expected 

pruritus with opioids. Excitement experienced with Entonox was 

unexplained [30]. 

Discussion 

The absence of evidence was the clearest outcome of this review, 

despite a broad search strategy and inclusion criteria, with 21 

studies and over 6,000 patients included. At least 11 different 

interventions were tested and outcomes used limited how much 

could usefully be adduced for any one of them. There were no 

clear winners between the opioids, although fentanyl tended to 


Pre-hospital analgesia CL Park, DE Roberts, DJ Aldington et al 

give the impression of being a good agent albeit with only a small 

sample, and a relatively large oral/transmucosal dose of 1,600 µg 

which is not without adverse effects [19]. 

Despite early onset of analgesia being a desired outcome of 

military and civilian physicians, the clear tendency was for up to 

30 minutes to be required for the proportion of patients with 

good analgesia to reach a maximum. It is also of interest to note 

the absence of efficacy data for the use of ketamine in the prehospital 

environment, despite its widely accepted use in this 

environment by both military and civilian practitioners. Fascia 

iliaca blocks showed great promise but are probably of limited use 

beyond analgesia for fractured femurs [28-29]. Finally, Entonox 

was characterised with a relatively high proportion of complete 

or partial failures while using the gas (53% partial, and 8% with 

mild or no relief) and with pain recurring within minutes of 

stopping the gas [30-32]. 

While the propensity of NSAIDs to increase bleeding and 

possible renal complications were an obvious reason why 

this class of drug has not been tested, it was less clear why 

cyclooxygenase-2-inhibitors have been omitted. These drugs 

can provide high levels of pain relief and long duration of action 

by virtue of a high acute pain dose without increasing bleeding 

[37-38]. There is also obvious scope for use of paracetamol 

and/or analgesic combinations, none of which was tested; only 

single analgesics were tested alone, and no test of multimodal 

analgesia was made. 

This review used several methodological techniques to 

maximise its relevance. These involved systematic searching 

and broad acceptance of study design, a consensus approach to 

desirable outcomes of efficacy and harm, and the definition of 

analgesic failure as a universal outcome. Moreover, in addition 

to electronic searches, retrieved articles were read for any other 

sources of data, as were general review articles and book chapters, 

because observational studies can be poorly elicited by electronic 

searching [39,40]. 

Although a number of reviews have been undertaken 

previously, this is, we believe, the first attempt at a systematic 

review of pre-hospital analgesia. As is so often the case, we 

found limited evidence without any clear-cut answer. It is likely 

that considerable valuable information exists as audits and 

surveys, but is not published because such methods are generally 

considered inferior to randomised trials. While that may be the 

case for explanatory studies about whether an analgesic works, 

it may be less so for pragmatic issues of how to use analgesics 

of proven efficacy to obtain the best results in particular clinical 

circumstances [41]. 

This reasoning underpinned the broad entry criteria used to 

maximise the amount of available data; restriction to randomised, 

double blind trials would have meant excluding 95% of the 

patients. We balanced the broader inclusion criteria, with many 

more patients, against the increased possibility of bias. 

The Delphi study provided outcomes that experienced senior 

clinicians considered of pragmatic importance. Despite the 

relatively small sample sizes it is still interesting to note that the 

two populations of physicians rated analgesic onset and verbal 

response somewhat differently. The military tended to recognise 

that the onset could be slightly delayed if side effects were to 

be minimised; civilian physicians were less tolerant of delay in 

analgesic effect. This difference may be due to experiences of 

treating multiple simultaneous casualties in a hostile environment 

rather than single casualties in a relatively benign environment. 

This dichotomy is important, since the only way of achieving 

rapid onset of analgesia, certainly with opiates, is by using 

relatively high doses with increased risks of adverse effects. Even 

the use of inhalational agents, which may provide a suitably rapid 

onset, may be expected to be associated with troublesome side 

effects such as the excitement of Entonox or the sedation with 

methoxyflurane. 

Most, but not all, physicians agreed that a pain score of below 

30/100 mm (mild pain, 1/3 numeric rating scale) was a desirable 

analgesic outcome. We chose this because it has been shown to be a 

consistent border between verbal and VAS scales [16], and because 

anything more than mild pain could reasonably be described as 

uncontrolled or unacceptable. Many studies reported average 

pain scores, but the wide standard deviations demonstrated how 

differently individuals had recorded their pain, indicating that the 

average response was perhaps experienced only by a few. Future 

studies should consider reporting information on individuals, 

particularly after defining what constitutes analgesic or other 

failure. The failure rate then becomes the primary outcome of any 

study of any design. 

The large number of options available for scoring pain, from 

100 mm visual analogue scale to 0-3 numerical rating scale, with 

their many variants, is a potential confusing factor. Teasing apart 

the effects of variation in dose levels and dosing schedules will 

always be difficult, but a simple scoring system may enable a 

clearer recognition of clinically significant differences between 

techniques. That should be the goal, rather than being lost in 

statistical differences of dubious clinical relevance. The military 

rule since 2008, has been to use the simpler 0-3 scale equating to 

no pain, mild, moderate, and severe pain [42]. 

There is no obvious guidance from the evidence available. 

More, better, and better thought out research is needed, and 

this review suggests some ways in which that could be achieved; 

publication of surveys and audits of appropriate quality would 

help. Given the paucity of information and the extreme variation 

in patients, providers, and environments, the pragmatic advice 

would be to take heed of the title of Ella Fitzgerald’s 1939 song: 

“T’aint what you do (It’s the way that you do it)”, and then find 

ways of doing it better. 

Disclaimer 

The views expressed in this work are those of the authors and 

are not necessarily those of the Defence Medical Services nor the 

Ministry of Defence. 

Conflict of interest statement 

DJ Aldington and R A Moore have been consultants for various 

pharmaceutical companies and members of scientific and clinical 

advisory boards, they have received speakers’ fees, participated in 

meetings supported by unrestricted grants from industry, and have 

received sponsored research funding from several companies. RAM 

is funded by NIHR Biomedical Research Centre Programme. All 

authors state that none of these declarations presents a conflict of 

interest in relation to the content of this review. 

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Total Intravenous Anaesthesia for War Surgery 

S Lewis 1 , S Jagdish 2 

1 Specialist Registrar in Anaesthesia & Critical Care, St George’s Healthcare NHS Trust, London; 2 Associate Specialist in 

Anaesthesia, 33 Field Hospital, Gosport & Chief of Staff, Dept of Military Anaesthesia, Pain & Critical Care 

Abstract 

Total Intravenous Anaesthesia (TIVA) and Target-Controlled Infusion (TCI) of anaesthesia are techniques that have benefited 

from recent advances in microprocessor technology and drug design. Though dependant on technology, they offer significant 

clinical benefits and logistic advantages. Manipulation of complex data derived from population pharmacokinetics has enabled 

greater understanding of drug handling models, thus enabling individual patient titration of anaesthesia. This has also informed 

manual techniques of intravenous anaesthesia. These approaches constitute a useful and logical alternative in the field, both in 

austere circumstances as well as the more established deployed setting. The pharmacodynamics and pharmacokinetics of potent 

intravenous anaesthesia agents in the complex combat trauma patient require continued examination. 

Introduction 

Total Intravenous Anaesthesia (TIVA) describes the technique 

of inducing and maintaining anaesthesia purely by intravenous 

means. The use of Volatile Gas Anaesthesia (VGA) is consequently 

avoided. Agents are delivered either by infusion or bolus to achieve 

the desired balance of hypnosis, analgesia and muscle relaxation. 

TIVA for war surgery can be traced back to the use of 

barbiturates during the Spanish Civil War (1936-9). Despite 

being associated with an increased mortality rate in casualties 

of the attack at Pearl Harbour [1] (a proposition that has since 

been challenged [2]), British military anaesthetists successfully 

employed continuous thiopentone anaesthesia during World War 

II [3]. The use of ketamine during the Falklands conflict informed 

the development of TIVA regimes [4] and in the first Gulf War, 

further examples of TIVA were described [5, 6]. Advances in 

pharmacology and technology continue to inform and help refine 

its use in current conflicts. Table 1 outlines the areas in which 

TIVA is employed by the Defence Medical Services (DMS). 

Pre-hospital care 

Role 2/Role 3 

surgical facilities 

Sedation 

During strategic 

transfer 

Role 4 hospitals 

During tactical transfer of intubated 

patients to the Field Hospital by the 

Medical Emergency Response Team 

(MERT) 

As a substitute for the more traditional 

VGA 

For intubated patients on the Intensive 

Care Unit (ICU) and during transfers to 

CT scan 

For sedation of intubated patients to 

role 4 by RAF Critical Care Air Support 

Teams (CCAST) 

For further surgical procedures (e.g. 

wound wash outs, second looks, 

reconstructive surgery) 

Table 1. Operational areas in which TIVA is employed 

Corresponding Author: Major S Lewis RAMC; C/O Army 

Medical Directorate Support Unit, The Former Army Staff 

College, Slim Road, Camberley, Surrey GU15 4NP 

E-mail: drselewis@googlemail.com 

Comparison of TIVA against VGA for War Surgery 

TIVA possesses certain desirable features for war surgery when 

compared with VGA and these are described below, followed by 

potential disadvantages. 

Advantages of TIVA 

Small Logistic Footprint 

Deployed surgical teams work in austere conditions at the end of 

a long supply chain and must be prepared to move at short notice. 

Traditional anaesthetic machines are bulky, difficult to transport 

and require compressed oxygen and a power source to function. 

A method of waste gas disposal is also required. This is in contrast 

to a single programmable syringe driver, which can be carried in 

the pocket of a rucksack with space for additional batteries [7]. 

Even the battle-proven lightweight Tri-Service Apparatus (TSA) 

cannot boast this simplicity and is known for its 20 separate tube 

connections [8]. 

Recovery Characteristics 

Provision of post-operative recovery facilities is highly limited 

in a deployed field hospital, both in terms of space and trained 

personnel. A technique that reduces the burden on anaesthetic 

and recovery staff is beneficial for the facility as a whole. Whilst 

speed of recovery from propofol-based TIVA may not be 

significantly different to that from VGA with the newer volatile 

agents desflurane and sevoflurane, a recent systematic review [9] 

found that nausea, vomiting, antiemetic use and headache were 

all lowest in the propofol group. 

Modulation of the Stress Response 

The stress response to surgery is characterised by increased 

sympathetic outflow, immunosuppression and a catabolic state. 

Attenuation of this response has become a treatment goal of perioperative 

medicine. Compared with VGA, propofol-based TIVA 

has been shown to delay and reduce the rise in IL-6 [10] (a proinflammatory 

cytokine) and stress hormone levels [11] in response 

to surgery. The clinical benefits of this effect, and whether it exists 

in the military trauma population, remain to be characterised. 

No potential for triggering Malignant Hyperthermia (MH) 

MH is a rare but potentially fatal condition that is resource-heavy 

to treat. It may be triggered by halogenated volatile agents (or 

suxamethonium), but not by TIVA. 


TIVA for War surgery 

Continuity of anaesthesia 

The continuity of agent delivery with TIVA has benefits both during 

and after the operative phase. At intubation there is no ‘twilight 

period’ as may occur in VGA between the offset of intravenous 

induction agents and the onset of volatile agents, reducing the risk 

of awareness [12]. Also, intraoperative manipulation of the airway 

will not disrupt the delivery of anaesthetic. 

Severely injured patients who have undergone damage 

control surgery often remain intubated in the ICU and during 

CCAST transfer to Role 4. The sedation required to keep these 

patients stable can be delivered by the same TIVA infusion 

as was used for the initial surgery (albeit at a reduced dose). 

It makes pharmacological sense to avoid the haemodynamic 

instability that may arise when one form of sedation is changed 

for another [7]. 

Disadvantages of TIVA 

Lack of familiarity 

All DMS anaesthetists are expected to be proficient in the use 

of TIVA, but are likely to be more familiar with VGA. Opinion 

remains divided whether TIVA is an appropriate technique for use 

in the cold, shocked, coagulopathic military trauma patient. Some 

consider it to be relatively contraindicated during the immediate 

resuscitation phase and prefer the security of an end-tidal volatile 

agent concentration to titrate delivery of a haemodynamically 

stable anaesthetic. 

Perceived risk of awareness 

With VGA the end-tidal volatile agent concentration is measured, 

providing an assurance that anaesthetic is actually reaching the 

patient. By contrast, unrecognised disconnection and underdosing 

are major considerations when using TIVA as there is 

no readily available clinical equivalent measure to the end-tidal 

volatile agent concentration. The closest would be the estimated 

blood (C p) or effect (C e) site concentration provided by a Target 

Controlled Infusion (TCI) pump. 

It is advisable to use a dedicated intravenous line for the TIVA 

infusion that is visible throughout the operation. 

Neuromuscular blockade increases the likelihood of awareness 

occurring since it prevents patient movement, a useful direct 

indication of nociception and indirectly one of inadequate 

anaesthesia. With TIVA, the use of muscle relaxants should be 

avoided or minimised where possible. Some advocate the use of a 

small dose of midazolam to reduce the risk of recall of awareness. 

Despite the above, the use of properly conducted TIVA/TCI is 

not associated with increased risk of awareness. 

Need to service and power infusion pumps 

Although TIVA represents a relatively small logistical requirement 

when compared with VGA, there is still the need to service, 

maintain and power infusion pumps. In the event of pump 

failure, TIVA regimes that require only a standard intravenous 

giving set have been proposed. 

Dependant on intravenous access 

By definition, intravenous access is required for TIVA. This 

is likely to be difficult in the shocked, unresuscitated military 

trauma patient where intraosseous access is normally the first 

technique used. Any drug may be given by this route (e.g. a 

bolus of ketamine), but an ongoing infusion would require 

intravenous access. 

302 

S Lewis, S Jagdish 

Drugs used for TIVA 

Drugs available for use by DMS anaesthetists for TIVA consist 

of the anaesthetic agents propofol and ketamine. Thiopentone 

is available but is a poor choice for TIVA due to its tendency 

to accumulate within the body. Midazolam may be given by 

infusion to provide sedation in critical care patients but would 

rarely be used as a sole agent to maintain surgical anaesthesia. 

Some regimes include infusion of an opioid or muscle relaxant. 

Propofol 

Propofol is a phenol derivative that is thought to act by 

potentiating inhibitory gamma-aminobutyric acid (GABA) 

receptors. It is the most commonly used intravenous anaesthetic 

agent in Western medicine. Features that favour its use for TIVA 

in war surgery include: 

• Familiarity 

• Extensively characterised context-sensitive behaviour 

• Low incidence of allergy 

• Reduction in postoperative nausea and vomiting (consensus 

guidelines recommend its use in susceptible patients [13]) 

Drawbacks to its use include: 

• Reduced cardiac output and systemic vascular resistance, 

which could be catastrophic in a shocked trauma patient. 

Dosage may need to be significantly reduced in such patients. 

A study of TIVA in a porcine model revealed that after 

haemorrhagic shock the blood propofol level increased by 

375% in unresuscitated animals [14]. 

• Vulnerability to temperature damage. Propofol should 

be stored between 4°C and 22°C [15]. A study of a US 

helicopter drug box found that the temperature exceeded 

25°C for 37% of the time during the summer [16]. One 

author’s experience (SJ) during Operation TELIC was that a 

stock of propofol had almost solidified during its presumably 

unmonitored journey along the supply chain at the height of 

an Iraqi summer. 

• Pain on injection 

Ketamine 

Ketamine is an intravenous anaesthetic agent derived from 

phencyclidine that acts via antagonism of N-methyl-D-aspartate 

(NMDA) receptors. It has many properties that favour its 

use within military and trauma anaesthesia, summarised by 

Grothwohl [17] as: 

• Haemodynamic stability with no evidence of human in vivo 

myocardial depression) 

• Reduced redistribution hypothermia [18] 

• Maintenance of protective airway reflexes and respiratory 

function 

• Bronchodilation 

• Maintenance of the hypoxic pulmonary vasoconstriction reflex 

• Analgesic effects (opioid synergy and reduced opioid tolerance) 

Concerns over certain side effects have prevented its use becoming 

widespread within the UK [17]. They include: 

• Increased ICP – which is now contested [19], ketamine may 

even be neuroprotective [20] 

• Psychotropic effects - these may be reduced if benzodiazepines 

are used concurrently or as premedication. The S(+)-ketamine 

isomer may have reduced psychotropic effects whilst providing 

better analgesia than its R(-)-ketamine equivalent [21]. 


TIVA for War surgery S Lewis, S Jagdish 

• Increased salivation and tracheobronchial secretions – these 

can be prevented or treated with an antisialogogue such as 

glycopyrrolate 

• Prolonged recovery time 

Recently the United States Tri-Services Anesthesia Research 

Group Initiative on TIVA (TARGIT) conducted a case-matched 

retrospective study of 214 cases of traumatic brain injury using 

data from their Joint Theatre Trauma Registry [22]. It compared 

those managed with ketamine-based TIVA against those who 

received VGA. They were unable to demonstrate a significant 

difference in neurological outcome. 

Midazolam 

Midazolam is a water-soluble imidazobenzodiazepine that acts 

at specific GABA-linked benzodiazepine receptors throughout 

the CNS. Its main actions are hypnosis, sedation, anxiolysis and 

anterograde amnesia. In bolus dose it has a short duration of 

action due to its high lipophilicity (at body pH) and metabolic 

clearance. With infusion it may accumulate and elimination halflife 

is significantly increased in the critically ill patient. There is 

also the potential for withdrawal phenomena after prolonged 

infusion, particularly in children. 

In the context of TIVA for war surgery, midazolam is useful 

as an adjunct to a ketamine-based technique. Advantages 

include [23]: 

• Reduced potential for recall of awareness 

• Reduced psychotropic effects of ketamine 

• Reduced postoperative nausea and vomiting 

• Muscle relaxation 

• Modest cardiorespiratory depression 

• Reversibility with flumazenil 

Opioids 

Opioid infusions are often used as part of a TIVA technique. 

Studies examining the interaction of propofol and opioids 

have demonstrated a reduction in Cp50 [24, 25] (the plasma 

concentration of propofol required to prevent movement to a 

surgical stimulus in 50% of subjects – analogous to MAC). This 

propofol-sparing effect is useful as it allows a reduction in the 

amount of propofol administered and thus greater haemodynamic 

stability. 

Remifentanil is now available to DMS anaesthetists and 

deserves special mention. It is a synthetic anilidopiperidine that 

acts as a pure mu-opioid receptor agonist. It is notable for its 

short context-sensitive half time of 3-5 minutes, regardless of the 

duration of infusion. Propofol TIVA with high-dose remifentanil 

provides a clean, rapid recovery that reduces the burden on 

recovery facilities. The obvious consequence of this property is 

that remifentanil will make no contribution to post-operative 

analgesia. 

Future Areas of Development 

Target Controlled Infusion (TCI) Pumps 

TCI pumps employ microprocessor technology to administer 

an infusion regimen at rates determined by models derived from 

population pharmacokinetics. Modern pharmacokinetic models 

are based around a ‘three-compartment model’, where the central 

compartment represents blood and the other compartments 

represent tissues into which the drug may distribute. The 

momentary drug concentration displayed on the device is a 

trended estimate, not the actual tissue concentration. The threecompartment 

model is the basis for the step changes performed by 

the TCI device in response to alterations in target concentration 

by the anaesthetist (Figure. 1). 

Figure 1: The traditional compartmental model of drug distribution 

with a continuous intravenous infusion. The effect site (represented by 

the blue compartment) is a recent addition that allows TCI systems to 

target brain concentration of drug. This compartment is considered 

volumeless for the purposes of mathematical modelling [26] 

A detailed description of the practical aspects of using TCI 

techniques is beyond the scope of this article. However, two aspects 

of TCI that are central to safe practice are the pharmacokinetic 

models used and the site targeted. They are discussed below. 

Pharmacokinetic Models 

The two in widest use for propofol are the eponymously named 

Marsh and Schnider models. There are significant differences 

between them. The volume of the central compartment (V c) 

used in the Marsh model is nearly four times greater than that of 

the Schnider model. The Schnider model allows for the slowed 

rate of distribution between V c and V 1 (Figure 1). Though 

it has been suggested that the Marsh model correlates best for 

depth of anaesthesia [27], neither have been designed for use 

specifically in trauma patients. Failing to account for the altered 

pharmacokinetics of a patient with haemorrhagic shock could 

lead to dangerous overdosing and circulatory collapse. Reduced 

propofol and opioid requirements in haemorrhagic shock are 

thought to be partly due to decreases in central clearance and 

central and second compartment volumes of distribution [28]. 

Additionally, these models require patient parameters such as 

weight (and height in the case of the Schnider model), which can 

only be estimated in the immediate stages of treatment. This does 

not preclude the use of TCI in trauma patients, but constitutes an 

area of future research. 

Targeting 

Recognition of the need to titrate dosing strategies in order to 

influence the effect site (i.e. the brain) has driven the desire to 

target the effect site concentration. The newer generation of TCI 

pumps offer the ability to target effect site for both propofol 

and remifentanil. The effect site is considered volumeless for the 

purposes of mathematical modelling (Figure 1). For propofol, it 

needs to be appreciated that effect site targeting is based on certain 

critical suppositions arising from population pharamacokinetics, 

thus underlining the importance of “calibrating” the patient 



during induction. The benefits of utilising effect site targeting 

for remifentanil are yet to be determined and given the rapid 

equilibration achieved by remifentanil, may even be irrelevant. 

The case for TCI pumps in the DMS 

TCI pumps are not yet available to DMS anaesthetists, although 

the provision of this capability in the operational setting is likely 

to add value and is being actively pursued. The advent of ‘open’ 

TCI pumps has meant that generic propofol preparations can be 

used instead of expensive prefilled electronically-tagged syringes. 

Furthermore, the presence of a drugs library in these devices 

means that they are suitable for the safe infusion of other agents 

such as vasoactive drugs. The ability to deliver remifentanil and 

sufentanil as a TCI is an added feature of these newer “open” TCI 

pumps. 

TCI pumps have been used successfully in the field by the 

Austrailian Army Medical Services in East Timor, who concluded 

that TCI is a useful substitute for VGA [29]. 

It is important that the user is aware of the ergonomics, 

capabilities and pharmacokinetic specifications of the chosen 

device, as there are important aspects of drug handling to be 

considered. An understanding of the chosen pharmacokinetic 

model is essential to the rational administration of the relevant 

drug. Three commonly available commercial “open” TCI systems 

are shown in Figure 2: 

Figure 2: Commercially available open TCI systems 

A current area of research is closed-loop TCI technology, whereby 

depth of anaesthesia monitoring is employed to provide direct 

feedback to the microprocessor and facilitate automatic infusion 

rate adjustment. 

Depth of Anaesthesia Monitoring in the Field 

Systems available to monitor depth of anaesthesia may be divided 

into cortical activity-based and evoked potential systems. The 

system that enjoys widest support in the literature is the Bispectral 

Index (BIS) system. An electrode strip placed across the forehead 

measures potentials arising from the activity of the patient’s 

cerebral cortex. Data is integrated into an index between 0 

(cortical silence) and 100 (fully awake). Values below 60 indicate 

clinical anaesthesia and those below 40 indicate a deep hypnotic 

state. This single variable is meant to correlate with behavioural 

assessments of sedation and hypnosis. 

As a monitoring system, BIS possesses certain limitations. A 

study was published in 2003 in which the authors administered 

muscle relaxant to themselves without anaesthetic agent, 

304 


Figure 3: The ASPECT BIS VISTA monitor in use together with a 

TIVA system on Operation TELIC 12 

reporting that the BIS score was actually seen to fall [30]. Also BIS 

is incompatible with ketamine-based TIVA. BIS score is actually 

seen to increase following bolus injection of ketamine [31]. 

The case for a Depth of Anaesthesia Monitoring System in 

the DMS 

Presently, clinical signs are the only guides that the DMS 

anaesthetist has to assess the adequacy of TIVA, though 

these are known to lack sufficient specificity and sensitivity 

to confirm depth of anaesthesia. The quoted incidence of 

awareness under anaesthesia ranges from 0.11% to 0.18% 

and haemodynamically compromised trauma patients are 

particularly at risk of under-dosage given the caution that is 

necessary when anaesthetising them. Likewise, over-dosage can 

lead to cardiovascular compromise and prolonged recovery. The 

situation is also complicated by the use of remifentanil, which 

whilst possessing no hypnotic properties of its own, appears 

to allow downwards titration of co-administered propofol. An 

American Society of Anaesthesiology (ASA) task force released 

a Practice Advisory in 2006 that recommended brain function 

monitoring should be considered in situations when there was 

an increased risk of intraoperative awareness, including trauma 

surgery [32]. 

The introduction of depth of anaesthesia monitoring may 

bring other benefits. A prospective observational study of over 

1000 high-risk patients undergoing major non-cardiac surgery 

identified three independent variables as significant predictors of 

mortality [33]. These were patient co-morbidity, intra-operative 

systolic hypotension and cumulative deep hypnotic time (BIS < 

45). BIS scores in this range generated a 24.4% relative risk of 

death per hour. 



Technical 

Dependency 

‘Low Tech’ 

TIVA Regimes 

(without 

electronic 

infusion 

pumps) 

‘Medium Tech’ 

TIVA Regimes 

(electronic 

infusion pump 

required) 

‘High Tech’ 

TIVA Regime 

(utilising TCI 

technology) 

Agents Indication Method Notes 

Ketamine 

Propofol, 

Fentanyl and 

Ketamine 

[17] 

Ketamine and 

Midazolam 

[35] (+/- 

Vecuronium) 

[4] 

Propofol and 

Alfentanil [5] 

‘Classical’ 

Manual 

Propofol 

Infusion [37] 

Propofol and 

Remifentanil 

Prehospital 

care, austere 

environments 

Table 2. Suggested regimes for TIVA in the field 

Maintenance of 

general anaesthesia 

with TIVA when 

electronic infusion 

pumps are 

unavailable 

Cardiac-stable 

regime in the 

haemodynamically 

compromised 

casualty. 

Allows invasive 

ventilation. 

Invasive 

ventilation of 

casualties without 

haemodynamic 

compromise 

Anaesthesia for 

casualties without 

haemodynamic 

compromise. 

Ventilated 

anaesthesia 

preferably 

without the use 

of neuromuscular 

blockade. 

0.5-2mg/kg iv for induction (use less 

than 1mg/kg if shocked). Maintain 

with 0.5mg/kg boluses or 20- 

100mcg/kg/min. 2mg midazolam 

reduces emergence delirium. 200mcg 

glycopyrrolate reduces salivation. 

40ml of 1% propofol, 5ml of 

50mcg/ml fentanyl and 5ml of 

50mcg/ml ketamine is mixed with 

50ml of NaCl 0.9% (solution 

will contain 4mg/ml propofol, 

2.5mcg/ml fentanyl and 2.5mcg/ml 

ketamine). Initially one drop every 3 

seconds through a standard 20 drop/ 

ml giving set and titrate to effect. 

Induce anaesthesia with 1mg/ 

kg ketamine plus 0.07mg/kg 

midazolam. Maintain by infusion 

of 200mg ketamine plus 5mg 

midazolam made up to 50ml and 

run at: 

(patient’s body weight in kg/2)ml/hr 

12mg vecuronium may be added for 

muscle relaxation. 

50ml of 1% propofol and 2.5mg 

(5ml) alfentanil. Infuse mixture at an 

initial rate of 1ml/kg/hr following a 

standard induction. Reduce rate by 

up to half according to clinical signs. 

Initial bolus of 1mg/kg for 

induction then 10mg/kg/hour for 

10 minutes, 8mg/kg/hour for 10 

minutes followed by 6mg/kg/hour 

for subsequent maintenance of 

anaesthesia. 

50ml 1% propofol infusion and 

a 40ml solution containing 2mg 

remifentanil. 

If TCI pump available for each drug: 

Initial blood propofol target 

4 to 6µg/ml 

Initial remifentanil target 

8 to 10ng/ml. 

If TCI is not available for 

remifentanil: 

Infuse remifentanil at 0.5µg/kg/ 

min for 3 to 5 minutes followed by 

0.25µg/kg/min. Maintenance rates 

range from 0.12 to 0.5µg/kg/min. 

Commence propofol first as a rapid 

rise in effect site concentration of 

remifentanil can induce apnoea 

before loss of consciousness. 

Full effect of bolus persists for 

about 10 minutes. In most 

cases airway reflexes and selfventilation 

should be preserved. 

Relatively high concentration 

of ketamine therefore good 

analgesic properties and slow 

return to full arousal after 

discontinuing. Omit ketamine 

for more rapid emergence. 

The mixture has a 72 hour 

shelf life. 

Facilitates rapid emergence 

compared with isoflurane-based 

VGA [36]. Low incidence of 

nausea. 

Low incidence of nausea. 

It has been estimated that 

this schema delivers a steady 

state concentration of around 

3µg/ml. 

The initial Cp or Ce target 

for propofol is chosen to be 

just above the anticipated 

concentration required for 

loss of consciousness in that 

patient. The concept of 

“patient calibration” is central 

to the success of this technique. 

Caution is required with these 

targets especially where there is 

cardiovascular instability. 

Estimated Ce should be noted 

at points during induction such 

as loss of response to command, 

instrumentation of the airway 

and incision. This will identify 

the Ce and Cp below which it 

would be inadvisable to drop 

and also helps identify the likely 

emergence point. 



A field trial of the ASPECT BIS VISTA monitor was 

conducted by one of the authors (SJ) on OP TELIC 12 in 2008. 

A photograph of this monitor in use together with a TIVA system 

is shown in Figure 3. Apart from one episode of diathermyrelated 

interference the system performed well across a spectrum 

of anaesthetic procedures. 

Figure 4: Depth of Anaesthesia monitoring employing auditoryevoked 

potentials during Operation TELIC 13 

Direct injection of volatile agents into the bloodstream 

This intriguing concept is still at the animal testing stage. 

Experiments using intravenous emulsified isoflurane have 

characterised potential advantages of this approach. Its use requires 

no specific ventilatory circuits or reliance on pulmonary function. 

There is evidence that onset and offset is faster than propofolbased 

TIVA whilst being very haemodynamically stable. A further 

benefit is the preconditioning effect that isoflurane elicits against 

ischaemia-reperfusion injury [34]. 

Suggested regimes for TIVA in the field 

The method of TIVA used will be dictated by anaesthetist 

preference, clinical presentation and the availability of drugs and 

equipment. The regimes outlined in Table 2 are all ‘battle-proven’ 

techniques for use in adults that have been used by military 

anaesthetists. They also include approaches to TIVA for situations 

when electronic infusion pumps are unavailable. 

Conclusion 

There are some clear advantages of TIVA over VGA to the 

deployed military anaesthetist. The drugs and technique used can 

be tailored to both the patient’s physiological status and the wider 

logistical situation in which the surgical team is working. Future 

developments may further enhance the applicability of TIVA for 

war surgery. 

The purpose of this article is not to suggest that TIVA should 

replace VGA within the DMS, but to promote it as a valid 

alternative. It would certainly be wrong to assume that “…anyone 

who could depress the plunger of a syringe in response to movement in 

a patient could give an anaesthetic” [2]. There is great potential for 

harm with poorly administered TIVA, and advances in military 

pre-hospital care have meant that increasingly sick patients are 

now surviving to reach Role 2/3 facilities. When confronted with 

such patients, the best anaesthetic to give is probably the one 

with which the anaesthetist is most familiar, be that either VGA 

or TIVA. 

306 


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Anaesthesia at Role 4 

PR Wood 1 , AG Haldane 2 , SE Plimmer 2 

1 2 Consultant Anaesthetist; Speciality Registrars in Anaesthesia at University Hospital Birmingham NHS Foundation 

Trust 

Abstract 

The contribution of anaesthesia to the care of injured military personnel at Role 4 is described with particular emphasis on 

the working relationship between the Royal Centre for Defence Medicine and the civilian department of anaesthesia. The 

implications for operating theatre activity are discussed. 

Philosophy and Infrastructure 

The aims of anaesthesia at Role 4 may be described as a horizontal 

integration with the care given in operational theatres, the current 

focus of which is Op HERRICK. While easily stated this is not 

without its challenges. 

The clinical care of military personnel was concentrated at Selly 

Oak Hospital (SOH) but in June 2010 this hospital relocated to 

the new Queen Elizabeth Hospital Birmingham (QEHB ). 

The Department of Anaesthesia of University Hospital 

Birmingham NHS Trust has 75 consultants, 30 of whom have 

intensivist duties distributed across four critical care units, 

containing a total of 100 beds. Military patients constitute just 

one per cent of the Trust’s population but are resource intensive 

- arrangements exist with the Defence Medical Services and local 

NHS Trusts to manage increased numbers of patients during 

periods of heightened activity in theatres of conflict. 

The new QEHB theatre complex has 23 in patient operating 

theatres and during busy periods up to four of these may contain 

military casualties. Surgical care is dominated by ortho-plastics, 

hand and maxillo-facial surgeons with the input of general and 

urology surgery as necessary. The medical care of every military 

in-patient is reviewed at a weekly military ward round, which 

is a multi-disciplinary meeting starting at 0800hrs. Involving 

as many as 20 NHS and Tri-service clinicians with support staff 

every military casualty has all aspects of their present and future 

progress considered and plans made for ongoing surgery or key 

investigations. 

One of the authors (PW) participates in the first ‘sit down’ 

part of the ward round. The presence of a civilian consultant 

anaesthetist allows observations or comment to be made in relation 

to current clinical issues and to take note of any preceding or 

forthcoming events that have particular relevance for anaesthesia. 

In particular his presence allows prompt and ongoing liaison with 

the Defence Professor of Anaesthesia, the Army Subject Matter 

Expert (SME ) in pain and the consultant pain nurse responsible 

for the military ward. 

Patient admissions and theatre allocation 

Injured personnel arrive in Birmingham via the RAF Critical 

Care Air Support Team (CCAST ) or via routine aeromedical 

evacuation flights. By definition the first group require critical 

care and because of the rapid transit times from Afghanistan are 

still in the ‘damage control phase’ of their surgical journey. 

Corresponding Author: Dr Paul Wood, Dept of Anaesthetics, 

Queen Elizabeth Hospital Birmingham B15 2WB 

E-mail: paul.wood@uhb.nhs.uk 

For the anaesthetist back in the UK the process will often start 

with a phone call - a message that casualties are expected and will 

need further care that day or night. The surgical teams and trauma 

co-ordinators meet up in the ‘bunker’- in reality a secure room in 

theatres - but with the addition of a series of white boards it has 

become a co-ordination centre (Figure 1). The new patients are 

on the boards with details summarised from the aeromed signals, 

injuries listed and teams allocated. On admission to QEHB 

CCAST patients enter the critical care unit ( CCU ) where an 

immediate assessment of their injuries and physiological status 

are made prior to continued stabilisation or immediate surgery 

- in most cases this is the ‘2nd look’ following their resuscitative 

surgery at Role 3. 

Figure 1. The ‘Bunker’ 

Less severely injured aeromed admissions are admitted directly 

to the military ward , where an early review of their wounds is 

undertaken in the very likely event that within 2-8 hours they will 

also be in an operating theatre having their wounds inspected, and 

initial surgical management carried out. The theatre bunker is not 

only essential in the planning of ‘casualty surges’ but is indispensable 

in the daily planning of theatre lists for both military and civilian 

trauma patients. Planning meetings held daily at 1230 and 1630 

help to ensure that the normal theatre activity is maintained. 

Anaesthesia 

For those patients admitted to CCU their initial visits to theatre 

are characterised by rigorous attention in continuing to manage 

the lethal triad of coagulopathy, hypothermia and acidosis. Their 

surgery takes place in a designated emergency theatre under 

direct consultant surgical and anaesthetic supervision. The early 

care is an extension of the process carried out at Role 3 and initial 

theatre trips are often time critical if control of the lethal triad is 

to be maintained. 


Role 4 Anaesthesia PR Wood, AG Haldane, SE Plimmer 

There is significant use of blood and blood products – in 

particular fresh frozen plasma which is administered with packed 

red cells, most often in a 1:1 ratio, as practised during their 

haemostatic resuscitation in Role 3 [1]. When necessary platelet 

and cryoprecipitate preparations are also utilised. 

Critical care staff will undertake the changing of invasive 

monitoring and vascular access lines, however when the first 

surgical intervention is contemporaneous with the patients 

admission these may be undertaken in the operating theatre. At 

this time fine bore nasogastric feeding tubes are inserted and a 

feeding regime established, which in intubated patients continues 

uninterrupted. As their wounds evolve the concept of damage 

control surgery continues until such time as they are ready for 

transfer to the military ward and restorative surgery. 

For the less severely injured aeromed admissions there is the 

occasional unexpected ‘surprise’ when the dressings come down 

under anaesthesia.These patients are cross-matched prior to 

surgery and it is made clear to all - and the junior medical staff in 

particular - that there is no such thing as ‘just a dressing change’. 

The complex nature of the ballistic wounds means that as 

the patients condition stabilises multiple surgical 

interventions are the norm. Particular challenges 

for anaesthesia include establishing and maintaining 

intravascular access, pain control and avoiding 

prolonged perioperative starvation. Trust policy 

limits preoperative omission of solids to 6 hours, 

while clear fluids are permitted up to 2 hours before 

surgery. Anaesthetic considerations are summarised 

in Box 1, while Figures 2 and 3 reveal aspects of the 

surgical activity for all the military patients during 

February 2010, demonstrating some of the resource 

and clinical implications of managing these patients. 

The six casualties whose theatre time exceeded 10 

hours are of particular note. One patient required 

45 hours of surgery - his operative interventions continued in the 

following month. His situation is not unique – Table 1 details 

timings for three severely injured casualties treated in 2009. 

Critical Care 

• Damage control surgery - manage the lethal triad: acidosis, 

coagulopathy, hypothermia 

• Haemostatic resuscitation as per current CGO 

• Surgery is time critical 

• Sepsis – inotrope support 

• Renal function - K+ monitoring 

• Blast lung – complex ventilatory strategies may be required 

Military Ward 

• Recent transfer from intensive care – medically still 

challenging – high dependency 

• Reconstruction – prolonged procedures 

• Non opiate naive – high dose opiate background analgesia 

• Practical conduct of PNB regional anaesthesia made harder 

by stabilisation and negative pressure dressings 

• Epidural anaesthesia / analgesia not possible with unstable 

spinal fractures 

• Accentuation of tourniquet effect 

• Blood loss easily underestimated 

• Temperature control 

Box 1 Essential features of anaesthesia in Role 4 patients 

Figure. 2: Total time required in the operating theatre for patients 

undergoing surgery in February 2010 

Figure 3: Number of surgical operations performed on patients 

undergoing surgery in February 2010 

Number of 

operations 

Total time 

in operating 

theatre (to 

nearest hour ) 

Time required 

per operation 

A B C 

27 11 9 

75 hours 33 hours 17 hours 

shortest 1hr 

15 mins 

longest 6 

hours 

shortest 1hr 

longest 8hrs 

30 mins 

shortest 1 hr 

longest 3 hrs 

Table 1: Time utilised for three patients ( A ,B and C ). ( Data kindly 

supplied by Professor K. Porter ) 

Postoperative Care 

Critically injured patients are returned directly to the CCU. Noncritical 

patients are admitted to the recovery unit and returned 

to the ward when vital signs and analgesia are ensured. During 

awakening ‘flashbacks’ can be a problem requiring sensitive 

management from recovery staff. 


 

Role 4 Anaesthesia 

Despite their ‘non-critical’ status may of the patients on the 

military ward can present challenging medical problems. In an 

effort to provide a standardisation of care there are a number 

of protocols that are followed, in to which anaesthesia has had 

an input. Maintaining vascular access is a frequent issue and 

consequently peripherally inserted central catheter (PICC) lines 

(inserted under local anaesthesia by interventional radiologists) 

are used for maintenance fluids and repeat anaesthesia. 

Perioperative Analgesia 

This is managed by the acute pain team, lead by a consultant 

nurse, supported by a number of military and civilian consultant 

anaesthetic colleagues, including the Army SME in pain. 

Considerable attention has been given to the pain management 

of military patients. This has been well described elsewhere in 

this journal [2] but since that publication there have been further 

advances, particularly in respect of producing clinical guidelines 

and increased audit activity. 

A multimodal analgesic regime is prescribed for military 

patients and is described in detail in an analgesia document 

which is available on the Trust intra-net. Continued use is made 

of Peripheral Nerve Blockade (PNB) and epidural catheters sited 

in Role 3 [3] and where their removal is unavoidable replacement 

or substitution with a suitable alternative is often attempted. The 

department has two Sonosite (Sonosite Inc. Bothell, WA, USA) 

ultrasound machines available and a cadre of ultrasound trained 

anaesthetists who are available to assist in catheter placement. This 

has proved invaluable – particularly where complex reconstructive 

surgery to an upper limb has been undertaken. 

Epidural analgesia has despite some initial reticence concerning 

the risk of infection proved beneficial in patients with bilateral leg 

amputations. In these injuries the use of femoral and or sciatic 

catheters can be limited by the high nature of the amputation 

sealed with bulky negative pressure dressings. In such a setting 

identification of complications associated with epidural regional 

analgesia can also be problematical – one practical development is 

the ‘four and no more’ rule, devised in an attempt to ensure that 

any patient suspected of having an epidural haematoma is MRI 

scanned within 4 hours of suspicion (Box 2). 

Research and development 

The contribution of anaesthesia to the patient’s onward progress 

does not stand still. A series of acute pain team initiatives 

have simplified the management of regional anaesthesia. The 

promotion of regional techniques will strengthen in the near 

future with the introduction of a military pain fellow who will be 

attached to the unit for nine months at a time. This is one marker 

of success to drive the developing policy of regional anaesthesia 

for limb trauma as the default analgesic method of choice [4]. 

310 

PR Wood, AG Haldane, SE Plimmer 

We will consider an epidural infusion to be established in 

4 hours. The initial sensory level (if any) and motor function 

should be recorded in the patients notes (on an anaesthetic 

record). Thereafter: 

1. An awake patient should be assessed 4 hourly 

2. At each assessment the nurse should ask 4 questions: 

i. Is there an increase in motor block? 

ii. Is there back pain? 

iii. Is there an increase in / development of a sensory level? 

iv. Are there any other new abnormal/ unexpected 

symptoms i.e. bladder / bowel issues / increased pain in 

a previously comfortable limb. 

3. Positive answer to any one of the 4 questions - call the 

anaesthetic SpR as per ‘S4 pain call’ agreement - while 

awaiting response - STOP THE INFUSION. 

4. Repeat examination by SpR 4 hours after infusion stopped. 

If no improvement or further deterioration in neurology - 

patient needs EMERGENCY MRI. 

Box 2: Diagnosis of Epidural Haematoma – The ‘4 and no more’ Rule 

The management of patients in the operating theatre 

increasingly resembles the clinical guidelines for operations 

(CGO) employed in Role 3, an example of which is the near 

patient monitoring of coagulation with thromboelastography. 

This is available within CCU and the operating theatre suite. It 

is anticipated that this initiative will have the potential for more 

accurate administration of blood products, particularly in respect 

of the use of FFP [5]. 

It is anticipated that the present system of care will continue 

to evolve as the QEHB matures with the constant aim of making 

the 8000 mile journey from Bastion to Birmingham as seamless 

as possible. 

References 

1. Hodgetts TJ, Mahoney PF, Kirkman E. Damage Control 

Resuscitation. JR Army Med Corps 2007; 153 (4): 299-300 

2. Edwards D, Bowden M, Aldington DJ. Pain management at role 4. 

JR Army Med Corps 2009; 155 (1): 61-64 

3. Hughes S, Birt D. Continuous Peripheral Nerve Blockade on OP 

Herrick 9. JR Army Med Corps 2009; 155 (1); 69-70 

4. Clasper J, Aldington D. Regional Anaesthesia, Ballistic Limb 

Trauma and Acute Compartment Syndrome. JR Army Med Corps. 

2010; 156 (2): 77-78 

5. Woolley T. Coagulation Study. Paper Presented at the Academia 

and Armed Conflict Conference. Royal College of Anaesthetists, 

London 21st September 2009. 


Field Intensive Care - Weaning and Extubation 

R Thornhill 1 , JL Tong 2 , K Birch 3 , R Chauhan 4 

1 Consultant in Anaesthesia and Intensive Care Medicine, Nottingham University Hospitals and RCDM 2 Royal Centre 

for Defence Medicine and Honorary Senior Lecturer at the University of Birmingham; 3 Consultant in Anaesthesia and 

Intensive Care, North Bristol NHS Trust; 4 StR in Anaesthesia, Queens Hospital, Burton-Upon-Trent. 

Abstract 

Injury following ballistic trauma is the most prevalent indication for providing organ system support within an ICU in the 

field. Following damage control surgery, postoperative ventilatory support may be required, but multiple factors may influence 

the indications for and duration of invasive mechanical ventilation. Ballistic trauma and surgery may trigger the Systemic 

Inflammatory Response Syndrome (SIRS) and are important causative factors in the development of Acute Lung Injury 

(ALI) and Acute Respiratory Distress Syndrome (ARDS). However, their pathophysiological effect on the respiratory system 

is unpredictable and variable. Invasive mechanical ventilation is associated with numerous complications and the return to 

spontaneous ventilation has many physiological benefits. Following trauma, shorter periods of ICU sedation-amnesia and a 

protocol for early weaning and extubation, may minimize complications and have a beneficial effect on their psychological 

recovery. In the presence of stable respiratory function, appropriate analgesia and favourable operational and transfer criteria, 

we believe that the prompt restoration of spontaneous ventilation and early tracheal extubation should be a clinical objective 

for casualties within the field ICU. 

Introduction 

Injury following ballistic trauma is the most prevalent 

indication (50%) for providing organ system support to UK 

personnel within an intensive care unit (ICU) in the field [1]. 

In general the role of the field ICU is to continue the postinjury 

resuscitation process and provide organ system support, 

until the casualty is discharged to the ward or evacuated to the 

Role 4 facility. 

Trauma casualties may require admission to an ICU for 

mechanical ventilation, which may be indicated for a variety 

of reasons, which include: impaired ventilatory effort, impaired 

respiratory motor function, increased mechanical load and 

impaired alveolar gas exchange [2]. Postoperative respiratory 

support is also indicated in those casualties who require surgery 

for further haemorrhage control or pack removal, bowel 

anastamosis and abdominal wall closure. Tracheal intubation is 

usually performed to facilitate invasive mechanical ventilation, 

but may also be instituted for endobronchial suctioning or 

maintenance of upper airway patency and protection. 

Mechanical ventilation is associated with multiple 

complications (Table 1) and prolonged periods of ventilation 

and intubation should therefore be avoided. In some studies, 

greater than 40% of the total duration of mechanical ventilation 

involves the weaning process [3, 4] and adopting an early weaning 

and extubation policy, may minimize the risk of complications 

associated with mechanical ventilation. 

Following mechanical ventilation, up to 20% of patients 

fail their first attempt at weaning [3, 4]. Whilst data on the 

incidence of weaning failure in a military population remains 

unreported, premature extubation and re-intubation should 

be avoided, as this is associated with an increased morbidity 

and mortality [5]. The purpose of this manuscript is to review 

Corresponding Author: Lt Col R Thornhill, Department 

of Military Anaesthesia and Critical Care, Royal Centre 

for Defence Medicine, Raddlebarn Road, Selly Oak, 

Birmingham, B29 6JD 

Email: rjthorn@btinternet.com 

the evidence for a ‘prompt weaning protocol’ leading to the 

restoration of spontaneous ventilation and tracheal extubation, 

within a field ICU. 

Causative Factor Complication 

Endo-tracheal intubation 

Mechanical ventilation 

Immobility 

Sinusitis 

Ventilator-associated pneumonia 

(VAP) 

Tracheal stenosis 

Vocal cord trauma 

Formation of fistulae (trachealoesophageal 

or tracheal-vascular) 

Pneumothorax 

Oxygen toxicity 

Hypotension 

Ventilator associated lung injury 

(VALI) 

Venous thrombo-embolism 

Loss of skin integrity and 

pressure necrosis 

Muscle wasting and weakness 

Atelectasis 

Table 1: Complications of mechanical ventilation. 

Effect of Anaesthesia & Sedation on normal 

respiratory function 

Anaesthesia causes an impairment of pulmonary function, 

irrespective of whether the patient is breathing spontaneously, or 

is being mechanically ventilated. Impaired oxygenation of blood 

occurs in most subjects who are anaesthetised [6]. Lung function 

remains impaired postoperatively, and clinically significant 

pulmonary complications can be seen in 1% to 2% after minor 

surgery, and in up to 20% after upper abdominal and thoracic 

surgery [7]. 


Early Extubation on ICU 

The effects of anaesthesia and mechanical ventilation on lung 

function are described below. These effects are causative - in that 

they relate to a sequence of events the end result of which is a 

decrease in the lungs ability to oxygenate the blood and remove 

Carbon Dioxide. The first phenomenon that is seen following 

induction of anaesthesia is loss of muscle tone with a subsequent 

reduction in Functional Residual Capacity (FRC) due to a change 

in the balance between the outward forces (respiratory muscles) 

and inward forces (elastic tissue of the lung). This reduction in 

FRC is paralleled by an increase in the elastic behaviour of the 

lung (reducing compliance) and an increased airways resistance. 

The decreased FRC also predisposes to airway closure and the 

development of atelectasis - which is made worse by the application 

of high concentrations of inspired oxygen. These changes in lung 

patency alter the distribution of ventilation, and the matching 

of ventilation and perfusion, and impede efficient gas exchange. 

Lung Volume 

Resting lung volume (or FRC) is reduced by 0.8 to 1.0 L by 

changing body position from upright to supine, and there 

is another 0.4 to 0.5L decrease when anaesthesia has been 

induced [8]. End-expiratory lung volume is thus reduced from 

approximately 3.5 to 2L (this being close or equal to the Residual 

Volume of the lung (RV)). Anaesthesia itself causes a fall in FRC 

despite maintenance of spontaneous breathing [9, 10]; the average 

reduction corresponds to around 20% of awake FRC and may 

contribute to an altered distribution of ventilation. The decrease 

in FRC occurs regardless of whether the anaesthetic is inhaled or 

administered intravenously [11]. Muscle paralysis and mechanical 

ventilation cause no further decrease in FRC. 

This decrease in FRC seems to be related to loss of respiratory 

muscle tone, which shifts the balance between the elastic recoil 

force of the lung and the outward force of the chest wall to a lower 

chest and lung volume. 

Compliance and Resistance 

Static compliance of the total respiratory system (lungs and chest 

wall) is reduced on average from 95 to 60 mL/cm H 2 O during 

anaesthesia [12]. Resistance of the total respiratory system and 

the lungs during anaesthesia increases during both spontaneous 

breathing and mechanical ventilation [12]. 

Atelectasis 

Atelectasis (lung tissue collapse) appears in approximately 90% 

of all patients who are anaesthetised [13]. It is seen during 

spontaneous breathing and after muscle paralysis and whether 

intravenous or inhaled anaesthetics are used [11]. Up to 15% 

to 20% of the lung is regularly collapsed at the base of the lung 

during uneventful anaesthesia as a result of anaesthesia alone. 

Abdominal surgery does not add much to the atelectasis, but it 

can remain for several days in the postoperative period [14]. After 

thoracic surgery and cardiopulmonary bypass, more than 50% 

of the lung can be collapsed even several hours after surgery is 

complete [15]. It is likely that it is a focus of infection and can 

contribute to pulmonary complications [16]. 

The amount of atelectasis decreases toward the apex, which is 

mostly spared and thus fully aerated. There is a weak correlation 

between the size of the atelectasis and body weight or body mass 

index (BMI), with obese patients showing larger atelectatic areas 

[11,17]. Atelectasis is independent of age, with children and 

young people showing as much atelectasis as elderly patients [18]. 

312 

R Thornhill, JL Tong, K Birch et al 

There is a good correlation between the amount of atelectasis and 

the subsequent pulmonary shunt. 

Distribution of Ventilation and Perfusion 

Redistribution of inspired gas away from dependent to 

nondependent lung regions has been observed in anesthetized 

supine humans; ventilation was shown to be distributed mainly to 

the upper lung regions, and there was a successive decrease down 

the lower half of the lung [19]. Positive end expiratory pressure 

(PEEP) increases dependent lung ventilation in anaesthetised 

subjects, so the distribution of ventilation is more similar to that 

in the awake state [20]. Thus, restoration of overall FRC toward 

or beyond the awake level returns gas distribution toward the 

awake pattern. This is an effect of the recruitment of collapsed, 

dependent lung regions (atelectasis), of reopening of closed 

airways in the lower lung regions, and possibly of increased 

expansion of the upper lung regions so that they become less 

compliant and less ventilated. 

PEEP will impede venous return to the right heart and 

therefore reduce cardiac output. It may also affect pulmonary 

vascular resistance, although this may have less of an effect on 

cardiac output. In addition, PEEP causes a redistribution of blood 

flow toward dependent lung regions [21]. By this means, upper 

lung regions may be poorly perfused, thereby causing a dead 

space–like effect. 

Respiratory Drive 

Spontaneous ventilation is frequently reduced during anaesthesia. 

Inhaled anaesthetics [22], as well as intravenous agents [23] reduce 

sensitivity to CO 2 . The response is dose dependent, with decreasing 

ventilation with deepening anaesthesia. Anaesthesia also reduces 

the response to hypoxia. Attenuation of the hypoxic response may 

be attributed to an effect on the carotid body chemoreceptors [24]. 

Mechanical ventilation and acute lung injury 

Following major trauma, an acute lung injury (ALI) and the risk 

of Acute Respiratory Distress Syndrome (ARDS) is a significant 

clinical concern [25, 26]. The aetiology of ALI / ARDS following 

trauma is multifactorial and the risk factors are shown in (Table 

2). Recent studies have shown that inappropriate ventilator 

strategies can also induce ALI [27]. 

Old age 

Preexisting physiological impairment (diabetes, etc) 

Direct pulmonary or chest wall injury 

Aspiration of blood or stomach contents 

Prolonged mechanical ventilation 

Severe traumatic brain injury 

Spinal cord injury with quadriplegia 

Massive transfusion 

Haemorrhagic shock 

Occult hypoperfusion 

Sepsis 

Table 2: Risk factors for development of ALI/ARDS after trauma. 


Early Extubation on ICU R Thornhill, JL Tong, K Birch et al 

Following injury, casualties are immobilized in the supine 

position. This posture is responsible for the development of 

early dependent atelectasis, which may be further exacerbated by 

opioid analgesia and sedation, due to cephalad movement of the 

diaphragm into the thorax and compression of dependent lung 

parenchyma. General anaesthesia and the use of muscle relaxants 

may also exacerbate this problem [28]. Pulmonary contusions, 

if severe, can be life-threatening early in the hospital course and 

the disruption in pulmonary integrity due to “leaky” capillaries 

and lung parenchyma, may be further exacerbated by volume 

resuscitation with blood and crystalloid solutions. Rib fractures 

can cause splinting of the diaphragm leading to atelectasis and 

hypoxaemia. 

Mechanical ventilation can initiate lung injury. High peak 

inspiratory pressure and low PEEP, may lead to inflammatory 

processes in the lung that can progress to multi-organ dysfunction. 

Animal studies that induce pulmonary damage to simulate 

ALI or ARDS cannot be distinguished from the lung damage 

occurring after studies that use mechanical ventilation strategies 

to induce injury [29]. ALI causes an alteration in lung mechanics 

that leads to an uneven distribution of ventilation, resulting in 

a disordered pattern of pressure / volume changes as the lung 

inflates and deflates [30]. This non-uniform ventilation results in 

alveolar stress which effects alveolar gas exchange. Alveolar shear 

forces may also develop in dependent regions. The early stages 

of ventilator-associated lung injury develop at commonly used 

airway pressures (transalveolar pressure >35 cmH 2 O) in animals 

with normal lungs, but the threshold for lung injury may occur at 

lower pressure in injured lungs. 

Several studies [31-33] have shown that modern ventilatory 

strategies using low tidal volumes (6 to 8 ml/kg), limiting alveolar 

distending pressures (plateau pressure 10 

PO 2 /FiO 2 ratio 14 days) mechanical 

ventilation. (PEEP = positive end expiratory pressure; PO 2 /FiO 2 = 

arterial partial pressure of oxygen divided by the fraction of inspired 

oxygen ratio; AIS score = abbreviated injury scale). 



The weaning process – failure versus success 

Prior to discontinuing ventilatory support, the primary aim of 

treatment is to correct the pathophysiological processes which 

created the need for mechanical ventilation. However, it is not 

essential to achieve complete resolution of the causative processes 

prior to attempting to wean and discontinue ventilation. Partial 

resolution of the underlying pathophysiology may be sufficient. 

Studies have shown that 40% of the period undergoing 

mechanical ventilation may be devoted to the weaning process 

[41]. Current evidence supports a protocol driven approach to 

weaning, as extubation performed over the shortest possible 

period is associated with improved patient outcomes [4, 42, 43]. 

Extubation is 70 - 80% successful once the precipitating process 

has been corrected and the 20 - 30% who require re-intubation 

largely includes those who have been ventilated in excess of 48 hrs. 

Failure to wean can be viewed as an imbalance between the 

capacity of the respiratory system and the load placed on that 

system. This imbalance may be due to: inadequate resolution 

of the primary problem, the occurrence of a new problem, a 

ventilator associated complication, or combinations of these. The 

predominant pathophysiological characteristic of failure to wean 

is high levels of load relative to the strength of the respiratory 

muscles, which should be optimised to increase the success of 

weaning (Table 4). 

Haemodynamic 

instability 

Acid-Base 

imbalance 

Electrolyte 

abnormalities 

Intravascular 

volume 

Mental status 

Nutrition 

314 

Avoiding myocardial ischaemia or new 

arrhythmias, which decrease cardiac 

function (or require high inotropic 

support). 

A normal pH is desirable but not essential. 

Avoid an acidaemia as this may increase 

the minute ventilation. 

Hypophosphataemia,hypocalcaemia, 

hypomagnesaemia and hypokalaemia 

reduce muscle contractility and adversely 

effect weaning [25]. 

Avoid intravascular volume overloading, 

which increases the interstitial volume and 

decreases the functional residual capacity 

leading to alveolar collapse – leading to 

ventilation- perfusion mismatch and poor 

oxygenation. 

Mobilisation of the extra fluid usually 

occurs during resolution of the 

inflammatory processes. 

The aetiology of mental status alteration 

is multifactorial, but over-sedation may 

prolong mechanical ventilation [26]. 

Sedation holidays and a sedation scoring 

system is advised [27]. 

Malnutrition decreases muscle mass, 

strength and reduces immunity. 

Nutritional supplementation improves 

respiratory capacity and weaning [5, 25]. 

Table 4. Factors which effect weaning, by decreasing the capacity of or 

the demand on the respiratory system. 


A protocol driven approach to weaning 

Physiological parameters have been evaluated, which allow 

casualties who may benefit from prompt weaning and extubation 

to be identified early [4, 42, 43]. Unfortunately specialised 

measuring equipment is required which is not available in a field 

ICU. However, the Rapid Shallow Breathing Index (RSBI) has 

been shown to accurately predict weaning outcome [48]. This is 

the ratio of frequency (f) to tidal volume (VT) measured after 1 

minute of spontaneous breathing. In general, casualties who fail 

to wean have low tidal volumes and a high respiratory rate. The 

advantage of f/VT is that it is easy to measure and is independent 

of patient cooperation and effort. The predictive value of RSBI is 

highest when measured during spontaneous ventilation through 

a tracheal tube. 

Casualties who pass the initial RSBI assessment should 

proceed to a formal Spontaneous Breathing Trial (SBT). The 

optimal mode of ventilation for this weaning trial has not been 

established, but it is generally accepted that SIMV weaning 

prolongs the duration of mechanical ventilation. Daily T-Piece 

trials have consistently been shown to be superior to SIMV, but 

there is little evidence of an outcome difference between T-Piece 

based weaning and use of Pressure Support/Assist ventilation 

[44, 49]. An American task force has published evidence based 

guidelines [50] for discontinuing mechanical ventilation and the 

first seven of these guidelines which relate to weaning individual 

casualties are shown in Table 5. 

Evacuation to Role 4 

In a field hospital the general wards are usually staffed and equipped 

for basic care, observations and monitoring, which ensures that 

the ICU has a high bed occupancy rate. During a casualty surge, 

it is standard practice to review extubated casualties to determine 

their suitability for being moved to the ward, thus freeing beds 

and equipment for those who require ICU care. Adopting a 

prompt weaning and extubation protocol has obvious tactical and 

strategic implications for both current and future operations and 

may influence the decision process regarding whether to deploy 

the Critical Care Air Support Team (CCAST) or an aeromedical 

evacuation team. 

The CCAST provides an intercontinental critical care 

evacuation service. The well equipped team provides expert care 

in a flexible working environment aboard a fixed-wing airframe 

that can be adapted for transferring critically ill and ventilated 

casualties. Whilst vigilance should minimise many of the risks 

associated with transferring ventilated casualties, inadvertent 

extubation, disconnection and migration of tubes, may still 

occur. Some casualties require significant doses of sedation to 

allow optimal mechanical ventilation, which may mask the pain 

associated with a compartment syndrome. As a general rule if the 

casualty is unstable or is at risk of requiring re-intubation during 

flight, extubation should not be attempted at the field ICU. As 

a CCAST consultant is collocated at the field hospital in Camp 

Bastion, the decision to extubate can be quickly confirmed. In 

flight, the cabin pressure is lower than at ground level; so oxygen 

requirements are increased and gas filled spaces expand. The cabin 

may be pressurized to ground or sea level, but this negatively 

impacts on aircraft range and flight duration. 

Whilst enteral feeding is important following trauma e.g. 

burns, at the time of writing, the current CCAST policy is that 

intubated casualties are not fed during their evacuation flight to 

the Role 4. Until there is evidence to prove that in flight vibrations 



Recommendation 1 







A search for all contributing causes to ventilator dependence should be undertaken when mechanical 

ventilation is > 24 hours. All possible ventilatory and non-ventilatory issues should be corrected and are 

integral to the ventilator-discontinuation process. 

Casualties receiving mechanical ventilation for respiratory failure should undergo an individualised 

assessment of discontinuation potential if there is: 

a. Evidence for some reversal of the underlying cause for respiratory failure. 

b. Adequate oxygenation (e.g. Pao 2 /Fio 2 ratio > 150 to 200, requiring positive end-expiratory 

pressure [PEEP] < 5 to 8 cmH 2 O and Fio 2 < 0.4 to 0.5) and pH (e.g., pH > 7.25) 

c. Haemodynamic stability, as defined by the absence of active myocardial ischemia and conditions 

requiring no vasopressor therapy or therapy with only low-dose vasopressors. 

d. The capability to initiate an inspiratory effort. 

Note: Those not satisfying these criteria (e.g. casualties with chronic hypoxaemia values below the 

thresholds cited) may still be ready to wean from mechanical ventilation. 

Formal discontinuation assessments for casualties receiving mechanical ventilation should be performed 

during spontaneous breathing rather than while the casualty is still receiving substantial ventilatory 

support. An initial brief period of spontaneous breathing can be used to assess the capability of 

continuing onto a formal spontaneous breathing trial (SBT). The criteria with which to assess patient 

tolerance during SBTs are the respiratory pattern, the adequacy of gas exchange, haemodynamic 

stability, and subjective comfort. The tolerance of SBTs lasting 30 to 120 minutes should prompt 

consideration for permanent ventilator discontinuation. 

The removal of the artificial airway from a casualty who has successfully been discontinued from 

ventilatory support should be based on assessments of airway patency and the ability of the casualty to 

protect their airway. 

In casualties receiving mechanical ventilation for respiratory failure who fail an SBT, the cause of 

the failure should be determined. After reversible causes are corrected subsequent SBTs should be 

performed every 24 hours. 

Casualties receiving mechanical ventilation for respiratory failure, who fail an SBT, require a stable and 

comfortable form of ventilatory support, to lower work of breathing and to allow for rest and recovery. 

Anaesthesia or sedation strategies and ventilator management aimed at early extubation should be used 

in postoperative patients. 

Table 5. Guidelines for discontinuing mechanical ventilation [50]. 

do not exacerbate micro aspiration around the tracheal tube cuff, 

this policy is unlikely to change. 

Pain management 

In the polytrauma casualty, pain management issues may also 

influence the decision to prolong mechanical ventilation and 

sedation. Whilst regional anaesthesia and continuous peripheral 

nerve blockade has become an established method of providing 

analgesia for a large proportion of casualties with limb injuries 

[51], it may not be sufficient in every polytrauma casualty. Pain 

associated with thoraco-abdominal injuries can be difficult to 

manage and some casualties may require large supplementary 

doses of intravenous opioid. For this group, maintaining 

mechanical ventilation, analgesia and sedation until arrival at the 

Role 4 would be more appropriate and is an exception to rapid 

weaning and extubation at the field ICU. 

Psychological Stress 

At present we are uncertain if prolonging the duration of 

mechanical ventilation and sedation following traumatic injury 

and damage control surgery may affect the levels of postextubation 

psychological stress or post traumatic stress disorder 

(PTSD). 

In theory, pharmacologically prolonging the period of 

amnesia following injury, may potentially deny the casualty 

the opportunity to: begin to come to terms with the severity of 

their injuries, to be debriefed by their own unit personnel and 

supported by their colleagues. Clearly this theory requires further 

clinical investigation using, e.g. the PTSD checklist (PCL-C), 

which is a self-report instrument designed to assess symptoms 

of post traumatic stress disorder [52, 53]. Until reliable evidence 

is available that supports early psychological debriefing and 

extubation following a traumatic injury, maintaining ventilation 

and sedation should be determined on an individual patient basis. 

Conclusion 

All injured or ill service personnel should, whenever possible 

be offered medical care to a standard equal to that which they 

receive in the UK. Therefore, applying an early weaning and 

extubation protocol to appropriate military casualties does 

reflect best practice in the UK. Restoring a patent airway and 

spontaneous ventilation early in the postoperative period has 

significant clinical and logistical advantages, but conversely also 

requires that adequate analgesia be provided. 

Maintaining mechanical ventilation and sedation during the 

transfer to the Role 4 should be determined on an individual 



basis. Ensuring early consultation with the deployed CCAST 

anaesthetist should significantly reduce the risk of both 

reintubation being performed prior to evacuation from the 

field ICU, or conversely missing the opportunity to waken and 

extubate casualties early. 

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Traumatic Pneumorrhachis 

AG Haldane 

Specialty Registrar in Anaesthesia, Worcestershire Royal Hospital 

Abstract 

Pneumorrhachis or intraspinal air is an increasingly encountered phenomenon in the management of severe trauma. The case 

of a 23-year-old soldier, who sustained a gunshot wound to the chest, is presented and the subsequent discussion illustrates 

that while often benign this phenomenon may indicate serious occult injury. 

Introduction 

Pneumorrhachis is the presence of air in the spinal canal. This 

rare phenomenon has numerous aetiologies. It is a radiological 

diagnosis that, dependent on the location of the air, may be of 

varying significance. 

Case History 

A 23-year-old United States Marine Corps soldier was admitted 

to the Joint Force Medical Group (R2E) facility at Camp 

Bastion in September 2009. He had sustained a gunshot wound 

to the left chest. 

Pre-hospital management had included high flow oxygen, 

a chest-seal dressing placed over the chest wound and vascular 

access with a 16G cannula in the left antecubital fossa. At the 

primary survey on arrival in the emergency department he was 

alert and orientated and maintaining his own airway. Initial 

observations were: respiratory rate 16 breaths per minute, reduced 

air entry noted on the left, SpO 97%, pulse 78 beats per minute 

2 

and blood pressure 110/60 mmHg. No abdominal, pelvic or 

long bone injuries were 

identified. On examination 

of the back a single gunshot 

entry wound was identified 

in the left chest with an 

associated soft tissue injury 

to the left triceps. 

Chest radiograph taken 

as part of the primary 

survey showed mediastinal 

shift and a large left sided 

haemo-pneumothorax. 

The penetrating round 

was seen clearly in the 

left upper zone (Figure 

1). A thoracostomy tube 

was inserted and initially 

drained 300ml of fresh 

blood and a further 100ml 

over the next 15 minutes. 

The patient remained haemodynamically stable throughout. No 

neurological deficit was detected. 

The patient was subsequently transferred for computerised 

tomography (CT) scanning and images of the thorax and 

Corresponding Author: Maj Andrew Haldane RAMC, 

Specialty Registrar in Anaesthesia, c/o AMDSU, FASC, 

Slim Road, Camberley, GU15 4NP 

Tel: 07958 739 437 E-mail: aghaldane1@doctors.org.uk 

Figure 2 – CT Scan of upper chest showing spinal air and retained round. 

Figure 1 – Chest radiograph showing injury to left chest and retained 

round. 

abdomen were obtained. The CT images confirmed the 

haemo-pneumothorax, and also indicated large amounts of 

subcutaneous emphysema with air extending into the spinal 

canal from above C5 to T7. The bullet was found to be lying 

between the left carotid and subclavian arteries (Figure 2). No 

bony injuries were identified. 

The patient remained stable and was admitted to the intensive 

care unit for observation. Initial debridement of his wounds was 

undertaken later that day. Post-operatively the patient underwent 

insertion of a thoracic epidural for analgesia at 24 hours post- 


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Traumatic Pneumorrhachis AG Haldane 

injury. Delayed primary closure of the extremity soft tissue injury 

was undertaken at 48 hours. 

Discussion 

Air within the spinal canal is termed pneumorrhachis, first 

described by Newbold in 1971 [1]. Other terms include: aerorachia, 

intraspinal pneumocele, epidural pneumatosis, pneumosaccus, 

and traumatic pneumomyelogram. It is a rare but increasingly 

recognised epiphenomenon [2]. The air can be within the epidural 

or subarachnoid spaces. While it can be difficult for clinicians 

to distinguish between these two anatomical locations, varying 

distribution of air seen on CT may indicate its location. Air within 

the subarachnoid space may be located both anterior and posterior 

to the spinal cord. Air confined to the epidural space may be seen 

to have a predominantly posterior and/or lateral distribution [3, 

4]. This differentiation is important as the mechanism and causes 

of air entry are different and have different clinical implications 

[5]. Air in the epidural space is usually benign, while its presence 

in the subarachnoid space is commonly found in association with 

air within the cranial vault, basal skull fracture and dural tear, and 

is a marker of severe trauma. 

Epidural pneumorrhachis 

Epidural pneumorrhachis has numerous causes and these can be 

broadly divided into iatrogenic, non-traumatic and traumatic. 

Iatrogenic causes include the administration of epidural analgesia. 

Non-traumatic cases have been reported in association with 

degenerative disc disease, epidural abscess, synovial cysts and 

following spontaneous pneumomediastinum and pneumothorax. 

In traumatic cases pneumorrhachis is most commonly seen in 

association with pneumomediastium and/or pneumothorax but 

has also been reported secondary to pelvic and vertebral fractures 

and dural-enteric fistulae [6]. 

The mechanism whereby air enters the epidural space is a 

result of the fact that there is no true fascial envelope protecting 

the space [7]. Air may dissect along fascial planes from either the 

posterior mediastinum or retropharyngeal space, through the 

neural foramina and into the epidural space; this movement of 

air occurs down the pressure gradient caused by a pneumothorax 

or pneumomediastinum. This continuous pathway between 

the intervertebral foramina and the epidural space was first 

demonstrated in 1973 [8]. It has also been established that air 

may track along fascial planes between the retroperitoneum and 

mediastinum and thus the epidural space [9]. Therefore injury to 

abdominal viscera may also result in pneumorrhachis [10]. 

Epidural pneumorrhachis is usually benign. Identification 

of the underlying cause is important as its treatment will result 

in resolution of the intraspinal air. Criteria have been described 

that allow pneumorrhachis to be classified as benign, including: 

1) major thoracic trauma, 2) substantial pneumomediastinum 

with extensive subcutaneous emphysema, 3) a small amount of 

epidural air, 4) air demonstrable only by CT scan, and 5) the air 

was an incidental finding on CT scan performed for an indication 

unrelated to the spine [11]. 

It is rare for epidural pneumorrhachis to cause neurological 

symptoms; the few reported cases are most often in the context 

of the administration of epidural analgesia. The volumes of air 

injected during the “loss of resistance technique” are much larger 

than those likely to enter the spinal canal as a result of a traumatic 

injury [5]. Clinicians should rule out other possible causes of 

neurological symptoms before attributing them to intraspinal air. 

In cases of severe trauma consideration must be given that air 

may actually be present within the subarachnoid space. 

Subarachnoid pneumorrhachis 

Traumatic subarachnoid pneumorrhachis is a marker of severe 

injury. The most common reported causes are skull fractures and 

thoracic spine fractures and subarachnoid pneumorrhachis is 

almost always associated with pneumocephalus. 

In the case of skull fracture air enters the subarachnoid space 

either directly from the atmosphere in the case of a fracture of the 

cranial vault or from an air containing cavity or sinus. Once inside 

the intracranial subarachnoid space the air is free to migrate to the 

spine through the foramen magnum, this usually occurs when the 

patient has been in the head or face down position [5]. 

Pneumocephalus may cause both general and focal neurological 

symptoms as a result of intracranial hypertension [12]. In addition 

there is the risk of meningitis as a breach in the dura may act as a 

portal of entry for bacteria. 

Thoracic spine fractures may be associated with the formation 

of dural and pleural tears that may join to form a fistula. In 

penetrating trauma the missile may cause these tears directly; 

fistula formation has been reported in a case of gunshot injury to 

the chest [13]. In blunt trauma extreme flexion and compression 

of the thoracic spinal nerve roots and thoracic cage is felt sufficient 

to allow the formation of a fistula [14]. 

As with epidural air there is no specific treatment for 

subarachnoid pneumorrhachis and therapy is aimed at identifying 

and treating the underlying cause. Focussed investigation of 

the spinal column and base of skull should be considered. 

Consideration should also be given to closure of defects in the 

dura if such are present. 

Anaesthetic considerations 

Severely injured patients who are due to undergo surgery should 

not be exposed to anaesthetic techniques likely to increase the 

pressure or volume of intraspinal gas collections. Therefore the use 

of nitrous oxide should be avoided [15]. A high inspired fraction 

of oxygen may help to speed resolution of air pockets. 

Air in the epidural space has been shown to cause the failure of 

attempted epidural analgesia [16]. There are no reports of the use 

of epidural anaesthesia in the provision of analgesia for injuries 

associated with pneumorrhachis however we found that good 

analgesia was obtained from a thoracic epidural inserted 24 hours 

after injury despite the initial presence of intraspinal air. It would, 

however, seem prudent to use a “loss of resistance to saline” rather 

than a “loss of resistance to air” technique. 

Aeromedical evacuation considerations 

The aeromedical transfer of patients with pneumocephalus has 

always caused some concern. Pneumorrhachis may not always 

be associated with pneumocephalus. In the case of intracranial 

air a recent study concluded that the mechanism causing 

pneumocephalus, its time course, progression, and the rate of 

altitude change are likely more important factors in determining 

its clinical significance [17], and this probably holds true for 

intraspinal air. Advice should be sought from those who will be 

responsible for the patient’s in-flight care. 

Conclusion 

Pneumorrhachis, or intraspinal air, is a rare phenomenon. 

However with the early use of CT in the assessment of the 


Traumatic Pneumorrhachis 

severely injured patient it is likely to be increasingly encountered. 

The early management of the precipitating cause underpins the 

management of pneumorrhachis. While in the majority of cases 

intraspinal air is benign and of little significance efforts must be 

made to identify those situations where the underlying cause may 

dictate that morbidity may be high. 

References 

1. Newbold RG, Wiener MD, Vogler III JB, Martinez Z. Traumatic 

pneumorrhachis. Am J Roentgenol 1987;148:615-6. 

2. Chaichana KL, Pradilla G, Witham TM, Gokaslan ZL, Bydon A. 

The clinical significance of pneumorachis: a case report and review 

of the literature. J Trauma 2010;68(3):736-44. 

3. Dwarakanath S, Banerji A, Chandramouli BA. Posttraumatic 

intradural pneumorrhachis: a rare entity. Ind J Neurotrauma 

2009;6(2):151-2. 

4. Oertel MF, Korinth MC, Reinges MHT, Krings T, Terbeck 

S, Gilsbach JM. Pathogenesis, diagnosis and management of 

pneumorrhachis. Eur Spine J 2006;15(Suppl. 5):S636-S43. 

5. Goh BKP, Yeo AWY. Traumatic pneumorrhachis. J Trauma 

2005;58(4):875-9. 

6. Silver SF, Nadel HR, Flodmark O. Pneumorrhachis after jejunal 

entrapment caused by a fracture dislocation of the lumbar spine. 

Am J Roentgenol 1988;150:1129-30. 

7. Goh BK, Ng K-K, Hoe MNY. Traumatic epidural emphysems. 

Spine. 2004;29(22):E528-E30. 

320 

AG Haldane 

8. Burn JM, Guyer PB, Langdon L. The spread of solutions injected 

into the epidural space: a study using epidurograms in patients 

with lumbosciatic syndrome. Br J Anaesth 1973;45:334-8. 

9. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and 

mediastinal empysema: pathophysiology, diagnosis and 

management. Arch Intern Med 1984;144:1447-53. 

10. Gautschi OP, Hermann C, Cadosch D. Spinal epidural air 

after severe pelvic and abdominal trauma. Am J Emerg Med 

2008;26:740.e3-.e5. 

11. Willing SJ. Epidural pneumatosis: a benign entity in trauma 

patients. Am J Neuroradiol 1991;12:345. 

12. Bilsky MH, Downey RJ, Kaplitt MG, Elowitz EH, Rusch VW. 

Tension pneumocephalus resulting from iatrogenic subarachnoid– 

pleural fistulae: report of three cases. Ann Thorac Surg 2001;71:455-7. 

13. Lloyd C, Saha SA. Subarachnoid pleural fistula due to penetrating 

trauma: a case report and review of the literature. Chest 

2002;122:2252-6. 

14. Rocha-Campos BA, Silva LB, Ballalai N, Negrao MM. Traumatic 

subarachnoid-pleural fistula. J Neurol Neurosurg Psychiatry 

1974;37:269-70. 

15. Day CJE, Nolan JP, Tarver D. Traumatic pneumomyelogram. 

Implications for the anaesthetist. Anaesthesia 1994;49:1061-3. 

16. Boezaart AP. Epidural air-filled bubbles and unblocked segments. 

Can J Anaesth 1989;36:603-4. 

17. Donovan DJ, Iskandar JI, Dunn CJ, King JA. Aeromedical 

evacuation of patients with pneumocephalus: outcomes in 21 cases. 

Aviat Space Environ Med 2008;79(1):30-5. 


Special Situations

Paediatric Anaesthesia in Afghanistan: a Review 

of the Current Experience 

GR Nordmann 

Consultant Paediatric Anaesthetist, MDHU Derriford; Consultant Anaesthetist, 16 Medical Regiment; Research Fellow, 

Defence Science and Technology Laboratory 

Abstract 

This paper describes the author’s experience of the paediatric patient load on the UK medical services in Afghanistan. Over a 3 

month period there was a mean of 2.9 paediatric trauma admissions per week, mean age was 6.8 years with gunshot wound or 

explosive injury being the mechanisms of injury in 77% of the trauma admissions. Overall these children represented 10.8% 

of the surgical workload. Some of the issues of paediatric anaesthesia in this environment are discussed including paediatric 

equipment, resuscitation for paediatric massive haemorrhage and regional anaesthesia. The need to formally recognise the 

problem in training and equipping deployed medical personnel to deal with this challenge is examined. 

Introduction 

United Kingdom medical forces on operations are configured 

specifically to support the deployed military force in that 

area. In Afghanistan, as in most conflicts, civilians account 

for a significant number of the casualties. Present operations 

take place in close proximity to the local population and 

consequently UK forces in accordance with the Geneva 

Conventions will deliver medical support to non-combatants 

who are injured. Children are a prominent fraction of this 

group and are regularly placed in the UK medical treatment 

and evacuation chain where they can impose a significant 

workload on the hospital in Camp Bastion. 

Historical Experience 

To appreciate the numbers of children involved it is appropriate 

to review what information has been published recently. This 

is predominantly from papers describing paediatric workload 

to UK and US hospitals in Iraq and Afghanistan over the past 

decade. Creamer’s [1] paper is the largest review and looked at 

US Combat Support Hospital (CSH) admissions in Iraq and 

Afghanistan. They reported that 10% of their overall workload 

was paediatric but these children represented 50% of their civilian 

admissions. Of those admitted with trauma, penetrating injuries 

predominated (76.3%), the principal mechanisms of injury being 

gunshot wound (GSW, 39%) and explosive injury (32%). Just 

fewer than 6% required mechanical ventilation and mortality was 

6.9%, the primary causes of death being head injury and burns. 

Beitler [2] looked in more detail at their initial admissions in 

Afghanistan to the 48th Combat Support Hospital and found 

28.4% of all trauma victims were paediatric, paediatric admissions 

a week. Although they didn’t look at mechanism of injury in 

the paediatric population specifically, their overall population 

had explosive injury (41%) and GSW (20%) as their highest 

mechanisms of injury. Mean age was 9 years (range 1-16 years) 

with the paediatric population having a longer length of stay (10 

days) compared to adults (8.5 days). 

Corresponding Author: Lt Col Giles R Nordmann BSc(Hons) 

MBChB FRCA RAMC, Consultant Paediatric Anaesthetist, 

MDHU Derriford, Plymouth 

Tel: 01822 853334 E-mail: nordmann@waitrose.com 

UK data from Iraq in the initial war fighting stage in 2003 

from two different hospitals illustrates the work load and differing 

mechanisms of injury at that time. Gurney’s [3] paper was an 

Emergency Department based review of 34 Field Hospital’s 

admissions over the first month when it was initially positioned 

in Shaibah, Iraq after the first few days of the conflict. He found 

paediatric patients comprised 2.9% of all recorded admissions, 

but accounted for nearly a third of civilian patients. The workload 

was 13 paediatric admissions per week with burns (77%) and 

explosive injury (12%) being the most common mechanisms of 

injury in his trauma subset. Mean age was 7.9 years with a higher 

proportion being male (65.4%). Heller’s [4] review of paediatric 

patients followed their path through 22 Field Hospital based in 

Kuwait over the same initial war fighting stage. There were six 

paediatric admissions per week and again explosive (50%) and 

burns (42%) were the main mechanisms of injury. Mean age 

was 6.3 years in their trauma population (range 6 months to 15 

years). Their data is highly influenced by the number of transfers 

from the forward deployed 34 Field Hospital back to 202 Field 

Hospital in Kuwait. 

Local civilians without power were relying on Kerosene lamps 

for lighting and a high proportion of the injuries were burns 

secondary to accidents from this method of lighting rather than 

direct conflict casualties. Nonetheless unexploded ordnance 

from this and previous conflicts were exposed in this phase of 

the ground war and injuries secondary to these accounted for a 

significant part of the remainder. 

Present military operations in Afghanistan are producing a 

greater proportion of explosive and GSW penetrating injuries in 

the paediatric population in UK facilities. Harris’ [5] paper in this 

journal reviewed the paediatric workload on Critical Care in 2008. 

In the two months their data was collected they had 15 patients 

whose mechanism of injury was predominantly penetrating GSW 

or explosive. Mean age was 6 years (range 6 months to 17 years). 

This paediatric population was a significant workload for the 

Critical Care unit leading to children accounting for 30% of all 

bed occupancy. They reported one death from multi organ failure 

subsequent a penetrating injury to the chest and abdomen. 

Methods 

In order to obtain a more accurate review of paediatric admissions 

to the Role 3 hospital at Camp Bastion, data was collected for 


Paediatric Anaesthesia in Afghanistan 

a three month period over Op HERRICK 8b/9a looking at 

paediatric patients admitted with traumatic injuries. All paediatric 

surgical admissions medical records were examined retrospectively 

and the theatre operation log book was examined. Data collected 

included, age, sex, diagnosis, operations, number of operations, 

admission to ITU, length of admission. 

Results 

During the three months, 31 children were admitted for surgical 

intervention after trauma. There were 18 (58%) male and 13 

(42%) female patients with an average age of 6.8 years (range 6 

months to 14 years). This is similar to previous experience but of 

more particular interest was that a quarter of these were aged 2 

years or younger (Figure 1). 

Figure 1: Age distribution of paediatric trauma admissions as a 

percentage of total paediatric trauma admissions on Op HERRICK 

8b/9a. 

There were a mean of 2.9 paediatric admissions per week, a 

smaller number than in the previous papers, however this patient 

population still presented a significant workload for the surgical 

and anaesthetic teams. The quantity of surgical operations 

undertaken on this paediatric population was 10.8% of all 

operations carried out, with an operation on a child occurring 

every 1.9 days, each child needing a mean of 1.6 operations 

(range 1 to 5). 

The main mechanisms of injury were fragmentation (45.1%) 

and GSW (32.3%) and are shown in Figure 2 compared to the 

previous UK and US experiences in Iraq. 

Figure 2: Paediatric patients; mechanism of injury as percentage of 

total paediatric trauma admissions. 

324 

GR Nordmann 

Mean length of stay was 10.5 days (range 1 to 62 days) and 

35% of these paediatric patients were admitted to critical care. 

This was 11.9% of its total admissions over the data collection 

period. In the critical care sub-group of the most gravely injured 

children penetrating wounds secondary to GSW or explosive 

injury accounted for 91% of the injuries. For those admitted 

to critical care a thoracotomy was needed in 27% of cases, 

laparotomy in 82% and injuries to the liver, spleen or pancreas 

were involved in 36%. There was one death from a penetrating 

explosive injury with multiple wounds to chest and abdomen. 

A summative review of the above data predicts that any 

anaesthetist deploying to Afghanistan would be expected to deal 

with two to four paediatric admissions per week. These patients 

will have an average age of seven and a quarter of them may be less 

than two years of age. Each child will need around two operations 

and have an average length of stay of 10 days. 

Discussion 

This significant paediatric challenge means military anaesthetists 

need to be prepared to treat not just the injured paediatric patient 

but one that has had significant ballistic trauma and is suffering 

from the major haemorrhage and coagulopathy that can result 

from it, a rare occurrence in UK civilian practice. Military 

consultants and trainees need to be prepared to deal with this 

patient group by being adequately trained and equipped to 

provide the appropriate care. 

Critical Care 

Over a third of paediatric patients who had suffered trauma 

were admitted to critical care which seems a large proportion. 

It places a significant workload on the critical care staff who do 

not necessarily have the necessary paediatric experience. There is 

probably a combination of factors influencing this admission rate; 

significant penetrating injuries not normally seen in the UK, staff 

with little paediatric experience and the lack of local paediatric 

critical care provision are probably all of some significance. This is 

discussed in more detail in Harris’ paper [5]. 

Equipment 

The design and choice of breathing systems is determined by the 

child’s weight and age. The commonest being the Mapleson F and 

the circle system which comes in adult and paediatric sizes. The 

differences and advantages of these systems can be found in any 

paediatric anaesthesia text [6]. In summary the Mapleson F is in 

most common use and its advantages are: no valves, low resistance, 

Continuous Positive Airway Pressure (CPAP) and Positive End 

Expiratory Pressure (PEEP) can be applied and it can be used for 

spontaneous and controlled ventilation. It is of particular use in 

smaller children but its disadvantage is the need for high fresh gas 

flows. The main disadvantages of circle systems are the resistance 

from unidirectional valves and their higher compliance reducing 

tactile feedback when hand ventilating. This reduces its ability to 

be used in smaller children (less than 10kg). 

Until recently in the military environment the Triservice 

anaesthetic apparatus (TSAA) has predominated. It has been 

studied in children in its original format previously by Bell [7]. 

His team studied children weighing down to 10kg, comparing 

work of breathing between the Mapleson F breathing system 

and the TSAA. They found there was no significant difference in 


Paediatric Anaesthesia in Afghanistan GR Nordmann 

work of breathing between the two breathing systems proving the 

TSAA is suitable to be used in children over that weight. Despite 

this endorsement the TSAA has a number of problems when 

being used to anaesthetise children. When manually ventilating 

children it also provides poor tactile feedback back from the bag 

and an inability to accurately measure and set the inspiratory 

pressure. In spontaneous ventilation it is difficult to visually 

monitor the tidal volume and respiratory rate in addition to being 

unable to easily provide PEEP or CPAP. 

This has prompted some users to use the TSAA in different 

formats when anaesthetising children. The Oxford Miniature 

Vaporisers (OMVs) can be added to the fresh gas flow arm of 

the Mapleson F. This will require a high flow of gas through the 

vaporisers (in excess of 6 litres per minute) to prevent rebreathing. 

Further upstream from the OMVs is the oxygen inlet and the cage 

mount connector of the TSAA. This end has traditionally been 

occluded to minimise air entrainment and this occlusion is not an 

ideal solution for patient safety. Birt [8] describes the use of a short 

piece of extension tubing and a disposable Intavent adjustable 

pressure limiting (APL) valve at this end allowing pressure relief 

to occur when the circuit pressure exceeds a set level. This set up 

can be used for both spontaneous and manual ventilation in most 

paediatric weight groups. 

For children under 10kg, intubation and positive pressure 

ventilation is the norm. Manual ventilation compared to 

mechanical ventilation is useful as it provides constant feedback 

of airway resistance but it does not enable the anaesthetist to do 

concurrent tasks that are essential in resuscitation of the severely 

injured child. Ralph et al [9] addressed this issue recently and 

devised a method for ventilating children under 10kg using the 

TSAA in conjunction with the Pneupac ComPAC 200 ventilator. 

The ComPAC 200 ventilator is a flow generator which is 

inadequate for paediatric use. Children have significantly smaller 

tidal volumes and are at higher risk of barotrauma so they should 

be preferentially ventilated using a predetermined inspiratory 

pressure rather than volume. Ralph’s group described a series of 

six children under 10kg who were successfully ventilated using 

the TSAA and ComPAC 200. In a similar move to the conversion 

of a Penlon Nuffield 200 ventilator from flow to a pressure 

generator by the addition of a Newton Paediatric valve they added 

an Intavent APL valve between the ventilator and the OMVs thus 

converting the ComPAC 200 to a pressure generating ventilator. 

The changes described above give the military anaesthetist all 

options needed when anaesthetising a child using the TSAA. In 

recent months the new Dräger Fabius Tiro has been in place in 

Camp Bastion. This enables conventional methods of providing 

anaesthesia using the breathing systems discussed above that are 

well known in UK hospitals. 

Analgesia and Regional Anaesthesia 

Adequate pain relief is an essential part of any anaesthetic 

technique and this is true for children of any age. Pain management 

in children presents additional challenges not seen in adults; in 

particular the difficulty of assessment of pain. Anticipation of 

pain and pre-emptive treatment should be the norm. The use 

of regional anaesthesia is common in children and if given at 

induction has the advantage of providing good intra-operative 

analgesia where its effect can be assessed as to its subsequent postoperative 

effect. Blocks are virtually all performed under general 

anaesthesia. Virtually any block performed on adults can be used 

in children. The equipment does not have to be significantly 

different except for peripheral blocks in much smaller children 

and central blocks under a certain size. Paediatric regional 

anaesthesia though should only be carried out by an experienced 

practitioner who has the prior knowledge and skills to undertake 

them. It is not in the scope of this article to discuss the equipment 

requirements in detail nor the different local anaesthetic doses, 

volumes or infusion rates. 

Massive Haemorrhage 

Adult management of massive haemorrhage has been well 

described and there is formal guidance for all deployed physicians 

in its management [10]. The Paediatric Anaesthesia and Critical 

Care Specialist Interest Group (PACCSIG) has written a paediatric 

guide per weight that will enable anaesthetists to guide paediatric 

patient resuscitation and this is detailed further in the article by 

Bree et al [11]. 

Training 

It is imperative that military anaesthetists have adequate training 

to deal with this paediatric challenge. It is the author’s opinion 

that trainees should have at least 6 months paediatric training in 

their final 3 years of training, preferably at a tertiary paediatric 

hospital. Ideally this hospital should have a dedicated paediatric 

ED department and have a military anaesthetic consultant 

working there. For consultants there should be one consultant 

with a regular paediatric exposure in the UK deployed to Herrick 

at any one time. The other consultants should have refresher 

training in a tertiary paediatric centre before deploying. 

US experience 

The Americans have dealt with over 3,500 infants and children 

in Afghanistan and Iraq. Their combat support hospitals are 

‘doctrinally’ not staffed or equipped to provide care for this 

population. The US has recognised this and made changes to 

respond to this challenge [12]. Paediatric specific education 

including a web based education platform, modified paediatric 

equipment and a 24 hour paediatric critical care ‘teleconsultation’ 

service have been designed to improve pre-deployment training 

and in theatre care of the injured child. 

Paediatric Anaesthesia and Critical Care Specialist 

Interest Group (PACCSIG). 

This group has been commissioned by the Defence Consultant 

Adviser in Anaesthetics and meets bi-annually to address some 

of the issues raised in this article. At present it is working on 

equipment concerns, massive haemorrhage, audit and training. 

As part of its work improved Role 1 Paediatric training has 

occurred for HERRICK 12 and 13. Consultant anaesthetists 

deploying to HERRICK 13 have had clinical refresher sessions 

at Birmingham Children’s Hospital and guidelines for paediatric 

massive haemorrhage are published in this journal. 

Conclusions 

The current spectrum of operations imposes a tough challenge 

on deployed Defence Medical Services (DMS) personnel to 

manage and treat civilian children. The data collected for this 

paper illustrates that children with considerable ballistic and 

penetrating injuries are a significant part of this challenge and 

military anaesthetists need to be prepared for this. As such, the 

DMS has a duty to train and equip its personnel to the required 

standard in order to provide appropriate care to this population 


Paediatric Anaesthesia in Afghanistan 

group. The PACCSIG is addressing some of the issues described 

in this article and is working towards a more formal recognition 

of the training and equipment needs in addition to guidelines 

for best practice in paediatric anaesthesia and resuscitation in the 

deployed environment. 

Acknowldgements 

The author would like to thank Col P Mahoney OBE TD MSc 

FRCA L/RAMC for his advice on this article. 

References 

1. Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, 

Adelman . Pediatric Wartime Admissions to US Military Combat 

Support Hospitals in Afghanistan and Iraq: Learning from the First 

2,000 Admissions. J Trauma 2009; 67 (4): 762-768. 

2. Beitler AL, Wortmann GW, Hofmann LJ, Goff JM Jr. Operation 

Enduring Freedom: The 48th Combat Support Hospital in 

Afghanistan. Mil Med 2006; 171 (3): 189-193. 

3. Gurney, I. Paediatric Casualties During OP TELIC. J R Army Med 

Corps 2004; 150: 270-272. 

4. Heller D. Child Patients in a Field Hospital during the 2003 Gulf 

Conflict. J R Army Med Corps 2004; 151: 41-43. 

5. Harris CC, McNicholas JJK. Paediatric Intensive Care in the Field 

Hospital. J R Army Med Corps 2009; 155 (2): 157-159. 

326 

GR Nordmann 

6. Doyle E (Ed.). Paediatric Anaesthesia. 1st Edition. Oxford 

University Press. 

7. Bell GT, McEwen JP, Beaton SJ, Young D.. Comparison of work 

of breathing using drawover and continuous flow anaesthetic 

breathing systems in children. Anaesthesia 2007; 62: 359-363. 

8. Birt D. Modification of TSAA for Paediatric Use. Department 

of Military Anaesthesia, Pain and Critical Care website, Audit 

and Research, Clinical Answers. https://wss.armynet.mod.uk/ 

anaesthesia/default.aspx 

9. Ralph JK, George R, Thompson J. Paediatric Anaesthesia Using 

the Triservice Anaesthetic Apparatus. J R Army Med Corps 2010; 

156 (2): 84-87. 

10. Surgeon General’s Operational Policy Letter, 2009. Management 

of Massive Haemorrhage on Operations. 

11. S Bree, K Wood, GR Nordmann, J McNicholas. The Paediatric 

Transfusion Challenge on Deployed Operations. J R Army Med 

Corps 2010; 156(4 Suppl 1): S361-364. 

12. Fuenfer MM, Spinella PC, Naclerio AL, Creamer KM. The US 

wartime pediatric trauma mission: how surgeons and paediatricians 

are adapting the system to address the need. Mil Med 2009; 174 

(9): 887-91. 


Toxicology and Military Anaesthesia 

TC Nicholson-Roberts 

Specialist Registrar Anaesthesia and Intensive Care Medicine, MDHU Derriford 

Abstract 

The combination of trauma and poisoning is a situation likely to be faced by a deployed force at some point. This article provides 

practical advice on how to deal with poisoned patients without deviating from the concept of damage control resuscitation. 

The constraints of limited diagnostics, both at the scene and clinically, and lack of antidotal therapy are fundamental to the 

practice of clinical toxicology. Some of the specific therapies such as atropine and oximes were not evaluated prior to their 

introduction and there are few randomised controlled trials of poisoned patients. Most of the diagnoses will be made on 

clinical grounds and most of the therapy will be supportive; this article aims to reassure military anaesthetists in the process 

of dealing with the poisoned trauma patient. 

Introduction 

The changing landscape of toxicological threats to deployed troops 

might now be inclined towards toxic industrial chemicals (TICs). 

Exposure to these can be classified as an accidental or deliberate 

release and the casualties may or may not have associated trauma. 

For example, in the Bohpal disaster of 1984, an accidental release 

of methyl isocyanate, resulted in no direct trauma but thousands 

of poisoned patients. The Buncefield Oil Storage Depot fire in 

2005 had the potential to cause serious injury including blast and 

burns with the associated effects of inhaled combustion products 

and particles. Deliberate release would include the Iraq chlorine 

tanker incidents in 2007 [1]. Fortunately the temperature of the 

blasts were such that a large proportion of the chlorine burnt and 

that which did not, was dissipated, however the accompanying 

blast would have resulted in much trauma. In the management of 

a suspected chemical release, the identification of the compound, 

its combustion and reaction products are advantageous. Whilst 

this is relatively straightforward in the UK from registration of 

COMAH (Control of Major Accident Hazards) sites, the use of 

HazChem and a myriad of other data sources, it will be extremely 

difficult on operations. This knowledge is important, not only 

to determine scene management but also to establish levels of 

exposure and the effects arising from that. The importance of 

physicochemical properties such as solubility, volatility and 

reactivity are not confined to scene management. They are of equal 

importance in considering a compound’s journey through release, 

absorption, distribution to and metabolism by internal organs. 

These properties will not be known until much later during the 

management of a release and toxicological data will follow from 

that. From the innumerable TICs only a small fraction have 

antidotes or specific therapies that need instituting, most require 

supportive therapy only, and will be considered later. 

Predicting likely chemical scenarios is always difficult and 

different agencies will come up with various solutions. In general 

terms threats were first described in quasi-mathematical form by 

J David Singer over 50 years ago: Threat perception= Estimated 

Capability x Estimated Intent [2]. Whilst few traditional chemical 

warfare agents were discovered in Iraq, other threats such as 

Corresponding Author: Major TC Nicholson-Roberts BSc 

MRCP(UK) FRCA DipMedTox RAMC, Specialist Registrar 

Anaesthesia and Intensive Care Medicine, MDHU Derriford, 

Brest Road, Plymouth PL6 5YE 

Email: tcnr@doctors.org.uk 

chlorine abound. Rumours of chemical attacks on schools by 

Taliban indicate a degree of intent [3], however the exact nature 

of the agents used is not in the public domain. Locals likened the 

odour to that of a compound used to poison foraging birds [4]. 

Although the intent is high, the capability so far is limited to toxic 

substances readily available until superior agents become available 

to those hostile elements. 

The very nature of poisoning dictates that well performed 

studies are difficult, much data is derived from animal models, 

case reports and the experience of a few individuals. The poisoned 

patient presenting for surgery introduces an extra dimension 

to the care required. The immediate need for damage control 

resuscitation may result in continued treatment of poisoning in 

the operating theatre. Those patients who may be disadvantaged 

by general anaesthesia, for example in organophosphate poisoning, 

should have a regional anaesthetic technique where possible to 

avoid clouding of clinical assessment. 

Burns and Toxic Industrial Chemicals 

There are many thousands of chemicals in everyday use; some 

are inherently poisonous or react with others to become so, or 

form toxic products of combustion. Trauma in the presence of 

burns should be managed according to established guidelines 

with attention to management of airway burn, aggressive fluid 

resuscitation and prevention of sepsis. Early intubation is 

mandatory in the presence of an inhalation injury. After a burn 

extrajunctional expression of acetylcholine receptors is increased, 

there is a general agreement that after a delay of 24h or more 

then suxamethonium-induced hyperkalaemia becomes a real 

risk [5]. Potassium ions will leak out of myocytes in greater 

amounts, as a greater number of receptor ion channels are 

then held open by suxamethonium. On the other hand, nondepolarising 

neuromuscular blocking agents (NMBAs) require 

a dose increase. Inhalation injuries represent a huge spectrum 

of illness dependent on duration of exposure, concentration, 

composition and temperature of smoke. A simple house fire will 

result in production of significant quantities of carbon monoxide 

(CO) and hydrogen cyanide (HCN). The abundance of synthetic 

materials, some containing halogens and nitrogen, contribute to 

HCN formation and also to inorganic acids and nitrogen oxides 

with lung damaging properties [6]. Virtually all TICs have no 

specific treatment and supportive therapy with appropriate organ 

support, good nursing care and attention to microbial sampling is 

all that can be offered. 


Toxicology 

Smoke Inhalation 

Although rare, inhalation injury makes a considerable 

contribution to mortality and morbidity from burns. Efficient 

heat exchange in the upper airway reduces the risk of lower airway 

thermal injury, but will not protect from soot, inorganic acids 

and other toxins. Hypoxaemia results from shunt; blockage of 

bronchi by secretions, diffusion impairment; capillary leak and 

loss of hypoxic pulmonary vasoconstriction mediated by reactive 

oxygen and nitrogen species [7]. Cell necrosis will inevitably 

result in cytokine release and a generalised inflammatory response 

[8]. Lung compliance may be reduced by more than 50% in the 

first 24h due to surfactant loss and increases in extravascular lung 

water and pulmonary lymph flow [9]. 

The presence of hypoxia, pulmonary oedema or bronchospasm 

aside from anticipated or actual airway problems are indications 

for tracheal intubation and a period of postoperative ventilation 

and supportive care. This must include bronchial hygiene 

therapy and physiotherapy to effect the removal of retained 

secretions and casts [9], as the mucociliary escalator will have 

been destroyed or disabled. Fraction of inspired oxygen (F I O 2 ) 

and positive end expiratory pressure (PEEP) are titrated against 

arterial oxygen tension (P a O 2 ) and peripheral oxygen saturation 

(SpO 2 ); a protective ventilatory strategy is adopted for acute lung 

injury. There have been no well controlled studies comparing 

different modes of ventilation in inhalation injury [9]. Other 

supportive measures are outside the scope of this article but must 

include adequate nutrition and attention to microbiological 

sampling and tissue viability. There is limited evidence to suggest 

that nebulised heparin and N- acetylcysteine can improve 

outcome in severe inhalation injury [9,10]. These measures are 

unlikely to cause harm in themselves provided bronchodilators 

are used to counter the possibility of N- acetylcysteine mediated 

bronchospasm. Other simple measures include bronchoscopy 

to confirm inhalation injury and bronchial lavage with 1.4% 

sodium bicarbonate [11]. 

Carbon Monoxide 

Carbon monoxide poisoning (CMP) should be assumed, and if 

possible excluded, in any patient exposed to smoke, particularly 

in a confined space. It is a product of incomplete combustion of 

hydrocarbons and other carbon containing substances - in isolation 

it is colourless and odourless. Features of CMP include headache, 

nausea and cerebral irritation (Table 1). Loss of consciousness 

from cerebral oedema, myocardial ischaemia and acidosis occur 

in severe poisoning. It is possible that personnel accommodated 

in an environment with significant carbon monoxide from 

incomplete combustion by a heater could all present with 

symptoms mimicking ‘flu or food poisoning. Thus CMP should 

be considered when faced with an outbreak of food poisoning or 

‘flu–like symptoms. It will not be filtered by conventional personal 

protective equipment (PPE). The pathophysiology of CMP is 

complex, based upon extreme left shift of the oxyhaemoglobin 

and myoglobin dissociation curves and interfering with the 

mitochondrial respiratory chain and cellular oxygen utilisation. 

Common problems include cardiovascular injury, to heart and 

vascular endothelium and neurological injury, particularly to 

‘watershed areas’ of the brain such as basal ganglia, with some 

long term sequelae [12,13]. Most blood gas analysers will measure 

carboxyhaemoglobin automatically, non-smokers will have a level 

Toxicology TC Nicholson-Roberts 

a relative deficiency of sulphur donors. Sodium thiosulphate 

(Na 2 S 2 O 3 ) given intravenously acts as a sulphur donor for the 

enzyme rhodanase (thiosulphate: cyanide sulphurtransferase) 

located in mitochondria. This is a slower process than chelation 

by dicobalt edetate. First the rhodanase enzyme (E) forms a 

persulphide link with the thiosulphate ion [17]: 

E + S 2 O 3 2 - D ES + SO 3 2 - 

Rhodanase is then cycled back to the sulphur free form [17]: 

ES + CN - D E + SCN - 

By doing so, cyanide (CN - ) is converted to relatively harmless 

thiocyanate (SCN - ) which is excreted by the kidney. In the 

unlikely event that the diagnosis is confirmed then dicobalt 

edetate 300mg in 50ml of 50% glucose can be given [13,18,19]. 

Dicobalt edetate chelates cyanide in order that the kidneys can 

excrete it. There is a risk of hypotension, arrhythmias, laryngeal 

and facial oedema if dicobalt edetate is given in the absence of 

cyanide poisoning [19]. In reality the diagnosis will not have been 

confirmed and a safer approach is to use sodium thiosulphate 

12.5g over 10min [19]. Formation of methaemoglobin using 

amyl nitrate or sodium nitrite is a strategy that has been used in 

severe cyanide poisoning. Cyanide avidly binds methaemoglobin 

reducing the amount binding to cytochromes, the bound 

cyanide is metabolised by the mechanisms outlined. Of course 

this will reduce the oxygen carrying capacity of blood which 

may be compromised already by a significant proportion of 

carboxyhaemoglobin. Inducing methaemoglobinaemia in a 

patient with carboxyhaemoglobinaemia is not recommended 

unless there has been a significant cyanide exposure with mild 

carboxyhaemoglobinaemia. 

Accordingly, trauma anaesthesia for the cyanide poisoned 

patient must involve an index of suspicion in cases of smoke 

inhalation where there is hyperlactataemia contributing to a raised 

anion gap acidosis and a high central venous oxygen saturation. 

Sodium thiosulphate is likely to be the safest antidote unless 

cyanide poisoning is confirmed; other complications such as fits 

are managed in a conventional fashion. 

Chlorine 

Chlorine is in widespread use in industry and is familiar to all 

of us. Chlorine was used with devastating effect during the First 

World War [20], nowadays it is involved in both accidental 

(Figure 1) and deliberate releases. 

Chlorine is a largely predictable toxin. The effects of chlorine 

are predominantly in the eyes and respiratory tract and are worse 

with increasing dose, duration of exposure and in cases with 

underlying lung disease. Early features are, predictably, a sore 

throat, cough, chest tightness and dyspnoea [22]. Laryngeal 

oedema, bronchospasm and pulmonary oedema are seen with 

increasing doses (Table 2). 

Concentration Effect 

1-3ppm 3-10mgm-3 Mild mucous 

membrane irritation 

after 60min 

5-15ppm 15-45 mgm-3 Moderate irritation of 

upper respiratory tract 

30ppm 90 mgm-3 Immediate chest pain, 

vomiting, coughing 

40-60ppm 115-175 mgm-3 Pneumonitis and 

pulmonary oedema 

430ppm 1250 mgm-3 Lethal after 30min 

1000ppm 2900 mgm-3 Fatal within a few 

minutes 

Table 2. Anticipated effects of increasing concentrations of chlorine 

[23]. 

Cases of chlorine poisoning are managed in a supportive 

fashion as acute severe asthma with bronchodilator therapy and 

nebulised steroids, however the role of corticosteroids is not 

completely established [21]. In more severe cases, pulmonary 

oedema is managed in conventional fashion with non-invasive 

continuous positive airway pressure (CPAP) and tracheal 

intubation if that fails. F I O 2 and PEEP are titrated against P a O 2 

and SpO 2 and a protective ventilatory strategy adopted for acute 

lung injury. Chlorine toxicity can be delayed such that a period 

of post operative observation should include the anticipation of 

respiratory problems in patients with asymptomatic exposure. 

Phosgene 

Phosgene is widely used in the chemical manufacturing industry, 

however in UK most use is in factories that manufacture phosgene 

on site. This has virtually eliminated the transport of phosgene on 

the road and rail networks. It was first used as a War Gas during 

World War 1; initial exposure resulted in few symptoms and was 

succeeded by florid pulmonary oedema, sometimes up to a day 

later [20]. 

Figure 1. Chlorine release from a tanker in the 2005 Graniteville, 

South Carolina rail crash. Approximately 54 tonnes (35 000 litres) 

of chlorine escaped from a ruptured tanker resulting in 8 deaths: 

according to the Coroner’s verdicts, seven were from asphyxia and 

one, the Train Engineer, who died several hours post-exposure from 

‘lactic acidosis’. 554 casualties attended local hospitals with breathing 

difficulties, 75 of those were admitted [21]. Note that Chlorine does 

not always take on the textbook yellow- green colour; it can also 

appear brown. It is denser than air and, in the absence of wind will 

settle in low areas. 

Photo: Environmental Protection Agency 


Toxicology 

In common with other lung damaging chemicals there is no 

specific therapy for phosgene inhalation [24]. Lung damage occurs 

as a result of free radical generation leading to lipid peroxidation 

and associated glutathione depletion [24]. Supplementation or 

repletion of glutathione may be of value as demonstrated by a study 

in isolated rabbit lungs [25]. Postoperative patients exposed to 

phosgene require minimal exertion for 48h with close observations 

to identify the development of pulmonary oedema. The use of 

steroids remain controversial and are probably not indicated. At 

present supportive therapy using a protective ventilatory strategy 

with nebulised N-acetyl cysteine and bronchodilators is indicated; 

pulmonary oedema is managed with PEEP. 

Chemical Weapons 

The NATO definition of chemical weapons states that they are 

substances intended for use on military operations to kill, injure or 

incapacitate as a result of their physiological effects. This does not 

confine their use to the battlefield as seen in Tokyo 1995 when sarin 

was released in the underground. Cyanides, chlorine and phosgene 

have all been weaponised and the management of the poisoned 

soldier during conflict does not differ in these circumstances. 

Lung Damaging Agents 

Lung damaging agents, also known as choking agents include 

chlorine, phosgene and hydrochloric acid. These are non-persistent 

agents that do not require decontamination in current theatres of 

operations. Treatment is supportive and if patients survive the first 

48 hours they usually recover without sequelae [26]. 

Blister Agents 

Vesicants or Blister Agents were first used during World War I to cause 

burning and blistering of exposed areas. They include the mustards 

and lewisite. They are persistent in temperate and colder climates. 

Unless they have been ‘thickened’, decontamination should not be 

required in hotter climates, however vapour concentrations can be 

higher under these circumstances. The effects of mustards are due 

to oxidation and alkylation of DNA, RNA and other important 

biological molecules. Crosslinking of DNA and RNA at guanine 

residues results in cytotoxicity, errors in DNA repair mechanisms 

can result in transformation and malignancy. Decontamination of 

kit and equipment is beyond the scope of this article, however the 

surgical patient with blister agent exposure may require ongoing 

decontamination in the operating theatre. Contaminated clothing 

fragments should be placed in a bleach solution to prevent 

further vapour release, wounds are irrigated with 3000- 5000ppm 

chlorine (dilute Milton) solution before rinsing with crystalloid 

[27]. Mustards are degraded by water, forming hydrochloric 

acid. During its manufacture 0.9% Saline is rendered acidic with 

hydrochloric acid and therefore may not be the ideal solution to 

irrigate with. Decontamination of eyes and mucous membranes 

should not be attempted using skin decontamination preparations 

but 1.26% (isotonic) sodium bicarbonate should be used to irrigate 

if available, otherwise saline or Hartmann’s solution will have to 

substitute. Mydriatics should be used in corneal damage to prevent 

adhesions with the iris and local anaesthetics should be avoided, 

permanent blindness is rare [27]. For intraperitoneal, intrathoracic 

and intracranial wounds crystalloid is used as irrigation fluid. 

Lung manifestations occur after a latent period up to six hours 

beginning with symptoms of a severe upper respiratory tract 

infection. Burning throat pain results in a reluctance to cough until 

copious secretions supervene. Epithelial necrotic fragments and 

330 


pulmonary oedema will lead to hypoxaemia from shunt, diffusion 

impairment and a predisposition to pneumonia exacerbated by 

immune dysfunction [27]. There is a strong correlation between 

conjunctival damage and lung injury [27]. Lung support is 

achieved in a conventional fashion with escalation as necessary 

from non-invasive to invasive ventilation with titration of PEEP 

and F I O 2 against P a O 2 . 

Skin damage occurs within two minutes of exposure and 

progresses through erythema, blistering to full thickness burns. 

Skin damage is worst in warm wet skin [27]. The blister fluid is not 

vesicant and generally the blisters are not painful in postoperative 

patients with adequate systemic analgesia. 

Lewisite is an arsenical vesicant with a specific antidote, 

dimercaprol (British Anti Lewisite) which is used in metalloid and 

heavy metal poisoning. The onset of symptoms is faster than with 

mustard and although lung effects are less severe, blindness is more 

likely. Dimercaprol ointment can be applied to decontaminated 

skin and eyes or injected intramuscularly in severe exposure [27]. 

Perioperative management is as for mustard. 

Organophosphorus compounds 

Organophosphorus (OP) compounds include the nerve agents and 

agricultural insecticides; other infrequent uses are as fire retardants 

and lubricants. The commonest cause of organophosphorus 

morbidity is from accidental or intentional ingestion from the 

agricultural sector. 

OPs are irreversible inhibitors of plasma, red cell and tissue 

esterases, particularly butyrylcholinesterase (BChE) and 

acetylcholinesterase (AChE). It is inhibition of AChE that gives 

rise to the classic features of the cholinergic phase of nerve agent 

toxicity. This is brought about by overwhelming cholinergic 

stimulation by acetylcholine in the central nervous system, 

neuromuscular junction and autonomic nervous system. A 

summary of the effect sites of acetylcholine is shown in Figure 2. 

Figure 2. An outline of the utilisation of acetylcholine by the autonomic 

nervous system and neuromuscular junction. The parasympathetic 

effects are demonstrated at the top where pre and post ganglionic 

fibres are stimulated by acetylcholine (ACh) at nicotinic (N) and 

muscarinic (M) receptors. Preganglionic sympathetic fibres are 

generally shorter than those in the parasympathetic nervous system, 

nevertheless they utilise ACh to stimulate nicotinic receptors. The 

postganglionic sympathetic fibres release catecholamines shown as 

red hexagons acting viscerally, and hormonally from the adrenal 

gland demonstrated by the brown triangle. Crucially the sympathetic 

innervation of sweat glands is by ACh acting on muscarinic receptors. 



The characteristics of OP toxicity are outlined in Table 3. 

Cholinergic crises are not only seen in indirectly acting toxins 

such as OPs and carbamates, such as pyridostigmine, but also 

with directly acting cholinomimetics, fungi and betel, sodium 

channel openers, some animal venoms and aconitine poisoning. 

Central Nervous 

System. 

Nicotinic and 

Muscarinic Effects 

Confusion 

Agitation 

Coma 

Respiratory Failure 

Autonomic Nervous System Neuromuscular 

Parasympathetic 

Nervous System 

Muscarinic Effects 

Bradycardia, 

Hypotension 

Bronchospasm, 

Bronchorrhoea 

Salivation, Vomiting, 

Diarrhoea 

Miosis, Lacrymation, 

Urination 

Sympathetic 

Nervous System 

Nicotinic Effects 

Tachycardia, 

Hypertension 

Sweating Paralysis 

Table 3. Summary of effects of OP poisoning. Generally the 

parasympathetic features prevail to the extent that mydriasis is not 

seen and hypovolaemia must be excluded as a cause of tachycardia 

should it occur. Note the multiple causes of respiratory failure and 

how all except the neuromuscular junction’s contribution can be 

reversed by atropine. After Eddleston et al [28]. 

Low dose exposure to OPs may mimic an outbreak of influenza 

or gastroenteritis. On deployed operations the diagnosis is 

clinical. There may be no history (Figure 3); casualties presenting 

with pin point pupils, profound salivation, respiratory distress 

and bradycardia should least arouse suspicion of OP poisoning 

and fasciculations are almost pathognomic. Assays for BChE and 

red cell AChE will not be available in the field. They are classed 

as specialist or infrequent assays ideally available within three 

hours including journey time in UK [29]. BChE activity more 

closely tracks the clinical picture [28, 29] except in patients with 

suxamethonium apnoea. 

Figure 3. Mother and child who have succumbed to nerve agent as 

a result of the attack on Halabja 16 March 1988. Observe the dried 

copious secretions from lacrimation and salivation. It is thought that 

mustard and cyanide were also used [30] 

Photo: Sipa Press/ Rex Features Ltd with permission 

OPs bound to AChE become less likely to dissociate through 

a process known as ageing. Ageing is thought to represent loss 

of an alkyl group which means that the complex is less likely to 

undergo spontaneous dephosphorylation. Of the nerve agents, 

ageing occurs most rapidly with soman with a t ½ (time required 

Junction. 

Nicotinic Effects 

Muscle weakness 

Mydriasis Respiratory failure 

Fasciculation 

for half the enzyme to become 

resistant to reactivation) of 1.3 

minutes, whereas the ageing t 1/2 

of sarin is five hours and that of 

tabun, 46 hours [31]. Recovery 

is by synthesis of new enzyme 

which occurs at a rate of about 

1% per day [32]. 

Morbidity and mortality is 

primarily due to hypoxia from 

bronchospasm, bronchorrhoea 

and failure of ventilation 

by central and peripheral 

mechanisms. After the initial 

cholinergic phase follows a 

period of delayed neuromuscular 

weakness and respiratory failure first described as the Intermediate 

Syndrome [33], however further observations have demonstrated 

less of a distinction and a variable constellation of signs [34]. The 

Intermediate Syndrome has not been observed in cases of nerve 

agent poisoning [35] and there is no mention of it in the NATO 

Handbook on the Medical Aspects of NBC Defensive Operations 

AMedP-6(B) [36]. It is not clear why this is and clinicians should 

at least be alert to the possibility of it occurring. 

The principles of therapy include pre-exposure prophylaxis, 

maintenance of oxygenation during acute exposure and 

maintaining a period of post exposure observation in cases of 

agricultural OP poisoning. Pre-exposure prophylaxis is usually 

achieved using pyridostigmine 30mg eight hourly. Carbamates 

bind AChE less avidly, however they disrupt the binding of OPs 

to the extent that reactivation of AChE is made easier. Unbound 

OPs undergo hydrolysis before spontaneous dissociation of the 

carbamylated AChE produces active enzyme. Pyridostigmine 

should be discontinued once nerve agent poisoning has 

occurred as any unaffected AChE will be required to function. 

Unaffected patients who have been taking pyridostigmine may 

require antimuscarinic premedication and are likely to require 

increased doses of non-depolarizing neuromuscular blockers 

intraoperatively. 

The patient with OP poisoning presenting for surgery will need 

resuscitating first, and in patients who have been issued them, 

combopens may have been used. They contain atropine 2mg, 

pralidoxime 500mg and avizafone which is a diazepam prodrug, 

equivalent to 5mg. The overarching principle is maintenance of 

oxygenation and this is chiefly achieved by atropine in conjunction 

with standard resuscitative measures. In the presence of hypoxia 

or where oxygen supplementation is unavailable there is always 

the concern of precipitating ventricular tachyarrhythmias, 

however this is not borne out by clinical practice in agricultural 

OP poisoning [28]. Atropine will rapidly decrease bronchospasm 

and dry secretions, thus alleviating hypoxia. A useful guide to 

atropine dosing is shown in Figure 4 which illustrates doubling 

of doses as recommended by Eddleston [28]; rapid atropinisation 

is crucial in severe OP poisoning and should take precedence 

over giving other drugs. One should give as much as it takes to 

reach a heart rate greater than 80 beats per minute and to break 


Toxicology 

the bronchospasm, either by assessing lung compliance through 

positive pressure ventilation, including bag valve mask, or by 

auscultation in the self ventilating patient. Assessment of pupils 

should not guide atropine dosing. An infusion of atropine after 

‘loading’ may result in a smoother recovery profile [28,36]. 

An oxime such as pralidoxime is given as soon as practicable in 

order to restore some AChE activity, however it is ineffective in 

the aged OP-AChE complex. There is evidence that it will bind 

unbound OPs, preventing their binding to AChE [32]. Oxime 

infusions have been used after the loading dose - pralidoxime 

should be started at 2.1 mgkg -1 h -1 [36]. 

Fitting is commoner in nerve agent than agricultural OPs 

and should be treated in conventional fashion using diazepam. 

Agitated patients should also receive diazepam provided atropine 

is being given; paradoxically respiration under these circumstances 

is enhanced [37]. 

During the acute cholinergic phase, muscle relaxation will not 

be necessary as in moderate to severe poisoning the patient will 

already be paralysed and suxamethonium action will be greatly 

prolonged. Similarly, after carbamate pre-exposure prophylaxis 

the carbamylated BChE will not hydrolyse suxamethonium as 

readily resulting in prolonged action. It may be the case that non 

depolarising neuromuscular blockers will shield post synaptic 

nicotinic receptors from excess ACh stimulation during the 

acute phase [35]. Whether this is beneficial is not known. A type 

II neuromuscular block is one that exhibits fade on repeated 

stimulation and potentiation after induced tetany. It is usually 

seen after the administration of non-depolarising neuromuscular 

blockers and in the Intermediate Syndrome. It can be assessed 

using a conventional theatre monitor; the ‘train of four’ [32]. 

Consequently relaxants should be used with great care or avoided 

altogether in the Intermediate Syndrome. There is very little 

clinical experience in this regard. 

Other measures can be employed to hasten recovery such as 

decreasing ACh at the synaptic cleft. Drugs such as magnesium 

and clonidine reduce ACh secretion in central and peripheral 

neurones. Magnesium will also be useful in averting torsade de 

pointes in the event of severe poisoning sufficient to prolong the 

QT interval. Currently, there is little evidence to support the use of 

magnesium. A small study in Tehran of agricultural OP poisoning 

demonstrated a reduction in mortality and length of stay in an 

unrandomised and unblinded trial [38]. A larger Sri Lankan study 

is ongoing and will provide further clarification [39]. 

Surgery for the OP poisoned patient should be embarked upon 

following restoration of oxygenation and further therapy can be 

given intraoperatively. Consideration should be given to regional 

anaesthesia and interpretation of monitoring will be confused by 

a heart rate driven by atropine. It is likely, however in the event of 

OP poisoned patient(s) arriving at a Field Hospital that they will 

encounter anaesthetic expertise in managing a condition that is 

not too far removed from their own clinical experience. 

Future Developments 

OP poisoning represents a serious threat to health with 

approximately 200 000 deaths per year [28,32] mainly in 

developing countries. Advances in research by organisations such 

as the South Asian Clinical Toxicology Research Collaboration 

are limited by funding. Advances made in the military sector are 

often kept secret. Scavenging of OPs before they have bound 

AChE is an area that is currently under investigation, this can only 

be accomplished with rapid intervention and may reduce length 

332 

  

  

  

15 min up 

to 3 doses 

Double the 

previous 

atropine dose 

  


ORGANOPHOSPHORUS 

TREATMENT 

Buddy Aid/ Self Aid with 

Combopen (im) 

Atropine 2mg 

  

Pralidoxime 500mg 

Diazepam 5mg (equivalent) 

Atropine 

  

Begin with 

2-5 mg iv/ io 

Oxygen/ 

Ventilation 

iv/ io access 

3-5min 

Reassess: Bronchospasm 

Bronchorrhea 

Bradycardia 

• Establish 2nd iv access and give Pralidoxime 2g over 5-10 min 

and infusion at 2.1 mgkg-1h-1 if dermal or gastric absorption 

continues 

• Diazemuls 5mg every 5min iv if fitting 

• Continue atropine until HR >80 and bronchospasm is broken 

• Consider fluid replacement of losses 

• Consider atropine infusion of 10-20% of “loading dose” per 

hour 

Figure 4. An algorithm for the treatment of OP poisoning, combopen 

use is currently unlikely. Atropine is given in doubling doses until 

atropinisation is achieved, an infusion of 10-20% of that total 

dose can then be given per hour. Benzodiazepines should be given 

routinely in nerve agent poisoning but are less likely to be required in 

agricultural OP poisoning. Cutaneous VX absorption will continue 

after decontamination and will necessitate infusions of pralidoxime 

and atropine. After Bland [40] and Eddleston et al [28]. 

of stay. Recombinant BChE has been trialled in vitro and binds 

OPs stoichiometrically [41]. Another avenue that may be worth 

pursuing is the use of cyclodextrins. They have been in use for many 

years in pharmaceutical preparations but have only recently been 



used as drugs in the form of sugammadex that stoichiometrically 

binds the neuromuscular blocking agents rocuronium and 

vecuronium [42,43]. Sequestering of OPs by cyclodextrins is a 

possibility and candidates could rapidly be screened for activity 

as the act of sequestering represents a reduction in entropy. Any 

useful prototypes would therefore cool the reaction vessel. Whilst 

sequestering is useful, cyclodextrins can be modified to become 

catalysts [44] and this has been investigated with resulting 

hydrolysis of soman by b- cyclodextrins [45,46]. Unfortunately, 

due to rapid aging of soman this may not be clinically useful. 

Another possible spin off from the world of anaesthesia is the 

use of intralipid for local anaesthetic toxicity. So far there are two 

theories as to its mechanism of action; the lipid sink hypothesis 

and modulating carnitine acylcarnitine transferase activity in 

cardiac mitochondria [47,48]. A lipid sink hypothesis may provide 

another method of scavenging and there is a current vogue for 

using intralipid successfully in various scenarios of massive drug 

overdose refractory to conventional resuscitative methods [49,50]. 

Whether this might work in OP poisoning remains to be seen. 

Conclusions 

Military anaesthetists are familiar with the requirement for 

damage control resuscitation in military trauma [51]. Poisoned 

trauma patients will, at some point be delivered to a field hospital 

and undue delays in resuscitation will be detrimental. The 

additional complication of poisoning in trauma patients should 

not represent undue difficulty for the military anaesthetist in 

guiding the trauma patient through the perioperative period. 

There are few antidotes as compared to the number of potential 

toxins out there; most treatment is supportive and reacting to 

changes in physiology. 

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1436-1440 


Operational Anaesthesia for the Management of 

Traumatic Brain Injury 

CL Park 1 , P Moor 2 , K Birch 3 , PJ Shirley 4 

1 London HEMS Registrar; 2 Consultant in Neuroanaesthesia, MDHU Derriford; 3 Consultant, Intensive Care and 

Anaesthesia, Frenchay Hospital, Bristol; 4 Consultant, Intensive Care and Anaesthesia, Royal London Hospital, 

Whitechapel, London 

Abstract 

The primary brain insult that occurs at the time of head injury, is determined by the degree of neuronal damage or death 

and so cannot be influenced by further treatment. The focus of immediate and ongoing care from the point of wounding 

to intensive care management at Role 4 should be to reduce or prevent any secondary brain injury. The interventions and 

triage decisions must be reassessed at every stage of the process, but should focus on appropriate airway management, 

maintenance of oxygenation and carbon dioxide levels and maintenance of adequate cerebral perfusion pressure. Early 

identification of raised intracranial pressure and appropriate surgical intervention are imperative. Concurrent injuries 

must also be managed appropriately. Attention to detail at every stage of the evacuation chain should allow the headinjured 

patient the best chance of recovery. 

Introduction 

Military patients sustaining severe traumatic brain injury (TBI) 

often pose particular challenges. The treatment of the injury can 

be highly complex, from the point of initial wounding, surgical 

intervention, intensive care and ultimately rehabilitation. It has 

been recognized that mild, moderate and severe brain injuries have 

become a major focus of military medical services during current 

operations due to the high levels of kinetic activity [1]. Changing 

patterns of head injury are being seen, with a penetrating injury 

now often also as a result of blast as well as direct ballistic injuries 

[1]. The management of traumatic brain injury raises many issues 

to be considered (Table 1). This article examines the management 

of brain injured patients through four phases of care from point 

of wounding through the deployed field medical facilities, 

aeromedical evacuation and UK based definitive care. 

• Consideration of the injury mechanisms and potential 

structures at risk in blunt and penetrating trauma. 

• Pre-hospital management and the time line to definitive care 

• Peri-operative management of the trauma patient 

including intubation and approaches to fluid 

management. 

• Clearance of the cervical spine in a sedated and ventilated 

trauma patient. 

• Timing of fracture fixation and other injury management. 

• Maintenance of blood pressure and cerebral perfusion 

pressure 

• Timing of aeromedical evacuation to role 4 care 

• Role 4 management and multi-modality monitoring 

• Timing of neurosurgical interventions such as 

decompressive craniectomy 

• Rehabilitation from injury 

Table 1: Issues raised in the treatment of brain-injured patients. 

Corresponding Author: Wg Cdr Peter Shirley, Consultant, 

Intensive Care and Anaesthesia, Royal London Hospital, 

Whitechapel, London E1 1BB 

Email: Peter.Shirley@bartsandthelondon.nhs.uk 

Pre-Hospital Management 

This encompasses care at all levels from Care Under Fire (CUF) 

and Tactical Field Care (TFC) [2], to the Combat Medical 

Technician (CMT) or Regimental Medical Officer (RMO) at 

Role 1 and the Medical Emergency Response Team (MERT) 

retrieval. The level of intervention will depend on the stage of 

evacuation and medical skills present, but the medical care at all 

stages should be based on similar underlying principles. 

The pre-hospital management of TBI aims to prevent secondary 

brain injury by provision of adequate oxygenation and cerebral 

perfusion and treatment of other significant injuries while ideally 

ensuring rapid transfer to a neurosurgical centre. It has been 

shown that even when surgical intervention is not required, all 

TBI patients do better when managed in a neurosurgical centre 

[3]. In the military setting, this may not be immediately possible, 

as current UK Role 2 or 3 facilities do not include a neurosurgical 

capability. However, all deployed general surgeons should be 

capable of performing a burr hole in order to decompress an 

extradural haematoma [2]. 

MERT physicians in the operational setting should be aware 

of the location of neurosurgical facilities in theatre, and should 

make appropriate triage decisions immediately, and transfer 

directly to the available neurosurgical facility if the operational 

tempo will allow. 

Pre-hospital Resuscitation 

In accordance with Brain Trauma Foundation (BTF) guidelines 

[4], pre-hospital assessment of a head injured patient should 

include assessment and treatment priorities as listed in Table 2. 

Much of the civilian data for the pre-hospital management 

of TBI can be applied in the military setting. However, in some 

circumstances civilian guidelines will be impractical in the military 

setting, as discussed in the BTF Field management guidelines [5]. 

CUF, TFC and Role One management should be performed as 

described by Battlefield Advanced Trauma Life Support (BATLS) 

2008 [2] and in the context of TBI the interventions in Table 3 

should be focused on. 


Anaesthesia for TBI 

Assessment of: Oxygenation 

Blood pressure 

Treatment: Maintenance of a patent airway 

Maintenance of adequate oxygenation and 

ventilation, 

Appropriate fluid resuscitation 

Treatment of cerebral herniation 

Appropriate triage and transport 

Table 2: Priorities in the Pre-hospital assessment of brain-injured 

patients 

336 

BATLS 

Stage 

Prevention of further 

haemorrhage to 

maintain CPP. 

CUF / TFC Role 1 

A Maintenance of airway 

patency using adjuncts 

as necessary. 

B Optimisation of 

chest injuries causing 

pathology by needle 

decompression, & / or 

Aschermann or Bolan 

chest seal. 

C 250ml fluid boluses to 

maintain a radial pulse. 

D Identification of head 

injury Assessment of 

the Glasgow Coma 

Scale (GCS) score and 

pupil size. 

Alerting the casevac 

chain to the type of 

injury and level of 

consciousness will 

prompt accurate 

allocation of casevac 

assets. 

Continue to reassess 

adequate haemorrhage 

control. 

If the airway is not 

patent 

despite simple airway 

manoeuvres, a surgical 

airway should be 

performed as a definitive 

airway [2]. 

If ventilation is 

inadequate, aid with a 

bag valve mask either 

via face mask or surgical 

airway. 

250ml boluses of fluid 

should be given to 

maintain SBP of 90 if 

a BP cuff is available. 

Otherwise administer 

fluid boluses to maintain 

a good radial pulse, and 

verbal contact if the 

casualty is able to speak. 

If the casualty is 

hypotensive with no 

palpable radial pulse, 

hypertonic saline would 

be an appropriate prehospital 

resuscitation 

fluid. 

A drop in GCS would 

require expedition 

of evacuation to a 

neurosurgical facility 

where possible. 

Table 3 Management during CUF / TFC and at Role One: 

CL Park, P Moor, K Birch et al 

MERT and initial hospital resuscitation 

These should be similar as MERT is a forward projection of the 

resuscitation facilities available at Role 2 or 3. 

Airway 

A definitive airway should be obtained with a Rapid Sequence 

Induction (RSI) if the patient is unconscious, has airway 

compromise or ventilatory failure. A number of patients with 

head injury and a relatively high GCS (9 – 14) may also require 

intubation. Most of these patients have cerebral agitation and 

it has been shown that patients with a significant mechanism 

of injury who have cerebral agitation have a high incidence 

of intracranial pathology. Patients with a skull fracture who 

are not orientated have a 1 in 4 risk of having an intracranial 

haematoma [6]. These patients require urgent management to 

prevent secondary brain damage, an expeditious CT scan and 

appropriate neurosurgical intervention. 

A well-trained pre-hospital team such as the MERT, should 

have low intubation failure rates and should practice more 

permissive use of intubation without causing an increase in 

mortality. However, if the RSI procedure and ensuing mechanical 

ventilation are performed poorly, the negative effects have been 

shown to outweigh potential benefits [7]. Agitated patients with 

head injuries and additional injuries often require sedation and 

/or analgesia in order to gain control of the patient, therefore 

preventing secondary brain injury by adequately pre-oxygenating 

and performing a controlled RSI. 

It is imperative that pre-hospital teams at Role 1 perform the 

basics well, and do not attempt to perform an RSI when they 

are not appropriately trained to do so. Basic airway management, 

appropriate administration of pre-hospital fluids to maintain 

a systolic of over 90mmHg (i.e. a good radial pulse) and rapid 

evacuation should be the focus of treatment. MERT personnel 

should be able to safely administer sedation and carry out an RSI 

when the patient’s condition requires it. 

Choice of Anaesthesia, Analgesia and Sedation by the 

MERT or in the Emergency Department 

Current practice is commonly still to use etomidate as a prehospital 

induction agent for RSI in TBI, followed by morphine 

and midazolam to maintain analgesia and anaesthesia [8]. 

Traditionally ketamine has rarely been used in patients with TBI 

because of concerns that it causes a rise in intracranial pressure 

(ICP). However, there is emerging evidence that it in fact lowers 

ICP and maintains cerebral perfusion pressure (CPP) when used 

as an infusion on ITU [9-11] and there is evidence that it decreases 

ICP spikes and prevents spikes in response to procedures[12]. 

In hypotensive patients with TBI, ketamine is a more 

appropriate agent [13]. Especially in the presence of polytrauma, 

where brain injury and shock co-exist, and etomidate will 

reduce CBF as cerebral autoregulation is impaired and cerebral 

blood flow (CBF) is essentially CPP-related, the maintenance of 

hemodynamic stability will maintain CBF. In addition ketamine 

reduces cerebral oxygen consumption (CMRO 2 ) and so the 

overall balance of CBF and CMRO 2 in the presence of ketamine 

is favorable [13]. 

RSI technique 

The RSI technique in head injury should minimise CO 2 increases 

and pharyngeal and laryngeal stimulation in an attempt to 

minimise ICP rises. Meticulous attention to oxygenation is also 


Anaesthesia for TBI CL Park, P Moor, K Birch et al 

important as is the prevention of hyper and hypoventilation, 

which has been associated with poor outcomes [4,5,14]. 

Ventilation Aims 

Ventilate to low normocapnia (end-tidal CO 2 of 30 mmHg, 

4.0KPa) [4, 5]. This equates to a PaCO 2 of approximately 

4.5KPa in normal individuals. This minimises the risk of cerebral 

vasodilation from high PaCO 2 and cerebral vasoconstriction 

from low PaCO 2 . 

Use of IV Fluids and CPP 

After significant head trauma, the brain may lose the ability 

to autoregulate cerebral blood flow. A fall in mean arterial 

pressure (MAP) may therefore result in a reduction in cerebral 

oxygen delivery even if the ICP is normal. When active external 

haemorrhage has been stopped and splintage of limbs / pelvis has 

been maximised, then fluids should be administered to achieve 

a systolic blood pressure of 90mmHg. This can be increased to 

100 to 120mmHg in isolated head injury. On the MERT or 

during in-hospital resuscitation, if hypotension is secondary to 

traumatic injuries, damage control resuscitation (DCR) should be 

commenced. Fluid replacement should be with red blood cells and 

fresh frozen plasma in a 1:1 ratio, rather than crystalloid to replace 

blood loss. [15] Hypertonic saline may also be an appropriate 

fluid for use in multitrauma patients with head injuries – this is 

discussed below. 

Packaging 

Compression of the jugular veins will reduce venous return from the 

head and neck which can increase ICP by an average of 4.5mmHg 

[16]; the cervical collar should be left slightly loose and cervical 

spine immobilisation maintained with head blocks and tape where 

possible. The neck veins can also be constricted by a tight tracheal 

tube tie, which should be checked and loosened if necessary. 

Ideally, the patient should be maintained and transported in a 20 

degrees head up position to maximise venous drainage. 

Control of ICP / impending herniation with hyperosmolar 

therapies 

Mannitol 

The TBF guidelines [4, 5] support the use of mannitol in 

response to herniation at doses of 1.4–2.1 g/kg if supported by 

the capacity to provide high fluid volume compensation for any 

ensuing urine loss. 

In addition to the increased fluid requirement, however, 

mannitol is susceptible to cold and crystallizes in cold conditions, 

so is not practical in the military pre-hospital environment. A 

recent Cochrane review concluded that mannitol has a beneficial 

effect on ICP compared to pentobarbital, but may have a 

detrimental effect on mortality when compared to hypertonic 

saline. However, as that review highlights, there is a lack of prehospital 

evidence on its effectiveness [17]. 

Hypertonic Saline 

Hypertonic saline (HTS) has been shown to lower ICP in severe 

head injuries and in multiple studies has been shown to improve 

neurological outcome in TBI [18-21] especially in paediatric 

patients [22-26]. It may have other beneficial effects such as 

increasing circulating volume, minimal alteration to coagulation 

and anti-inflammatory properties [27]. 

There are very few reports of any side effects due to its use. 

There are, however, some studies [28] showing no difference 

compared to isotonic solutions, although overall survival in these 

studies has been shown to be better than predicted, which may be 

due to an adequate pre-hospital resuscitation protocol. HTS use 

with the goal of maintaining adequate haemodynamic parameters 

during resuscitation may therefore still be beneficial, especially 

in military pre-hospital care where transporting large volumes of 

isotonic fluids is impractical[27]. 

5% Sodium chloride is used by some pre-hospital services. It is 

available as a 250ml or 500ml infusion bag and is stable through 

a range of temperatures. A suggested policy for administration of 

5% Hypertonic saline [8] is 6 ml / kg (to a maximum of 350ml) 

of 5% HTS delivered by a well secured large bore peripheral (> 

18 gauge) cannula over 10 minutes in patients with signs of actual 

or impending herniation resultant from severe head injury with 

either unilateral or bilateral pupil dilation and GCS < 8 (and 

usually 3) or progressive hypertension (systolic BP > 160mmHg) 

and bradycardia (pulse below 60). 

The dose is given only once and regardless of blood pressure. 

In patients with multiple traumatic injuries, hypotension and 

head injury a bolus of HTS as above will help restore circulating 

volume and may protect against cerebral hypoperfusion and 

reduce oedema. For this indication it is suggested by the BTF 

guidelines that one or two boluses of 250ml of 5% HTS would 

be appropriate. [5]. 

Further Management At Role 2+ / Role 3 

Initial management of ABCD should be as before for airway 

and ventilation. Rapid infusion of blood products in hypotensive 

multitrauma patients to maintain a systolic BP of over 100mmHg 

should be via a central, usually subclavian, trauma line, inserted 

on arrival in the Emergency Department (ED) and damage 

control resuscitation (DCR) should continue [15]. 

There must be a rapid decision to proceed to CT scanning to 

look for intracranial haematoma and cervical spine clearance, or 

to go directly to theatre in the case of co-existing injuries requiring 

immediate surgical treatment. 

If the patient is haemodynamically stable, with no immediate 

need for surgical treatment, then a CT scan to exclude intracranial 

pathology, most importantly an extradural haematoma, should 

be performed as a priority. If intracranial pathology is detected 

in a stable patient, including intracranial or intraocular foreign 

bodies, as is often seen from IED blasts, then the images should 

be transmitted to the nearest neurosurgical facility. In Afghanistan 

at the time of writing, this is the US Role 3 facility at Kandahar 

Airfield. A neurosurgical opinion should be urgently sought, 

whilst the Tactical Critical care Air Support Team (CCAST) 

prepares to transport the patient. 

Intra- Operative Anaesthetic Management Of TBI 

Conduct of anaesthesia in the TBI patient should aim to preserve 

normal brain parenchymal homeostasis to reduce the risk of 

secondary brain injury (Table 4) [14, 29]. 

Any injury causing persistent hypotension should be 

addressed immediately and if intracranial space-occupying 

lesions are present, these should be evacuated simultaneously. 

Limb-saving peripheral vascular surgery should be performed 

urgently. Subsequent, operative treatment of long bone and 

other fractures can be delayed until the head injury has been 

stabilized [30]. 



GENERAL PRINCIPLES 

Maintenance of Mean Arterial Blood Pressure 

Control of Intracranial Pressure 

Maintenance of adequate Oxygenation 

Avoidance of hyper/hypocapnia 

Glycaemic Control 

Avoidance of Iatrogenic Injury 

Table 4: Physiological aims of anaesthesia for traumatic brain injury 

[4] 

Monitoring 

As with all military trauma patients, in addition to standard 

monitoring for anaesthesia, invasive arterial blood pressure, 

central venous pressure and core temperature monitoring should 

be initiated. Near-patient testing for blood gas analysis, blood 

glucose and coagulation is routinely available in the role 2E 

facility. 

Maintenance of anaesthesia 

After intubation, normoxia and low normal carbon dioxide 

should be the aim (ETCO 2 4.0-4.5 kPa). Hyperventilation 

should be preserved for herniation syndromes only. A systolic 

blood pressure of


• Head Injury Traumatic brain injury 

guidelines followed? 

Tertiary survey completed? 

Cervical Spine cleared? 

Surgical plan robust? 

• Infection control Strict adherence to hand 

hygiene? 

Field-placed venous access lines 

changed? 

Assess need for current central 

venous access? 

Appropriate antibiotics? 

• Ventilated patients Head-of-bed elevation? 

EtCO 2 in 4.0-5.0 range? 

ICP/MAP/CPP all within 

agreed limits 

Oral care protocol? 

Is a weaning plan appropriate? 

Sedation and analgesia protocol? 

Cooling required? 

Is paralysis justified? 

Pressure area protection 

optimised? 

• Deep vein thrombosis prophylaxis optimised? 

• Stress ulcer prophylaxis required? 

• Glycaemic control best and safest for circumstance? 

• Nutrition optimal? 

• Candidate for evacuation? Safe for transport? 

CCAST arrangements? 

Records ready? 

• Rehabilitation plan commenced 

Table 5: Intensive Care Unit checklist for the brain-injured patient 

causes a reduction in PAO 2 and subsequently a reduction in 

PaO 2 . Any gas present in enclosed spaces with no ability to vent 

to the atmosphere will expand and cause compression of adjacent 

structures. If this gas lies within sensitive areas such as within the 

cranium, the increase in pressure may have a deleterious effect. 

Noise prevents any effective auscultation and equipment alarms 

are unable to be heard and communication between crew members 

is degraded. Vibration can affect equipment and initial studies 

suggest that the risk of micro aspiration in intubated patients may 

beincreased (Unpublished data – K Birch). All these factors must 

be considered and efforts made tominimize their impact. 

Haemodynamic Monitoring and Management 

Invasive monitoring of arterial blood pressure is important 

to ensure maintenance of adequate systemic blood pressure. 

Treatment should be titrated to aim for a CPP of 60-70mmHg. 

If the ICP is not known, as ICP monitors are not currently sited 

at UK Role 2 or 3 facilities, and there are issues with accurately 

measuring ICP during flight, aiming for a MAP of 70-80mmHg 

would suffice. If augmentation of blood pressure is necessary, 

infusions of vasopressor agents or inotropes may be considered. 

Volume status of the patient should be assessed via a central 

venous catheter and/or by measuring hourly urine output. The 

aim is for a euvolaemic, normosmolar state with a haematocrit 

of around 0.3. If there is evidence of active bleeding or risk of a 

fall of heamoglobin concentration in flight, blood for transfusion 

should be carried. 

Respiratory Monitoring and Management 

The majority of patients with traumatic brain injury require 

intubation and ventilation to ensure a secure airway (if GCS 

≤8/15), adequate oxygenation and control of PaCO 2 . Low levels 

of Positive End Expiratory Pressure (PEEP) should be employed 

during ventilation and PaCO 2 maintained within the normal 

range (4-0-5.0KPa). Equipment to be able to measure arterial 

blood gases during flight should be carried for transfer. 

Sedation and Muscle Relaxation 

The level of sedation required for head injured patients will 

depend on the injury and the systemic physiological condition 

of the patient. Increased doses of sedation, narcotics and/or 

benzodiazepines may be required during transfer due to increased 

stimulation due to noise and vibration on the aircraft. Routine 

use of muscle relaxants is not recommended, however if use is 

required, monitoring of the degree of neuromuscular blockade is 

mandatory. 

Patient Positioning 

Ideally a 30-45° head up attitude should be sustained as part of 

the ventilatory care bundle and neurological management. The 

head should be maintained in a neutral position. The type and 

flying attitude of the aircraft will dictate if the patient is loaded 

head or feet first. 

Metabolic Treatment 

One should aim to maintain the patient’s biochemical parameters 

to as near normal as possible during transfer. If the ICP is known 

or believed to be significantly elevated, therapy such as increasing 

serum sodium concentration and use of mannitol (used in 

conjunction with other therapeutic measures) can be considered. 

The brain is an obligate glucose user so hypoglycaemia, as well as 

hyperglycemia must be avoided during transfer [37]. 

Hyperthermia is a recognized cause of secondary cerebral insult, 

therefore normothermia, or in certain circumstances therapeutic 

hypothermia, should be maintained [38, 39]. This may require 

active or passive cooling methods. 

Nutrition 

Ideally early enteral feeding is initiated for patients suffering 

traumatic brain injury. However the potential risk of increased 

microaspiration in intubated patients during flight requires 

discontinuation of nasogastric or orogastric feeding during 

aeromedical transfer. 

Role 4 Treatment of TBI 

Intensive care treatment is aimed at lessening the impact of 

secondary injury by controlling ICP. Maintenance of a CPP 

greater than 60 mm Hg is now widely recognized as a vital 

component of management of traumatic brain injury. A single 

recording of a hypotensive episode (SBP of < 90 ) is generally 

associated with a doubling of mortality and a marked increase in 

morbidity from a given head injury [40]. The highest blood sugar 

occurring in the first 24 hours of ICU care is linearly correlated 

with mortality [41]. Fever should be prevented in TBI patients, 

as it will merely increase the CMRO 2 . For the patient with TBI, a 



CPP of 60–70 mmHg is generally sufficient to maintain cerebral 

oxygenation. Excessive hyperventilation of patients with TBI will 

cause ischaemia if CO 2 reactivity is preserved. The interpretation 

of a given ICP measurement must be made in the light of the 

underlying pathology and the speed of its evolution. Current 

evidence suggests that 20–25 mmHg is the upper threshold above 

which treatment to lower ICP should be started. The management 

of hypotension must include not only fluid replacement but also 

identification of the cause. There is minimal evidence for the 

routine use of anticonvulsants to prevent seizures. 

Raised ICP after severe TBI is frequent in relation to altered 

cerebral compliance. Information obtained by ICP monitoring 

allows early detection of high ICP and goal directed therapy. ICP 

monitoring allows informed therapeutic decisions. Protocols need 

to be agreed jointly between the neurosurgical and intensive care 

medical team. There are a number of protocols for the prevention 

of secondary brain injury following major trauma. They are 

generally directed at the maintenance of CPP to ensure adequate 

cerebral blood flow. The Brain Trauma Foundation [42] found 

that mortality increased as the average CPP fell below 70 mm 

Hg, and that aggressive therapy was required to control ICP 

and systemic arterial pressure. A number of historical trials have 

suggested that the mortality for patients with head injuries on a 

neurosurgical ICU is reduced by the implementation of a target 

CPP-guided protocol but there are no pro spective randomised 

trials comparing goal-directed therapy with previous conventional 

head injury management. 

The European Society of Intensive Care Medicine has published 

guidance on the use of monitoring in neurological injuries [43]: 

1. There are insufficient data to recommend ICP monitoring 

and management as standard care in all brain-injury patients. 

Nevertheless, the evidence is “good enough” to recommend 

ICP monitoring of patients with severe injuries who are at 

increased risk of intracranial hypertension. 

2. Which patients are at “high risk” of ICP elevation is a matter 

of controversy. We recommend ICP should be monitored in 

all salvageable patients with a severe TBI (i.e. Glasgow Coma 

Scale Score ≤ 8) and an abnormal CT scan. 

3. The management of raised ICP should follow BTF 

guidelines with care to exclude surgical lesions, including 

haematoma,contusion and hydrocephalus. Local protocols 

should be developed that conform to international guidelines 

and include neurosurgical consultation. 

Invasive ICP Monitors 

Invasive ICP monitors have been used on neuro-intensive 

care units in head injured patients for many years and they 

have become a standard of care either as external ventricular 

drains (EVD) or monitoring bolts. All evidence suggests that 

morbidity of head injured patients is improved if treated on a 

neuro-intensive care unit. Whilst not risk-free, the incidence 

of adverse events from inserting intra-cranial pressure 

monitoring equipment is small and it should be safe to use in 

the field. However it is clear that it is not the monitor itself 

which makes the difference, and it has been pointed out that 

all military intensivists and ITU nurses would need significant 

pre-deployment exposure to these patients for all of the clinical 

governance issues to be covered [44]. 

The use of brain tissue oxygenation (PO 2 ) monitors is gaining 

acceptance at established neuro-intensive care units. There is 

340 

CL Park, P Moor, K Birch et al 

now evidence that the combined use of ICP and brain tissue 

oxygenation monitoring can be associated with reduced mortality 

in TBI when compared with ICP monitoring alone [45]. 

Other considerations 

General supportive measures are as important as specialised 

neuro-intensive care or surgical interventions. Sepsis is a major 

threat in this group of patients and efforts should be made to 

prevent and treat infections. Infection control and hand-washing 

in particular have a major role to play, in this respect. Early feeding 

and thrombo-embolic prophylaxis are also important. Chest and 

limb physiotherapy should be performed at least daily on patients 

who are unconscious. Successful outcome is often measured in 

terms of mortality but from the patients perspective a return to a 

functionally useful life and full employment is usually what they 

want. Intensive care only forms one link in the chain of survival 

and as such the goal should be viewed as enabling the patient to 

benefit from the rehabilitation phase, which commences in and 

follows discharge from ICU [46]. 

Conclusion 

The principles of TBI management remain consistant 

throughout all levels of care. From the point of injury, the aim 

should be to prevent secondary brain damage by optimizing 

oxygenation, ventilation, cerebral perfusion pressure and 

adequate sedation and analgesia. Coexisting injuries must 

also be managed simultaneously in order to optimize cerebral 

perfusion and ventilation. The recognition of TBI must trigger 

appropriate triage decisions at all levels of the casevac chain. 

Timely CT scanning, neurosurgical intervention, appropriate 

critical care transfer and management including monitoring of 

the intracranial pressure will allow optimization of the patient’s 

chances of recovery and rehabilitation. 

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Critical Care at Role 4 

CPL Jones 1 , JP Chinery 2 , K England 3 , P Mahoney 4 

1 Core Trainee in Anaesthesia, University Hospitals Birmingham (UHB) NHS Foundation Trust; 2 Specialist Trainee in 

Anaesthesia, UHB NHS Foundation Trust; 3 Consultant in Anaesthesia and Intensive Care, UHB NHS Foundation 

Trust; 4 Defence Professor Anaesthesia, Royal Centre for Defence Medicine 

Abstract 

This descriptive paper focuses on the sequence of events that occur during the admission and ongoing management of the 

Military Polytrauma patient to Critical Care, Area B, Queen Elizabeth Hospital Birmingham (QEHB). It is intended to 

inform new clinical staff, the wider DMS, and potentially other NHS intensive care units which may be called upon to manage 

such patients during a military surge or following a UK domestic major incident. 

Introduction 

Organisation of Critical Care at Role 4 

University Hospitals Birmingham NHS Foundation Trust (UHB) 

contains the combined clinical expertise to deliver optimum 

definitive care for injured personnel from military operations 

such as Operation HERRICK in Afghanistan. For this reason the 

Defence Medical Services (DMS) uses UHB as its Role 4 facility. 

At Queen Elizabeth Hospital, Birmingham, there are four critical 

care units, each offering a specific clinical capability supported by 

on-site specialists. 

Area B, formerly based at Selly Oak Hospital (SOH), provides 

critical care to vascular, orthopaedic, maxillofacial, burns and 

plastic surgical patients, and is therefore well placed to offer 

general critical care to the majority of severely injured military 

patients. QEHB’s other separate intensive care units, each has a 

particular sub-speciality interest: 

• Area A will soon house the Neurosciences Critical Care 

Unit (NCCU) providing tertiary level care for patients with 

neurosurgical and neurological problems - including head 

injuries. 

• Area C (formerly North 3 Critical Care) offers general intensive 

care, with a special focus towards pre and post-operative care 

of patients undergoing liver surgery including transplantation, 

complex upper and lower GI surgery, and maxillofacial surgery. 

• Area D formerly the Welcome Building Critical Care (WBCC) 

is for patients with cardiothoracic pathology including those 

requiring heart and lung transplantation. 

All four units are supported by general and specialist surgeons 

and physicians, with full microbiology, radiology, pharmacy 

and laboratory services. Each has the clinical experience and 

infrastructure to deliver intensive care for all types of patients, 

regardless of underlying pathology. 

‘A new cohort of trauma patients’ 

The predominant mechanism of injury for military patients 

received by Area B is the Improvised Explosive Device (IED). 

These devices can cause multiple patients from a single incident 

with extensive bone and soft tissue defects, each potentially with 

Corresponding Author: Colonel PF Mahoney OBE FRCA 

L/RAMC, Defence Professor Anaesthesia, Royal Centre for 

Defence Medicine, Birmingham Research Park, Vincent 

Drive, Birmingham B15 2SQ 

Tel: 0121 415 8858 Email: Peterfmahoney@aol.com 

multiple traumatic limb amputations, as well as facial, perineal, 

abdominal and ocular trauma. The cavitation effect of the IED 

blast sucks environmental contaminants high into wounds, 

beyond their obvious extent, sowing the seeds for subsequent 

infection and sepsis. 

This cohort of military patients, some who are surviving 

previously ‘non-survivable wounds’, are continually improving 

our understanding of the pathophysiology of major trauma. 

As such, many of the recommendations herein are based on 

consensus of expert professional opinion, following evidence from 

civilian practice where applicable. 

The Initial Signal 

Shortly after military casualties are received at the deployed field 

hospital, Camp Bastion, Helmand Province, initial damage 

control surgery and resuscitation is completed. Following this, 

an initial secure signal is transmitted from the Aeromedical 

Communications Cell to the Royal Centre of Defence Medicine. 

On arrival, the message is presented to the Area B Consultant 

on-call. The signal contains a summary of a patient’s clinical 

condition in the form of a MIST (Mechanism of injury / Injuries 

identified / Vital Signs / Treatment given) report. 

This concise picture of the extent and severity of the injuries, 

prompts planning for optimal ongoing critical care. Unless the 

patient has specific localised injuries indicating a need for ongoing 

neurosurgical or cardiothoracic surgery, the default plan is to 

admit to Area B. Repatriation to the UK is carried out by the 

Critical Care Air Support Team (CCAST) normally within 24-48 

hours, via a seamless continuation of Role 3 critical care through 

to UHB. Further description of this process is beyond the scope 

of this article [1, 2] 

Acute admission 

On arrival to Area B one of the CCAST anaesthetists provides a 

verbal handover to a receiving team of staff. During handover, the 

patient remains monitored and supported by CCAST equipment. 

The receiving Area B team is composed of an ITU junior doctor, 

the allocated nurse, the On-call Consultant Intensivist and a 

variable number of other nurses. During times of heightened 

activity when several critically ill patients are admitted via the 

same CCAST flight, a Second On-call Consultant Intensivist is 

also present to overlook other patients and guide ITU trainees. 

Once handover has taken place, patients are transferred to 

Area B monitoring and ventilators. The admitting ITU doctor 

performs a thorough top to toe clinical examination, assessing all 


Role 4 Critical Care CPL Jones, JP Chinery, K England et al 

systems and the extent of injuries sustained. This is a repeat of 

the tertiary survey performed in Camp Bastion. Particular note 

is made to assess for unrecognised ocular and tympanic trauma. 

All patients injured by IEDs, regardless of the aero-med signal 

identifying ocular trauma, require a formal examination by a 

senior ophthalmologist. 

In addition to the above, more specific and focused clinical 

examinations quickly follow. The trauma co-ordinator from the 

bunker [3] who also receives a copy of the initial signal pre-alerts 

the appropriate specialties so they are ready to provide input. It 

is not uncommon to see a Senior Registrar or Consultant from 

the following specialties: Orthopaedic, Plastic, Vascular, ENT, 

Maxillofacial and Ophthalmological surgery, who attend to assess 

the patient’s immediate needs for theatre all within the damage 

control mindset (Box 1). Once a patient has been examined and 

clinical notes completed, the following points are addressed. 

• The Damage Control ‘mindset’ underpins clinical activity 

during the initial reception period as patients can rapidly 

become unstable, with unrecognised and/or evolving 

injuries. 

• It entails focussing activity towards providing life, 

limb and sight saving treatment in order to prevent 

the progression of the lethal physiological triad of 

coagulopathy, hypothermia and acidosis. 

• Integrated Simulators including instructor 

and model driven mannequins. 

Box 1: Damage Control - the unifying principle directing initial 

clinical activity 

Vascular access 

Major polytrauma patients admitted to Camp Bastion commonly 

receive immediate placement of a subclavian 8.5 French Gauge 

pulmonary artery catheter introducer sheath to provide large 

bore central venous access for massive transfusion. All central 

and peripheral venous catheters are considered to have been 

inserted with potentially incomplete aseptic precautions in a less 

than ideal environment and are therefore subsequently removed 

on admission to Area B. The preferred site for replacement of 

central venous catheters in Area B is the internal jugular vein, 

under ultrasound guidance. After placement, a portable chest 

radiograph is performed to confirm correct catheter position and 

exclude an iatrogenic pneumothorax. 

Arterial lines are also changed when possible. However 

alternative access can often be difficult with patients having 

multiple amputations, perineal and pelvic trauma. Placing a 

new arterial line into the brachial artery of an arm with a distal 

forearm amputation is considered inappropriate. Risk benefit 

analysis is required on an individual basis with consultant 

guidance. Routine blood investigations taken on admission are 

displayed in Table 1. 

Infection control 

Following an IED explosion, wounds become contaminated by 

endogenous host micro-flora and exogenous agents in the soldiers’ 

environment such as soil, dust, stones, water, device fragments, 

uniform and equipment particles. Massive tissue devitalisation 

and haematoma compromise the microcirculation, producing 

tissue ischaemia. Such tissue offers the ideal environment for 

microbial proliferation. On admission to Area B patients remain 

• Full blood count 

• Urea and electrolytes 

• Magnesium and Phosphate levels 

• Liver function test 

• Clotting screen 

• Fibrinogen level 

• Arterial blood gas measurement including lactate level 

• C-reactive protein 

• • Creatine Kinase level – assessed on admission and 

if high repeated daily to guide maintenance fluid 

prescription 

• Drug levels (as required) 

• ROTEM (thromboelastometry) 

Table 1: In order to guide further clinical treatment the following tests 

are regularly repeated during a military patients admission to Area 

B. Once patients are clinically stable, requiring less frequent trips 

to theatre, daily blood requests reduce significantly. Further daily 

blood tests help act as an early surveillance screen for infection, renal 

failure, adverse drug reactions etc. 

at high risk of wound infection and sepsis. Some patients present 

to Area B already in a “septic state” and commenced on inotropic 

support by CCAST in-flight. 

Nosocomially acquired MDR (multi-drug resistant) infections 

such as Acinetobacter baumanni and Pseudomonas aeruginosa, 

remain an extremely serious issue for injured military personnel 

[4,5] and concerns have previously been raised regards risk to 

civilian populations nursed in close proximity. 

Surprisingly, our experience with regards to MDR-Acinetobacter 

seems to be different to that published by allied forces, causing 

minimum serious infections in military personnel admitted 

to UHB since 2003. Transmission of MDR-Acinetobacter to 

civilians, especially those with chronic lung disease, remains 

a significant risk and is prevented on a daily basis by applying 

infection control measures. 

Standardization of infection control practice with emphasis on 

the basics of hand hygiene and isolation procedures remains key to 

prevent such organisms being a risk to others. Table 2 summarises 

two key infection control measures that are addressed during the 

admission of all military patients. Clinical audit can be used to 

assess if all these measures are carried out correctly. 

Antimicrobial cover 

On admission to Area B all complex polytrauma patients are 

prescribed broader spectrum antimicrobials according to their 

injury profile (Figure 1) and such treatment is guided by expert 

microbiological advice. A common question raised by new 

trainees on the unit is why patients’ are not commenced on such 

broader spectrums at Role 3? 

Routine Role 3 practice is to give early empirical antibiotic 

therapy to help prevent severe infection caused by the well 

recognised and more aggressive pathogens in the period shortly 

after injury (Staphylococcus aureus, beta-haemolytic streptococci and 

clostridia causing gas gangrene and tetanus) [6]. Co-amoxiclav is 

used for non-penicillin allergic patients. 

The less pathogenic environmental organisms acquired as a 

result of an IED blast injury are unlikely to cause serious infection 

soon after injury, and are controlled in the early stages of treatment 

by surgical debridement. Debridement can be difficult and as a 

result some environmental organisms may remain in tissues for 


Role 4 Critical Care 

Additional Barrier 

Protection 

Initial Septic 

Screen 

some time, hence the reason broad spectrum antibiotics, which 

cover such organisms, are started on Area B. 

An American study from Iraq assessed war wound bacteriology 

soon after initial injury and the results revealed a predominance 

of gram positive organisms of low virulence and pathogenicity, 

supporting the early use of narrow spectrum antibiotics, as first 

choice [7]. Our own experience in treating such patients from 

Iraq and Afghanistan supports this approach. 

After admission to Area B most patients are promptly taken to 

theatre for “a second look”, further debridement and change of 

dressing, or for more specific time critical surgical interventions. 

For such patients new antimicrobial treatment is delayed until 

tissue samples and wound swabs have been taken. Once all 

samples are collected the initial septic screen is complete and 

the anaesthetist commences appropriate broader spectrum cover 

(Figure 1). Once results return from microbiology, antimicrobials 

are changed according to sensitivities. 

During times of heightened activity when an initial trip to 

theatre may be delayed, or when patients are admitted in a septic 

state broader spectrum antimicrobials are given as soon as possible 

(Box 2). 

344 

Thumb looped gowns and gloves 

must be worn by all staff and family 

occupying patient bed spaces. This is 

practiced for the first seven days whilst 

an initial septic screen is completed 

and results confirmed. Once cleared 

normal infection control measures are 

taken; standard aprons worn within the 

bed space, apron gown and gloves if 

clinically assessing the patient. 

Swab all wounds available to sample. 

Do not remove any dressings as further 

samples are sent from theatre. 

Complete MRSA screen – axilla, groin 

and nasal swabs required. 

Send for microscopy, culture and 

sensitivity: 

Urine 

Sputum 

Pleural fluid (if intercostal chest drain 

in-situ) 

Abdominal drain fluid (if drains in-situ) 

Cerebral spinal fluid – consider lumbar 

puncture in all patients with penetrating 

head and spinal injuries (consultant 

request only) 

Blood cultures – required from all 

patients on admission regardless of 

body temperature. Nursing staff to send 

cultures from new central and arterial 

lines. If insertion of new lines delayed 

perform a peripheral stab. 

Tips from all central lines removed. 

Tissue samples taken in theatre, include 

a samples for histology. 

Table 2 Infection Control measures implemented in Area B Critical 

Care. 

Box 2: Antimicrobial cover – an overview 

CPL Jones, JP Chinery, K England et al 

• Invasive fungal infections may present acutely or after 

several weeks of care [22]. 

• All patients initially commenced on pre-emptive 

antifungal treatment need to continue this for fourteen 

days. 

• If an invasive fungal infection is diagnosed the treatment 

is much longer, stopping only when there is no evidence 

of systemic spread or any surgical concern for wounds and 

graft healing. 

• When an initial septic screen is complete broad spectrum 

cover is started (Figure 1). 

• The default for any concerns regarding antimicrobial cover 

is to discuss with the consultant microbiologist on-call. 

• For all patients allergic to penicillin this discussion must 

occur as soon as possible. 

Malaria 

Afghanistan has a malarial season with the risk determined by 

military environmental health personnel, which generally runs 

from March to the end of October. Plasmodium Vivax malaria 

is the most prevalent; nevertheless up to 10% of infections 

can be due to the more pathogenic Falciparum malaria. Across 

Afghanistan there have been about 400 malaria cases in NATO 

troops since 2001, all of which have been due to P. vivax to date 

(unpublished data confirmed by Military Infection Control) 

Malarial prophylaxis is prescribed to all military personnel 

deployed to at risk areas across the world and medication 

compliance is mandatory. Despite this soldiers on operational 

duties often fail to take prophylaxis treatment and should be 

considered high risk when they develop persistent pyrexias. 

All military personnel admitted to Area B from Afghanistan 

during the “at risk” season are prescribed the standard regime of 

Chloroquine 310mg once weekly and Proguanil 200mg once 

daily - both given via the nasogastric (ng) route. If there are 

any contraindications, patients are prescribed Doxycycline or 

Malarone. All malaria prophylaxis is continued for the appropriate 

time, for example: four weeks on return to UK for those taking 

Chloroquine and Proguanil. 

Analgesia 

The timely aggressive provision of analgesia from time of 

admission is of great importance, not only for humanitarian 

reasons. It has been widely recognised that adequate analgesia 

reduces sympathetic nervous system activation, aids coagulation, 

and reduces the catabolic endocrine stress response to injury [8]. 

Additionally, the nervous system retains the ability to remodel 

itself, particularly in response to excessive or untreated pain. This 

is thought to underpin the development of abnormal responses 

e.g. sensitisation to non-noxious stimuli, amplified responses 

to normally minimally noxious stimuli, and other chronic pain 

symptoms. 

Different types of analgesia impact on the nociceptive pathways 

at different points and/or at different sites, e.g. central/spinal/ 

peripheral opioid receptors, so in combination complement each 

other’s activity [9]. 

Critical Care Air Support Team (CCAST) patients arriving 

intubated and ventilated at Area B are commonly transferred with 

ongoing intravenous infusions of morphine and midazolam. This 

combination is usually effective at providing immediate strong 



Figure 1 Antimicrobial cover according to injury profile. 

opioid analgesia and sedation, facilitating mechanical ventilation. 

Others opioids such as Fentanyl and Alfentanil, as well as the 

N-methyl-D-aspartic acid (NMDA) antagonist, Ketamine 

and the α2 receptor agonist Clonidine, although available, are 

infrequently utilised on Area B. 

Although designed for ward use, the Acute Pain Guidelines 

for Military Personnel [10] are a helpful benchmark for analgesic 

prescription on admission to Area B. They remind the clinician 

to prescribe regular and as required analgesia via both the oral/ 

nasogastric and intravenous routes. If not already present, a 

nasogastric tube (NGT) is placed to allow early commencement 

of Amitriptyline 25mg at night and Pregabalin 75mg twice daily. 

This is often at the same time as placement of central venous lines 

to minimise radiation from check x-rays. This is appropriate for 

patients with amputations or extensive soft tissue injuries who, 

having sustained direct neural damage, are likely to develop 

neuropathic and or phantom limb pain. Dose escalation of these 

agents is carried out after three and seven days. 

NG tubes also facilitate feeding and delivery of Senna 10mls 

nocte and Docusate Sodium 100mg tds, the preferred stimulant 

and softening laxatives. These minimise constipation and aid 

onward intestinal motility and absorption of enteral nutrition 

and drugs. They are prescribed on admission and continue 

until patients develop persistent loose stools, diarrhoea or opiate 

medications are stopped. 

If the patient is not coagulopathic on admission, a NSAID, 

typically Diclofenac is prescribed, along with a H2 receptor 

antagonist such as Ranitidine for gastric protection. It is likely 

that the increased use of thromboelastometry (ROTEM) [11] 

at Area B (to measure coagulation parameters) will enhance the 

appropriate use/omission of NSAIDS. All patients should receive 

regular paracetamol, initially intravenously, as it enhances the 

central effects of strong opioids 

and other NSAIDS [12]. 

The Defence Medical 

Services pain scoring system 

is used on the Area B charts. 

This is a verbal descriptive pain 

rating scale from 0-3[8]. When 

communication is impaired 

such as with a sedated intubated 

patient, other cues such as 

sedation score and autonomic 

reflexes, are used to provide an 

external indirect estimation of 

the adequacy of analgesia. 

Patients with traumatic 

amputations often have 

adjuvant analgesia provided via 

low concentration Bupivicaine 

delivered by an epidural or 

continuous peripheral nerve 

block (CPNB) catheter. This 

modality of analgesia seems 

to reduce concomitant opioid 

use, resulting in less sedation, 

aiding weaning and earlier 

extubation. Although there are 

a panoply of additional risks 

[13] associated with epidural 

and/or CPNB placement, 

these have not occurred with great frequency at Area B. The 

Regional Anaesthesia Outcome Reporting system developed 

by Buckenmaiers’ Army Regional Anaesthesia and Pain 

Management Initiative (ARAPMI) group, indicate a very low 

rate of complications following CPNB [14]. 

Nutrition 

High operational tempo on a day-to-day basis places the average 

infantry soldier working in the Green Zone at risk of malnutrition. 

Prevention strategies for this are currently being addressed and 

remain beyond the scope of this paper. Nevertheless, the premorbid 

state of malnutrition combined with a physiological 

catabolic response to major trauma places such patients at risk 

of severe nosocomial infections, delayed tissue healing, increased 

length of stay in critical care and increased muscle wasting, 

amongst other complications [15]. 

Nutritional support with Nutrison HE (high energy) 

is commenced for all poly-trauma patients without 

contraindications, at an initial rate of 30ml/hr and increased 

according to the protocol to a final goal rate. Compensation 

for the catabolic response to trauma is paramount to improve 

long-term prognosis and is commenced as soon as possible 

on admission via NGT. Patients admitted with a NGT insitu, 

on free drainage are assessed for commencing immediate 

enteral feeding. Clinical Guidelines for Operations [16] dictate 

that enteral nutrition should be commenced at Role 2/3 when 

possible. However, enteral feed is paused during an aeromedical 

CCAST flights as it is thought patients may be at an increased 

risk of micro-aspiration and subsequent nosocomial pneumonia 

[17]. NGT sited in Afghanistan should not routinely be replaced, 

but prior to use for enteral feeding will require checking for 

correct placement. 



For patients failing to absorb enteral feed, with persistent large 

aspirates, prokinetics are prescribed early (Metoclopromide 10mg 

tds IV and Erythromycin 125mg qds ng). 

Patients with abdominal injuries, in particular bowel 

perforations require total parenteral nutrition (TPN). This is 

discussed with the critical care dietetics team and ordered by 

the unit pharmacist. Patients failing to absorb via the NG route 

are listed for endoscopic insertion of a nasojejunal tube (NJT). 

Unfortunately, this can take a number of days to organise and 

during this time TPN is given. Once the NJT is in-situ TPN 

continues concurrently until gut absorption is established. 

Blood products for theatre 

Massive blood transfusions provided during damage control 

resuscitation and surgery place patients at high risk of developing 

antibodies to subsequent blood products. As a result regular 

cross matches are required for this cohort increasing blood bank’s 

overall workload. 

During times of heightened tempo the total demand of blood 

products for military patients returning to and from theatre is 

significant. To preserve the pool of fresh frozen plasma and 

platelets particularly a general consensus now exists for blood 

product requests: 

• Initial theatre trip: Request a minimum of 4 x packed red blood 

cells (PBRC) and 4 x fresh frozen plasma (FFP). Total request 

is dictated by the extent of planned surgery and a patient’s 

pre-op condition – for example haemoglobin level, underlying 

state of coagulopathy or active bleeding. 

• Subsequent trips to theatre: Send a fresh group and save sample, 

and request only PRBC according to the extent of planned 

surgery and patient pre-op haemoglobin. 

Between theatre trips low platelet and haemoglobin counts are 

often tolerated on Area B, as long as patients are not coagulopathic 

or actively bleeding. 

Anticoagulation 

Initial damage control resuscitation with massive transfusions 

(delivery of blood products: PRBC and FFP at a ratio of 1:1 

with platelets when needed), use of recombinant factor VII, 

cryoprecipitate and antifibrinolytics controls coagulopathy in 

severe trauma [18-20]. Our understanding of the short and 

long term effects of such management nevertheless remains 

unclear. 

Lower limb and pelvic fractures place patients at a significant 

risk for developing venous thromboembolic disorders (VTED). 

For the military cohort of patients admitted to Area B, such 

injuries are common and generally form part of the long list of 

other injuries sustained. Despite patients receiving prophylactic 

anticoagulation, Area B has diagnosed multiple deep vein 

thromboses and pulmonary emboli in the military cohort. 

Damage control resuscitation aims to return or maintain 

patients in a state of normal coagulation. In reality after such 

intensive treatment patients may move past “normality” and 

become pro-thrombotic, increasing the risk for VTED. Further 

research relating to the following questions is required (Box 3) 

Currently anticoagulation prophylaxis is considered following 

a patient’s initial trip to theatre and after assessment of 

coagulopathy (a full clotting screen completed, including 

fibrinogen and platelet levels). 

346 


• Does blast wave disruption caused by an IED explosion 

change the architecture of vessels on a micro and macro 

structural level, increasing overall risk of a VTED? 

• How does an IED blast wave affect the normal clotting 

cascade (e.g. clotting factor proliferation, platelet 

activation and function etcetera)? 

• Is there a direct correlation between the amount of blood 

products, factor VII, cryoprecipitate etc used to control 

coagulopathy and risk for subsequent VTED? 

• Is there a role for IVC filters to be used in such polytrauma 

patients? If so, when should they be inserted? [21] 

• What is the optimum dose of anticoagulation for such 

patients, and when is it best to start treatment in order to 

minimise risk of VTED. 

• How do we best identify patients becoming prothrombotic? 

How effective is ROTEM for this? 

Box 3 – Current coagulation research questions 

A general consensus exists to prescribe Enoxaparin 40mg OD 

s/c when: 

• there are no concerns regards active bleeding 

• fibrinogen level > 1.0 

• APTT Ratio and INR both < 1.5 

• Platelets are maintained at an adequate level (i.e. not being 

consumed requiring regular top up transfusions). 

A ROTEM has recently become available to assess, closer to real 

time, a patient’s coagulation status. Once in full practice, the 

frequency of formal coagulation screens requested may be reduced. 

After initial damage control 

Once these patients have been stabilized and have moved out of 

the damage control phase, sometimes over several days, ongoing 

critical care management is as for any patient requiring multiple 

organ support. 

• Systems support is reduced as possible. For example, sedation 

will be reduced / stopped and ventilatory support gradually 

weaned. Similarly, if haemofiltration has been required for the 

management of acute renal failure, this too will be paused to 

assess renal function etc. 

• Pre-operative optimisation and post-operative observations. 

Once a patient enters a period of relative stability, more 

definitive surgical interventions are planned and the frequency 

of theatre trips may increase once again. 

• Ongoing clinical surveillance. Early identification of sepsis, 

renal failure, disseminated invasive fungal infections, adverse 

reactions etc. remain key to patients overall prognosis. 

Sepsis 

When patients become septic, identifying the exact cause can be 

challenging. Deep-seated invasive infections and occult collections 

are commonly sought by performing CT scans and sometimes the 

whole body is scanned in search of a source. Occasionally patients 

may be too unstable for transfer to a CT scanner, theatre or both 

and optimisation on Area B remains the only option. 

Soft tissue infection secondary to invasive fungi should be 

considered in all patients, even if previous microbiology results 

do not indicate a presence of fungi, and ‘pre-emptive’ antifungals 

have been commenced. Prompt review of wounds should be 

considered in these patients as such infections can progress rapidly. 



Sepsis care bundles including fluid resuscitation (guided by 

oesophageal doppler studies), inotropic support, reinforced 

antimicrobial cover, and early input from appropriate specialties, 

including microbiology, are vital at such a time. During such 

periods of clinical deterioration, Area B consultants review all 

clinical steps regardless of the time of day. 

Hyperpyrexia 

Hyperpyrexia, with persistent temperatures above 39.5°C, is 

occasionally seen in Area B military patients (Box 4). The reason 

for this is not entirely understood. As expected when patients 

initially develop hyperpyrexia, the first thoughts are towards 

finding a possible septic source. All patients have a full septic screen 

completed, routine bloods sent for assessment, and surgeons 

are asked to review wounds etc. When all the results return as 

negative, the differential diagnosis for pyrexia of unknown origin 

(PUO) needs to be considered. 

Pre-deployment training for Op HERRICK may take soldiers 

to Kenya, Belize, Brunei and wider afield. Screening for tropical 

and communicable diseases appropriate to the areas they have 

travelled must be included in the differential. Advice on such 

diseases is available from the Department of Infectious Diseases 

at Birmingham Heartlands Hospital. Malaria and “Helmand 

fever” (sand-fly fever, Q-fever and rickettsia spotted fever) are 

tropical diseases screened for during PUO. Malaria screens are 

sent to Haematology. Results from a Helmand fever screen (sent 

to HPA Porton Down) are usually not received in time to directly 

influence patient management. Hence if no other cause for fever 

is found, Doxycycline 200mg OD is prescribed on consultant 

microbiological advice. 

Following evidence that all wound samples are clear of 

fungus and confirmation of a negative septic screen, discussion 

often takes place between consultant intensivists, surgeons and 

microbiologists to consider stopping antifungal treatment. After 

stopping treatment, hyperpyrexia has resolved in some patients, 

a phenomenon noted in haematology patients also taking 

antifungal treatment - cause and effect not yet understood. 

• It is advised all “unexplained fevers” be treated as 

objectively as possible. An initial logical approach is first 

explored to assess if the fever is related to: 

• Trauma and infection (which means occult collection(s) of 

pus/blood, foreign bodies, necrotic tissue etc) 

• Health care associated infection and ICU stay (e.g: line 

infection, ventilator associated pneumonia, urinary tract 

infection) 

• Therapy (all antimicrobials can cause hyperpyrexia, not 

just antifungals) 

• Patient travel history (which means a work up for tropical 

diseases) 

Box 4 An overview of the diagnostic approach to hyperpyrexia, 

The Patient’s Family 

Following a patient’s admission and initial trip to theatre, one 

of the operating Consultant Surgeons and a Senior ITU doctor 

will explain the extent of the their injuries, the treatment given 

so far, and answer any questions the family raise. This discussion, 

although difficult, is of immense importance and the manner of 

its delivery is not quickly forgotten. 

The military patient’s next of kin or immediate family have a 

vital role to play in the reassurance, reorientation, and recovery of 

patients when sedation holds and extubation are on the clinical 

agenda. It is not uncommon for military patients to emerge from 

sedation agitated and showing signs of delirium. When extubated 

they may believe the incident in which they were injured is still 

ongoing, mistaken in the belief that they are still in Afghanistan. 

Having family members present can often provide patients the 

reassurance they need to believe they are safe and home in the UK. 

Occasionally agitation requires treatment with chlorpromazine or 

haloperidol in order to prevent invasive lines, epidural catheters, 

NGTs etc being pulled out. 

As well as explanation from medical and nursing staff, 

families at Area B may receive pastoral support from an 

experienced member of the Defence Medical Welfare Services, 

Military Liaison Officers, the RCDM Padre and Hospital 

Chaplains. Coincidentally, many of these support personnel 

at SOH come from a nursing background. This is in addition 

to the support provided by the individual patients’ Regimental 

Liaison Officer. 

Temporary residential accommodation onsite or at the 

nearby SSAFA Norton House can be organised free of charge, 

to allow family who are not close residents, to remain in close 

proximity during this stressful period. They are also able to 

provide information about the relevant statutory and charitable 

organisations that can provide immediate and longer-term 

practical and financial assistance. Though adherence to set 

visiting times is encouraged – it is recognised that family 

members often desire to be with their relative outside these 

periods, particularly shortly after admission and during times 

of clinical deterioration. Wherever possible a compassionate 

approach is adopted. 

Discharge from Area B 

Patients discharged from Area B are usually transferred to a military 

trauma ward with a six bed high dependency unit attached. 

Individuals with multiple amputations requiring ongoing 

intravenous medications, in particular antifungal treatment, need 

a more definitive, long-term solution for vascular access. For such 

patients Peripherally Inserted Central Catheters (PICC) lines are 

the ideal solution. These are placed under radiological guidance 

as early as possible when a discharge from Area B to the ward is 

planned. This process is coordinated by the hospital IV team who 

liaise with interventional radiology. 

Conclusion 

As with Anaesthesia at Role 4, Critical Care for complex 

polytrauma military patients is still evolving. Much has already 

been learned, but there still remains many questions to be 

answered, some of which we have highlighted. To continually 

improve the level of care provided all possible avenues of research 

need to be further explored. 

Acknowledgements 

The authors would like to acknowledge the extensive help and 

advice from Dr M Gill, Consultant Microbiologist UHB and Wg 

Cdr AD Green, Director of Infection Prevention and Control, 

DCA in Communicable Diseases in the writing of this article. 



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3. Wood PR, Haldane AG, Plimmer SE. Anaesthesia at Role 4. J R 

Army Med Corps 2010; 156(4 Suppl 1): S308-310 

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5. Calhoun JH, Murray CK, Manring MM. Multidrug-resistant 

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IV filters required in combat support hospitals? JR Army Med Corps 

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22. Gill, M. Hospital Guideline: Invasive fungal infection & 

antifungals. UHB, Department of Microbiology. 


Maritime Anaesthesia 

RM Heames 1 , JE Risdall 2 

1 Consultant Anaesthetist, Southampton University Hospitals NHS Trust and Role 2 Afloat, RFA Fort Victoria, BFPO 

442; 2 Consultant Anaesthetist, Honorary Visiting Specialist, Addenbrooke’s Hospital, Cambridge University Hospitals 

NHS Foundation Trust and Foundation Senior Lecturer, Department of Military Anaesthesia and Critical Care, Royal 

Centre of Defence Medicine, Birmingham 

Introduction 

Anaesthesia (other than local infiltration) at sea, in the 21 st 

century, is a relatively unusual occurrence. It can only be provided 

in ships carrying a Role 2 (damage control resuscitation) or Role 

3 (hospital) medical capability. RFA ARGUS is the Royal Navy’s 

sole maritime Role 3 facility (Figure 1). She carries a bespoke 

hospital facility, of up to 100 beds, with a wide range of specialist 

capabilities and has the ability to hold patients at all levels of 

dependency, until further evacuation can be effected. 

Figure 1 Main theatre complex on board RFA Argus 

The maritime Role 2 capability is not linked to any specific 

platform. In the early 1990s, the aircraft carriers had a permanent 

complement of two medical officers as a Principal Medical Officer 

(PMO) and Deputy PMO. One of these two medical officers was 

an anaesthetist and the other a surgeon and whilst one was usually 

an accredited consultant, the other was frequently a trainee. They 

provided an organic Role 2 capability for any task group with 

whom they deployed (Figure 2). However, the limited numbers 

of theatre operations performed meant that core specialist medical 

skills were difficult to maintain. Following the Calman review and 

subsequent changes in training, and with the emergence of clinical 

governance, it was deemed inappropriate to have Secondary Care 

trainees working unsupervised. The surgical team was therefore 

removed from the permanent ship’s complement and replaced by 

an accredited General Practitioner. 

Corresponding Author: Surgeon Commander Richard M 

Heames FRCA Royal Navy, Role 2 Afloat, RFA Fort Victoria, 

BFPO 442 

Email: richard.heames@suht.swest.nhs.uk 

Figure 2 Administration of a general anaesthetic on board HMS Ark 

Royal in 2007 

When the ship deployed to an area of perceived risk (e.g. 

East of Suez), the medical department was augmented by a Role 

2 surgical team, consisting of a surgeon and anaesthetist (both 

consultants at OF4) and an Operating Department Practitioner. 

However, after several deployments in this configuration, it 

became apparent that resources for damage control surgery were 

still inadequate. 

From the early 2000’s, Fleet has scrutinised deployments 

requiring Role 2 support to ascertain which vessel is most suited 

to host this facility. Maritime Role 2 can therefore be expected 

to configure differently, due to differing platforms and medical 

schemes of complement, on each occasion it is utilised. At the 

same time, advances in Role 2 care have developed based on the 

experience gained in both Iraq and Afghanistan. This has also 

necessitated changes in the composition of the maritime Role 2 

team deployed. The current configuration encompasses casualty 

retrieval, emergency medicine, surgery and anaesthesia, critical 

care and onward transfer. The anaesthetist has the potential to 

play a part throughout this care pathway. 

In both the Role 3 platform and whichever vessel is selected for 

Role 2, certain constraints, unique to the maritime environment, 

influence the delivery of anaesthetic (and indeed all clinical) care. 

All ships are fighting platforms and although clinical care would be 

expected to continue during contact, no surgery and anaesthesia 

would be envisaged. The priority under these circumstances is the 

engagement and the survival of the ship. All embarked personnel, 

irrespective of speciality, are therefore required to support this aim 

and can be required to fight fires or undertake damage control as 

well as provide first aid medical care. These skills, plus sea survival 

in the event of ship loss, are a mandatory part of maritime predeployment 

training. 



Pre-Operative 

The anaesthetist is likely to be involved with any serious casualty, 

often at, or close to, the point of wounding or accident. The Royal 

Navy has now formed and tested a Maritime Medical Emergency 

Response Team which variably includes an Emergency Nurse 

(Practitioner), a Medical Assistant and an anaesthetist (Figure 3). 

The process of reaching the casualty and then extracting him to 

the medical facility can often be time-consuming and convoluted. 

This process may involve a helicopter or sea boat. 

Figure 3 Preparation for deployment as MERT from RFA Fort Victoria 

Utilising a helicopter for a patient transfer creates many 

difficulties. Of course, the issues with helicopters and casualties are 

applicable to any environment such as the limited space, vibration, 

poor lighting and noise. All of this would be complicated in a 

contact situation where the helicopter may have to perform evasive 

manoeuvres. A specific problem in the maritime environment is 

lifting the casualty from the deck of a vessel into the helicopter. 

The sea state could be such that it is taxing for the pilot to 

maintain a hover over the deck and the winch is only designed 

for the winchman, the casualty and the lightweight stretcher. It 

takes careful planning to manage an intubated casualty needing 

ventilation during winching. One potential solution is to have one 

medic in the helicopter ready to receive and take over ventilation 

and one medic with the lightweight stretcher on the deck. Once 

all parties are ready, ventilation is stopped and there is a period of 

apnoea whilst the winching occurs. 

Ships’ sea boats create their own difficulties when used 

for casualty transfer. Firstly, the sea state can result in extreme 

movements of the boat when either stationary or under way. 

Attempting to treat or even handle a casualty in this situation is 

difficult. Many of the sea boats used are Rigid Inflatable Boats 

and have very limited space, especially if the patient is on a 

spinal board. Once the boat is back alongside the ship, it has to 

be winched up to deck level (providing the hoist is man-rated 

for lifting) with further casualty handling required to bring the 

casualty inboard. 

The transfer of casualties through the ship to the medical 

facility requires teams of personnel and frequent practice. Army 

field pattern stretchers are not conducive to being carried up and 

down ladders and through narrow hatches. Certain platforms 

allow the use of lifts (e.g. aircraft lifts or bomb lifts) to facilitate 

movement between decks. The alternative is to use either a spinal 

board, a Neil-Robertson stretcher or a hose lift technique to hoist 

the casualty between decks. 

350 

RM Heames, JE Risdall 

Per-Operative 

The layout of the hospital is very variable depending on the 

platform. On the warships it is fixed, whereas the RFA platforms 

have a greater amount of space which can be utilised as a hospital. 

Modern anaesthesia providing damage control resuscitation 

requires laboratory support and preferably radiography, which in 

turn need further dedicated space for equipment. 

An operating theatre, triage bay and critical care bed all require 

significant amounts of equipment to carry out their respective 

functions. Most ships have their core power supply running on 

115V although further circuits of 230V have been overlaid for 

standard UK 3 pin plugs. There may be insufficient 230V plug 

sockets in the hospital area and even if extra sockets are added, the 

system may not be rated to support the power required. 

The ship is a closed environment holding everything from fuel 

to armament in relative close proximity. Therefore, explosive gases 

such as oxygen and nitrous oxide, need to be carefully stored in a 

secure area that can be flooded to prevent explosions in the event 

of a ship fire. 

Overall, medical stores become an issue due to the limited 

storage space on board and the potential difficulty of resupply at 

sea. All stores whether in a hold or in the hospital need to be fully 

secured for sea when not in direct use, due to motion from sea 

states. It is very easy for an anaesthetic machine on wheels, stacked 

with kit and a monitor on top to roll and have equipment fall off 

and break (Figure 4). 

Figure 4 The anaesthetic machine set up on board RFA Fort Victoria 


Maritime Anaesthesia RM Heames, JE Risdall 

Anaesthesia at sea is similar to that on land in a Role 3 facility. It 

is based on an anaesthetic machine (currently the Smiths Lamtec 

330) which has pipeline input for oxygen, air and nitrous oxide 

and cylinder input for oxygen and nitrous oxide only. There is one 

vaporiser mount taking either isoflurane or sevoflurane. A circle 

system is used with ventilator support from the field Compac 220. 

Monitors are the Datex S5 with full invasive capability. There is 

equipment to perform regional or neuraxial blocks, intravenous 

warming, rapid infusion and patient warming. 

The space of the operating theatres is minimal and usually the 

size of a standard anaesthetic room in UK hospitals. This makes 

teamwork and communication absolutely essential between all 

members of the theatre team, as sterility and free movement 

become problematic (Figure 5). 

Figure 5 The narrow operating theatre on board RFA Fort Victoria 

Room ventilation in theatre is often on a shared, partially closed 

circuit with other compartments of the ship. It is unlikely to meet 

the standards of a modern orthopaedic theatre. Scavenging of 

vapours can be done using a Cardiff Aldasorber, although with the 

current scale of equipment it is impossible to scavenge and utilise 

PEEP at the same time. If nitrous oxide is used, the quantities 

which could build-up in theatre are unknown. Total intravenous 

anaesthesia could be used but the pumps on scale do not have 

target-controlled infusion capability. 

Re-sterilisation of anaesthetic and surgical instruments is 

an essential component of afloat anaesthesia and surgery. The 

steriliser used on board all ships is the Portoclave Field Steriliser 

which has now become obsolete. Future sterilisation should be 

delivered on board as a separate module covering all equipment 

needed for decontamination, disinfection and sterilisation. 

Post-Operative 

Post-operative care is delivered within the same constraints 

as pre- and peri-operative care. Low dependency patients are 

likely be nursed in the bottom bunks of standard mess deck 

accommodation, appropriated as a ward area. Such bunks are 

fixed and accessible from only one side. They have limited (or 

no 230V) power sockets and securing ancillary equipment 

(monitors, infusion pumps, oxygen cylinders or concentrators 

and even drips) is challenging. As standard sea-going berths 

they do provide lee-cloths and straps to secure the occupant 

in the event of heavy weather. Access to toilet, sluice and 

washing facilities may also be less than optimal, raising issues 

of infection control. 

Higher dependency patients will require nursing in the critical 

care area. A limited number of standard hospital beds, with 360° 

access, are available as part of the Role 2 Afloat. These beds have 

to be secured to the deck and ideally secondary securing points 

should be available in the event that the bed has to be moved 

or re-angled (for example to facilitate access for re-intubation) 

(Figure 6). The scope and quality of the critical care capability in 

Role 2 Afloat is limited by the nature of the equipment and stores 

held and the fragility of the resupply chain. 

Figure 6 Critical care beds in RFA Fort Victoria 

The medical mission for any military operation is to 

contribute to the physical and moral wellbeing of the force 

deployed, in part through the timely treatment and evacuation 

of the sick and injured. Currently accepted clinical timelines for 

treatment are as follows [1]: 

1 hour from point of wounding to advanced resuscitation 

2 hours to damage control surgery 

4 hours to primary surgery 

Role 2 is configured to meet the requirement for damage control 

surgery. Primary surgery requires onward transfer to a Role 3 

facility at sea (RFA ARGUS) or ashore (foreign hospital) or to a 

Role 4 facility in the UK. These doctrinal timelines for casualty 

treatment may not be met at sea. An incident may occur remotely 

from the ship and the subsequent transit will delay receipt of Role 

2 care. Once on board, there may be an extended timeline to 

reach the nearest Role 3 facility. 

There are many locations where the local hospital will not be 

able to provide the level of care that can be delivered by the Role 2 

Afloat team. Under these circumstances it may be in the patient’s 

best interest to be held for longer at the Role 2 facility, whilst 

direct liaison takes place with the Critical Care Aeromedical 

Support Team (CCAST) to arrange transfer directly to UK Role 

4. However, the holding capacity and endurance of the Role 2 

Afloat is limited by the number of medical and nursing personnel 

embarked, the number of beds, the space available and the 

quantity of stores held. 

Where an appropriate Role 3 facility has been identified, the 

successful transfer of a patient can still be delayed due to the 

sea state, an unserviceable helicopter or the distance of the ship 

from the facility. 



Patient Transfer 

Medical evacuation (medevac) is the process of moving patients 

between medical facilities. For maritime operations this transfer 

may be conducted by boat or helicopter. In the latter case it is 

more properly known as aeromedical evacuation (AE). Transfer 

to Role 3 or Role 4 facilities will usually be by AE. The Royal Air 

Force (RAF) is the UK lead service for AE. As a consequence, 

the Royal Navy has no bespoke maritime AE capability. However, 

since it is frequently inappropriate to fly the RAF transfer team 

out to maritime platforms on operations, it is accepted that the 

Role 2 Afloat will generate its own transfer capability, including 

transfer ashore of critically ill patients, from within its own 

organic assets (Figure 7). 

Figure 7 Casualty being prepared for transfer on board RFA Fort 

Victoria 

352 

RM Heames, JE Risdall 

Although no RN personnel are currently trained to undertake 

CCAST, RN anaesthetists, intensivists and intensive care 

nurses are all experienced in patient transfer. In the absence of 

a bespoke critical care transfer module, equipment for patient 

transfer has to be drawn from that available to the Role 2 Afloat 

which is unlikely to have been tested for aeromedical use in 

the airframe available. In removing equipment for transfer, 

the Role 2 capability is potentially reduced. The equipment 

available is not the most suitable for use in transfer, particularly 

with regard to portability (weight) and battery life (endurance). 

It is also unlikely to be directly compatible with that brought 

out by the CCAST team. 

Conclusion 

Anaesthesia in a maritime environment differs in many ways from 

that on land. The concept of operations has to remain totally 

flexible. Personnel and equipment may well change with the 

differing platforms used, the operational area and the task group 

mission. At maritime Role 2, the anaesthetist will be involved 

in all aspects of patient care from retrieval and triage, through 

theatres and critical care to transfer to a Role 3 facility. Specialist 

knowledge of underwater medicine may also be required and the 

anaesthetist has to be in date for fire fighting, damage control 

and sea survival. This makes the job of an anaesthetist at sea a 

challenging and rewarding one. 

Reference 

1. 1. JDP 4-30 2nd Ed Medical Support to Joint Operations 


Challenges for the Future

Creating Airway Management Guidelines for 

Casualties with Penetrating Airway Injuries 

SJ Mercer 1 , SE Lewis 2 , SJ Wilson 3 , P Groom 4 , PF Mahoney 5 , 

1 Specialist Registrar in Anaesthesia & Critical Care, University Hospital Aintree NHS Foundation Trust, Merseyside; 

2 Specialist Registrar in Anaesthesia & Critical Care, St George’s Healthcare NHS Trust, London; 3 Consultant 

Anaesthetist, James Paget University Hospital Foundation NHS Trust, Great Yarmouth; 4 Consultant Anaesthetist, 

University Hospital Aintree NHS Foundation Trust, Merseyside; 5 Defence Professor Anaesthesia and Critical Care, 

Royal Centre for Defence Medicine Birmingham Research Park, Vincent Drive, Birmingham 

Abstract 

Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence 

of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult 

tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult 

airway experienced in the deployed field hospital. In order to establish an overview of current practice, three methods of 

investigation were undertaken; a literature review, a survey of DMS Anaesthetists and a search of the UK Joint Theatre Trauma 

Database. Results are discussed in terms of anatomical site, bleeding in the airway, facial distortion, patient positioning and an 

anaesthetic approach. There are certain key principles that should be considered in all cases and these are considered. Potential 

pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented. 

Introduction 

Combat trauma airway management is distinctive because of 

the increased prevalence of penetrating airway injuries [1]. The 

majority of UK military deployed trauma consists of blast/ 

fragmentation injuries (53.8%) and gunshot wounds (GSW) 

(29.9%), in contrast to National Health Service (NHS) trauma 

where the bulk is blunt airway injury due to motor vehicle 

collisions [2]. Penetrating injuries are often dramatic with severe 

disruption of both soft tissue and bone [3], and airway injury is 

likely in ballistic and penetrating injury to the face and neck. The 

proximity of the carotid vessels means that penetrating carotid 

injury may impact airway patency. Consequently the team dealing 

with such injuries need to consider the likely fragment /projectile 

trajectory and potential airway effects. 

UK Defence Medical Services (DMS) anaesthetists spend 

the majority of their clinical practice working with civilian 

patients in the NHS and will generally deploy on military 

operations every six to 18 months. Not only does the deployed 

environment have a different case mix, but clinicians are also 

required to use what may be unfamiliar equipment and Standard 

Operating Procedures (SOPs). SOP’s have been developed for 

management of the difficult airway by the American Society of 

Anesthesiologists (ASA) [4], and for the unanticipated difficult 

airway by the Difficult Airway Society (DAS) [5]. Both protocols 

were designed to deal with a civilian patient population in the 

setting of a general hospital and do not reflect the circumstances 

currently encountered in the deployed military environment. 

Although the management of anticipated difficult airway has 

recently been evaluated to some extent in a civilian setting [6], we 

felt the unusual nature of penetrating airway injury necessitated 

its own SOP for use in the deployed field hospital. It is hoped that 

this will allow anaesthetists to improve their non-technical skills 

Corresponding Author: Surgeon Lieutenant Commander 

Simon J Mercer Royal Navy, 22 The Knowles, Blundellsands 

Road West, Crosby, Liverpool, L23 6AB. 

Mobile number: 07970153168. Email: simonjmercer@hotmail.com 

or human factors [7] in a clinical environment that has recently 

be identified as exceptional by the Healthcare Commission [8]. 

There is a lack of literature reporting the anaesthetic 

management of penetrating neck injuries [9,10] with manuscripts 

often concentrating on surgical management [11]. Currently, 

there is no consensus amongst the anaesthetic community on 

the management of casualties with penetrating airway injuries 

[12] and much variability has been described [11]. We reviewed 

the current literature, the experience of previously deployed UK 

DMS anaesthetists as well as documented experience from the 

UK Joint Theatre Trauma Registry (JTTR) [2] and present our 

initial guidelines. 

Methods 

In order to establish a complete overview of current practice, three 

separate methods of investigation were undertaken. 

Literature Review 

The databases and search terms used to identify papers published 

after 1995 are summarized in Table 1. Two of the authors (SEL/ 

SJM) evaluated each paper for relevance to the anaesthetic 

management of penetrating head and neck injuries and 

summarized any case reports. 

Survey of DMS Anaesthetists 

All 185 DMS Anaesthetists whose details were held on the 

Defence Consultant Advisor (DCA) database were contacted by 

e-mail on 23 November 2009. The details of any cases of blast or 

ballistic airway injury that they had treated were requested. This 

email was repeated on 23 January 2010. All cases were collated in 

tabular form. 

Search of the UK Joint Theatre Trauma Registry (JTTR) 

The UK JTTR has already been described in this journal [13] 

and is maintained by the Academic Department of Military 

Emergency Medicine at the Royal Centre for Defence Medicine. 

Essentially this registry contains continuous data from 2003 for 


Guidelines for Penetrating Airway Injuries 

Database Search Terms 

Pubmed [14] 

Sciencedirect [15] 

Google Scholar[16] 

AMED 

BNI 

EMBASE 

HMIC 

MEDLINE 

PsycINFO 

CINAHL 

HEALTH BUSINESS ELITE 

Table 1. Literature Search Terms 

all casualties who trigger a trauma team activation in either the 

deployed field hospital or the Primary Casualty Receiving Facility 

afloat. Over 3000 records were interrogated for the search terms 

listed in Table 2. Cases identified by this search were analyzed by 

one of the authors (SJM) and those consisting of casualties with 

blast and ballistic head and neck trauma were recorded. 

Search Term 

Casualty Reference Numbers 

Gender 

Major Trauma 

UK Military 

Survivors 

Blast Injury or Ballistic Injury 

New Injury Severity Score (NISS) >16 

Airway Interventions 

Mechanism of Injury 

Brief Incident History 

Injuries 

Information from free text boxes. 

Table 2. Search terms used to identify cases in JTTR 

Results 

The literature review revealed 51 papers that were considered 

relevant to this study; 23 were civilian case reports and three 

contained military case reports. There were 17 case reports 

submitted by DMS Anaesthetists and the cause of injury in all 

cases was either GSW or Improvised Explosive Device (IED). 

Over 3000 were searched on the JTTR and 19 were identified 

of soldiers with penetrating head and neck injury. These injuries 

were either caused by blast (from IED, mine, mortar or rocket 

propelled grenade) or were due to GSW. Common themes from 

all three areas of investigation are summarized in headings below. 

356 

Ballistic airway 

Blast airway 

Penetrating airway 

Laceration airway 

Fragmentation airway 

Gunshot airway 

Knife airway. 

Ballistic-airway 

Ballistic AND airway 

Blast-airway 

Blast AND airway 

Penetrating-airway 

Penetrating AND airway 

Laceration-airway 

Laceration AND airway 

Fragmentation-airway 

Fragmentation AND airway 

Gunshot AND airway 

Knife AND airway 

SJ Mercer, SE Lewis, SJ Wilson et al 

Penetrating injury though the mouth 

Case reports included projectiles or objects transfixing facial 

structures and interfering with mouth opening. Examples 

included transfixion through the floor of the mouth with a 

bamboo cane [17], penetration of the mouth floor with a nail 

[18], a spear gun shaft penetrating the floor of the mouth [19] and 

a crossbow arrow entering under the chin and passing through the 

tongue, nasal cavity and between the frontal lobes [20]. Methods 

of management included awake fibreoptic intubation (AFOI) 

[17-20] rapid sequence induction of anaesthesia (RSI) [22,23] 

and surgical tracheostomy following failure of AFOI [19]. 

Injuries to the Face 

Two articles summarized case series of GSW to the face from 

Level 1 Trauma Centres in the USA [23] and South Africa [24]. 

Of 73 patients in the USA case series, 36 underwent AFOI, 30 

were conventionally intubated and seven had a cricothyroidotomy 

performed. In the South African case series there were 28 

emergency orotracheal intubations (18 of which were performed 

in the prehospital phase), two cricothyroidotomies and six 

tracheostomies. The DMS survey revealed five case reports 

of soldiers with facial injuries as a result of IED blasts and 

four of these underwent uneventful RSI (one had a surgical 

tracheostomy performed in the prehospital phase). There were 

4 case reports of GSW to the face of which two had RSI, one 

had a cricothyroidotomy and the other had an emergency surgical 

tracheostomy. The JTTR search contained three casualties who 

had undergone blast injuries to the face, two of which were 

managed by RSI and one who underwent cricothyroidotomy in 

the prehospital phase. 

Laceration to the neck 

There were several case reports of isolated neck laceration 

injuries [25,26] and an open laryngeal injury in a patient with 

multiple injuries [27]. Management included a pre-hospital 

cricothyroidotomy [27], surgical tracheostomy [25] and intubation 

directly though the defect [26,27]. There was a case report 

concerning a crush injury to the chest resulting in complete tracheal 

transection. This was managed with a surgical tracheostomy as 

the patient developed subcutaneous emphysema in the neck and 

anterior chest following orotracheal intubation [28]. 

Penetrating Neck Injuries 

Case reports included a bullet fragment in the supraglottic region 

[29] and GSWs [30-32] to the neck. These were managed by 

orotracheal intubation [30], inhalational induction of anaesthesia 

[31], flexible bronchoscopy [32] and use of a light wand following 

failure of direct laryngoscopy [29]. Case series of penetrating neck 

injuries from US Trauma Centres [33,34] reported a combination 

of techniques including RSI, surgical tracheostomy, AFOI and 

orotracheal intubation without paralysis in comatose patients. A 

Canadian case series [11] also reported the use of AFOI and RSI. 

Another case series from a Level 1 Trauma Centre in the USA [35] 

reviewed the airway management of 89 patients with penetrating 

neck injuries who had undergone blind nasal intubation. The 

authors concluded that this technique was a valuable tool for 

the management of patients with penetrating neck trauma. 

There were three case reports in the literature of soldiers who 

sustained penetrating neck injuries as a result of improvised 

explosive devices (IEDs). Management included emergency 

cricothyroidotomy following failed orotracheal intubation [36], 


Guidelines for Penetrating Airway Injuries SJ Mercer, SE Lewis, SJ Wilson et al 

surgical tracheostomy in the operating theatre following failed 

orotracheal intubation [37] and orotracheal intubation followed 

by surgical tracheostomy [38]. 

The DMS survey reported several cases of penetrating neck 

injury these included: 

• A GSW causing damage to the posterior tracheal wall associated 

with bleeding into the airway, managed with a RSI. 

• An IED blast to the face and neck, managed by transferring 

the patient to theatre in the prone position to maintain their 

airway. RSI was performed as soon as the patient was turned 

supine. A trauma surgeon was ready to perform a surgical 

airway if needed. 

• A penetrating neck injury, managed by orotracheal intubation 

following gaseous induction using the Tri-service Anaesthetic 

Apparatus [39] with two Oxford Miniature Vaporizers filled 

with Sevoflurane. 

• A GSW through the larynx was managed by direct 

intubation through the defect and then a subsequent surgical 

tracheostomy. A GSW injury disrupting the cricoid ring was 

managed with RSI. 

Results from the JTTR included four cases of penetrating neck 

injury of which one was managed by RSI. In addition to this 

there were seven case reports of injury to the trachea and larynx. 

Of these, four patients underwent RSI, (one of which failed and 

required cricothyroidotomy), one received a primary surgical 

tracheostomy and one had an endotracheal tube placed directly 

through the tracheal defect. 

Carotid Artery Injury 

One case reported the use of AFOI to manage a penetrating neck 

injury tearing the common carotid artery that was causing a rapidly 

expanding haematoma [40]. Another case report describing a 

patient with neck compression due to strangulation with a chain 

and this was managed by conventional orotracheal intubation [41]. 

There was also a case report of a patient who sustained internal 

and external common arteries injuries following a laceration from 

a flying metal sheet, this was managed by intubation into the 

perforation of larynx [42]. A case report from the DMS survey 

described a casualty with a GSW to the neck associated with a 

laceration to the carotid artery resulting in respiratory distress and 

this was managed by inhalational induction of anaesthesia. There 

were an additional three cases of penetrating neck injury on the 

JTTR database (all as a result of IED blast) resulting in laceration 

of the carotid artery. Anaesthetic details were entered for only one 

of these cases, which was managed with an RSI. 

Discussion 

There are multiple potential approaches to the airway management 

of casualties penetrating injuries [43] and although the incidence 

is low, we felt that it was important to develop guidelines to allow 

planning and anticipation of these cases prior to deployment as 

an aide memoire. The anaesthetist may wish to base their decision 

making process on the clinical scenario rather than a preset algorithm 

taking into account their own skills and equipment available [11]. 

It has already been commented that most case series only contain 

small numbers of patients and that the injuries are diverse, meaning 

a didactic treatment algorithm would be unhelpful [12]. Our three 

different methods of investigating the anaesthetic management of 

penetrating airway injury resulted in a wide variety of opinions and 

our conclusions are enumerated below. 

The anatomical site of the injury 

This is a crucial consideration as penetrating neck wounds are best 

approached on a zonal basis [44] 

Zone I - between the clavicles and the cricoid cartilage. 

Zone II - between the inferior margin of the cricoid cartilage and 

the angle of the mandible 

Zone III - between the angle of the mandible and the base of the 

skull. 

Reference to a zone allows the prediction of potential injuries 

and so the potential for urgent airway management problems 

[12]. It should be noted that wounds in the anterior and lateral 

aspects of the neck compromise the airway more often than those 

in the posterior region [12]. Once the zone(s) involved have 

been identified the clinician should then consider the presence of 

injury to the airway’s lumen (with associated blood and debris), 

injury within the airways wall itself or injury outside the wall 

(e.g. expanding haematoma or surgical emphysema). Optimal 

intubation conditions may be difficult to achieve and injuries may 

compromise positive pressure ventilation with bag-valve-mask 

devices [11]. Not all patients will be in extremis however and there 

may be time to consider additional investigations to characterise 

the injury. CT is considered the first-line investigation in stable 

patients with penetrating neck injuries [45] to identify the 

location, nature and extent of any airway injury. 

Airway bleeding/facial distortion and patient positioning 

Blood and debris may be soiling the airway and if the casualty 

is maintaining their airway satisfactorily they do not require 

immediate airway intervention apart from a jaw thrust. They 

should be allowed to adopt their most comfortable position. 

Lateral, sitting and prone positions have all be described in case 

reports and the importance of this must be reinforced during 

patient handover. 

Anaesthetic approaches to penetrating airway injury 

The principle clinical features mandating early tracheal 

intubation are acute or worsening respiratory distress, an airway 

that is compromised by blood and secretions, extensive surgical 

emphysema, tracheal deviation by haematoma and a decreasing 

level of consciousness [46]. Although anaesthetists perform 

endotracheal intubation routinely, it should be approached with 

great caution in a patient with a penetrating airway injury [47]. 

Direct Laryngoscopy/ Rapid Sequence Induction (RSI) 

It is important that anaesthetists are aware that despite the 

laryngeal inlet appearing intact, there may be a tracheal tear 

present below this and placing an endotracheal tube under direct 

laryngoscopic vision could lead to the tip passing through the 

defect. This may go unrecognized and risks airway obstruction, 

pneumomediastinum and the creation of a false passage [47] as 

this is in effect a ‘blind technique’, which may completely disrupt 

the larynx. The incidence of these phenomena is unknown but is 

most likely lethal and difficult to reverse even with an emergency 

surgical airway (especially if gross surgical emphysema has been 

created) [12]. Others recommend an ‘awake look’ under topical 

anaesthesia but this will obviously not indicate if there are any 

injuries distal to the vocal cords [11]. 

Some authors hold that RSI should be the default method of 

airway control [48]. Evidence is available to suggest that it is safe 

[49] and has a high success rate [33,34,50]. Despite this, there are 

others who argue against RSI in certain cases [36,37], where the 



airway is penetrated below the vocal cords (risking unrecognized 

misplacement of the ETT). It is also not recommended in cases 

of near or total airway transection, where paralysis will abolish the 

supportive muscle tone, which may be all that is holding the airway 

together [11,51]. For these reasons, some authors actively support 

the casualty maintaining spontaneous ventilation at all costs [47]. 

Current UK anaesthetic practice includes the use of cricoid pressure 

[52] during an RSI but this may distort the airway, change the 

anaesthetist’s view and result in a more difficult airway [47,53]. 

Blind Nasal Intubation 

The consensus of opinion is that blind intubation methods 

including blind nasotracheal intubation should not be used in 

patients with penetrating neck injury because further injury or 

complete airway obstruction may be induced [54]. A single paper 

reviewing a case series of patients successfully managed with blind 

nasotracheal intubation has challenged this advice [35]. As this 

technique is rarely taught in UK hospitals, we would discourage its 

use by clinicians for whom it is not part of their regular practice. It 

also requires extension at of the upper cervical spine while the lower 

cervical spine is extended, as part of the technique, which may risk 

neurological injury in the unstable cervical spine in trauma. 

Fiberoptic Intubation 

AFOI is the gold standard for safely securing the airway in a 

casualty with a traumatic airway injury. This technique allows the 

lumen of the airway to be identified by direct vision throughout the 

intubating process and allows the anaesthetist to be confident about 

siting the endotracheal tube (ETT) distal to any visualized tear. 

This technique depends on availability of a fiberscope, the cooperation 

of the patient [47,55] and the skills of the operator. 

Another confounding factor to this method of securing the 

airway is that any foreign bodies or blood will hinder the use 

of the fiberscope [47] although in skilled hands it has proved 

very effective [17-20, 23,24,40]. Difficulties regarding AFOI 

in the field hospital also arise from the sterilization aspect of 

the fiberscope, however recently disposable versions have been 

developed, but are yet to be evaluated in this setting. 

Surgical Airway 

A case could be made to consider surgical airway as the first choice 

intervention for laryngeal injuries [47,56] as it is done under 

direct vision reducing the potential for worsening an injury by 

misplacement the endotracheal tube. Both cricothyroidotomy 

and tracheostomy have been described as safe techniques to 

perform in an awake, spontaneously ventilating patient with local 

anaesthetic infiltration [47]. Cricothyroidotomy itself has further 

been described as a safe, rapid technique of obtaining an airway 

in an emergency setting [57]. Tracheostomy should be performed 

at least one tracheal ring below the injury to avoid complications 

[12]. Whenever a difficult intubation is suspected it is advisable to 

have the patient’s neck prepared and the surgeon ready to perform 

a surgical airway [47]. The anaesthetist should be mindful that 

the rapid creation of a surgical airway might be a difficult task for 

the surgeon, particularly if there is overlying haematoma or other 

gross anatomical disruption. 

Recommendations 

Despite the variety of anaesthetic management strategies present 

in the literature, there are certain key principles we believe should 

be considered in all cases. These are listed in Table 3. Human 

358 


factors play an important role in ensuring that individuals in a 

clinical team perform to the highest standard [58]. We believe 

that the principles of Anaesthesia Crisis Resource Management 

(ACRM) [59] are crucial to ensuring the best possible outcome 

when faced with a patient with severe blast or ballistic injuries. 

Monitor patient with full AAGBI standard monitoring 

[60] (especially ETCO 2 ) 

Preoxygenation (even in patients with marginal functional 

reserve [43,47,54]) 

Airway optimization 

• If conscious allow patient to adopt 

most comfortable position [46]. 

• If unconscious use jaw thrust 

Consider the urgency with which a secure airway is 

required 

Consider the site of injury 

Availability of suction (preferably two devices) 

Table 3. Key principles to consider for all casualties with a penetrating 

airway injury 

Potential Pitfalls 

The literature review and DMS Anaesthetists experience and 

JTTR search have enabled us to suggest certain pitfalls when 

dealing with patients with penetrating airway injuries. These 

should be considered when constructing a plan of securing the 

airway and are listed in Table 4. 

Ventilation: Positive pressure ventilation risks enlarging tears 

and causing surgical emphysema 

• Try to preserve spontaneous ventilation prior to 

intubation 

• Use bag-valve-mask ventilation is a last resort 

• Avoid LMA in injuries distal to cords 

• Avoid transtracheal jet ventilation 

Intubation: Blind placement of the tube risks the tip 

passing through the defect and lying outside the airway 

and is only avoided by fibreoptic intubation or a surgical 

airway. 

Intubation: Endotracheal intubation should be 

approached with caution 

• Avoid oral intubation when the injury is distal to the 

vocal cords 

• Avoid blind nasal intubation 

• Fibreoptic intubation is likely to be difficult/ 

impossible when there is bleeding into the airway 

Surgical Airway 

• Is potentially extremely difficult in face of subcutaneous 

emphysema or an expanding haematoma (direct 

laryngoscopy is also likely to also be difficult). 

Drugs: Avoid muscle relaxants in near/complete airway 

transection 

• Muscle tone may be important for airway integrity 

Table 4 Potential Pitfalls to consider when drawing up plans to secure 

the airway. 


Guidelines for Penetrating Airway Injuries SJ Mercer, SE Lewis, SJ Wilson et al 

In proposing initial guidelines for DMS anaesthetists, we have 

been strongly influenced by the comments made in the review 

article by Abernathy [47] regarding the placing of an endotracheal 

tube when a distal airway injury has not been excluded. In such 

cases a primary surgical airway may be the most appropriate plan 

[43]. Whether it is the anaesthetist or the trauma surgeon who 

performs this will be decided by the skills and experience of the 

individuals within the team. 

Our initial guidelines based on site of injury are summarized 

in Table 5. We anticipate that this preliminary work will now 

lead to further studies to develop guidelines and training systems. 

We also hope to work with national bodies such as the Difficult 

Airway Society to further develop our guidelines. 

Zone I injury 

• Consider direct intubation through a large defect 

• Consider tracheostomy 

• Consider a thoracotomy in complete tracheal 

transection [62] 

Zone II injury 

• Consider a CT scan to exclude distal airway injury 

• (Provided that there is no immediate impending 

obstruction of the airway). 

• Consider oral intubation by RSI for injuries proximal 

to the larynx 

• Consider fibreoptic intubation for injuries distal to the 

larynx 

• Consider a surgical airway for injuries distal to the 

larynx 

Zone III injury 

• Consider oral intubation by RSI for small defects 

• Consider surgical airway for gross disruption. 

For any large airway defect 

• Consider direct intubation through the defect 

Table 5 Suggested Guidelines for the Airway Management of 

Penetrating Airway Injury 

Acknowledgements 

The authors would like to thank Major Suzi Robinson QARANC 

and her team at the Royal Centre for Defence Medicine for their 

help performing the search of the Joint Theatre Trauma Database 

and Mr. Michael Rowe, Defence Librarian for his help with the 

Literature Search. 

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The Paediatric Transfusion Challenge on 

Deployed Operations 

S Bree 1 , K Wood 2 , GR Nordmann 3 , J McNicholas 4 

1 Consultant Paediatric Anaesthetist, MDHU Derriford, Plymouth and Chair Paediatric Anaesthesia and Critical 

Care Special Interest Group (PACCSIG); 2 Specialist Registrar in Anaesthesia, James Cook University Hospital, 

Middlesborough; 3 Consultant Paediatric Anaesthetist, MDHU Derriford and 16 Medical Regiment, Colchester; 

4 Consultant in Anaesthesia and Intensive Care, MDHU Portsmouth, Department of Critical Care, Queen Alexandra 

Hospital, Portsmouth 

Abstract 

This paper briefly touches on the problem of dealing with the severely injured child requiring massive transfusion and produces 

a guide on the management of this based on the current Surgeon General’s Operational Policy Letter. There are no known 

UK guidelines on massive transfusion in trauma in the paediatric population although many specialist centres have guidance 

for dealing with cases in theatre during elective surgery. It is hoped that these guidelines will be used by deployed military 

anaesthetists to aid in their management of these difficult cases, not normally seen in the UK. 

Introduction 

The last few years have proved a busy time for the Defence 

Medical Services (DMS) in terms of operational commitments 

and the development of military medical techniques. War fighting 

has historically provided a rich environment for the advance of 

medical care including blood transfusion, antibiotics, wound 

care and casualty retrieval to name but a few. The recent conflicts 

have proved no exception with major advances in blood product 

therapy, a refining of damage control resuscitation techniques, 

from the early extraction of casualties, through to rapid damage 

control time-limited surgery and the rapid evacuation back to UK 

Role 4 through our Critical Care Air Support Team (CCAST) 

capabilities. 

Much attention and energy has been directed towards improving 

the lot for our injured troops with a perceived improvement in 

outcome. An unfortunate but inevitable outcome of the current 

war fighting is the presence of casualties amongst the paediatric 

population. The causes for this are varied, but include legacy 

munitions, enemy and coalition activities, as well as ongoing 

domestic accidents. The UK military has traditionally treated all 

those appearing at our medical facilities according to an eligibility 

matrix whose interpretation can vary depending on tempo of ops 

and state of medical facilities. Irrespective of this, it is incumbent 

on UK medical personnel to provide the best quality care possible 

to those admitted to our Role 2 and 3 medical facilities. This is 

not always straightforward nor is it a purely medical decision. 

Very difficult ethical and logistic dilemmas can arise, which must 

be looked at on an individual basis. 

Paediatric Anaesthesia and Critical Care Special 

Interest Group 

The challenge of paediatric patients in the military environment is 

now accepted across the DMS and appropriate provision is being 

undertaken to provide the equipment to deal with this situation. 

As part of this process, the Defence Consultant Adviser (DCA) 

Corresponding Author: Surg Cdr Steve Bree RN, 

Consultant Paediatric Anaesthetist, MDHU Derriford, 

Plymouth PL6 8DH 

Tel 01752 439203/4/5 Email stephen.bree@phnt.swest.nhs.uk 

in Anaesthetics has commissioned the formation of the Paediatric 

Anaesthesia and Critical Care Special Interest Group (PACCSIG). 

The PACCSIG consists of four consultant anaesthetists (one an 

intensive care specialist), two trainees and a nurse with a sub 

speciality interest in paediatric issues across the board. It meets 

twice a year and has the following remit: 

1. Examine equipment issues, staff training and standards 

of care where anaesthetists may be involved in the care of 

children including pre-hospital care, ED, theatres, ICU, 

wards and transfer. 

2. Outputs to include annual module review for the anaesthetic 

specialist interest group 

3. Production of an annual activity report to the DCA. 

Minutes of PACCSIG proceedings are sent to DCA’s in all 

relevant disciplines and it is hoped that it will act as a focus for 

paediatric issues throughout the DMS. 

Workload 

Current paediatric workload is still to be determined but some raw 

data has been retrieved. For the purpose of looking at paediatric 

casualties in both Iraq and Afghanistan a request was put in to the 

Joint Theatre Trauma Registry (JTTR) at Birmingham to obtain 

data on all children treated under the age of 16 from March 2003 

to August 2009. On Op TELIC (Iraq) 29/271 (4%) of admissions 

were children compared to 147/1769 (8%) for Op HERRICK 

(Afghanistan). The age and gender of the children admitted are 

given in Figures 1 and 2. 

Figure 1. Age Breakdown of Paediatric admissions 


Paediatric Transfusion 

Figure 2 Gender Breakdown 

A review of US data has recorded 10% of all admissions to 

their Combat Support Hospital (CASH) facilities in Iraq and 

Afghanistan as paediatric, with penetrating injuries accounting 

for three quarters of cases [1]. 

This correlates well with data collected from Herrick 8B/9A [2] 

where 10.1% of all surgical operations within the UK Med facility 

were carried out in children and one third of all the paediatric 

surgical population were admitted to the ICU, which comprised 

11.9% of the total ICU admission load. These figures do not 

necessarily reflect the real contribution of paediatric casualties to 

ICU work. Coalition casualties are generally evacuated to the UK 

within 24 hours, whereas paediatric ICU admissions may spend a 

protracted period on the intensive care unit. 

A review by Gurney in 2004 [3] looked at activity in the UK 

surgical field hospital during the war fighting phase of the TELIC 

1 campaign and quoted paediatric patients as comprising 2.9% 

of all recorded admissions. This figure is lower than others have 

experienced on previous campaigns and may be a reflection of the 

relatively peaceful period which was in place prior to the sustained 

insurgency campaign when kinetic activity ie the- use of munitions 

and firearms, escalated considerably, often in an indiscriminate 

manner or directly targeting the civilian population This small 

figure of 2.9% has the potential to be slightly misleading as 

children accounted for nearly a third of all non-coalition patients, 

a figure which may need to be borne in mind when planning 

medical aspects of future operations. 

Present military operations in Afghanistan are generating a 

large number of fragmentation and gunshot wounds (GSW). 

Harris and McNicholas [4] in this journal reviewed the paediatric 

workload on Critical Care with 15 admissions over two months in 

mid-2008. Mechanism of injury was predominantly penetrating 

GSW or fragmentation (absolute numbers not given) and a mean 

age of six years (range 6 months to 17 years) was recorded. This 

population was a significant part of the Critical Care workload 

with a paediatric admission present for 66% of the time and 

accounting for 30% of all bed occupancy. 

PACCSIG continues to retrieve data, but it is clear that the 

challenge of paediatric admissions is impacting significantly on 

field hospital resources and must be taken into account when 

planning personnel, equipment and patient disposal. The current 

matrix of Medical Rules for Eligibility (MRE) ensures that the 

hospital front door is open for many of the civilian population 

at risk (PAR). Whilst considerable effort is being devoted to the 

development of local medical facilities, the reality is that they are 

a long way from providing critical care of a standard comparable 

to the joint UK/US hospital in Helmand. 

362 

S Bree, K Wood, GR Nordmann et al 

Massive Transfusion in Trauma 

The Surgeon Generals Operational Policy Letter (SGPL) on 

massive transfusion [5] updated the most recent advice on the 

management of major haemorrhage on operations. This is an adult 

based guideline which has developed extensively over the past few 

years and is still part of the ongoing evolution of trauma transfusion 

medicine. The Association of Anaesthetists of Great Britain and 

Ireland (AAGBI) is in the process of generating a document on this 

subject and will include a section on the management of paediatric 

massive transfusion. As part of the process some of the authors of 

this article in conjunction with the PACCSIG have developed a 

simple guideline based on reverse engineering of the adult SGPL. 

This has been carried out to provide a protocol on which to base 

a weight guided massive transfusion for situations where major 

haemorrhage is a problem in children. It enables physicians to 

guide paediatric patient resuscitation with greater confidence, and 

is intended to be used in conjunction with the clinical monitoring 

and near patient testing already available. 

The adult protocol dictates that on arrival in the ED, laboratory 

staff will provide 4 units of O negative packed red blood cells 

(PRBC) and 4 units of Fresh Frozen Plasma (FFP) for initial 

resuscitation in the massive transfusion case although a trend 

towards 2 unit packs of FFP and blood is now developing and 

may certainly be more appropriate for paediatric resuscuation. 

This constitutes the first phase. The second phase is entered when 

the lab issues the second major haemorrhage pack consisting of 6 

units of cross matched PRBC and 6 units of FFP. 

As a practical guide to the laboratory and the resuscitation 

teams we recommend the following guide (Figure 3) be used with 

reference to the key points in Table 1, to ensure appropriate fluid 

therapy and efficient use of blood products. 

• In the first phase, order 1 unit (U) of PRBC and 1 U of 

FFP for every 20kg weight of the child, e.g. a 23kg child 

will need 2 U blood and 2 U FFP initially. This will ensure 

a minimum of approximately 15 ml/kg, i.e. approx 300ml 

each of FFP and PRBC for a 20kg child. 

• A bag of PRBC or FFP for an adult is equivalent to 

approximately 4ml/kg for the child. 

• Alternate boluses of PRBC and FFP are given in a volume 

of 5ml/kg. 

• The first phase of transfusion for an adult, 4 U of PRBC 

and 4 U of FFP, is equivalent to approximately 15 ml/kg 

(3 boluses) of each product for the child. 

• Use all clinical signs to help guide resuscitation, including 

arterial wave form, central venous pressure, blood pressure 

and urine output, as well as laboratory results, particularly 

arterial blood gases and rotational thromboelastometry 

ROTEM® (TEM Innovations GmBH, Munich Germany). 

• Order more PRBC/FFP as required. (remember bool 

can be returned to labs within 30 minutes if cold box 

unopened) 

• Platelets should be given at 3ml/kg, however ROTEM® 

may indicate a requirement for more platelet transfusion. 

SGPL guideline aims for platelet count above 100 x 109/l. 

• The dose for Calcium Chloride is 0.2ml/kg. 

• The dose for Tranexamic Acid is 15mg/kg bolus, followed 

by an infusion of 1mg/kg/hr. 

Table 1 Paediatric Massive Haemorrhage Key Points 


Paediatric Transfusion S Bree, K Wood, GR Nordmann et al 

Decision to enter massive 

transfusion protocol made 

early (first shock pack 

issued by labs containing 

non crossmatched blood) 

and FFP) 

Request clotting, full 

blood count, fibrinogen 

and ROTEM ® tests as 

soon as practical, as well 

as formal cross match 

Child arrives in ED 

Estimate weight (using 

Broselow tape or age 

formula [(age + 4) x 2] 

Blood 5ml/kg 

FFP 5ml/kg 

Alternating (ensuring 

warming of blood and 

FFP) 

End of 1 st phase, after a 

total of 15ml/kg blood 

and 15ml/kg FFP 

Consider 

Platelets 3ml/kg* 

Cryoprecipitate 3ml/kg** 

CaCl2 0.2ml/kg *** 

rFVIIa **** 

Transfusion end points 

Arresting of haemorrhage 

Heart rate, BP, CVP 

Cap refill 

Blood gases and lactate 

Hb 

Risks 

Hypothermia 

Hyperkalaemia 

Hypocalcaemia 

Hypomagnesaemia 

Give Tranexamic Acid 

bolus +/- infusion 

Start 2 nd phase of protocol 

again with aliquots of 

blood and FFP in 

alternating 5ml/kg 

boluses 

Repeat the cycle using 

20ml/kg PRBC and 

20ml/kg FFP to indicate 

of the end of each “adult 

6 unit shock pack” 

*consider transfusing whole bag if platelets required and volume 

not an issue; ** aim for fibrinogen above 1g/l; *** Aim for ionised 

Ca above 1mmol/l; ****1 Dose of 100mcg/kg repeated after 20 

minutes if necessary. Aim for as near normal physiology as possible 

pre administration 

Fig 3. Framework for Paediatric Massive transfusion based on SGPL 

Paediatric Massive Haemorrhage: Practicalities of 

Resuscitation 

The practicalities of this process are not as straightforward as 

for adult transfusion and a system for delivering the blood 

products must be assembled and rehearsed with all staff who 

may be involved in this process. There may be several “rigs” 

which staff may have used within different hospitals and but it 

is recommended one single assembly is agreed amongst deployed 

clinical staff to promote familiarity and minimise risk of mishaps. 

Practical points to be considered during major haemorrhage 

management in the paediatric population include the following: 

• Invasive pressure monitoring is essential. 

• Large bore central venous access is ideal. Multiple peripheral 

cannulae may not be possible and lead to the risk of multiple 

“ectopic” fluid transfusions. 

• A fluid warmer is essential. 

• The ability to deliver air free warmed boluses of blood products 

and fluids is an important practical issue. A set up such as the 

one described below can be used successfully, but teams need 

to be briefed and trained in its safe use before the event. 

• At the proximal end of the fluid warmer 4 three way taps 

should be attached in series to 4 bags of fluid and their 

giving sets. The 4 bags may contain any of the following; 

crystalloid, colloid, blood and FFP. At the distal end of 

the fluid warmer a further 2 three way taps should be 

attached in series. One for a 50 ml syringe to use as the 

main ‘pump’ to use for each fluid bolus and a further tap 

for the addition of drugs. Distal to this should be a short 

connector to the central line. This connector should be 

secured in some manner to the bed so it takes the weight 

of the 50ml syringe and lines. This approach has been used 

to good effect in the ICU during the current phase of Op 

HERRICK. It shoud be borne in mind that with the Level 

1 Infusor (Smiths Medical Level 1® H-1200 Fast Flow 

Fluid Warmer) currently in use in rhe British military there 

is a potentially significant dead space of up to 60 mls from 

the upstream to the down stream locations of the warming 

element. This will become increasingly important for the 

smaller child and alternative arrangements should be 

explored in these circumstances. 

• The physical arrangement described will provide an 

accurate method of administering specific volumes of 

the required fluid. Fluid will be warmed and speed of 

administration controlled by hand. Drugs can be given 

without interruption of transfusion. 

• It is vital to record the volumes given with accuracy. Ideally 

these should be recorded concurrently and in a location which 

all can see (e.g. wipe board). 

• Platelets should be given through a different giving set to a 

different line and consideration should be given to transfusing 

the whole bag on the basis that our recommended 3ml/kg is 

reasonably conservative and once issued this scarce resource 

needs to be utilised efficiently. 

Management of major haemorrhage is often an obvious 

clinical picture in the emergency room and the operating theatre 

but it may also require recognition and initiation in other areas 

within the hospital and useful definition of massive transfusion in 

the paediatric population is given in Table 2 to aid in this aspect, 

particularly with respect to ongoing blood loss 

• Replacement of 1 blood volume in 24 hours 

• 10 units of Red Cells in 24 hours (40ml/kg) 

• 4 units in 1 hour (16ml/kg) 

• Replacement or loss of50% blood volume in 3 hours 

• Rate of blood loss >150ml/min (2ml/kg/min) 

Table 2: Definition of Massive Transfusion (proposed paediatric 

figures in brackets) 

Valuable lessons can be gained from observing treatment of 

massive haemorrhage and coagulopathy in children undergoing 

elective surgery in UK specialist paediatric hospitals. Procedures 

such as hepatic transplantation, scoliosis surgery and craniofacial 

surgery are examples of practice in which important 

anaesthetic experience can be gained, not only in the practicalities 


Paediatric Transfusion 

of resuscitation of massive haemorrhage and coagulopathy, but 

also in logistics of how the volumes can be transfused. It is the 

opinion of the PACCSIG that military paediatric anaesthetists 

should have regular exposure to this experience or attend refresher 

training in a specialist paediatric unit prior to deploying. 

Conclusions 

This paper describes a guide for resuscitation in paediatric 

massive haemorrhage to be used by deployed anaesthetists in 

Afghanistan. It should be used in addition to conventional 

clinical signs and monitoring, including near patient laboratory 

investigations. 

Although not forming our core work on military operations 

the challenge of the injured and sick child is real and 

something that we face weekly on current deployed operations. 

It is important that we provide a well trained cadre with an 

appropriate skill mix, in order to deal with the full spectrum 

of clinical cases including children. Improved awareness and 

delivery of first class care to children will lead to both a better 

outcome for the injured child and a more efficient use of limited 

hospital resources. 

Further work is being undertaken with the PACCSIG across 

a whole range of paediatric deployed issues and covering aspects 

of daily care, training and audit of outcome. It is hoped that the 

authors can communicate developments through this journal as 

our work proceeds. 

364 

S Bree, K Wood, GR Nordmann et al 

Acknowledgments 

The authors would like to thank Dr Isabeau Walker, Consultant 

Anaesthetist, Great Ormond Street Hospital, London and Col T 

Hodgetts CBE QHP L/RAMC for their help and advice on the 

massive haemorrhage protocol, the writing of this article and the 

use of the JTTR data. 

References 

4. Creamer KM, Edwards MJ, et al. Pediatric Wartime Admissions to 

US Military Combat Support Hospitals in Afghanistan and Iraq: 

Learning from the First 2,000 Admissions. J Trauma 2009; 67 (4): 

762-8. 

5. Nordmann G. Paediatric anaesthesia in Afghanistan; a review of 

current experience. J R Army Med Corps 2010; 156(4 Suppl 1): 

S323-326. 

6. Gurney I. Paediatric Casualties During OP TELIC. J R Army Med 


7. Harris CC, McNicholas JJK. Paediatric Intensive Care in the Field 

Hospital. J R Army Med Corps 2009; 155 (2): 157-159. 

8. Surgeon General’s Operational Policy Letter Management of 

massive haemorrhage on operations, June 2009, SGPL 08/09. 


Simulation, Human Factors and Defence 

Anaesthesia 

SJ Mercer 1 , C Whittle 2 , B Siggers 3 , RS Frazer 4 

1 Specialist Registrar in Anaesthesia & Critical Care, Royal Liverpool University Hospital, Prescot Street, Liverpool; 

2 Consultant in Anaesthesia & Critical Care, Frenchay Hospital, North Bristol NHS Trust, Bristol; 3 Consultant in 

Anaesthesia, Salisbury Hospital NHS Foundation Trust, Odstock Road, Salisbury, Wilts; 4 Consultant in Anaesthesia, 

SO1 Clinical, HQ 2 Med Bde, Strensall, York. 

Abstract 

Simulation in healthcare has come a long way since it’s beginnings in the 1960s. Not only has the sophistication of simulator 

design increased, but the educational concepts of simulation have become much clearer. One particularly important area is 

that of non-technical skills (NTS) which has been developed from similar concepts in the aviation and nuclear industries. 

NTS models have been developed for anaesthetists and more recently for surgeons too. This has clear value for surgical 

team working and the recently developed Military Operational Surgical Training (MOST) course uses simulation and NTS 

to improve such team working.The scope for simulation in Defence medicine and anaesthesia does not stop here. Uses of 

simulation include pre-deployment training of hospital teams as well as Medical Emergency Response Team (MERT) and 

Critical Care Air Support Team (CCAST) staff. Future projects include developing Role 1 pre-deployment training. There is 

enormous scope for development in this important growth area of education and training. 

Introduction 

Simulation can be defined as the artificial representation of 

the real-world to achieve an educational goal via experiential 

learning [1]. A number of different levels of simulation exist 

and in some areas Defence medicine is taking a leading role at 

national and international levels. This article will review current 

concepts of simulation and the increasingly important area of 

non-technical skills (NTS) or human factors (HF). It will review 

current Defence Medical Services (DMS) simulation output and 

consider the future for simulation in the DMS and especially 

Defence Anaesthesia, including the increasing opportunities for 

individuals to take part in this growth area. 

Simulation and Clinical Learning 

Simulation in medical education can be thought of as any 

educational activity involving the use of a simulated as opposed to 

live patient, thus in its broadest interpretation, a simple case-based 

discussion between consultant and trainee could be regarded as 

simulating the management of a “virtual” patient. 

Simulation can vary in complexity from the use of part-task 

trainers (often used in surgical training) through to the use of 

mannequins for individual and small team training. Some 

common platforms are listed in Table 1. In addition to this a 

conceptual framework of three different levels of simulation has 

been proposed. Micro-simulation focuses on the needs of the 

individual clinician and usually consists of basic motor skills (e.g. 

knot tying). The second level is Meso-simulation and this focuses 

on clinical teams looking at higher cognitive skills and behaviours 

(e.g. NTS). The highest level is Macro-simulation and this really 

focuses on an entire organisation [2]. 

Corresponding author: Lt Col RS Frazer, SO1 Clinical, HQ 2 

Med Bde, Strensall, York. YO32 5SW. 

Tel: 01904 442611 Fax: 01904 442689 

Email: scottfrazer@doctors.net.uk 

• Part task trainers 

(e.g. for airway management or intravenous access) 

• Computer based systems 

• Virtual reality and haptic systems 

• Simulated patients 

• Simulated environments 

• Integrated Simulators including instructor 

and model driven mannequins. 

Table 1: Common simulation platforms 

Anaesthesia as a specialty has led the way in the development 

of simulation training in medicine. Following the creation of 

the first mannequin in the late 1960s [3], they have become 

increasingly sophisticated. Some are now completely wireless 

while others possess an inherent software-driven physiology. They 

have also become cheaper resulting in an increasing number of 

centres delivering high-fidelity scenario-based training [4]. 

In scenario-based training, learners are required to respond to 

simulated clinical situations as they would to real situations and 

then review and discuss their performance aided by their peers and 

a facilitator (debriefing). Clinicians can practice the management 

of uncommon emergencies to improve competence. An important 

element in this training, and its educational effectiveness, is 

the degree of realism, or ‘fidelity’ of the scenario. Physical (or 

Engineering fidelity) is the degree to which the training device or 

environment replicates the physical characteristics of the real task 

[5]. Functional or psychological fidelity is thought to be of greater 

importance and is the degree to which the skills in the real task are 

captured in the simulated task. The greater the reality, the more 

the learner will ‘buy into’ the process and the greater the learning. 

Numerous NHS anaesthetists have benefited from the 

experience of mannequin based scenarios in a simulation centre 

and the majority of those surveyed have been positive about 

simulation as a means of delivering training [6]. A recent survey of 

Defence Anaesthetists has shown similar enthusiasm, particularly 


Simulation and Defence Anaesthesia 

in pre-deployment training using operational clinical scenarios, for 

example massive transfusion and familiarisation with operational 

medical equipment [7]. 

The increasing importance of simulation is such that the Chief 

Medical Officer of England & Wales has recently suggested that 

simulation-based training should be fully funded and integrated 

within training programmes for clinicians at all stages. He also 

states that simulation-based training needs to be valued and 

adequately resourced by NHS organisations, and that a faculty 

of expert clinical facilitators should be developed to deliver highquality 

simulation training [8]. 

Non-technical Skills or Human Factors 

In the 1970s simulation in healthcare started to gain recognition 

as a means to limit human error and improve patient safety, taking 

a lead from the aviation and nuclear power industries as well as 

the National Aeronautics and Space Administration (NASA). 

NASA revealed that 70% of its errors were due to human factors 

such as failed interpersonal communication, decision-making 

and leadership [9]. Similar figures have been seen in an analysis 

of adverse events in anaesthesia [10]. Case reports and a report 

from the National Patient Safety Agency (NPSA) also suggest that 

human factors contribute to the majority of medical errors [11 - 

14]. The report “To err is human” confirmed the same situation in 

the USA [15]. 

Much of the research from the airline and nuclear power 

industries into human factors is transferable to the clinical arena. 

Detailed analysis of critical events and in particular the human 

behaviours that contributed to their occurrence and management 

has led to the development of a set of behavioural principles. 

These behavioural `best practice` principles are known to aircrew 

as Crew Resource Management (CRM). 

Several groups have brought these same principles into 

anaesthesia, notably a team led by David Gaba at Stanford, 

USA which developed Anaesthesia Crisis Resource Management 

(ACRM) [16] and another led by Ronnie Glavin in Aberdeen, 

UK which developed Anaesthesia Non-Technical Skills (ANTS) 

[17]. These behavioural frameworks include elements such as 

‘knowing your environment’, ‘leadership’, ‘communication’, 

‘situational awareness’, ‘dynamic decision-making’, ‘prioritisation 

and delegation of tasks’. The key components of the two systems 

are shown in Table 2. It is easy for these broad headings to sound 

trite and obvious. However, communication itself was found to 

be a causal factor in 43% of errors by surgeons in three American 

teaching hospitals [18]. 

Clinical scenarios using a high-fidelity environment and 

mannequin, combined with carefully facilitated debriefing, 

are the ideal educational method for teaching these principles 

[19]. However it must be stressed that training and experience 

in debriefing and NTS are key to the success of scenario based 

training. A poor debrief can adversely impact upon the educational 

aims of any scenario. 

Army Medical Training Centre (AMSTC) 

It is believed that the first Defence Medical establishment to 

develop simulation was the Army Medical Services Training 

Centre (AMSTC) at Strensall, York where the Hospital Exercise 

(HOSPEX) takes place. This is a macro simulation where layers 

of simulation exist, from the overall simulated hospital down to 

individual patient scenarios. This is in contrast to the majority 

of simulation centres which run single scenarios for individuals 

366 

ACRM [17] ANTS [19] 

Know the environment 

Anticipate and plan 

Call for help early 

Exercise leadership and 

followership 

Distribute the workload 

Mobilize all available 

resources 

Communicate effectively 

Use all available information 

Prevent and manage fixation 

errors 

Cross (double) check 

Use cognitive aids 

Re-evaluate repeatedly 

Use good teamwork 

Allocate attention wisely 

Set priorities dynamically 

Table 2: Two Non-Technical Skills Systems 

SJ Mercer, C Whittle , B Siggers et al 

Situational awareness: 

Gathering information 

Recognising & understanding 

Anticipating 

Decision Making: 

Identifying options 

Balancing risks and selecting 

options 

Re-evaluating 

Task management: 

Planning & preparation 

Prioritising 

Providing & maintaining 

standards 

Identifying & utilising 

resources 

Team working: 

co-ordinating team activities 

exchanging information 

using authority & 

assertiveness 

assessing capabilities 

supporting others 

and small teams. At HOSPEX the staff of the entire hospital live 

out a simulated hospital day. One of the main aims is to allow 

multidisciplinary teams to rehearse together in the safety of the 

simulated environment. The team in question will be deploying 

together and so can work, not only on their clinical skills, but also 

on their team dynamics. 

Figure 1: Mannequin based team scenario during HOSPEX 

AMSTC uses SimMan® and SimMan 3G® (Laerdal Medical 

Ltd, Orpington, UK) but the use of simulators has been 

associated with a number of practical difficulties. The limitations 

that the original SimMan® imposed due to hard wiring are now 

being over come by the wireless version, however work-arounds 

are required for monitoring (the mannequin communicates to 

its own monitor and not to that used by the DMS) and the 


Simulation and Defence Anaesthesia SJ Mercer, C Whittle , B Siggers et al 

more dynamic or visual casualty simulation. The use of actors 

has developed enormously and a contract has been established 

with a civilian casualty make-up artist and “Amputees in Action” 

[20], the visual impact is now very striking. Although this has a 

number of advantages the Emergency Department team are still 

faced with a ‘casualty’ who is physiologically normal, however by 

using the SimMan® monitor and laptop to display the required 

physiology, elements of technology and live simulation are 

combined to create greater fidelity. 

Figure 2: View of 3 Resuscitation bays during HOSPEX 

Another difference between the scenarios played out at 

HOSPEX and those at a high fidelity simulation centre is the 

length of simulated case. At HOSPEX it is necessary for cases 

to run through the Hospital Trainer for 12 hours or more. Areas 

which are still being developed include the simulation of ITU 

cases to providing staff with changing physiology over long 

periods and, as for the Military Operational Surgical Training 

(MOST) course, the ability to provide simulation of surgery and 

anaesthesia concurrently. 

Triservice Anaesthetic Apparatus Simulation Course 

The tri-service anaesthetic apparatus (TSAA) was developed in 

the 1980s [21] for Air Assault Operations. It is a unique set of 

equipment that is rarely used in the NHS and so the majority 

of trainees and new reserve consultants have had no experience 

of it. Although senior anaesthetists are familiar with it, many do 

not use it on a regular basis. A high fidelity simulation course 

has been developed to deliver training in this equipment. The 

course is delivered at the Cheshire and Merseyside simulation 

centre which uses the METI Human Patient Simulator® (Medical 

Education Technologies, Inc., Sarasota, USA) as this can actually 

be given an anaesthetic. On the one-day course the anaesthetists 

and ODPs are introduced to the TSAA and to the capabilities 

of the simulator as familiarization is also important for effective 

non-technical skills [22]. Subsequently four scenarios are run 

with each scenario being designed by Military Subject Matter 

Experts (SMEs) and civilian simulation staff to combine realistic 

medical and equipment related problems and to explore the team 

dynamics in critical problem solving. 

Military Operational Surgery Training Course 

Although HOSPEX has an important role in delivering larger 

team training, developments in military anaesthesia, particularly 

the management of massive transfusion, have driven the need to 

provide specific clinical training for complex clinical scenarios 

not seen in the NHS. In 2008 the Defence Professor of Surgery 

combined several pre-deployment surgical courses into one and at 

this stage the concept of a surgical team-training course emerged. 

The authors and colleagues have developed the anaesthetic 

component of the course and the team simulation element. The 

course is held at the Royal College of Surgeons (RCS) due to 

surgical training requirements and a dedicated simulated operating 

theatre with a Laerdal SimMan 3G® is used. The simulation based 

training is delivered to varying sized teams culminating in full 

team resuscitation scenarios. The clinical scenarios, developed 

from Operational cases use deployed equipment and are directed 

to specific learning objectives. 

Figure 3: Team scenario in RCS Team Skills Training Theatre during 

MOST course 

Although simulation and training in NTS has been undertaken 

before by anaesthetists and surgeons, MOST has been a clear step 

forward in bringing the entire surgical team together. Future 

courses will bring ED staff into the team, adding complexity to 

the team dynamic as well as continuing the improvements in 

scenario design and fidelity. Another aim is to develop an operative 

team simulator to improve surgical team training during Damage 

Control Resuscitation (DCR) and especially Damage Control 

Surgery which is part of DCR but although work on integrated 

procedure simulators has been described, the technology is at an 

early stage. 

MERT Course 

The Medical Emergency Response Team (MERT) course 

familiarises the paramedics, nurses and doctors with their 

operational team, environment and equipment. Clinical scenarios 

are exercised in a pre hospital setting, in the CH47 trainer and, 

airborne, in a C130. SimMan® and SimMan 3G® are used to 

rehearse clinical skills and drills such as rapid sequence induction 

(RSI). Actors are also used, as at HOSPEX. The final Exercise 

exposes the team to a mannequin based cardiac arrest scenario in 

the Hercules (C-130) during a live training flight. 

CCAST 

The development of affordable wireless simulators is changing 

the way Critical Care Air Support Teams (CCAST) are being 

trained. Using a SimMan 3G® the clinical instructors can deliver 

more realistic scenarios inside the C-130 and Chinook (CH-47) 

trainers at RAF Lyneham. Future training for both CCAST and 


Simulation and Defence Anaesthesia 

the Air Transportable Isolator (ATI) will benefit considerably 

by the improved fidelity and interaction of the mobile wireless 

mannequins. The use of simulators is also benefiting the 

CCAST(E) equipment course held at John Radcliffe Hospital, 

Oxford, UK. Here candidates familiarise themselves on the 

Aeromedical transfer equipment and then undertake transfer 

training initially using patient simulators and then moving on to 

transfer patients within the hospital. 

Simulation for Role One Training 

Simulation is also being developed for the pre-deployment training 

of Role 1 clinical staff. A workshop has been held to examine 

the challenges facing Role 1 personnel [23]. Common themes 

included team working, patient evaluation prior to transfer, 

equipment familiarisation and communication. Six scenarios 

have been developed which include technical and non-technical 

learning objectives. There are many aspects of NTS which can be 

transferred directly into a Role 1 healthcare setting. Simulation 

can deliver training in a safe, controlled environment and ensure 

that specific learning outcomes are achieved. A pilot course will 

take place in the near future. 

Clinical Fellowship in Simulation in Healthcare 

The need for competent instructors with training and experience 

of simulation and NTS has been recognised [8]. Faculty need to 

have a range of skills to design and run these courses: 

• Generic course design 

• Scenario development in conjunction 

with subject matter experts 

• Control of the mannequin 

• Facilitating scenarios 

• Post Scenario debriefing in terms of 

technical and non-technical skills 

Whilst the DMS has a number of anaesthetists who have 

been trained in recent years through fellowships at simulation 

centres of excellence, more are needed and the development of 

a sizeable cohort will take time. Whilst overseas fellowships are 

attractive, internationally recognised simulation centres do exist 

in the UK, the most recent being undertaken at the Cheshire and 

Merseyside Simulation Centre [24]. Such fellowships combine 

the opportunity to maintain clinical skills whilst embarking on 

formal training in simulation and medical education. Interested 

DMS trainees are strongly encouraged to contact their Defence 

Professors for further information. 

Conclusions 

Defence medicine is catching up rapidly with the growth in 

civilian simulation training and in some areas is taking a lead. 

The organisation is already a national leader in surgical trauma 

team training and an international exemplar in macro-simulation. 

Roles for simulation do not end with the areas described above. In 

the future, operational experience may not be so easily achieved as 

it is at present and simulation may be able to deliver elements of 

the Military Anaesthesia Higher Training Module. Revalidation 

is also an area in which simulation may find a place in the future. 

The joint working with surgical colleagues to deliver MOST is 

developing important links with the Royal College of Anaesthetists 

(RCOA) and RCS. However, all those involved in Defence 

Simulation must liaise closely with civilian simulation and 

educational bodies such as The Association for Simulated Practice 

368 

SJ Mercer, C Whittle , B Siggers et al 

in Healthcare and the Society for Education in Anaesthesia (UK) 

to ensure that valuable resources and expertise are used to best 

effect. The creation of a joint Senior Lecturer post in Anaesthesia 

Education with the Royal Centre for Defence Medicine and the 

RCOA will assist here and also encourage research in this field. 

There is enormous scope for further development in this area 

of clinical training, and for those with an interest in medical 

education, opportunities for involvement, including simulation 

fellowships, should be encouraged to ensure the future delivery of 

Defence medical simulation. 

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Equipment

Use of Transoesophageal Echocardiography 

during the Peri-operative Period for Trauma 

Patients. 

K Smyth 1 , R Hebballi 2 , MK Peterson 3 

1 Specialist Registrar in Anaesthetics and Intensive Care Medicine, Royal Air Force, University Hospitals of Leicester 

NHS Trust, Glenfield Hospital, Groby Road, Leicester; 2 Consultant in Cardiothoracic Anaesthesia, University Hospitals 

of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester; 3 Consultant in Anaesthetics and Intensive Care 

Medicine, Royal Air Force, Frimley Park NHS Foundation Trust, MDHU, Portsmouth Road, Frimley. 

Abstract 

The medical facility at Camp Bastion continues to evolve as a consequence of the increased throughput of battlefield trauma 

patients. There is a requirement for rapid and accurate diagnosis of haemodynamic instability and continued haemodynamic 

monitoring throughout the peri-operative period. Transoesophageal echocardiography (TOE) has been used for this purpose 

in the arena of cardiac anaesthesia since the mid 1980s. It is being introduced to other peri-operative settings where severe 

haemodynamic instability is expected. The old proverb: ‘There are none so blind as those who cannot see’ (Jeremiah 5:21) 

is applicable to this topic, in that TOE is proven to be a rapid, portable, safe and effective tool in the assessment of the 

haemodynamically unstable patient. This paper explores the application of TOE for the assessment of the major causes of 

haemodynamic instability in the trauma population. 

Introduction 

British military forces are currently committed to Operation 

HERRICK in Afghanistan. The medical support includes a 

Role IIE (enhanced) medical facility at Camp Bastion, Helmand 

Province, Afghanistan. The facility was initially designed as a 

surgical resuscitation node with limitation of clinical imaging, 

laboratory support and holding ability. As the operational 

workload has increased the facility has greatly expanded, but 

continues to be supported by a multi-national Role III facility 

at Kandahar. Records show that the majority of cases present as 

a consequence of traumatic injuries sustained in the battlefield 

[1,2]. The majority of the caseload presented for orthopaedic 

management of traumatic injury to the limbs. There was a wide 

variation in the severity of injuries, with 36% presenting with an 

injury severity score of greater than 16 during the period April 2006 

to July 2008 [2]. Battlefield injuries are incited by external forces 

produced by blast, deceleration and concussion, either in isolation 

or in combination. It is well recognised that these mechanisms 

can affect central structures in addition to the limbs [3-5]. Severe 

central vascular injury occurred in 27 UK military trauma patients 

during the period 2003-2007, with only 3 patients surviving [6]. 

This is reported as the most common unsuspected visceral injury 

resulting in death in civilian accident victims [7]. In consideration 

of the potential compound pathology of the cases and of the 

expansion of facilities at the Role IIE hospital, it seems reasonable 

to have access to accurate, rapid and portable imaging of the heart 

and great vessels. Transoesphageal Echocardiography (TOE) is 

becoming more established in the peri-operative period of civilian 

trauma patients [8-10]. The quality of images acquired with TOE 

is equivalent to that acquired by helical computed tomography 

Corresponding Author: Dr R Hebballi, Consultant in 

Cardiothoracic Anaesthesia, University Hospitals of Leicester 

NHS Trust, Glenfield Hospital, Groby Road, 

Leicester LE3 9QP 

Tel: 0300 303 1573 E-mail: hebballiravi@hotmail.com 

MINOR CAUSES MAJOR CAUSES 

Left ventricular systolic 

dysfunction 

Right ventricular systolic 

dysfunction 

Low systemic vascular 

resistance 

Dynamic left ventricular 

outflow obstruction 

Valvular pathology 

Massive pleural effusion 

Pericardial compression Ventricular septal rupture 

Hypovolaemia Pulmonary embolus 

Reduced left ventricular Traumatic myocardial 

compliance 

contusion 

Mitral regurgitation 

Abnormal heart rhythm 

Tension pneumothorax 

Table 1: Causes of haemodynamic disturbance that may be diagnosed 

by TOE. 

and magnetic resonance imaging for the assessment of aortic 

lesions [11-14]. The only exception being that the air space of the 

trachea produces a blind spot in the distal ascending aorta and the 

proximal aortic arch. The ability of TOE to predictably provide 

high quality images of the heart and guide surgical intervention 

has been well established in cardiac surgical patients [15-20]. 

TOE has clear benefits over standard haemodynamic 

monitoring and the pulmonary artery catheter when assessing 

volume status and regional ventricular function [21-22]. 

Diagnosis of some of the less common causes of haemodynamic 

instability (Table 1), are difficult to diagnose without some form 

of imaging. In 2003 the American College of Cardiology and 

American Heart Association Task Force on Practice Guidelines 

(ACC/AHA/ASE) published that there was sufficient evidence 

of improved clinical outcome when TOE was utilised as a 

continuous haemodynamic monitor [23]. The mass of evidence 

supporting the utility of TOE since 1994 has led to a similar 


Peri-operative Transoesophageal Echocardiography 

revision of the ‘Practice Guidelines for Peri-Operative TOE by 

the American Society of Anesthesiologists (ASA) and the Society 

of Cardiovascular Anesthesiologists’ in May 2010 [24]. They 

recommend the use of TOE when the nature of the planned 

surgery or the patient’s cardiovascular physiology may precipitate 

adverse haemodynamic, pulmonary or neurological sequelae. 

Furthermore, it is recommended for use when life-threatening 

circulatory instability persists despite corrective therapy. It has 

been consistently demonstrated that examination with TOE can 

alter the management of the patient in the critical care and postoperative 

setting [25-30]. As a consequence, the ASA and the 

Society of Cardiovascular Anesthesiologists recommends its use if 

the clinician expects it will be beneficial and that other modalities 

can not be instituted in a timely manner [24]. 

Equipment for Transoesophageal Echocardiography 

The equipment consists of an echocardiography machine together 

with a TOE probe. Ultrasonic images are formed by the reflection 

of pulses of sound from tissues. The frequency of sound utilised 

in ultrasound is greater than 20 kHz, which is above the human 

audible frequency range (20 – 20 kHz). TOE probes are fitted 

with very high frequency transducers (3.5–7 MHz) to produce 

high resolution images. Low frequency transducers (2-4 MHz) are 

required in transthoracic echocardiography to penetrate through 

the chest wall, but the resolution is greatly attenuated. 

The multiplane angle TOE probe can be moved physically 

as well as steered electronically (‘phased array’ system) from 0 0 - 

180° to optimise the image. Further optimisation is achieved 

by adjusting: image depth, focal zone, sector width, brightness, 

zoom and freeze. Two-dimensional images are supplemented 

with Doppler tracking of tissue motion. Colour Doppler, pulsed 

wave (PW) Doppler and continuous wave Doppler is applied 

depending on the tissue being analysed. 

Echocardiographic Evaluation for Trauma 

The American Society of Echocardiography (ASE) and the 

Society of Cardiovascular Anesthesiologists (SCA) have developed 

guidelines for comprehensive examination of the heart and great 

vessels, suggesting that between 12 and 20 standard views are 

required to avoid missing an unsuspected abnormality [31]. It 

has been demonstrated that this examination can be performed 

expeditiously [32, 33]. Brooks et al [34] reported a mean time 

of 27 minutes for complete examination in a series of patients 

presenting with trauma to the chest. This was in stark contrast to 

76 minutes required for arch aortography. Many algorithms have 

been postulated for rapid, focused, goal-directed and simplified 

transthoracic echocardiography in trauma and critically ill patients 

[35-38]. In a similar manner, the order of image acquisition for 

TOE could be tailored to clinical suspicion. 

Assessment of Hypovolaemia 

Hypovolaemia is often the main contributor to haemodynamic 

instability in multiple trauma patients. It appears as a small, 

vigorously contracting left ventricle with reduction of the end 

diastolic area (EDA) and end systolic area (ESA). Accurate 

measurement of the areas can be performed using the transgastric 

mid short axis view. These values have been shown to correlate 

well with pre-load [39, 40]. M-mode imaging at the level of 

the papillary muscles will give the impression of obliteration 

of the cavity. This is termed ‘kissing’ of the papillary muscles. 

Hypovolaemia is associated with a reduction in the diastolic filling 

374 

K Smyth, R Hebball, MK Peterson 

velocity of the left ventricle (LV). This can be demonstrated by the 

application of PW Doppler across the mitral valve. The tendency 

of the superior vena cava to collapse when it is under-filled 

provides a useful surrogate marker for hypovolaemia. The pressure 

across the wall of the vessel varies throughout the respiratory 

cycle, which is manifest by changes in its diameter. A variation in 

diameter of greater than 36% is indicative of hypovolaemia [41]. 

Assessment of Left Ventricular Function 

It is vital to differentiate between hypovolaemia and pump failure. 

Injury to the myocardium can occur as a direct consequence of 

the trauma or secondary to ischaemia. Cardiac contusion has 

been reported to occur in up to 70% of patients with blunt 

thoracic trauma [42, 43]. Changes in cardiac isoenzymes, 

electrocardiograph and increases in pulmonary artery wedge 

pressure may occur later and are insensitive [3, 44, 45]. 

Global LV function is assessed by viewing the contractility and 

thickening of the myocardium. Quantification of contractility 

is achieved by measuring the EDA and ESA in the transgastric 

mid short axis view (Figure 1). The fractional area change can be 

calculated as (EDA-ESA)/EDA x 100. Derivation of the ejection 

fraction, stroke volume and cardiac output from a 2D image 

requires the application of formulae to calculate the end diastolic 

volume (EDV) and end systolic volume (ESV). The biplane and 

single plane ellipsoid methods have been recommended by the ASE 

[48]. The latter method requires acquisition of the end diastolic 

and end systolic frames from a single mid oesophageal four 

chamber loop. The endocardial borders are traced and volume is 

calculated (8A 2 /9L) using the assumption that the LV is ellipsoid. 

The volumes are applied to calculate the ejection fraction, defined 

as (EDV-ESV) / EDV x 100 and stroke volume, defined as EDV- 

ESV. Error can be incurred by foreshortening of the ventricle and 

by regional wall motion abnormalities (RWMA). RWMA are 

defined as areas of the myocardium that do not thicken during 

systole (Figure 2). The myocardium has been divided into 16 

anatomical segments to facilitate matching of the RWMA to its 

concomitant blood supply [31]. Five echocardiographic views are 

required to visualise all of these segments. 

Figure 1. Assessment of left ventricular function (Transgastric mid 

short axis view). Doppler has been applied across the left ventricle. 

Movement of the inferior and anterior walls are plotted against time 

(M mode). EF, ejection fraction; FS, fractional shortening; LVIDs, 

left ventricular internal diameter in systole; LVIDd, left ventricular 

internal diameter in diastole. 


Peri-operative Transoesophageal Echocardiography K Smyth, R Hebball, MK Peterson 

Figure 2. Inferior wall akinesia (Transgastric mid short axis view). 

Doppler has been applied across the left ventricle. Normal thickening 

and movement of the anterior wall can be seen during systole. In 

contrast, the inferior wall is akinetic. EF, ejection fraction; FS, 

fractional shortening; LVIDs, left ventricular internal diameter in 

systole; LVIDd, left ventricular internal diameter in diastole. 

Assessment of Right Ventricular Function 

The right ventricular (RV) wall is most vulnerable to cardiac 

contusion by virtue of its proximity to the sternum. A multicentre 

trial demonstrated that 32% of 117 patients presenting 

with blunt chest trauma suffered damage to the right ventricle [3]. 

The RV is best evaluated in the mid oesophageal four-chamber 

(Figure 3) and transgastric mid short axis views. Global function 

is assessed in a similar way to that discussed for the LV. 

Pulmonary embolism should always be considered in the context 

of cardiorespiratory deterioration in the trauma population. A 

large and sudden increase in RV afterload is manifest as: dilatation 

and hypokinesis of the RV, diastolic septal flattening, functional 

tricuspid regurgitation and pulmonary hypertension. In severe 

cases the thrombus can be visualised in the proximal pulmonary 

arteries or right heart chambers. Small emboli may not produce 

any echocardiographic abnormalities. 

Figure 3. Assessment of right ventricular function (Mid oesophageal 

four chamber view). The right sided heart structures are on the left 

and the atria are at the apex of the view. This view shows failure of the 

right ventricle with concurrent dilatation of the right atrium. 

Assessment of Cardiac Tamponade 

Haemopericardium or pericardial effusion can present with 

or without frank tamponade. The classical clinical signs of 

tamponade may not be present in the mechanically ventilated 

patient. Further diagnostic difficulty may arise because 

the collection of blood can clot and become loculated in a 

specific area. Unclotted blood appears as an echolucent space 

encompassing under-filled or collapsed cardiac chambers. It is 

best evaluated in the four-chamber and transgastric mid short 

axis views (Figure 4). It is graded as small (2cm). As little as 1cm has been shown to 

cause tamponade [46]. 

Figure 4. Pericardial effusion and tamponade of the heart (Transgastric 

mid short axis view) 

Assessment of Valvular Function 

The mitral valve (MV) and aortic valve (AV) are at a greater risk 

of traumatic injury than right-sided valves because of the higher 

pressures in the left side of the heart [42]. The aortic valve is the 

most vulnerable to trauma, with laceration or detachment of the 

cusps from the aortic annulus occurring [43]. The four standard 

views for systematic examination of the AV are: mid-oesophageal 

AV short axis and long axis views; deep transgastric long axis view; 

and transgastric long axis view. The most common traumatic 

injury to the mitral valve is rupture of the chordae tendinae and 

papillary muscles [47]. Examination of the MV and its apparatus 

requires four standard mid oesophageal views and two transgastric 

views. Each valve should be assessed using 2D imaging, colour 

flow Doppler and spectral Doppler. The normal area of the AV 

is 2.5 cm 2 and that of the MV is 4-6 cm 2 with pressure gradients 

across them being


attributed to the combination of hypovolaemia, increased LV 

contractility and reduced afterload. Clinically, it can result 

in collapse of the patient and requires urgent management 

with intravenous fluids, vasopressors and beta blockade. The 

latter treatment is quite distinct from routine management of 

haemodynamic instability. 

Assessment of the Aorta 

TOE is becoming the tool of choice for the diagnosis of aortic 

dissection and the evaluation of its complications due to its 

high sensitivity and specificity [11-14]. Dissection involving 

the proximal aorta is best assessed in the mid oesophageal AV 

long axis view. An intimal flap may be seen to moving freely 

within the proximal aorta and can prolapse through the AV 

into the outflow tract. Entry and exit points may be identified 

using colour flow Doppler. The diagnosis is complicated 

when the false lumen contains haematoma, with the only 

echocardiographic finding being thickening of the wall of the 

aorta. Various imaging artifacts can resemble dissection of the 

aorta, including the presence of the innominate vein in the 

upper oesophageal aortic arch view. 

Rupture of the aorta is associated with deceleration injury. 

The common site of injury is the isthmus, where the aorta is 

tethered by the ligamentum arteriosum just distal to the origin of 

the subclavian artery. However, the site of rupture can vary and 

it is recommended that the whole of the aorta from the arch to 

the diaphragm is examined. The aorta is imaged in the short and 

long axis views, starting in the upper oesophagus and its course 

followed distally. The screen depth should be reduced to 6cm. 

The echocardiographic image of rupture is typically an intimal 

flap with a characteristic free edge (Figure 5). The aorta is usually 

surrounded with haematoma and a false aneurysm may be seen. 

The diameter of the aorta should decrease from the arch to the 

proximal descending aorta, with even a small increase raising 

suspicion of rupture. 

Figure 5. Dissection of the descending thoracic aorta with intimal flap 

(Descending thoracic aorta short axis view) 

Assessment of Pleural Cavities 

Aerated lung tissue is poorly visualised with echocardiography, 

but pleural spaces and pleural fluid can be seen. The left pleural 

space is in the far field beyond the descending thoracic aorta in the 

long and short axis views of the descending aorta. In the short axis 

view a pleural effusion is seen as an echo-free space in the shape of 

a tigers claw (Figure 6). The right pleural space is in the right field 

376 


beyond the mid-oesophageal four chamber view. Pleural effusions 

can cause compression of the heart and haemodynamic instability 

if larger than 1.5 litres. 

Figure 6. Left pleural effusion (Descending thoracic aorta short axis 

view) 

Ventricular Septal Rupture 

Rupture of the ventricular septum can be a direct consequence of 

the trauma or a late complication of infarction of the myocardium. 

The defect is best identified with the application of colour flow 

Doppler across the septum. A turbulent jet on the RV side of the 

septum or a region of flow acceleration on the LV side is diagnostic. 

Associated findings may include: biventricular dysfunction; 

tricuspid regurgitation; and pulmonary hypertension. It should 

be remembered that a defect in the apex may be missed if the view 

of the ventricle is foreshortened. 

Safety of Transoesophageal Echocardiography 

This is an invasive form of imaging, but complications are 

infrequent provided the contra-indications are respected and 

care is exercised during manipulation of the probe. In three 

large surveys the incidence of complications associated with 

the procedure ranged from 0% to 0.5%, with only one death 

being reported. [20, 49, 50] This rate has been consistently 

quoted and is comparable to the complication rate of 

0.08% to 0.13% associated with upper gastrointestinal tract 

endoscopy [51-53]. The most frequently reported symptom 

is odynophagia (Table 2). Haemorrhage and oesophageal 

perforation occur infrequently and are more likely to occur 

in patients with pre-existing upper gastrointestinal pathology. 

As a consequence, insertion of the probe is avoided in patients 

with proven or suspected upper gastrointestinal pathology. The 

management of patients presenting with mild dysphagia in the 

absence of proven pathology is controversial. However, there 

is evidence that these patients tolerate the procedure; under 

the proviso insertion of the probe is performed cautiously and 

terminated if resistance is met [54]. Failure to insert or advance 

the probe has been reported to occur in 0.7% of sedated adult 

patients [49] and in 0.8% of anaesthetised patients [50]. This 

is associated with an increase in the incidence of injury to the 



COMPLICATION INCIDENCE (%) 

Odynophagia 0.1 

Swallowing abnormality 0.01 

Oesophageal abrasions 0.06 

No associated pathology 0.03 

Upper gastrointestinal 

haemorrhage 

0.03 

Oesophageal perforation 0.01 

Dental injury 0.03 

Endotracheal tube 

malposition 

0.03 

Table 2. Complications associated with TOE [50]. 

oropharynx and odynophagia [55]. It is widely accepted that 

the procedure should be abandoned rather than risk injury to 

the patient. 

It has been suggested that prolonged contact of the probe with 

the oesophageal mucosa can result in pressure necrosis. It is further 

proposed that thermal injury from vibration of the piezoelectric 

crystals may be deleterious [55, 56]. Although these hypotheses 

have not been supported in animal studies [56], it may occur in 

patients suffering from circulatory compromise [57]. 

Misinterpretation of the echocardiography data is an obvious 

risk, which is why the Association of Cardiothoracic Anaesthetists 

(ACTA) and the British Society of Echocardiography (BSE) 

have established a rigorous program for accreditation in 

echocardiography. 

Accreditation in Transoesophageal 

Echocardiography 

The Association of Cardiothoracic Anaesthetists (ACTA) and 

the British Society of Echocardiography (BSE) have jointly 

developed a process for training and accreditation in TOE in 

the UK [58]. It is not a compulsory or regulatory certificate 

of competence. The model is similar to that produced by the 

BSE for accreditation in transthoracic echocardiography and 

is designed to include all specialities that utilise TOE. The 

accreditation process consists of the compilation of a logbook 

and a written examination [59]. A logbook of 125 TOE 

studies should be collected and reported on over a period of 24 

months. Ten of these cases, with full reports, should be retained 

electronically. A supervisor is appointed by the BSE to oversee 

the compilation of the logbook and to certify the clinical 

practice of the candidate. The written examination consists 

of 125 single best answer questions covering the range of the 

syllabus. The BSE states that the attainment of accreditation 

is a minimum standard and candidates will be expected to 

begin a process of continuing medical education towards reaccreditation. 

The re-accreditation process will include evidence 

of continuing clinical activity, distance learning and attendance 

at courses and conferences. 

Conclusion 

TOE equipment is evolving. Currently emphasis is being 

placed on the development of real time 3-dimensional imaging 

and miniaturisation of the probe. It is envisaged that this will 

improve portability and simplify the process for acquisition and 

interpretation of the images. The increasing availability of TOE 

equipment in the civilian sector combined with a structured 

training process means that it may become a routine tool in the 

peri-operative management of unstable trauma patients. 

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Accessed June 30, 2010 


The Triservice Anaesthetic Apparatus: A Review 

RS Frazer 1 , DJ Birt 2 

1 Consultant in Anaesthesia, SO1 Clinical, HQ 2 Med Bde, Strensall, York; 2 Consultant in Anaesthesia, MDHU 

Derriford, Derriford Hospital, Plymouth. 

Abstract 

The Triservice Anaesthetic Apparatus was designed around 30 years ago as a robust and highly portable anaesthesia delivery 

system for medical support to airborne operations and it has been the core anaesthesia system for the Defence Medical Services 

since then. Over this period there have been a number of equipment changes but issues remain which are in part mitigated by 

recent training developments. This article reviews these changes and developments and considers the future of this equipment. 

Introduction 

The Triservice Anaesthetic Apparatus (TSAA) was designed by 

Brigadier Ivan Houghton to improve the provision of surgical 

services to 23 Parachute Field Ambulance and was first described 

in Anaesthesia in 1981 [1]. It was designed to be robust, portable 

and minimally dependent on resources. Over the years it has been 

modified and although it has been replaced by a conventional 

anaesthetic machine at the UK deployed R3 facility in Camp 

Bastion, it remains in service as the Defence Medical Services 

(DMS) core anaesthetic equipment for contingent Operations. 

This article describes the history of the TSAA, its components 

and philosophy of use. We will highlight developments and issues 

over the years. 

Draw-over Anaesthesia 

The delivery of anaesthesia in austere environments, including 

military operations depends on equipment with a minimal 

requirement for resources and infrastructure. For example, 

compressed gas cylinders are heavy, cumbersome and dangerous 

to move and, although a modern field surgical team would not 

have to exist without electricity, anaesthetic equipment that can 

continue to function during an interruption in supply is clearly 

an advantage. Table 1 lists suggested characteristics of anaesthetic 

equipment for use in austere environments. Regional and total 

intravenous anaesthesia also meet a number of these requirements 

but draw-over techniques maintain their popularity amongst the 

increasing competition. 

• Minimal reliance on compressed gases and electrical 

supplies 

• Robust 

• Compact and portable 

• Simple to operate 

• Able to withstand climatic extremes 

• Easily maintained and serviced 

• Economical in use 

• Versatile in the use of volatile agents 

• Versatile with regard to patient age/size 

Table 1. Anaesthetic system requirements for austere environments 

Corresponding author: Lt Col RS Frazer, SO1 Clinical, 

HQ 2 Med Bde, Strensall, York. YO32 5SW. 

Tel: 01904 442611 Fax: 01904 442689 

Email: scottfrazer@doctors.net.uk 

In its simplest form draw-over anaesthesia requires a suitable 

vaporiser and a one-way or non-return patient valve. In contrast to 

conventional anaesthetic machines which pass gases under pressure 

through flow meters and a vaporiser, draw-over systems rely on 

atmospheric air, usually enriched by oxygen, as the main carrier 

gas. During draw-over anaesthesia the patient’s respiratory effort 

moves air through the vaporiser in proportion to their minute 

ventilation. This requires a very low resistance system and the 

ability to maintain vapour output despite wide variations in flow. 

The TSAA 

There are still a number of draw-over vaporisers available for 

use. Examples include the Epstein-Macintosh-Oxford (EMO), 

the Ohmeda Portable Anaesthesia Complete (PAC) and the 

Oxford Miniature Vaporiser (OMV, Penlon, Oxford, UK). 

Despite the overwhelming numerical superiority of plenum 

vaporisers worldwide, developments in drawover vaporiser 

design continue [2]. 

Figure 1: The OMV50 

The TSAA is designed around a modified OMV50. This has 

a capacity of 50mls of volatile agent, three fold-out “feet” and an 

interchangeable concentration indicator scale (Figure 1). Although 

some drawover vaporisers are temperature compensated, the 

OMV50 is described as thermally buffered. Changes in vapour 

output with temperature are smoothed by the mass of metal in the 

vaporiser and the presence of “Forlife” antifreeze in the base. As 

originally described two OMVs were used in series, one delivering 

halothane and the other trichloroethylene (TCE). This combined 


The Triservice Anaesthetic Apparatus RS Frazer, DJ Birt 

the analgesic properties of TCE with the anaesthetic properties 

of halothane. Reversible calibrated indicator scales were fitted for 

these 2 agents. Subsequently scales became available for Isoflurane 

and this has been the agent of choice in later years. 

Circuit 

The other key component of any drawover anaesthesia circuit 

is the one-way patient valve. Although a number of options are 

available, Brig Houghton chose a Laerdal valve which was part 

of a set including a Self-inflating Bag (SIB), which provided the 

means for manual ventilation. The system is still in existence 

today as the Resuscitator® (Laerdal Medical Ltd, Orpington, 

UK). In order to appropriately extend the circuit, corrugated 

silicone rubber tubing is used (Figure 2). Silicone rubber was 

originally specified because it was autoclavable, but it makes for 

a heavy system by modern standards. It should be noted at this 

stage that all of the connections in the circuit have cagemount 

(23.1mm) fittings (although the OMV50 can be supplied with 

22mm fittings if required). 

Figure 2: A common configuration for spontaneous respiration. For 

clarity the monitoring set-up is not shown. 

Although a number of variations are possible, the most common 

arrangement for spontaneous respiration is described here (Figure 

2). From the patient end, the one-way valve is connected to 

the SIB by a length of corrugated cage-mount tubing, the SIB 

is connected to the OMV50s by another length of tubing and 

upstream of the OMVs is a T-piece to allow the connection of 

supplementary oxygen followed by another length of corrugated 

tubing to act as a reservoir. 

Additional Components 

The ventilator 

For mechanical ventilation, the original circuit simply replaced 

the SIB with an in-line ventilator such as the Penlon Oxford 

or the Cape TC 50. Following the Gulf war the Pneupac ® 

CompPACTM ventilator (Smiths Medical, Ashford, Kent, U.K.) 

was designed and replaced the TC50. It is a robust, relatively 

compact, time cycled, volume preset flow generator with an I:E 

ratio of 1:1.8 and can deliver minute volumes between 6 and 14 

litres per minute at rates of 10 to 30 breaths per minute. It can 

be powered by its internal air compressor using mains voltage, 

a vehicle supply or the internal battery. It is possible to deliver 

oxygen enrichment to a port at the rear of the machine when the 

delivered FiO 2 can be calculated using a nomogram attached to 

the side of the ventilator. It can also be driven from an external 

compressed oxygen supply (e.g. in the Emergency Department) 

when it can provide an inspired oxygen fraction of 0.45, if 

switched to “airmix”, or 1.0 on “no airmix”. This is the only way 

to deliver 100% oxygen with the ComPACTM 200. 

Figure 3: A common configuration for mechanical ventilation 

When used with the TSAA the Sanders T-piece is kept in circuit 

to supply oxygen rather than the options above. The ventilator is 

used to provide a gas piston from the distal end of the circuit 

which is described colloquially as the “pushover” arrangement. 

The output from drawover vaporisers and for the OMV is similar 

in both arrangements [3]. As shown in Figure 3, the SIB must 

be removed from the circuit during mechanical ventilation due 

to its compliance and the tendency for the system to predispose 

to ”breath stacking”. This latter situation is due to a pressurised 

bolus of air being held between the one-way patient valve and 

the valve in the rear of the SIB: although ventilation occurs in 

inspiration, expiration is not possible. A detailed description of 

the operation of the CompPACTM 200 is beyond the scope of 

this article but may be found in the article by Roberts et al [4]. 

DeVillbis Oxygen Concentrator 

Although the circuit can be supplied from an oxygen cylinder, 

in recent years it has been more usual to take this supply from 

an oxygen concentrator. Oxygen concentrators commonly use 

the properties of zeolite. The granules selectively absorb nitrogen 

from air under pressure, leaving a higher concentration of oxygen 

in the remaining gas, the zeolite is regenerated later in the process. 

The DeVillbis concentrator (DeVillbis, Somerset, Pennsylvania) 

has a maximum output of 5 litres/ minute producing an oxygen 

concentration of up to 95%. The device is simple to use the only 

controls being an on/off switch and a flow knob for the rotameter. 

There are warning lights for oxygen concentration and an audible 

alarm if the oxygen output is less than 75%. At normal minute 

volumes, inspired oxygen concentrations of up to 80% are 

achievable with the concentrator at maximum flow. 

Monitoring 

Although a luxury in the developing world, modern monitoring 

is an absolute requirement for DMS anaesthetists. The current 

monitor is the Datex-GE S5 Compact (GE Healthcare, Chalfont 


The Triservice Anaesthetic Apparatus 

St Giles, UK). It allows advanced monitoring of anaesthetic gas 

mixtures and has improved the safety of the TSAA more than any 

other recent development. 

Common Modifications and Clinical Strategies 

Alternative Reservoir 

Unlike a conventional anaesthetic circuit there is little visible 

indication of respiration when using the TSAA. The final upstream 

piece of corrugated tubing acts purely as a reservoir but does 

not give any indication of spontaneous breathing. The Laerdal 

resuscitator 2.6L collapsible reservoir bag can be attached in its 

place to act as a crude respiratory monitor. It includes protective 

valves to allow entrainment and to protect against overpressure 

[5]. Figure 4 illustrates this setup. 

Figure 4: Use of the reservoir bag to indicate spontaneous respiration. 

Note also the alternative oxygen supply arrangement. 

The Revised Laerdal Resuscitator 

A recent change in the design of the Laerdal resuscitator has 

made the new model incompatible with the original TSAA 

configuration. Assembly with the new model requires the 

“pushover” arrangement with the SIB and its reservoir bag 

connected to the distal (upstream) end of the OMVs (Figure 5) 

Figure 5: Laerdal Resuscitator®: the new version is on the right 

382 

RS Frazer, DJ Birt 

Paediatric Modification 

The non-return valve offers little resistance and TSAA has been 

found to be safe in its original configuration for children of 10 kg 

and over [6]. For smaller children, the OMVs can be converted 

into a crude continuous flow anaesthetic machine for use with a 

Mapleson F system. To provide an overpressure blow-off valve, an 

APL valve can be attached via a short length of corrugated tubing 

to the upstream end of the T-piece. Oxygen and other gases are 

introduced into the system via the T-piece to fill the Jackson-Rees 

bag and allow spontaneous breathing or hand ventilation. This is 

illustrated in Figure 6 and described in more detail in the recent 

article by Ralph et al [7]. 

Figure 6: Setup for paediatric anaesthesia using an APL valve 

Preoxygenation 

Preoxygenation is normally undertaken with a supply from an 

oxygen cylinder in addition to the concentrator due to the limited 

flow from the latter device. This can be achieved by connecting 

the SIB to the cylinder and the T-piece to the concentrator. A 

disadvantage with this approach is that inadvertently leaving 

the cylinder supply on results in significant dilution of volatile 

agent and therefore awareness is likely. This is only the case where 

the SIB is in circuit so it should not be seen during established 

mechanical ventilation. A popular alternative is to connect both 

oxygen sources to a 3 way connector (typically a Luerlok 3-way 

tap) which is joined to the T-piece. As both supplies are upstream 

of the OMs, dilution of volatile agent is not seen. 

In preparation for induction, preoxygenation is achieved 

with both oxygen sources feeding into the circuit and the SIB 

connected. Anaesthesia is induced in the usual fashion and hand 

ventilation may be started using the SIB. For maintenance, the 

SIB is removed, the cylinder supply switched off, the ventilator 

tubing connected and mechanical ventilation begun. An 

alternative approach for RSI only is to preoxygenate and induce/ 

intubate with the Bag-valve-mask separate from the rest of the 

circuit which avoids the potential to leave the SIB in circuit 

during IPPV as well as the potential for dilution of volatile agent 

if the cylinder supply is left running. 

Volatile Agents and Gas Induction 

Although isoflurane is normally used in the OMV50, as it is a 

“universal” vaporiser a number of anaesthetists have looked 

at the possibility of using sevoflurane. Liu & Dhara tested the 

vaporiser on a flow-bench and suggested that the output should 


The Triservice Anaesthetic Apparatus RS Frazer, DJ Birt 

be suitable [8]. Brook and Perndt subsequently used sevoflurane 

clinically and stated that it was possible to perform an inhalation 

induction with two vaporisers [9] but the modern penchant for 

gas induction with sevoflurane has been difficult to satisfy with 

the TSAA. The OMV was designed when the relatively potent 

halothane was the volatile agent of choice and maximum outputs 

are limited when 4 MAC of sevoflurane is the target. Results are 

conflicting but the original TSAA does not appear to lend itself 

to this technique [10]. Sevoflurane has been used in the Universal 

PAC [11] and more recently Diamedica (Diamedica (UK) Ltd, 

Bratton Fleming, Devon, England) has developed a sevoflurane 

vaporiser which for the first time appears to produce a sufficient 

output for inhalational induction using a single vaporiser in a 

drawover system [2] 

Common Pitfalls 

The TSAA is not without its problems and has many critics. It is 

generally agreed that there is still a need for a portable drawover 

anaesthetic system to be available to the UK military [12] but 

the original TSAA is overdue for replacement. It has a number of 

particular problems: 

Disconnections and practical hazards 

Unfamiliarity, heavy tubing and complex procedures for changing 

configurations all contribute to the hazards of using the TSAA. It 

is a useful system for insertion and mobile operations but should 

not be the first choice equipment for an enduring mission. This 

was highlighted in January 2009 when a Patient Safety Incident 

report was submitted from Op HERRICK to PJHQ regarding 

the TSAA. The concerns identified included the potential for 

disconnection due to the number of connections in the circuit 

and the lack of familiarity amongst multi-national personnel. 

Scavenging 

Active scavenging is rarely available in the field so volatile agents 

are usually scavenged by activated charcoal in the form of a 

Cardiff Aldasorber (Shirley Aldred & Co Ltd, Derbyshire, U.K.). 

This adds to the hardware at the patient end as a scavenging 

connection must be made to the outlet of the non-return valve. 

Consumption of Volatile Agent 

Recycling of volatile agents cannot be achieved with the TSAA so 

consumption is high. Furthermore, as the capacity of the OMV is 

low refilling of vaporisers during anaesthesia is a common event. 

The presence of two vaporisers allows maintenance of anaesthesia 

but care must be taken to avoid disruption of the system, spillage 

and boluses of volatile to be delivered inadvertently. 

Dead Space 

Although it has improved safety, the addition of patient 

monitoring, spirometry, scavenging and heat and moisture 

exchange have increased the length of the TSAA beyond the nonreturn 

valve by an significant amount. This increases dead space 

and the potential for disconnections. That said, such additions 

would be needed on any modern anaesthetic system. 

Training 

Training on the TSAA has been difficult since the demise of 

the military hospitals and the reluctance of NHS Trusts to use 

equipment which is unconventional. Although it is possible to 

view the equipment at the pre-deployment Hospital Exercise 

(HOSPEX), because of fidelity limitations it is not the ideal 

location to simulate an anaesthetic with the equipment. In view 

of these short comings a high fidelity simulation course has 

been developed. The requirement to actually give an anaesthetic 

to a mannequin which would be monitored by the equipment 

that is deployed meant that only the physiologically modelled 

mannequin, METI HPS® was suitable and a contract has been 

established with the Cheshire and Merseyside Simulation Centre 

to deliver the training. 

On the one-day course the team is initially introduced to the 

TSAA and to the capabilities of the simulator as familiarisation 

is also important for effective non-technical skills. Subsequently 

four scenarios are run with one or more anaesthetists and an ODP. 

Each scenario has been designed with input from military Subject 

Matter Experts and the civilian simulation staff to combine 

realistic medical and equipment related problems and to explore 

the team dynamics in critical problem solving. 

Allied Approaches to Drawover Anaesthesia 

US forces have also used a draw-over apparatus for light scales of 

effort. Their system has been based around the Ohmeda Universal 

PAC. This vaporiser has some differences from the OMV, the 

main one being that it is temperature compensated. At present US 

forces still make use of it but are actively seeking a replacement 

because manufacture of the PAC has ceased. 

The Australian Defence Force use draw-over equipment 

also and the system they have chosen is also based around the 

OMV50. This has been developed into a set of equipment such 

that, although the OMV is not CE marked, the entire setup has 

been given type approval. It is the Field Anaesthesia Machine 

(FAM 100) manufactured by Ulco Medical (Marrickville, NSW, 

Australia) [11]. 

Conclusion 

The TSA was first described in 1981 as the ideal anaesthetic 

apparatus for airborne and amphibious entry operations. Some 

equipment changes have been necessary over the years but the 

original requirement for robust, portable equipment is unchanged. 

That said, anaesthesia no longer has to depend on volatile agents. 

Robust, lightweight and accurate intravenous pumps are available 

with long battery lives for TIVA and this also removes the need for 

scavenging. Although TIVA is increasing in popularity, especially 

for repeat procedures, the support for volatile agent based 

anaesthesia remains strong. Indeed the position of conventional 

anaesthesia worldwide, especially from drawover apparatus in 

austere environments is such that new equipment is still being 

developed. 

The DMS is likely to maintain a drawover volatile anaesthesia 

capability especially for entry operations and this is widely 

supported by Defence Anaesthetists. This article highlights a 

number of areas where the TSAA fails to satisfy the expectations of 

DMS Anaesthetists and in a number of cases causes real concern. 

The disconnection risks, unfamiliarity and lack of CE marking 

of the OMV50 are examples. The issue of CE marking is an 

interesting one as there is no CE standard for drawover vaporisers. 

It is, however, possible for a set of equipment (including a drawover 

vaporiser) to obtain CE certification (e.g. the FAM 100). The 

above concerns suggest that a replacement is required but many of 

the original features of the TSAA are still relevant. Any replacement 

must be compact, lightweight and robust. It is difficult to envisage 

a modern field surgical unit without electricity, but an anaesthetic 


The Triservice Anaesthetic Apparatus 

apparatus that is independent of compressed gas supplies would 

be preferable. 

Although the replacement for the TSAA is yet to be identified, 

options exist and are being examined. In the meantime potential 

users must be aware of the issues highlighted in this article 

and ensure that they are appropriately trained in its use before 

deployment. Instruction from experienced users is available on 

pre-deployment training courses. 

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Vascular Access on the 21 st Century Military 

Battlefield 

EJ Hulse 1 , GOR Thomas 2 

1 Specialty Registrar in Anaesthetics, Royal Cornwall Hospital, Truro, Cornwall; 2 Honorary Consultant Anaesthetist, The 

Royal London, and Queen Victoria’s Hospital, East Grinstead, London & 16 Air Assualt Medical Regiment. 

Abstract 

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It 

allows the administration of emergency drugs, analgesics and rapid replacement of blood volume. Methods used to gain access 

can include; the cannulation of peripheral and central veins, venous cut-down and intraosseus devices. This article reviews the 

current literature on the benefits and complications of each vascular access method. We conclude that intraosseus devices are 

best for quick access to the circulation, with central venous access via the subclavian route for large volume resuscitation and 

low complication rates. Military clinicians involved with the care of trauma patients either in Role 2 and 3 or as part of the 

Medical Emergency Response Team (MERT), must have the skill set to use these vascular access techniques by incorporating 

them into their core medical training. 

Introduction 

Timely and appropriate access to the vascular circulation is 

critical in the management of 21 st century battlefield trauma. 

This essential procedure allows the administration of emergency 

drugs, analgesics and rapid replacement of blood volume using 

crystalloid, colloid or blood products. It encompasses the 

cannulation of peripheral and central veins, venous cut-down 

and intraosseus (IO) devices. 

The type of access employed in any given situation will be 

determined by the skill of the operator, the environment in which 

it is used, the degree of hypovolaemic shock and the extent and 

pattern of injury. Gaining access to the human vascular system 

has been practised for millennia, most notably for bloodletting 

procedures believed to improve health [1, 2]. IO access was first 

documented by Drinker in 1922 [3], but it was during the Second 

World War that IO infusions were more widely used to resuscitate 

patients in haemorrhagic shock [4]. After the war, it’s use largely 

died out in the adult population, but has seen resurgence during 

the Iraq and Afghanistan conflicts with the introduction of 

modern needle and introducer systems [5]. 

The Sapheno-femoral venous cut-down was popularised 

during the Vietnam conflict to manage casualties with severe 

haemorrhagic shock [6]. 

During the recent conflict in Iraq and Afghanistan the use of 

large bore central venous access (Figure 1) has been popularised 

by experienced military trauma clinicians. This has been driven 

by the severity of today’s battlefield casualties and the requirement 

for large volume fluid resuscitation. This is often used in 

conjunction with the transfusion protocol advocated by Borgman 

and colleagues [7] using the ratio of 1 bag of red cells: 1 bag of 

plasma in the shocked trauma patient [8-11]. 

Flow 

Flow through a vessel or tube is determined by Poiusselle’s 

equation describing laminar flow: 

Corresponding Author: Surg Lt Cdr Elspeth J Hulse MBChB 

FRCA, Specialty Registrar, Anaesthetics Department, 

Derriford Hospital, Plymouth PL6 8DH 

Tel: 0845 155 8155 Email: elspeth_uk@hotmail.com 

Figure 1: Size 9 French Cook Introducer central venous catheter which 

can be used for high volume fluid resuscitation 

With kind permission from Cook Medical 

Q = ΔP π r 4 

8ηl 

Q = Flow rate ml/min, P = Pressure gradient between the proximal 

and distal ends of the tubing, r = radius of the tube, η = viscosity, 

l = length of the tube. 

Importantly, if you double the diameter of the cannulae, the 

flow rate increases by a factor of 16. To aid flow, the venous 

cannulae and connecting tubing must be short and wide, the 

fluid administered warm, pressurised and the viscosity of the 

fluid reduced [12]. Although Poiseuille’s law demonstrates the 

principles of flow, the actual flow rate of fluid under pressure is 

determined by a quadratic equation which takes into account 

the development of turbulence. Barcelona et al surmised that 

this partly explained why even large bore catheters are not 

capable of delivering the flows predicted using Poiseuille’s 

equation [13]. 


Vascular Access 

386 

Device Internal 

Radius (mm) 

Length 

(mm) 

Flow Rate 

Gravity 

ml/min 

(3.2mm 

tubing) 

Hartmann’s/ 

H 2 O 

Intraosseous Access 

Many British casualties from the recent conflicts in Iraq and 

Afghanistan present with severe haemorrhagic shock associated 

with multiple traumatic limb amputations from improvised 

explosive devices. In these situations IO can be utilised with 

substantial effect. The intravenous (IV) or IO route is now 

accepted as first line access in paediatric resuscitation by the 

UK Resuscitation Council [18]. The Defence Medical Services 

(DMS) currently have two IO systems in place; The EZ-IO® and 

the FAST 1®. 

EZ-IO® System 

The EZ-IO® system (Vidacare, SanAntonio,USA) was introduced 

into UK DMS in December 2006. It consists of a battery 

powered disposable drill, a bevelled, hollow needle with a cutting 

needle central trocar and a short connection tube (with a one 

way valve) for fluid /drug administration. There are three needle 

sizes and the insertion point is just below and medial to the tibial 

tuberosity on the upper flat aspect of the tibia. EZ-IO can also be 

inserted into the lateral aspect of the humeral head or iliac crest. 

Contraindications are rare, but EZ-IO should not be inserted into 

a fractured bone to avoid extravasation into soft tissues or through 

infected tissue. 

FAST 1 IO 

The FAST 1® sternal IO device (Pyng Medical Corporation, 

Richmond Canada) is designed exclusively for use in the 

manubrium sternum (Figure 2) and has advantages of rapid, 

Flow Rate 

300mmHg 

ml/min 

(3.2mm 

tubing) 

Hartmann’s/ 

H 2 O 

Flow rate 

300mg 

ml/min 

(5.0mm 

tubing with 

filter) 

Blood 

Level 1 

Infuser 

(300mm Hg) 

Ml/min 

Hartmann’s 

EJ Hulse, GOR Thomas 

Rapid 

Infusion 

System 

(approx 

285mm Hg) 

ml/min 

Hartmann’s 

20G venflon 0.423 32-33 40 - 67 n/a n/a 140 144 

18G Venflon 0.515 45-52 103 n/a n/a 209 205 

16G 

venflon 

14G 

venflon 

10G 

Angiocath 

0.705 45-55 151+/-3 - 236 448+/-19 444+/-25 368 412 

0.895 45-64 194+/-5 - 270 577+/-22 779+/-39 488 584 

2.25 76.2 162 496 1,248 n/a n/a 

8 French 2.2 160.02 162 492 1,200 n/a n/a 

8.5 French 

(Arrow) 

Sternal IO 

(FAST) 

Tibial IO 

EZIO 

Humeral IO 

EZIO 

1.43 112 245+/-4 645+/-20 1,622+/-120 596 857 

n/a 6 17.9+/-9.1 

(30-80) 

15G 25 

Paed 15 

15G 25 

Paed 15 

104.1+/-46.5 

- 125 

Table 1: Flow rates of vascular devices [12- 17] – The manufacturers’ details are marked in bold. 

n/a n/a n/a 

68-73 165-204 n/a n/a n/a 

81-84 148-153 n/a n/a n/a 

easy to locate placement, reasonable flow rates (Table 1), can 

be used during cardio-pulmonary resuscitation and has low 

risk of dislodgement. The device is not MRI compatible and is 

contraindicated in sternal fractures. 

Figure 2 : Photo of FAST 1® sternal insertion. 

With kind permission from Trauma.org 

Using the adhesive guide, the FAST is inserted perpendicular 

to the manubrium made possible by the 10 guide needles 

surrounding the I/O which will only release the cannulation 

mechanism when the pressure in all 10 needles is equal. The 


Vascular Access EJ Hulse, GOR Thomas 

rationale for having 2 different IO systems is that multiple ballistic 

or fragmentation limb injuries are common and may preclude 

the use of EZ-IO. However, the large ballistic chest plate usually 

protects the sternum. Teaching is simplified by indicating that 

FAST1 is only for sternal placement and the EZ-IO for anywhere 

but the sternum. In the authors’ experience the preferred sites of 

IO access are ideally tibial, then humeral followed by sternal. 

Complications 

Operation of the EZ-IO device is intuitive and insertion times are 

fast with most operators being able to insert an IO in less than 10 

seconds. Published DMS experience involving EZ-IO for vascular 

access for 26 patients demonstrated 97% effective function. No 

complications of infection were noted, but pain was observed in 

responsive patients with the pain of infusion exceeding that of 

their underlying injuries in three cases [5]. This was also reported 

by Davidoff et al who noted the average pain upon fluid infusion 

was rated as ‘5’ on a modified visual analogue scale (1-10) [19]. 

From the authors experience this is indeed correct, however pain 

decreases markedly after completion of the first fluid flush. 

Frascone et al evaluated provider performance for obtaining 

IO access with the FAST1 and the EZ-IO and noted that 72% 

of FAST1 and 87% of EZ-IO were successful. EZ-IO (p=0.009) 

[20]. An interesting study was performed by Suyama et al 

comparing EZ-IO and peripheral intravenous cannulation in full 

personal protective equipment simulating a Chemical-Biological- 

Radionuclear (CBRN) environment. In all the scenarios the IO 

was found to be both faster and easier at gaining access [21]. 

The most notable and recent complications with the FAST1 

have involved difficulty in removing the needle, some of which 

required surgery in order to extract. The device has apparently 

been modified so that no removal tool is required and the infusion 

tube can be pulled out by hand [22]. Although the observed risk 

of infection is low, this can take the form of cellulitis or in more 

severe forms osteomyelitis [23]. When the tibia is used as an IO 

site it has been reported that occasionally fluid resuscitation can 

lead to compartment syndrome in children [24]. 

Other potential but not as yet reported complication is 

the use of the IO in patients with an unstable pelvis. In the 

authors opinion the practice of insertion of IO’s in patients at 

high risk of pelvic instability (Blast/Blunt trauma from victim 

operated explosive device) is potentially dangerous and should be 

discouraged. Misplacement of IO’s also seems to be increasingly 

common especially with the humeral approach. Common causes 

for this are: haste, patient movement on transfer, lack of training 

and not doing the ‘wiggle test’ (if the IO wiggles it’s not in). 

Peripheral venous access 

Combat medics, nurses, doctors and other health professionals are 

trained to place intravenous peripheral cannulae. An experienced 

practitioner takes a mean of two minutes to cannulate a patient 

in the Emergency Department [25] , but in a case series over 

120, 000 procedures, gaining intravenous access (IVA) in the 

pre hospital setting was associated with an increase in on-scene 

duration of between 3.17 - 5.4 minutes [26]. 

Site 

Peripheral venous cannulae are usually sited in the dorsal 

metacarpal veins, tributaries of the basillic and cephalic veins in 

the forearm or ante-cubital fossa. The external jugular vein may 

also be utilised in arrest situations [27]. Battlefield advanced 

trauma life support (BATLS) recommends that two attempts 

should be made to secure two 14G cannulae [28]. In cases of 

severe multi-trauma in which occult thoraco-abdominal damage 

is suspected, it is recommended to secure IV access both above 

and below the diaphragm and as close to the heart as possible. 

These measures attempt to secure a route to deliver fluid and 

medications to the central circulatory system with minimal risk 

of disruption [29]. IV access should ideally not be placed in limbs 

with massive oedema, burns, sclerosis, phlebitis, thrombosis or on 

the side of radical mastectomies. Cannulation at sites of cellulitis 

or extremities with shunts or fistulas should be avoided because it 

may cause bacteraemia or thrombosis [30]. 

Complications 

Common complications include bruising, irritation, failure, 

haematoma, thrombophlebitis and extravasation of fluids or 

drugs causing pain and irritation to the surrounding tissue [29]. 

Tricks 

Methods to increase peripheral venous distension include asking 

the patient to open and close their fist, light tapping of the vein, 

lowering the arm below the level of the heart and heat packs 

applied for 10 to 20 minutes [30]. A technique for up-gauging 

peripheral venous cannulae in volume resuscitation has been 

described whereby an initial small cannulae is inserted into a 

limb, and whilst the tourniquet remains up, 30-50mls of saline is 

injected into the veins via this cannulae. This then allows a large 

bore cannulae >18G to be inserted into the same limb [31]. Small 

cannulae can also be up gauged using a Rapid Infusion Catheter 

which employs the Seldinger (guidewire) technique. 

The use of Ultrasound (US) guided peripheral IVA has shown 

to be of use and superior to external jugular IVA in the Emergency 

Department when IVA is difficult [32]. A review of the literature 

has shown that it requires less time, decreases the number of skin 

punctures and improves patient satisfaction [27]. 

Venous Cut-down 

The practice of peripheral venous cut-down has declined due to 

the efficiency of the Seldinger technique for central venous access 

and limited clinician exposure [33]. 

However, in the profoundly hypovolaemic trauma patient 

where there may be distorted central anatomy, lack of femoral 

pulses and scarring of peripheral veins, it remains a useful tool. It 

enables reliable vascular access to be obtained with direct vision of 

the vein and reduces cannulae misplacement. 

Westfall found that in shocked trauma patients, venous cutdown 

took longer to perform than inserting a femoral 8.5French 

Central Venous Catheter (CVC) with a mean of 5.6 and 3.2 

minutes respectively. The cut-down also had a decreased flow rate 

(150ml/min compared to 219ml/min for CVC) [34]. Venous 

cut-down sites include the proximal and distal greater saphenous 

vein, the cephalic and basillic veins. 

The most commonly used access is the greater saphenous 

vein proximally in the groin because of its large diameter and 

ease of dissection. 

This can be reliably located 5cm distal to the junction between 

the middle and medial one third of the imaginary line between 

the anterior superior iliac spine and the pubic tubercle or by the 

“Rule of Two’s”; two fingerbreadths below and lateral to the pubic 

tubercle. These points form the midpoint of a 5cm horizontal 

incision which can also be approximated by a 5cm horizontal 



incision starting just distal to where the labia/scrotal fold meet the 

thigh [35]. A vertical venotomy in the vein can allow the passage 

of a straight wire (within the dilator) within the 8.5F CVC. 

Absolute contraindications are major blunt or penetrating 

trauma to the ipsilateral groin or limb. Complications occur in 

2-15% of cases and include haemorrhage, damage to the femoral 

artery and nerve, wound infection and dehiscence, thromboembolism 

and phlebitis [33]. 

Central Venous Access 

The first central venous catheter was pioneered by a German 

surgeon in 1928 who described advancing a plastic tube near the 

right atrium using his own left ante-cubital vein [36]. Aubaniac 

followed, when he described the insertion of a catheter using the 

subclavian vein [37]. The technique was improved by the Swedish 

radiologist, Seldinger in 1953 with use of a guidewire whose 

technique we still use today [38]. 

Obtaining central venous access is important to military 

clinicians as it is not only the most effective route for administering 

emergency drugs [39, 40], but is the quickest and most effective 

means to resuscitate haemorrhagic shock in trauma patients with 

a relatively low complication rate [41]. The 8.5F Swan introducer 

sheath for a pulmonary artery catheter (Figure 1 and 3) is 

commonly used for this purpose, delivering high volumes under 

pressure quickly (Table 1) [12, 41]. 

Site 

In the trauma setting, cannulation of the internal jugular vein 

is often impractical due to neck collar and blocks for C-spine 

protection. Also, in severely hypovolaemic casualties the internal 

jugular vein (IJV) collapses and therefore increases the risk of 

carotid puncture as 54% of people have their IJV overlying their 

carotid artery [42]. 

Figure 3 : Photo showing the insertion of a left sided subclavian 

central venous trauma line (the light blue plastic tube placed on the 

end of a blue syringe in the operators right hand). 

With kind permission of Major R Dawes. 

The subclavian vein is large and anatomically easy to locate 

in the face of hypovolaemia and so makes an ideal candidate for 

use in the trauma setting [11]. Subclavian lines should be placed 

on the ipsilateral side in the presence of penetrating trauma to 

chest wall, pneumothorax or haemothorax [8, 43]. Femoral vein 

cannulation may be complicated by arterial puncture if there is 

388 


no palpable femoral pulse [44]. It should be avoided in ipsilateral 

limb or presumed inferior vena caval injury to avoid extravasation 

[8, 44]. 

Complications 

Controversy over the use of CVC’s in trauma casualties 

exists because of the perceived increase in complication rates. 

Complications include haematoma, arterial puncture, haemo/ 

pneumothorax, malposition of the catheter, air embolism, 

line sepsis, thrombosis, embolism and thrombophlebitis. The 

most common complications in IJV catheterisation are arterial 

puncture, and pneumothoraces with subclavian cathterisation 

[8, 41]. Abraham et al [45] and Ferguson et al [43] suggest that 

success rates are lower and complication rates higher (14% and 

15% respectively) in emergent CVC placement in trauma patients. 

The decrease in central blood volume following haemorrhage and 

potential venous anatomical changes in trauma patients may 

complicate the technique [9]. 

However Pappas et al found no significant difference in 

complication rates (7.8%) between trauma patients irrespective 

of the degree of shock [10]. Scalea et al [9] noted that even in 

the presence of hypotension (

Vascular Access EJ Hulse, GOR Thomas 

Discussion 

In many patients IV therapy cannot be initiated because of 

inadequate access to peripheral veins. This lack of vascular access 

delays the resuscitation process and limits the benefit of medical 

intervention due to late administration of medications [51]. 

Both speed and overall success of vascular access are important 

when evaluating potential methodologies for their use in the prehospital 

and hospital environment. 

In critically ill paediatric patients, vascular access may 

present substantial difficulties [52]. IO access will provide a 

significant time saving which will benefit critically ill trauma 

patients, both by decreasing the time to achieve access and 

time to drug administration. In 2005 the American Heart 

Associations’ resuscitation guidelines were updated to reflect 

this and now recommends the IO route be the first alternative 

to difficult or delayed intravenous access [53]. From Table 1 it 

is clear that if rapid fluid resuscitation is required, then large 

bore IV access via the central route is preferable. However, 

there is anecdotal use of multiple IO access ports to achieve 

increased fluid administration. 

Current medical training is heavily weighted towards 

theoretical rather than practical training. Placing IV cannulae 

in haemodynamically unstable casualties with multiple limb 

amputations is very challenging even for experienced clinicians 

in ideal situations. This should be balanced against IO insertion 

which is rapid, intuitive and requires minimal training and in less 

than ideal environments. 

The current Gold Standard for resuscitation is the subclavian 

large bore 8.5 French ‘Trauma Line’. It provides rapid access, fast 

flowing large volume fluid resuscitation. This technique however 

requires skill and training which currently only a limited number 

of specialities provide. The authors feel this should be updated 

and become a core competency for military clinicians involved in 

the management of severely injured trauma casualties providing 

advanced resuscitation on the Medical Emergency Response 

Team (MERT) Role 2 and 3 hospital setting. 

Conclusion 

Vascular access in the military polytrauma patient is difficult and 

can take up precious time that could be used for fluid resuscitation 

and drug administration. 

The authors propose that to avoid delay initiating resuscitation 

in pre-hospital or hospital setting, the IO approach should be 

the first line vascular access in casualties with severe trauma. This 

is then to be augmented by two large bore peripheral cannulae 

or ideally an 8.5F central venous catheter in the subclavian vein 

depending on the experience of the practitioner and the severity 

of the injury. 

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Research and Audit

Current Epidural Practice – Results of a Survey of 

Military Anaesthetists 

KL Woods 1 , D Aldington 2 . 

1 Specialist Registrar Anaesthetics, James Cook University Hospital, Middlesbrough. 2 Consultant in Pain Medicine, Pain 

Relief Unit, Churchill Hospital. OXFORD. 

Abstract 

Objectives: As epidurals are now used for pain relief on deployment a survey was conducted to look at the current epidural 

practice of UK military anaesthetists. The aim was to identify any potential issues with regard to equipment and training to 

allow future development of pre-deployment training. 

Methods: An internet based survey was carried out. All military anaesthetists were sent an e-mail containing a link to the 

survey and the results of those who responded were analysed. 

Results: A total of 49 surveys were completed. 78% of respondents carried out epidurals more than once a month, in a 

wide range of specialities. There was considerable variation in methods of securing epidurals and in drug choice amongst 

respondents. 

Conclusions: The results of this survey show that whilst epidurals are commonly carried out amongst military anaesthetists 

during their UK practice, there is significant variation within the practice. Areas have been identified for development of 

educational courses, for example methods of securing epidurals, and these have already been acted upon. 

Introduction 

Epidurals are now carried out routinely whilst on deployment. 

However, on deployment the range and availability of equipment 

is limited when compared to the UK. As military anaesthetists 

deploy from a wide variety of hospitals within the UK and have a 

range of interests within their UK practice, it was felt that it would 

be useful to identify any potential problems that could arise from 

having to use unfamiliar equipment on deployment. Identification 

of any such problems allows training courses to be considered and 

allows deploying clinicians time to acquaint themselves with issues 

and enhance their knowledge prior to deployment. 

The aim of this survey was to look at current UK epidural 

practice amongst military anaesthetists. 

Method 

We developed a series of questions for the survey and designed 

these into an internet based survey using the Survey Monkey® 

tool [1]. Questions included frequency of insertion of epidurals, 

specialities in which they were inserted, use and type of prepacked 

epidural sets and methods of securing epidurals. Other questions 

involved drugs used within epidurals and choice of epidural 

pump. Anaesthetists were also asked the lowest age at which 

they would be happy to insert an epidural. This questionnaire 

(See right) was distributed to all military anaesthetists on the Tri- 

Service Anaesthetic Society (TSAS) mailing list with a request 

asking them to access the survey via a URL in the e-mail and 

complete the questionnaire. The results were analysed using the 

built in analysis on Survey Monkey. 

Results 

The survey was started by a total of 58 people of whom 49 

completed the questionnaire. Sadly the “true” response rate is 

impossible to judge as the invitation to complete the questionnaire 

Corresponding Author: Lt Col Aldington, FFPMRCA 

RAMC, Consultant in Pain Medicine, Pain Relief Unit, 

Churchill Hospital. OXFORD. 

1: What grade are you? 

Consultant 

Staff and Associate Specialist 

ST 5,6,7 (SpR 3,4,5) 

ST 3,4 

ST 1,2 

Other 

2: On average, how often do you carry out 

epidurals as part of your usual practice? 

More than once a week 

Once a week 

Once a fortnight 

Once a month 

Less than once a month 

Never 

3: Approximately how many epidurals do 

you carry out in a year? 

Please state 

4: What speciality do you carry out 

epidurals in routinely? Please tick all 

that apply 

General Surgery 

Orthopaedics 

Obstetrics 

Gynaecology 

Urology 

Other (please specify) 

5: Do you use a pre-packed epidural set? 

Yes / No 

If yes please specify which set 

6: What do you use to secure your epidural 

catheters? Please tick all that apply 

Tegaderm 

Hypafix 

Epifix 

Other (please specify) 

7: How often do you tunnel your routine 

epidurals? 

Always 

Occasionally 

Depends on the case 

Never 

8: Do you use glue to secure your epidural 

catheters? 

Always / Sometimes / Never 

9: What drug do you use for your test and 

loading doses? Please specify, including 

concentration and additives 

10: What drug mixture do you use for your 

standard epidural infusions? 

Please specify, including concentration 

and additives 

11: Do you use PCEA outside maternity? 

Yes / No 

12: What epidural pump do you use 

routinely? Please specify 

13: Is the epidural pump used exclusively 

for epidurals or does it have multiple 

uses? 

Epidural only / Multiple uses 

14: How comfortable would you be using 

the following drugs in epidurals on 

deployment? 

Very Comfortable/ Fairly Comfortable/ 

Uncomfortable/ Never used 

Bupivacaine 

Levobupivacaine 

Lignocaine (Lidocaine) 

Ropivacaine 

15: In paediatric practice, what is the 

youngest age you would be happy to 

insert an epidural in? 


Epidural Practice Survey 

was sent by email with instructions to cascade which may or may 

not be accurate. The majority of respondents were consultants 

(Table 1). 

Grade Number (%) 

Consultant 35 (60.3) 

Staff and Associate Specialist 

(SAS) 

394 

1 (1.7) 

ST 5,6,7 (SpR 3,4,5) 11 (19.0) 

ST 3,4 7 (12.1) 

ST 1,2 4 (6.9) 

Table 1: The grade of respondents 

Of these the majority carried out epidurals regularly as part of 

their UK practice (Table 2) with the number of epidurals per year 

ranging from nil to approx 125. (Figure 1) 

Frequency Insertion Number (%) 

More than once a week 15 (26.3) 

Once a week 10 (17.5) 

Once a fortnight 9 (15.8) 

Once a month 7 (12.3) 

Less than once a month 14 (24.5) 

Never 2 (3.5) 

Table 2: Frequency with which respondents insert epidurals 

Figure 1: Frequency of epidural insertion 

KL Woods, D Aldington 

The majority of epidurals were carried out for General Surgery, 

Orthopaedics and Obstetrics (Figure 2) 

Figure 2: Specialty in which epidurals inserted 

48 of the responders used pre-packed epidural packs and of the 19 

who replied to the question regarding make of pre-packed set the 

majority used Portex (9 respondents) with Braun being the next 

most commonly used (4 respondents). Hospital order and other 

brands each having 3 responses. 

The majority of people who responded used either Tegaderm® 

or Epifix® to secure their epidural catheters (Figure 3). However 

most people do not routinely tunnel or use glue to secure the 

catheter (Tables 3&4). 

Figure 3: Method of securing epidural catheter 

Frequency of tunnelling use Number (%) 

Always 1 (1.9) 

Occasionally 6 (11.3) 

Depends on the case 10 (18.9) 

Never 36 (67.9) 

  

Table 3: Frequency of epidural tunnelling 


Epidural Practice Survey KL Woods, D Aldington 

Frequency of glue use Number (%) 

Always 9 (5.8) 

Sometimes 1 (1.9) 

Never 48 (92.3) 

Table 4: Frequency of glueing of epidurals 

There were a wide variety of drugs and concentrations used for a 

test dose but the commonest was 0.25% Bupivacaine followed by 

0.5% Bupivacaine (Figure 4). 

Figure 4: Choice of drug for epidural test dose 

There was a very wide range of drug combinations used for 

infusions. This was particularly noted with the added opiates 

and the concentration of opiate varied significantly. The most 

common drug combination for infusion was 0.1% Bupivacaine 

with 4mcg/ml fentanyl (Table 5). 

Patient controlled epidural anaesthesia (PCEA) is not used 

outside maternity in the majority of people’s current UK 

practice with only 36.7% of respondents using PCEA in nonobstetric 

settings 

The majority of responders to the questionnaire did not know 

the make of the epidural pump that was used in their hospital. Of 

those that did know, the most commonly used were the Gemstar 

and Graseby pumps. (Figure 5) In over 90% of those who replied 

these pumps are used exclusively for epidural use. 

When asked how comfortable responders felt about using 

different drugs in epidurals on deployment, most people were 

happy using bupivacaine or levobupivacaine, but were less 

comfortable using lignocaine or ropivacaine (Figure 6). 

Drug Choice Number 

0.1% Bupivacaine + 4mcg/ml fentanyl 16 



0.1% Bupivacaine + opiate (range of doses) 5 

0.1% Bupivacaine (plain) 1 

0.125% Bupivacaine + opiate (range of doses) 1 

0.125% Bupivacaine (plain) 3 

0.15% Bupivacaine + opiate (range of doses ) 3 

0.2% Bupivacaine + 2 mcg/ml fentanyl 1 

0.075% Bupivacaine + 2 mcg fentanyl 1 

0.2% Ropivacaine 2 

0.125% Levobupivacaine + 2 mcg/ml fentanyl 1 

Depends 3 

Table 5: Combinations of drugs used for infusion 

Figure 5: Make of epidural pump used 

Figure 6: How comfortable responders would be to use different drugs 

on deployment 


  

 

Epidural Practice Survey 

When asked what the youngest age of child responders would 

be happy inserting epidurals in on deployment, the total number 

of people happy to insert an epidural decreased as the age of the 

child decreased. (Figure 7) 

396 

Frequency 

Figure 7: Youngest age (vertical axis) responders were happy inserting 

epidurals into 

Discussion 

Although there has been a recent national survey of central neuraxial 

block [2], there are very few published audits or surveys of current 

practice with regards to personal epidural practice. It is only in 

recent years that epidurals have been carried out on established 

military deployments [3]. This change has been due to the move 

from tents to hard accommodation, which is significantly less dusty 

than a hospital under canvas and therefore allows epidural insertion 

in a clean environment. The move towards use of epidurals has also 

been facilitated by the ability of the Aeromedical Evacuation Teams 

to use them during repatriation of patients. The military medical 

environment is, by necessity, relatively austere and the range of 

equipment available to the deployed anaesthetist is reduced when 

compared to that of the NHS. Part of the reason for this is the 

need to reduce the logistical requirement on operations. The intent 

behind our survey was to identify any issues with training and 

equipment in order to allow personnel to prepare and enhance 

their knowledge. This will then help to allow for the provision of 

an epidural service on deployment. 

The survey demonstrated that the vast majority of respondents 

do carry out epidurals regularly in their UK or NHS practice and 

in specialities that are comparable to those seen on deployment. 

Securing of epidurals was one area identified by the survey 

as having potential requirement for further discussion and 

training. While the majority of people used Tegaderm, Epifix 

or Hypafix to secure their epidurals, only a minority tunnelled 

their epidurals. Tunnelling of epidurals reduces the incidence 

of movement of epidural catheters and so reduces the chance of 

displacement [4-6] and in patients in whom an epidural may be 

of benefit for a prolonged time this is an advantage. This is also 

suggested in guidance on epidural management from the Royal 

KL Woods, D Aldington 

College of Anaesthetists and The Association of Anaesthetists of 

Great Britain and Ireland [7]. Although there is some evidence 

suggesting that tunnelling of epidural catheters may reduce 

bacterial colonisation [8] there is little to say that it reduces epidural 

infection rates. This is likely to be due to the fact 

that despite bacterial colonisation of catheters 

infection rates remain very low. However, there is 

evidence that demonstrates tunnelling of caudal 

catheters in paediatric patients, where the site of 

insertion is at higher risk of contamination than 

that of lumbar or thoracic epidurals, reduces 

colonisation of catheters to similar levels as that 

seen in lumbar epidurals [9]. This may be of 

particular significance for the military patient 

population where patients may present having 

been contaminated by significant amounts of 

dirt and dust. 

Glue can also be used to prevent accidental 

removal [10] and this survey has also highlighted 

the fact that very few responders use this as part 

of their routine UK practice. As with tunnelling 

the use of glue to reduce the chance of catheter 

displacement is of particular relevance on 

deployment where patients who have epidural 

catheters inserted in the Field Hospital may have them running 

all through their repatriation (with all the moving and handling 

this entails) and on into their management in the UK. Securing 

epidural catheters as much as possible to minimise the chance 

of movement is therefore essential to help maintain epidural 

analgesia through this time. 

Drug choice for test and loading doses and also the 

combinations used for infusions varied significantly amongst 

the responders to this survey. The guidelines on good practice 

in epidural management suggest that there should be a strict 

limitation on the number of drugs and the concentration of these 

drugs in each hospital [7]. On deployment plain local anaesthetic 

infusions are preferred rather than those containing opiates. This 

allows opiates to be used via PCA during repatriation, both 

for backup in case of problems with the epidural and also for 

analgesia for other wounds in areas not covered by the epidural. 

Education about which drugs are available in theatre will help 

prepare personnel prior to deployment. 

Another area identified by the survey for further training is that 

of paediatrics. As children form a proportion of those treated on 

deployment [11,12] it follows that some of them will benefit from 

an epidural. The survey demonstrated that responders became less 

comfortable inserting epidurals as the age of the child reduced. 

How this can be improved for anaesthetists who do not routinely 

do any paediatric anaesthetics as part of their current UK practice 

is outside the remit of this survey. 

What next? 

The results of this survey have been fed back to both the Defence 

Consultant Advisor (DCA) in Anaesthetics and Professor of 

Military Anaesthesia. The data has also been incorporated in 

some of the teaching on the Military Operational Surgical 

Training (MOST) course for personnel about to deploy and will 

also be used on the pre-deployment hospital validation exercise 

(HOSPEX). 

  


Epidural Practice Survey KL Woods, D Aldington 

References 

1. URL: http://www.surveymonkey.com/s/HTGYLML 

2. Cook TM, Counsell D, Wildsmith JAW. Major Complications of 

Central Neuraxial Block: report on the Third Audit Project of the 

Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-90 

3. Connor DJ, Ralph JK, Aldington DJ. Field Hospital Analgesia. J R 


4. Bougher RJ, Corbett AR, Ramage DTO. The effect of tunnelling 

on epidural catheter migration. Anaesthesia 1996; 51: 191-194 

5. Kumar N, Chambers WA. Tunnelling epidural catheters: a 

worthwhile exercise? Editorial. Anaesthesia 2000; 55: 625-626 

6. Tripathi M, Pandey M. Epidural Catheter Displacement: 

Subcutaneous tunnelling with a loop to prevent displacement. 


7. Good practice in the management of continuous epidural analgesia 

in the hospital setting. The Royal College of Anaesthetists, The 

Royal College of Nursing, The Association of Anaesthetists of Great 

Britain and Ireland, The British Pain Society and The European 

Society of Regional Anaesthesia and Pain Therapy. November 

2004. 

8. Compere V, Legrand JF, Guitard PG et al. Bacterial Colonization 

After Tunneling in 402 Perineural Catheters: A Prospective Study. 

Anest Analg 2009; 108: 1326-1330 

9. Bebeck J, Books K, Krause H et al. Subcutaneous Tunneling of 

Caudal Catheters Reduces the Rate of Bacterial Colonization to 

That of Lumbar Epidural. Anest Analg 2004; 99:689-93 

10. Wilkinson JN, Fitz-Henry J. Securing epidural catheters with 

Histoacryl glue. Anaesthesia. 2008; 63: 324 

11. Gurney I. Paediatric Casualties During OP TELIC. J R Army Med 

Corps. 2004; 150:270-272 

12. Creamer KM, Edwards MJ, Shields CH. Paediatric Wartime 

Admissions to US Military Combat Support Hospitals in 

Afghanistan and Iraq. Learning from the First 2,000 Admissions. J 

Trauma. 2009; 67: 762-768 


Evolution of the Role 4 UK Military Pain Service 

L Devonport 1 , D Edwards 2 , C Edwards 3 , DJ Aldington 4 , PF Mahoney 5 , PR Wood 6 

1 Royal Centre for Defence Medicine. 2 Consultant Nurse, Queen Elizabeth Hospital Birmingham, UHB NHS 

Foundation Trust. 3 Consultant Anaesthetist, Royal Centre for Defence Medicine, 4 Consultant in Pain Medicine, DMRC 

Headley Court, 5 Defence Professor Anaesthesia, Department of Military Anaesthesia, 6 Consultant Anaesthetist, Queen 

Elizabeth Hospital Birmingham, UHB NHS Foundation Trust. 

Abstract 

The early development of the UK Role 4 pain service has already been described. This article will describe developments up to 

October 2010, and present the results of projects used in assessing the effect of this service. 

Introduction 

The Royal Centre for Defence Medicine (RCDM), based at 

University Hospital Birmingham NHS Foundation Trust (UHB) 

has been the primary Role 4 receiving unit for British military 

casualties since 2001 and the early development of the UK Role 

4 Pain service has already been described [1]. Although many of 

the staff are military, they are embedded in a new tertiary referral 

teaching hospital (Queen Elizabeth Hospital Birmingham, 

QEHB) that is currently undergoing accreditation as a Level 1 

Trauma centre. Prior to the opening of QEHB in June 2010 the 

patients were treated by the same Defence Medical Services and 

civilian personnel at Selly Oak Hospital (SOH), which was also 

part of the UHB Trust. 

Patient Numbers 

The number of military casualties has varied over the past nine 

years, as have their injury patterns. Table 1 indicates admission 

rates for physical injury to both RCDM and the Defence Medical 

Rehabilitation Centre (DMRC) at Headley Court [2]. Table 2 

gives numbers of amputees that have been received [3]. Together, 

these tables reveal the work load has increased significantly in 

both the number of cases and complexity. 

Developments 

Personnel 

Key to improving the service was the development of a Military 

Pain Team (MPT) on the military ward. The core of this team 

has been 3 military nurses who spend at least 80% of their time 

with the Pain Team during their attachment. They are led by a 

civilian Consultant Nurse who also leads the hospital critical 

care outreach team and the team has daily consultant anaesthetic 

support. Each week there is a multidisciplinary pain ward round. 

This multidisciplinary group is made up of the MPT, a senior 

physiotherapist and the ward pharmacist, often with the military’s 

Subject Matter Expert (SME) in Pain to help ensure integration 

with the other echelons. 

During the ward round every patient is asked about their pain, 

their sleep pattern and about side effects from pain medications. 

It must be stressed that every patient is interviewed and not only 

those requiring risk management because they have epidurals 

Corresponding Author: Dr Paul Wood, Consultant 

Anaesthetist, Queen Elizabeth Hospital Birmingham, 

Mindelsohn Way, Edgbaston. Birmingham. B15 2WB 

Tel: 0121 627 2000 Email: paul.wood@uhb.nhs.uk 

2007 2008 2009 2010 

from 08 

Oct 07 

to 30 

June10 

or catheters in situ. Following the ward round the MPT have a 

group meeting to discuss clinical, audit, research and educational 

developments. At this point they are joined by a Consultant 

Anaesthetist who attended the multidisciplinary military clinical 

care conference held on the same morning. This arrangement 

ensures that members of the MPT have an integrated role with 

the other specialties involved in the care of the patients. Finally, 

members of the MPT attend quarterly Military Pain Special 

Interest Group meetings that examine issues and developments 

in pain management from the point of wounding through to 

established rehabilitation. 

The relationship of the MPT to other essential clinical teams 

can be illustrated by a hub and spoke model (Figure 1). 

398 J R Army Med Corps 156 (4 Suppl 1): S398–401 

Op 

Telic 

Op 

Herrick 

104 198 131 67 

148 432 736 643 

Table 1: Casualty admissions to RCDM and DMRC Headley Court [2] 

Op 

Telic 

Op 

Herrick 

2006 2007 2008 2009 2010 

from 01 

Apr 06 

to 30 

June10 

Amputees 6 10

UK Military Pain Service L Devonport, D Edwards, C Edwards et al 

Figure 1. Relationship of MPT to RCDM / UHB clinical teams 

Medication - the Military Standard Operating 

Procedure 

All patients admitted to the military ward are prescribed a 

standard analgesic regime with a minimum of regular paracetamol 

and a non-steroidal anti-inflammatory, together with codeine 

or tramadol [1]. The details are described in a ward analgesic 

document which is made available to all the ward junior doctors 

and military and anaesthetic registrars. A paper copy is kept 

on the ward and an electronic version resides on the Trust’s 

intranet. Medication is prescribed electronically on the Patient 

Information and Communication System (PICS), which is a 

Trust development. This electronic tool is invaluable in tracking 

and auditing medication use. In tandem with the introduction 

of the PICS prescribing system the ability of nurses to prescribe 

regular oral morphine has been facilitated since March 2010 by 

the introduction of a Single Nurse Check Analgesia protocol. 

As a result of the mechanisms of injury, many of the patients 

are expected to have a neuropathic component to their pain, 

some, such as traumatic amputations, more than others; thus 

there is a low threshold for the early use of anti-neuropathic pain 

agents, particularly pregabalin and amitriptyline. A recent survey 

(Table 3 study V) showed 66% of the ward’s 25 patients were 

on a combination of these, with half prescribed the maximum 

pregabalin dose. 

Regional Anaesthesia 

Regional anaesthetic techniques are encouraged. Their use at 

the Role 3 Hospital has been described [4, 5]. In Birmingham 

it was noted that the number of patients returning with regional 

catheters in situ increased during Operation HERRICK 9B in 

early 2009. To date approximately 66% of the catheters have been 

initiated in the deployed field hospital (Table 3 Study VI) and 

will have been used to provide analgesia for the repatriation, a 

development anticipated in an earlier paper [6]. 

There have been concerns about the use of regional catheters in 

limb injuries delaying diagnosis of compartment syndrome and 

its management [7]. A consensus meeting was undertaken at the 

Birmingham Research Park to examine this issue in June 2009 

and a subsequent editorial offered guidance on this issue [8]. 

Managing Peripheral Nerve and Epidural Blocks 

When casualties arrive at RCDM, receiving clinicians know not 

to remove the catheters but to leave them in place. If there is any 

doubt about the neurological status of the limb the infusion is 

stopped. Once the degree of function has been confirmed, the 

infusion can be restarted and analgesia restored. With the excellent 

support provided by the anaesthetic department at UHB, re- 

siting or de novo placement of both continuous peripheral nerve 

and epidural catheters can be facilitated with little delay. 

The duration that the peripheral nerve infusions are maintained 

is of interest. Our surveillance data of 133 cases show that our 

longest is 17 days, with approximately one quarter in place for 

a week or longer (Table 3, Study VI). It is also clear that the 

geographical location of insertion does not influence duration 

of use. The most common technique (41%) in both Afghanistan 

and Iraq was a lumbar epidural, followed by femoral and then 

sciatic nerve blocks (Table 3, Study VI). 

The concerns surrounding the use of epidurals in the current 

conflict are mentioned in a review of field hospital analgesia [4]. 

It has been standard practice for all catheter tips to be sent for 

microscopy, culture and sensitivity testing after removal (Table 

3, Study VII). We have been supported in this venture by the 

UHB microbiology department. While a number of the cultures 

have returned “positive” none have been of clinical significance; 

this data includes that for catheters for continuous peripheral 

nerve blockade (Table 3, Study VII). Another concern is the 

development of an epidural haematoma, particularly in patients 

who may be at greater risk following the coagulopathy associated 

with significant polytrauma [9]. Traditional signs of limb 

weakness rely on the existence of lower limbs; in the case of some 

of our patients this is not possible. Other signs and symptoms 

that could be proxy measures are also difficult to use given the 

frequency of perineal injury and urinary catheterisation. Instead 

we have developed our “4 and No More Rule” supported by the 

neuroradiologists as required [10]. 

Practical procedures 

The ability to perform regional anaesthesia, changes of dressings 

and similar tasks often undertaken in theatre has been facilitated 

by equipping a room on the military ward exclusively for such 

tasks. This innovation has several advantages: 

• it allows the provision of appropriate sedation, analgesia (which 

may include the use of ketamine ), and monitoring; 

• it has a consequent reduction in demand on scarce operating 

theatre resources; 

• it provides rapid access with minimal transit time 

• it maintains continuity of nursing care 

• it enhances the education of both military medical and nursing 

staff in appropriate pain management 

Mental Health and psychosocial issues 

The importance of psychological support was emphasized in the 

earlier article [1], and the broader issues and complexities of forces 

mental health have been the subject of a recent Journal of the Royal 

Army Medical Corps Special edition [11]. The interface between 

pain, analgesia and mental health issues can be convoluted [12] 

and this fact is respected in liaison with the mental health team. 

After RCDM - Discharge Care 

Their stay at RCDM is just one phase of a patient’s rehabilitation 

and the importance of what will happen to the patients when they 

leave RCDM is addressed. Most will go on a period of leave before 

posting to either DMRC or one of the Regional Rehabilitation 

Units. Prior to leaving RCDM patients are provided with several 

leaflets about their analgesia together with a telephone contact 

number should they have any concerns about their medication. 

There are military consultants in pain medicine at DMRC some 

of whom also attend RCDM with the intention of ensuring this 


UK Military Pain Service 

Serial Topic Dates Aim / Description 

400 

I Duration of Stay April – June 

2009 

II Surgical activity April 2008 

–January 

2009 

To record the mean duration 

of stay on the military ward 

To quantify the number 

of operations casualties 

undergo 

III Opioid use May 2010 To survey the use of opioids 

by interrogation of PICS 

IV Bowel Function February - 

April 2010 

V Anti -neuropathic 

Analgesic 

VI Regional analgesia 

techniques 

VII Surveillance 

of Regional 

Anaesthetic + 

Epidural Catheter 

Infections 

October 

2009 

January - 

April 2010 

January 

2008 - 

present 

VIII Ward Pain Scores February – 

March 2010 

IX S4 ( SOH ) 

Military ward 

Take home 

medication 

X Trauma Pain 

Recollection 

Surveillance 

XI Patients 

experience of pain 

management 

XII Opiate Use in 

Amputees at 

DMRC 

April to 

June 2009 

February 

2010 - on 

going 

September 

2010 

Oct 2008 

and Feb 

2010 

To establish the prevalence 

of problems with bowel 

function given the opiate 

load some patients require 

To record how many of the 

patients on the military ward 

were prescribed medication 

for neuropathic pain 

Where sited, geographically 

and anatomically, plus 

duration 

To establish whether or not 

infection of catheters is a 

clinical issue. 

A record of pain scores as 

measured twice daily over a 

5 week period 

Establish the discharge 

medication profile at SOH 

To survey patient’s 

recollection of pain 

management from point of 

wounding to discharge from 

UHB 

Examines patients concerns 

with pain and interaction 

with medical staff 

( interview questionnaire ) 

Establish whether long term 

opiate use occurs in military 

amputees. 

Patient 

numbers 

L Devonport, D Edwards, C Edwards et al 

Outcome & Comment 

35 During the 3 month snap shot the mean 

duration reduced from 19 to 9 days. This study 

predated an increase in more seriously injured 

casualties during the second half of 2009 

144 Maximum 15. Averages 2. 

64% one operation only. 

8% experience more than 3. 

21 All taking opioids. 70% on more than one 

opioid. 30% are on 3 or more. 60% codeine, 

55% oramorph, 45% tramadol, 10% PCA 

(morphine), 

25% Morphine SR, 5% oxycontin 

Multiple concurrent opioid prescriptions are 

common (rare in NHS practice ) 

All 

patients 

All inpatients assessed weekly 

Routine prescription of aperients maintains 

acceptable bowel function 

25 66% taking amitriptyline and pregabalin; 

33% on max. pregabalin dose. This is a very 

important departure from normal NHS practice. 

133 In both locations, epidurals were the most 

common technique used. Femoral and sciatic 

catheters were more common in Camp Bastion 

while axillary were sited in RCDM but not 

Camp Bastion 

153 This data is continually reviewed - no significant 

issues to date 

All 

patients 

Less than 10% experience moderate and severe 

pain -compared with 20-80% severe pain 

expected from other studies. 

35 75% on paracetamol became 86%. 

NSAID use increased from 60 - 76%, of these 

diclofenac accounted for 2/3. 

Codeine increased from 25 to 50%, while 

tramadol decreased from 55% to 39%. 

Amitriptyline, gabapentin and pregabalin all 

reduced: 30% to 8%, 35 to 11% and 30 to 

8%. MST reduced 25 to 3% The reduction 

in neuropathic medication reflected the injury 

patterns (see I above) 

All 

patients 

All 

patients 

Monthly review of all data. 

Excellent results to date. 

Overall satisfaction with pain management - 

69% 

49 + 50 Two iterations. No evidence of problem 

with opiate use. 

Table 3 List of audit and survey activity conducted by MPT from January 2008. Principle researchers for all studies were Cpl L Gofton RAF, 

Sgt L Devonport QARANC, Mrs D Edwards and Sqn Ldr C Flutter RAF except Study XII (Col S Jagdish L/RAMC ( October 2008 ) & Capt 

B.Coghill RAMC ( February 2010 )) 


UK Military Pain Service L Devonport, D Edwards, C Edwards et al 

continuity of care. Steps are currently being taken to provide 

this military consultant support to the Regional Rehabilitation 

Units as well. The first joint clinics with consultants from DMRC 

were initiated in April 2010 and have already successfully been 

undertaken in Edinburgh, and Catterick. Going forward the plan 

is to also introduce them in Tidworth and Plymouth, with the 

intention of Colchester, Halton and Lichfield being supported in 

due course. 

Prior to leaving, Birmingham the casualties complete an 

audit questionnaire asking about their analgesia from point of 

wounding to discharge from RCDM. Despite efforts to educate 

otherwise the use of opioid analgesics, is still associated with a fear 

of “addiction”. Two completed surveys of amputees undertaken at 

DMRC have shown that there is no evidence of this being an issue 

within our population (Table 3; Study XII). 

The Evidence 

It is suggested that 30-80% of post-operative patients experience 

moderate to severe pain [13, 14]. A collection of the twice daily 

ward pain scores was undertaken during a five week period (Table 

3, Study VIII). These scores are recorded routinely by the nursing 

staff but were later collected by the MPT for analysis. The results 

indicated that less than 10% of the casualties reported pain scores 

of 2 or 3 on our 4 point scale; this approximately equates to pain 

scores of 4/10 or more, or moderate and severe pain. 

Discussion 

The population we are treating often have complex pain issues. 

We are also dealing with mechanisms of injury that are not 

routinely seen except in a few centres around the world. To what 

extent these various injuries create their own patterns of pain is 

impossible to quantify. 

In an attempt to support our approaches we have tried to 

look for evidence but have had to rely on fairly “weak” levels 

of evidence. This is because, fortunately, the actual numbers of 

individuals coming thought our system are so small as to make 

high quality prospective double blind randomised control trials 

impossible. Instead we have relied on a number of surveillance 

projects, surveys and a few audit results and the more important 

of these are mentioned in this text and are highlighted in Table 3. 

It is important to be clear that no one intervention is responsible 

for these results. They derive from a combination of effects. Most 

importantly we would argue it is the change in attitude towards 

“pain”, and recognition by all healthcare workers, particularly the 

ward nursing staff, that pain is not an acceptable experience. We 

also know to look at the wider aspects of a patient’s experience 

and not just focus on the medical aspects. We try to develop a 

patient’s sense of control as early as we can. It is their pain, their 

problem, and when they are discharged they will need to know 

how to manage it. 

Finally, we are clear that what occurs here must link with 

what has gone before and what will follow. The service’s name, 

the Military Pain Team, makes no reference to acute pain. This is 

because we see the service not as an isolated “acute” pain service 

but as one step in the continuum of care that may extend many 

miles and years from point of wounding to leaving the Service; 

the 30 year, 13,000 mile pain service. 

References 

1. Edwards D, Bowden M, Aldington DJ. Pain management at role 4. 

JR Army Med Corps 2009; 155:58-61. 

2. Monthly Op TELIC and Op HERRICK UK Patient Treatment 

Statistics- RCDM and DMRC Headley Court. Edition: 30 June 

2010 (Released 30 July 2010) http://www.dasa.mod.uk Accessed 

October 2010 

3. Quarterly Op HERRICK and Op TELIC amputation statistics. 

Edition: 1 April – 30 June 2010 (Released 30 July 2010) http:// 

www.dasa.mod.uk Accessed October 2010 

4. Connor DJ, Ralph JK, Aldington DJ. Field hospital analgesia. JR 

Army Med Corps 2009; 155:49-56. 

5. Hughes S, Birt D. Continuous peripheral nerve blockade on OP 

HERRICK 9. JR Army Med Corps 2009; 155:57-58. 

6. Flutter C, Ruth M, Aldington D. Pain management during Royal 

Air Force strategic aeromedical evacuations. JR Army Med Corps 

2009; 155:61-63. 

7. Hayakawa H, Aldington DJ, Moore RA. Acute traumatic 

compartment syndrome: a systematic review of results of 

fasciotomy. Trauma 2009; 11:5-35. 

8. Clasper JC, Aldington DJ. Regional anaesthesia, ballistic limb 

trauma and acute compartment syndrome. JR Army Med Corps 

2010; 156:77-78. 

9. Walker C, Ingram M, Edwards D, Wood P. Use of 

thromboelastometry in the assessment of coagulation prior to 

epidural insertion after massive transfusion. Anaesthesia 2010; In 

Press 

10. Wood PR, Haldane AG, Plimmer SE. Anesthesia at Role 4. JR 

Army Med Corps 2010; 156(4): 156(4 Suppl 1): S308-310 

11. Alexander DA, Klein S. Combat-related disorders: a persistent 

chimera. JR Army Med Corps 2008; 154:96-101. 

12. Holbrook TL, Galarneau MR, Dye JL, Quinn K, Dougherty AL. 

Morphine use after combat injury in Iraq and post-traumatic stress 

disorder. N Engl J Med 2010; 362:110-117. 

13. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute 

postoperative pain management: I. Evidence from published data. 

Br J Anaesth 2002; 89:409-423. 

14. Drew J, Aldington D. A Hospital Audit of Pain. IASP World 

Congress. 2005 


Society of Triservice Anaesthetic Trainees 

Annual Scientific Meeting 2010 

This meeting was held at RAF Wyton, Cambridgeshire, on the 22-23 Jul 2010. Sq Ldr Elise Haites RAF won the Dave Hughes 

Memorial Prize for the best Trainees presentation. There were nine presentations in all and their abstracts are published here; three (*) 

have been written as full articles in this supplement of the Journal of Royal Army Medical Corps. 

Are CCAST patients developing a metabolic acidosis 

in-flight and if so is lactate monitoring necessary? 

EM Haites 1 , S Turner 2 

1 Royal Infirmary of Edinburgh; 2 Leeds General Infirmary 

Introduction: Critical care aeromedical transfer flights run by 

the Royal Air Force Critical Care Air Support Team (CCAST) 

serve to transfer severely ill trauma victims. At present on CCAST 

flights the base excess is used to assess acid-base balance. Lactate 

monitoring is not currently carried out although it is possible. 

Cardiac output monitoring is not available. The primary aim 

of this audit was to assess whether our patients are developing 

metabolic acidosis in flight as demonstrated by a change in base 

excess and to assess whether there was a case for the introduction 

of routine lactate monitoring on CCAST flights. Secondary 

aims were to assess fluid balance in flight for CCAST patients 

and percentage of fluid delivered which is crystalloid. Methods: 

A retrospective audit was performed by analysis of aeromedical 

notes for all CCAST patients during the period of 12 July – 22 

December 2009 (n=70). Results: There was a mean change in 

base excess of -0.99 (95% CI -1.55 to -0.42) P

STAT 2010 

it useful. The majority of trainees (188/345) disputed the fairness 

of the Mini-CEX, found annual numbers difficult to achieve 

(173/340) and tended to conduct them in a way to optimise 

results (173/340). The free text comment suggested the utility of 

all the tools could be increased by improving assessor training. 

Conclusion: UK anaesthetic trainee attitudes do not mirror 

the New Zealand trainees’ positive acceptance of this style of 

assessment tool and effort should be directed towards improving 

assessor training to help improve the perceived educational benefit. 

References: 

1. The Royal College of Anaesthetists. The CCT in Anaesthestics 

I: General Principles. A manual for trainees and trainers. 

Edition January 2007. Available at: http://www.rcoa.ac.uk/docs/ 

CCTPartIJuly2010.pdf (accessed 11/10/10) 

2. Weller J, Jolly B, Merry A et al. Mini-clinical evaluation exercise in 

anaesthesia training. Br J Anaesth 2009;102: 633-41. 

Thin or Fat, Age or Beauty-The Red Cell in Critical 

Care 

MT Davies 

University of Leicester Hospitals NHS Trust 

Introduction: The transfusion of blood products has been 

occurring since the 17th century. The indication for treatment 

can be varied but the overriding indications are to increase the 

circulating plasma volume and the concentration of the oxygencarrying 

molecule Haemoglobin. It is a therapy that is not without 

side effects and annual Serious Hazards of Transfusion (SHOT) 

reports show an increasing number of incident reports though 

thankfully a reducing number of deaths as a result of transfusion. 

A paper from 2009 [1] suggested a link between the age of the 

red blood cell transfused and mortality amongst trauma patients. 

A paper this year looked at transfusion in Paediatric patients and 

found a suggested increased risk when the blood transfused was 

over 15 days old. Methods: During a 6 month period I reviewed 

all transfusions given on 3 separate ITUs across Leicester and 

recorded the transfusion trigger level of Haemoglobin and the age 

of the packed red cell product given. 32 patients were given a 

total of 64 units of blood. All patients were from a general ITU 

and none were being actively resuscitated when the blood was 

administered. Results: 18 (56%) of patients were transfused when 

their haemoglobins were over 7 g d/l (our current transfusion 

trigger identified from the TRICC group). The graph below 

shows a plot of the age of each blood unit given. The red dotted 

line is 28 days, which was the age above that Spinella [1] group 

associated with increases risk. Karam group [2] identified a risk in 

blood aged 15 days and over. 

Conclusions: Red blood cells are administered on a regular basis 

in our military and civilian Critical Care patients. It is clearly a 

therapy that provides enormous benefit but the question of when 

to transfuse and with what aged cell contains to be debated and on 

going research continues. I do not think there is much doubt that 

the younger the red blood cell is the better it serves its purpose and 

we need to identify the patients in who that will make a difference. 

References: 

1. Spinella PC, Carroll CL, Staff I, et al. Duration of red blood 

cell storage is associated with increased incidence of deep vein 

thrombosis and in hospital mortality inpatients with traumatic 

injuries. Critical Care 2009, 13: R151 

2. Karam O, Tucci M, Bateman ST, et al. Association between length of 

storage of red blood cell units and outcome of critically ill children: a 

prospective observational study. Critical Care 2010; 14: R57 

* Current Epidural Practice – Results of a Survey of 

Military Anaesthetists 

KL Woods 1 , D Aldington 2 . 

1 James Cook University Hospital, Middlesbrough; 2 Pain Relief Unit, 

Churchill Hospital. Oxford. 

Introduction: Epidurals are now used for pain relief on 

deployment [1] and although a National Audit on complications 

of central neuraxial blocks [2] has been recently carried out there 

are few published studies looking at personal epidural practice. A 

survey was conducted to look at the current epidural practice of 

UK military anaesthetists. Due to the fact equipment available on 

deployment may vary from that in the UK, the aim of the survey 

was to identify any potential issues with regard to equipment and 

training to allow future development of pre-deployment training. 

Methods: An internet based survey was carried out. All military 

anaesthetists were sent an e-mail containing a link to the survey 

and the results of those who responded were analysed. Results: 

A total of 49 surveys were completed. Within their UK practice 

78% of respondents carried out epidurals more than once a 

month, in a wide range of specialities. There was considerable 

variation in methods of securing epidurals and in drug choice 

amongst respondents. Conclusions: The results of this survey 

show that whilst epidurals are commonly carried out amongst 

military anaesthetists during their UK practice, there is significant 

variation within the practice. Areas have been identified for 

development of educational courses, for example methods of 

securing epidurals, and these have already been acted upon. 

References: 

1. Connor DJ, Ralph JK, Aldington DJ. Field Hospital Analgesia. J R 


2. Cook TM, Counsell D, Wildsmith JAW. Major Complications of 

Central Neuraxial Block: report on the Third Audit Project of the 

Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179-90 

A Survey Of Ketamine Use Within The Defence 

Medical Services 

J Warren 1 , DJ Aldington 2 

1 Frimley Park Hospital; 2 John Radcliffe Hospital, Oxford 

Introduction: Ketamine is a versatile drug that can be used for 

analgesia, sedation and anaesthesia. It is provided in military prehospital 

modules for use by General Duties Medical Officers. 

However, its use is not without side effects, some of which may 

be significant [1]. Unfortunately, while ketamine can be of great 


STAT 2010 

use to the military healthcare provider [2], experience of its use 

in UK civilian practice is often very limited [3]. The aim of 

this study was to establish how widely, within the UK Defence 

Medical Services (DMS), ketamine is used, how often side effects 

occur, and how people are trained in its use. Method: An internet 

based questionnaire was designed (www.surveymonkey.com). It 

comprised 10 multiple-choice questions. Invitations to complete 

the questions were promulgated via the Defence Professors of 

Anaesthesia, General Practice and Emergency Medicine. Results: 

159 respondents completed the survey. Just under half (46%), 

73 respondents were trainees. Anaesthesia was the predominant 

speciality (63%), 19% from Emergency Medicine and 18% 

General Practice. 15% of respondents had never used ketamine 

citing lack of familiarity as the predominate reason. Of the 85% 

who had used it few reported having difficulties with side effects. 

Only 38% of those involved in military pre-hospital care reported 

receiving formal training. Discussion: A high proportion of the 

respondents were anaesthetists so an inherently biased sample; but 

they of all groups should have access to training and experience 

in its use in the UK, together with experience of handling many 

of the side effects. This is the first survey of its kind to have 

been undertaken across such a broad-spectrum of physicians. 

This survey, despite its weaknesses, has been used to provide 

formal evidence of a training opportunity that has recently been 

recognised by the DMS. 

References: 

1. P P Bredmose, D J Lockey, G Grier, et al. Pre-hospital use of 

ketamine for analgesia and procedural sedation. Emerg Med J 2009 

26: 62-64 

2. Mackenzie R. Analgesia and Sedation. J R Army Med Corps 2004; 

150: 45-55 

3. Green SM, Krauss B Ketamine is a safe, effective, and appropriate 

technique for emergency department paediatric procedural 

sedation. . Emerg Med J 2004; 21: 271–272. 

*Vascular Access on the 21st Century Military 

Battlefield 

EJ Hulse 1 , GOR Thomas 2 

1 Royal Cornwall Hospital, Truro, Cornwall; 2 The Royal London, and 

Queen Victoria’s Hospital, East Grinstead, London, 16 Air Assault 

Medical Regiment. 

404 

Introduction: Timely and appropriate access to the vascular 

circulation is critical in the management of 21st century battlefield 

trauma, allowing the administration of emergency drugs, 

analgesics and rapid replacement of blood volume. Methods 

used to gain access can include the cannulation of peripheral and 

central veins, venous cut-down and intraosseus devices. Method: 

We reviewed the current literature in both English speaking and 

non-English speaking countries on the benefits and complications 

of each vascular access method. Conclusion: Intraosseus devices 

are best for quick access to the circulation, with central venous 

access via the subclavian route for large volume resuscitation and 

low complication rates. Military clinicians involved with the care 

of trauma patients either in Role 2 and 3 or as part of the Medical 

Emergency Response Team (MERT), must have the skill set to 

use these vascular access techniques by incorporating them into 

their core medical training. 

*TIVA for War Surgery 

SE Lewis 

Total Intravenous Anaesthesia (TIVA) may be defined as the 

delivery of agents into the bloodstream to achieve a balance of 

hypnosis, analgesia and muscle relaxation. Military Anaesthetists 

have been using TIVA for war surgery since World War II and 

every conflict has produced advances in its practice. TIVA finds 

application at every echelon of care including the pre-hospital 

phase and during strategic transfer to the UK. Advantages that 

it possesses over Volatile Gas Anaesthesia (VGA) include a much 

smaller logistic footprint, favourable recovery characteristics, no 

potential for triggering malignant hyperthermia and potentially 

beneficial modulation of the stress response. Disadvantages 

include a perceived increase in risk of awareness and reduced 

familiarity with its use amongst the anaesthetic cadre. A 

literature search and survey of subject matter experts within the 

DMS anaesthetic cadre produced a selection of protocols for 

achieving TIVA appropriate to different patients and situations 

including one based on drip rate through a giving set with no 

infusion pump required. Future areas of development for TIVA 

within the DMS might include the introduction of Target 

Controlled Infusion (TCI) pumps and/or depth of anaesthesia 

monitoring. TIVA should be considered as a valid alternative to 

VGA for war surgery. 


…And Finally

Images of Anaesthesia 

Gulf War 1991- Anaesthesia at 32 Field Hospital (Photo: Col PF 

Mahoney L/RAMC) 

The Resus dept at 32 Field Hospital, Op Granby. Teams were of three 

people (a doctor, a nurse and a medic) to look after two trestles. At 

night teams slept in the department. (Photo: Col PF Mahoney L/ 

RAMC) 

Receiving a casualty in Resus in Macedonia in 1999 prior to the move 

forward into Kosovo. (Photo: Col PF Mahoney L/RAMC) 

Retrieval of a casualty by the Immediate Response Team (IRT) from 

Macedonia, 1999. The IRT was the forerunner of the MERT. (Photo: 

Col PF Mahoney L/RAMC) 



Col Trip Buckenmaier undertaking 

regional anaesthesia with ultrasound 

guidance, Bastion 2009 

(Photo: Lt Col Simon Orr RAMC) 

Surgeon Commander Heames giving the first general anaesthetic 

(semi-elective) on RFA ARGUS in 2003 before the start of 

operation TELIC. It is for a non-battle injury. Name of surgeon 

unknown. (Photo: Surg Cdr R Heames RN) 

408 

Emergency moulage on board RFA Fort Victoria (2010) where a 

patient is getting log-rolled. (Photo: Surg Cdr R Heames RN) 


This was the portable operating theatre carried by the 22 Squadron 

FST of the Medical Support element of 16 Air Assault Brigade during 

the invasion phase of the Iraq campaign. Two MacVicar operating 

tables with supporting anaesthetic kit, based on the Tri-Service 

vapourizers and CompPac ventilators, and supplies were packed onto 

trailers towed by Pinz-Gaur non-armoured trucks. Two squadrons 

(22 and 19) leapfrogged, setting up and taking down every 48 hours, 

to keep abreast of the advancing Coalition forces. Op TELIC 1, 2003 

(Photo Lt Col NJ Jeffries RAMC) 



GIAT Industries (Groupement des Industries de l’Armée de Terre, 

a French government-owned weapons manufacturer) produced a 

modular, containerized operating theatre which was deployed in 

FRY to the SFOR UK Med Group hospital set up in a vacant shoe 

factory on the outskirts of Sipovo. It contained an operating table 

with associated lighting, a (barely...) overhead track to carry an 

X-ray, and a Kontron 5100 anaesthetic machine. There was a 

separate module for compressed gas supplies. The Kontron 5100 

was a sophisticated “civilian” apparatus in common use in French 

and other European hospitals. It featured several ventilation 

options including variable I:E ratios and SIMV, and two common 

gas outlets which was a little confusing. There was an option for 

a circle system but this had not been purchased. The instructions 

were only in French. Sipovo 1998. 

(Photo: Lt Col NJ Jeffries RAMC) 

ROTEM thromboelastometry analyser in use, revealing 

hyperfibrinolysis in a brain-injured patient, Camp Bastion Operating 

Room, Op HERRICK 11b (Photo: Maj N Tarmey RAMC) 

Vital signs displayed on an Operating Room monitor following 

successful resuscitation from hypovolaemic cardiac arrest. Camp 

Bastion, Op HERRICK 11b (Photo: Maj N Tarmey RAMC) 

410 

Air-freighted platelets for transfusion arrive at Camp Bastion Role 3 

Hospital Op HERRICK 11b (Photo: Maj N Tarmey RAMC) 

Incident involving multiple casualties in Iraq 2004. This was a 

fixed tented field hospital and highlight multiple resuscitation teams 

working simultaneously in a co-ordinated fashion. There is an 

anaesthetist in every resuscitation bay. (Photo: Lt Col DA Parkhouse 

RAMC) 



Preparation of equipment at the start of the day. Preanaesthetic 

equipment checks are similar to those carried 

out in hospitals in the UK everyday. Same skill set, different 

environment. (Photo: Lt Col DA Parkhouse RAMC) 

Transfer of casualty from CH47 to Battlefield 

Ambulance at Camp Bastion. Care is 

uninterrupted throughout. 

(Photo: Lt Col DA Parkhouse RAMC) 

Four man team carries out resuscitation on a 

MERT mission; the other troops look on calmly. 

(Photo: Lt Col DA Parkhouse RAMC) 


The DMACC Coins 

PF Mahoney 

‘Challenge’ coins display the emblem or insignia of an organisation and are popular in the US military. Their origins and traditions 

are debated but probably originate in the United States Army Air Service in World War One. The coins have been used in a semi 

official capacity to mark membership of a unit or as awards to denote special achievements. In some military units members can be 

‘challenged’ to produce their coin- and if they fail to do so owe the challenger a drink. Members of the Royal Centre for Defence 

Medicine (RCDM) academic units came across these coins while working with US Forces in Iraq and Afghanistan- and thought the 

tradition would translate well to the Defence Medical Services (DMS). 

The 2008 Coin has a Triservice theme. The three small pictures show a triservice anaesthesia 

apparatus, a CH47 and RFA Argus. The main picture is taken from a photograph of an 

anaesthetic being given for rapid sequence induction and endotracheal intubation on the MERT 

in Afghanistan in 2007. 

The 2010 Coin has a regional anaesthesia theme and shows a drawing of the brachial plexus above 

a picture of ultrasound being used to locate the brachial plexus. Col Trip Buckenmaier US Army 

provided the original pictures from which these images were created during his deployment to 

Bastion in 2009. 

The original coin was made by the Academic Department of Military 

Emergency Medicine (ADMEM) in 2006 and features the RCDM crest 

on one side and a medical team off loading a patient from a CH47 on 

the other, based on images from the 2003 Gulf War. The Department 

of Military Anaesthesia and Critical Care (DMA&CC) coins have been 

designed to reflect the different elements of Defence Anaesthesia and the 

intention is to produce a different coin each year. 

The 2009 Coin was made jointly with ADMEM for OP HERRICK 

10 when the Role 3 hospital at Bastion became joint UK-US and also 

hosted the Danish Field Hospital. The coin includes UK, US, Danish 

and NATO flags surrounding a Red Cross on one side. One the other 

are the crests of Royal Centre for Defence Medicine, the Royal College 

of Anaesthetists and the College of Emergency Medicine. 

The 2011 Coin is themed around massive transfusion. The images used are of a surgical team working 

at Bastion, a pile of empty blood bags, and a member of the Field Hospital managing the infusions. 

These images were created from photographs taken by Lt Col Simon Orr RAMC during HERRICK 

10, 2009. 

To date the coins have been given out on operational deployments to mark special achievements, to mark presentations at military 

anaesthetic meetings, to thank people within the cadre for their efforts on behalf of Defence Anaesthesia and thank members of the 

Royal College of Anaesthetists and the Association of Anaesthetists for support to DMA&CC. 

412 J R Army Med Corps 156 (4 Suppl 1): S412

Defence Anaesthesia - Journal of the Royal Army Medical Corps

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