Objectives Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. Methods This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports. Results There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. Conclusions Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

SummaryOver the past 12 years, the United Kingdom Defence Medical Services have evolved an integrated ‘damage control resuscitation – damage control surgery’ sequence for the management of patients sustaining complex injuries. During 2009, over 3200 units of blood products were administered as massive transfusions to severely injured UK personnel. An important part of the approach to traumatic bleeding is the early, empirical use of predefined ratios of blood and clotting products. As soon as control of bleeding is achieved, current practice is to switch towards a tailored transfusion, based on clinical and laboratory assessments, including point‐of‐care coagulation testing. A key goal is to provide resuscitation seamlessly throughout surgery, so that patients leave the operating room with their normal physiology restored. This article outlines the current management of haemorrhage and coagulation employed in Afghanistan from the point of wounding to transfer back to the National Health Service.

Microalbuminuria is increasingly recognized as a marker of pathologies that cause acute systemic capillary leak. We report a case of an anaphylactic reaction to general anaesthesia involving cardiac arrest. In this case the urinary excretion of albumin following resuscitation suggests that severe anaphylaxis is another condition for which microalbuminuria is a sensitive monitor.

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Ketamine is a unique anaesthetic drug which produces dissociative anaesthesia. In this condition the patient is insensible, with excellent analgesia but with minimal depression of respiration and circulation. The analgesia can be maintained at subanaesthetic doses. The pharmacology and practical use of ketamine is discussed with practical emphasis on its use in trauma patients, for whom it has special advantages.

We have calculated gastric intramucosal pH (pHi) from Trip catheter saline tonometered samples in two patients undergoing ventilation using four different sampling techniques, each repeated five times. pHi was calculated from measurement of PCO2 in tonometered saline (TCO2). TCO2 was measured immediately, and then at 6-min intervals for 30 min. Variation in measurement was greatest for capped syringes stored at room temperature, and least when stored uncapped on ice. TCO2 always decreased significantly within 12 min. The mean difference in pHi (all sampling techniques) over 30 min was 0.1005 pH units. The results indicate that the calculated pHi was subject to variation as a result of both the method of sample storage and delay in measurement. An error of +/- 0.1 pH units may have clinically important implications if pHi is used to monitor either severity of illness or efficiency of resuscitation.

SummaryThe American College of Surgeons' Advanced Trauma Life Support protocol for managing the airway in patients with a cervical spine injury is reviewed. The relative risks and benejts of oral and nasotracheal intubation are discussed and the potential hazards of alternative methods of airway control are considered with particular respect to British practice.

We performed a study to assess the effectiveness of a fluid infusion strategy currently used in the military pre-hospital environment using the patient's own body weight as an infusion device. Thirteen healthy volunteers were cannulated and 0.9% sodium chloride infused over a period of ten minutes. The volumes infused were measured and flow rates derived. A mean flow rate of 40 ml per minute was seen through an 18 g cannula. This strategy generates reasonable flow rates, but whether this is sufficient to the clinical aim of fluid resuscitation in pre-hospital settings is unknown.