Extending existing recommended military casualty evacuation timelines will likely increase morbidity and mortality: a UK consensus statement

Abstract

IntroductionFuture conflicts may have limited use of aviation-based prehospital emergency care for evacuation. This will increase the likelihood of extended evacuation timelines and an extended hold at a forward hospital care facility following the completion of damage control surgery or acute medical interventions.MethodsA three-round Delphi Study was undertaken using a panel comprising 44 experts from the UK armed forces including clinicians, logisticians, medical planners and commanders. The panel was asked to consider the effect of an extended hold at Deployed Hospital Care (Forward) from the current 2-hour timeline to +4, +8, +12 and +24 hours on a broad range of clinical and logistical issues. Where 75% of respondents had the same opinion, consensus was accepted. Areas where consensus could not be achieved were used to identify future research priorities.ResultsConsensus was reached that increasing timelines would increase the personnel, logistics and equipment support required to provide clinical care. There is a tipping point with a prolonged hold over 8 hours, after which the greatest number of clinical concerns emerge. Additional specialties of surgeons other than general and orthopaedic surgeons will likely be required with holds over 24 hours, and robust telemedicine would not negate this requirement.ConclusionsRetaining acute medical emergencies at 4 hours, and head injuries was considered a particular risk. This could potentially be mitigated by an increased forward capacity of some elements of medical care and availability of a CT scanner and intracranial pressure monitoring at over 12 hours. Any efforts to mitigate the effects of prolonged timelines will come at the expense of an increased logistical burden and a reduction in mobility. Ultimately the true effect of prolonged timelines can only be answered by close audit and analysis of clinical outcomes during future operations with an extended hold.

Torso body armour coverage defined according to feasibility of haemorrhage control within the prehospital environment: a new paradigm for combat trauma protection

“…Essential structures were those deemed likely to result in death within 60 min of significant injury unless damage control surgery (DCS) could be achieved within this time. This was representative of the clinical timelines seen in recent conflicts in Afghanistan specifically 7. Desirable structures were of three types: (1) those which if injured would lead to death outside 60 min from injury, (2) those in which it was recognised that injury may cause life-changing morbidity and (3) those for which rehabilitation is particularly challenging 2.…”

“…For example, the current anatomical structures requiring essential medical coverage were based on the premise that, if injured, death is highly likely within the first 60 min unless DCS is performed within this timeframe to arrest haemorrhage 2. These medical and logistic timelines were representative of the mature medical evacuation chain present in the latter part of the UK combat operations in Afghanistan 7 24. Such timelines may not be possible to replicate in both present or future operations 7.…”

“…These medical and logistic timelines were representative of the mature medical evacuation chain present in the latter part of the UK combat operations in Afghanistan 7 24. Such timelines may not be possible to replicate in both present or future operations 7. For this reason, we recommend that future consensus will be required about the effect extended timelines may have on the medical coverage required by personal armour.…”

Military thoracic gunshot wounds: A systematic review

“…The AJP 4-10 was updated in 2019 to follow these time frames but the +2 refers to further surgical, diagnostic, specialist care etc. being made within 2 h of tactical evacuation after DCS (Scallan et al 2020).…”

Resuscitation with whole blood or blood components improves survival and lessens the pathophysiological burden of trauma and haemorrhagic shock in a pre-clinical porcine model

“…The burden associated with the delivery of clinical care over extended timelines is increased personnel, logistics and equipment [ 2 ]. In the pre-hospital environment this burden may be partially reduced with the forward deployment of blood/blood products as they as they have been shown to reduce mortality.…”