Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014).

INTRODUCTION: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care. METHODS: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR). RESULTS: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively. Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant. CONCLUSION: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase

Greenhouse gas emissions from the energy crop oilseed rape (Brassica napus); the role of photosynthetically active radiation in diurnal N2O flux variation

Oilseed rape (OSR, Brassica napus L.) is an important feedstock for biodiesel, hence carbon dioxide (CO2), methane (CH4) and particularly fertiliser-derived nitrous oxide (N2O) emissions during cultivation must be quantified to assess putative greenhouse gas (GHG) savings, thus creating an urgent and increasing need for such data. Substrates of nitrification (ammonium (NH4)) and denitrification (nitrate (NO3)), the predominant N2O production pathways, were supplied separately and in combination to OSR in a UK field trial aiming to: i produce an accurate GHG budget of fertiliser application; ii characterise short to medium-term variation in GHG fluxes; iii establish the processes driving N2O emission. Three treatments were applied twice, one week apart: ammonium nitrate fertiliser (NH4NO3, 69 kg-1N ha-1) mimicking the farm management, ammonium chloride (NH4Cl, 34.4 kg-1N ha-1) and sodium nitrate (NaNO3, 34.6 kg-1N ha-1). We deployed SkyLine2D for the very first time, a novel automated chamber system to measure CO2, CH4 and N2O fluxes at unprecedented high temporal and spatial resolution from OSR. During three weeks following the fertiliser application, CH4 fluxes were negligible, but all treatments were a net sink for CO2 (ca. 100 g CO2 m-2). Cumulative N2O emissions (ca. 120 g CO2-eq m-2) from NH4NO3 were significantly greater (p< 0.04) than from NaNO3 (ca. 80 g CO2-eq m-2), but did not differ from NH4Cl (ca. 100 g CO2-eq m-2), and reduced the carbon-sink of photosynthesis so that OSR was a net GHG source in the fertiliser treatment. Diurnal variation in N2O emissions, peaking in the afternoon, was more strongly associated with photosynthetically active radiation (PAR) than temperature. This suggests that the supply of carbon (C) from photosynthate may have been the key driver of the observed diurnal pattern in N2O emission and thus should be considered in future process-based models of GHG emissions

Balloons on the battlefield: REBOA implementation in the UK Defence Medical Services

Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians

Defence Medical Services' REBOA training course

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors’ perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation

Selective Aortic Arch Perfusion: A First-in-Man Report of a Novel Endovascular Resuscitation Modality

Background Selective aortic arch perfusion (SAAP) is a novel endovascular technique that combines thoracic aortic occlusion with extracorporeal perfusion of the brain and heart. SAAP may have a role in both haemorrhagic shock and in cardiac arrest due to coronary ischaemia. Despite promising animal studies, no data is available that describes SAAP in humans. The primary aim of this study was to assess the feasibility of selective aortic arch perfusion in humans. The secondary aim of the study was to assess the feasibility of achieving direct coronary artery access via the SAAP catheter as a potential conduit for salvage percutaneous coronary intervention. Methods Using perfused human cadavers, a prototype SAAP catheter was inserted into the descending aorta under fuoroscopic guidance via a standard femoral percutaneous access device. The catheter balloon was infated and the aortic arch perfused with radio-opaque contrast. The coronary arteries were cannulated through the SAAP catheter. Results The procedure was conducted four times. During the frst two trials the SAAP catheter was passed rapidly and without incident to the intended descending aortic landing zone and aortic arch perfusion was successfully delivered via the device. The SAAP catheter balloon failed on the third trial. On the fourth trial the left coronary system was cannulated using a 5Fr coronary guiding catheter through the central SAAP catheter lumen. Conclusions For the frst time using a perfused cadaveric model we have demonstrated that a SAAP catheter can be easily and safely inserted and SAAP can be achieved using conventional endovascular techniques. The SAAP catheter allowed successful access to the proximal aorta and permitted retrograde perfusion of the coronary and cerebral circulation

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

Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment

Prehospital tranexamic acid shortens the interval to administration by half in Major Trauma Networks: a service evaluation

Fondazione Cassa Rurale di Trento, Italy