RETRACTED: Decision making in junctional trauma care

Abstract

Paul Parker, Decision making in junctional trauma care. Trauma. Published online ahead of print 4 June 2013. DOI: 10.1177/1460408613489088. This article was published in error and is therefore retracted. Improvised explosive devices cause 60% of all UK military fatalities. The signature injury produced is that of a bilateral above-knee amputation, significant perineal trauma and an open-book pelvic fracture. Shorter timelines deliver these patients to hospital at the very edge of the physiological envelope of survivability. The available time period for their haemorrhage control and initial wound surgery is short – often of the order of 75 min. The concepts and practise of ‘right turn resuscitation’, damage control surgery and orthopaedics, on-table ‘ITU’ pause/catch-up and then further resuscitative surgery are now commonplace. In Helmand in 2013, multiple-team operating is now the norm on these casualties with up to seven surgeons and three anaesthetists contemporaneously involved in the operative care of one patient. This usually involves one consultant orthopaedic surgeon and trainee per lower limb, a plastic surgeon on the upper limb or face/eyes and two general surgeons obtaining proximal vascular control or in-cavity haemorrhage control. A series of consensus statements were issued by the UK Military Limb Trauma Working Group and Torso Trauma Working Group of the UK Academic Department of Military Surgery and Trauma. Twenty-five clear and didactic statements were produced to provide advice to the newly qualified consultant team dealing with significant junctional or terrorist-related trauma. The fundamental message is that bleeding is always a surgical problem. Some adjuncts are available; massive transfusion, pressure (direct and indirect), compressive bandaging, haemostatic dressings and tourniquets. However, only formal surgical control, whether by the surgeon’s finger, soft clamp or tie, is definitive. Early proximal control is mandatory: In all cases, we state, ‘rapidly obtain the most distally appropriate proximal control – above the zone of injury.’