title: UK specialist cardiothoracic management of thoracic injuries in military casualties sustained in the wars in Iraq and Afghanistan.
abstract: OBJECTIVE
  Outcomes of casualties with thoracic wounding at the deployed UK military field hospital (Role 3(R3)) have been previously described. The level of cardiothoracic specialist input required on repatriation to the UK is less clear. This study aimed to assess the outcomes of casualties with thoracic injuries repatriated to the UK (Role 4 (R4)) and evaluate the impact of specialist cardiothoracic care.
  
  
  METHODS
  Casualties were identified through the UK Joint Theatre Trauma Registry. Casualties coded for pulmonary contusions and/or thoracotomy between March 2006 and March 2011 were identified and case-notes reviewed. Subgroup analysis was performed for patients with a documented thoracic abbreviated injury score ≥3.
  
  
  RESULTS
  One hundred and eighty-two UK patients were admitted to UK R4 coded to have a thoracic injury; overall mortality 4.9%. Ninety-three were classified as a thoracic AIS of ≥3; mortality 6.5%. Sixty-four were coded for pulmonary contusions and/or thoracotomy; mortality 1.6, and 66% had thoracic AIS ≥3. Improvised explosive devices injured 54 and 62% had a penetrating injury. Pulmonary contusions were present in 70%; 43% developed a chest infection. Thoracotomy/sternotomy was performed in 13 casualties in R3; 3 re-explored in R4. Oscillatory ventilation and extracorporeal membrane oxygenation was required in 1 case. Cardiothoracic surgery was involved in managing 39% (n = 24) of cases; 11 (45%) required surgical intervention and 19 (79%) had cardiothoracic outpatient follow-up.
  
  
  CONCLUSIONS
  Morbidity and mortality associated with significant thoracic injury is low at UK R4. Follow-up is required to assess long-term outcomes. Specialist cardiothoracic support and intervention was required in the management of complex thoracic trauma. Early specialist support at R4 may improve morbidity and outcomes associated with life-threatening thoracic injury.
authors.affiliation: Department of Cardiac Surgery, University Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.
authors.forename: Eshan L
authors.initials: EL
authors.lastname: Senanayake
authors.affiliation: Academic Department of Military Surgery and Trauma, Birmingham, UK henrietta.poon@nhs.net.
authors.forename: Henrietta
authors.initials: H
authors.lastname: Poon
authors.affiliation: Department of Cardiac Surgery, University Hospital Birmingham, Birmingham, UK.
authors.forename: Tim R
authors.initials: TR
authors.lastname: Graham
authors.affiliation: Academic Department of Military Surgery and Trauma, Birmingham, UK School of Population and Health Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Midwinter
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D015505:Chest Tubes; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008887:Military Medicine / Q000379:methods; D008889:Military Personnel / Q000706:statistics & numerical data*; D013898:Thoracic Injuries / Q000453:epidemiology* / Q000601:surgery*; D013908:Thoracotomy; D006113:United Kingdom / Q000453:epidemiology; D014945:Wound Healing; D055815:Young Adult
keywords: Emergency; Surgery; Thoracotomy; Trauma; Wound healing