Vascular disruption with concomitant hemorrhage is a leading cause of death in civilian and military trauma.^1,2 Experience from the wars in Iraq and Afghanistan has led to advances in resuscitation for hemorrhagic shock, with identification of optimum ratios of blood components to be used in this setting.^3-5 These new strategies are based on early and balanced administration of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate to restore circulating volume and clotting factors.⁶ Despite these advances, the effectiveness of a medication to improve mortality in the setting of hemorrhagic shock has not been established.

Background: Spiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear. Methods: Forty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings. Results: The final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery. Conclusion: EUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.

Hemorrhage resultant from vascular disruption remains the predominant cause of preventable battlefield mortality^1,2 and the leading cause of preventable death in civilian trauma.^3-5 Acute traumatic coagulopathy is associated with a 4-fold increase in mortality and is characterized by both anticoagulation and fibrinolysis.⁶ Fibrinolysis is a key protective or regulatory mechanism that prevents the extension of formed clot beyond the site of injury⁷ but may become pathologic following injury and shock.⁸ When present in the setting of trauma, excessive fibrinolysis (ie, hyperfibrinolysis) is associated with a mortality rate of 48% to 100%.^9-12

BACKGROUND The United Kingdom was at war in Iraq and Afghanistan for more than a decade. Despite assertions regarding advances in military trauma care during these wars, thus far, no studies have examined survival in UK troops during this sustained period of combat. The aims of this study were to examine temporal changes of injury patterns defined by body region and survival in a population of UK Military casualties between 2003 and 2012 in Iraq and Afghanistan. METHODS The UK Military Joint Theatre Trauma Registry was searched for all UK Military casualties (survivors and fatalities) sustained on operations between January 1, 2003, and December 31, 2012. The New Injury Severity Score (NISS) was used to stratify injury severity. RESULTS There were 2,792 UK Military casualties sustaining 14,252 separate injuries during the study period. There were 608 fatalities (22% of all casualties). Approximately 70% of casualties injured in hostile action resulted from explosive munitions. The extremities were the most commonly injured body region, involved in 43% of all injuries. The NISS associated with a 50% chance of survival rose each year from 32 in 2003 to 60 in 2012. CONCLUSION An improvement in survival during the 10-year period is demonstrated. A majority of wounds are a result of explosive munitions, and the extremities are the most commonly affected body region. The authors recommend the development of more sophisticated techniques for the measuring of the performance of combat casualty care systems to include measures of morbidity and functional recovery as well as survival. LEVEL OF EVIDENCE Epidemiologic study, level III.