LETTER TO THE EDITOR doi: 10.1111/nicc.

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Nursing challenges with a severely injured patient in critical care: the importance of hypothermia mitigation
To the Editor: We read with interest the article written by Crossan and Cole (2013) entitled Nursing challenges with a severely injured patient in critical care, which provided an interesting case study relating to the care of a polytrauma patient. Many of the principles outlined in this article are similar to those used by the UK Defence Medical Services (DMS). We would like to share our specic experiences in relation to the management of hypothermia in the surgical trauma patient. Crossan and Coles case study identied that the patient was admitted to the Emergency Department with a core temperature 34 C. On admission to the Critical Care Unit (CCU) the core temperature remained 34 C, and even with their hypothermia mitigation strategies, the reason for this is unclear. From a military perspective hypothermia is regarded as a major but poorly visible problem, which is also associated with signicantly increased mortality and morbidity in trauma and surgical patients (Joint Service Publication 950, 2011; Jurkovich et al., 1987). Within the DMS much research has been conducted relating to hypothermia mitigation throughout the patient pathway from the point of injury to the military CCU. A key to success is cross-speciality working, and within the DMS this concept is common practice. The enduring principles of Damage Control Resuscitation and Surgery were identied and discussed as far back as 1996 (Clark et al., 2002). Since 2007, our Surgeon Generals operational policy outlines methods of hypothermia prevention, monitoring of temperature in the
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critically ill patient, as well as training and audit standards (Joint Service Publication 950, 2011). This has translated into mitigation and treatment equipment being provided throughout the casualty pathway. Hypothermia is used as a key performance indicator (KPI) of British military trauma outcomes studies and casualty simulation training which includes the recognition and management of hypothermia (Stannard et al., 2008). A recent meeting of the multidisciplinary trauma physiology working group reviewed the issues surrounding hypothermia and developed a series of cross-discipline consensus statements, which further highlights the need for a joint approach to hypothermia management from the point of injury to CCU and beyond (Mossadegh and Parker, in press). Even with our developments in the early use of blood, plasma and platelets in the resuscitation pathway (so-called 1:1:1 resuscitation) it is clear that without normothermia, outcomes are universally poor. Overall, Crossan and Coles article contributes to nursing the critically ill trauma patient and highlights the challenges and advances in trauma care. It is hoped that this letter raises the prole of hypothermia management in trauma and surgical patients amongst our colleagues regardless of speciality, as simple hypothermia continues to persistently kill trauma and needs to be prevented, recognised and aggressively treated. Chris Carter Major Queen Alexandras Royal Army Nursing Corps

Intensive Care Nursing Ofcer E-mail: chris.carter946@mod.uk Wanda Hughes Flight Sergeant Princess Marys Royal Air Force Nursing Services, Intensive Care Nurse Jayne Cumming Lieutenant Colonel Queen Alexandras Royal Army Nursing Corps Clinical OF4 Critical Care Paul Parker Colonel L/Royal Army Medical Corps Senior Lecturer in Trauma Physiology, Academic Department of Military Surgery and Trauma Consultant Orthopaedic Surgeon, Royal Centre for Defence Medicine

REFERENCES
Clark JR, Trooskin SZ, Doshi PJ. (2002). Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. Journal of Trauma; 52: 42025. Crossan L, Cole E. (2013). Nursing challenges with a severely injured patient in critical care. Nursing in Critical Care; 18: 236244. Joint Service Publication 950. (2011). Prevention of onset or deterioration of hypothermia in trauma cases. Dated 01 May 07. Leaet 2-4-1 Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. (1987). Hypothermia in trauma victims: an ominous predictor of survival. Journal of Trauma; 27: 10191024. Mossadegh S. Parker P. (2013). Hypothermia a multidisciplinary military consensus. Journal of the Royal Army Medical Corps. (In press). Stannard A, Tai NR, Bowley DM, et al. (2008). Key performance indicators in British Military Trauma. World Journal of Surgery; 32: 18701873.

2014 British Association of Critical Care Nurses Vol 19 No 1