Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice

Unusual pattern of firearm injury to trunk and limbs: Two case reports and review

This article presents two cases of fatal injuries from rifled weapons with unconventional shapes of inlets and exits mismatched with the distance of firing. According to forensic literature, in long-distance ranges, we expected to see rounded entry wounds smaller than bullet size, circular in shape without associates with limited damage in the tissues. In the first case, there were large wounds which did not match a distance of more than 2 m, while in the second case, the distance was more than 30 m with large wounds 21 × 10 cm and massive damage to bones and lungs. In the first case, a 25-year-old male, he had multiple wounds in the front of the chest, the first one over the sternum end measuring 9 × 7 cm rounded in shape with fracture of the ribs, sternum and lung laceration. The second wound was 3 × 5 cm in the lateral aspect - mid axillary line and it was superficial due to tangential passage of the missile. In the left thigh, two inlets, each approximately 5 × 7 cm, were seen, the first one over the left iliac bone rounded and the second inlet was in the midshaft of the femur. The exit was below the left gluteus, rounded in shape 5 × 7 cm. The second case a 19-year-old male, he showed single oval wound in the middle third of the back, and it measured 21 × 10 cm. The missile passed tangentially and led to broken ribs and the vertebral column with a lung laceration.

The wounding potential of assault rifles: analysis of the dimensions of entrance and exit wounds and comparison with conventional handguns. A multicentric study

The appearance of a gunshot wound (GSW) is greatly influenced by the velocity of the projectile, where high-velocity projectiles (HVPs) are defined as ballistic agents reaching a muzzle velocity of > 600 m/s fired from assault rifles. The aim of the study is to present and explain the differences in the dimensions of entrance and exit wounds between the most used handguns and assault rifles and to propose a predictor of HVP, i.e., the ratio of exit and entrance wounds (EX/ENR). The surface area of entrance and exit GSWs and the EX/ENR were calculated. 66 perforating GSWs produced by NATO FMJ 7.62 × 52 mm and 5.56 × 42 mm fired from assault rifles were assigned to the HVP, while 64 lesions produced by conventional projectiles fired from revolvers and semi-automatic pistols were assigned to the low-velocity projectile (LVP) group. The dimensions of the exit wounds of the HVP group were significantly higher when compared to the LVP group (95% CI 0.9886-2.423, p < 0.05). The HVP group showed significantly higher values for the EX/ENR when compared to the LVP group (95% CI 2.617-7.173, p < 0.05). The evaluation of the EX/ENR can be considered an adequate tool to assess the type of weapon involved and to roughly estimate the associated wounding mechanisms, which can guide both the physician in the management and treatment of the patients affected by GSW, and the forensic pathologist in crime investigation.

Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.

Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study

BACKGROUND

Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients.

METHODS

This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden's Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age.

RESULTS

There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 21.

CONCLUSIONS

Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.

Thoracic trauma in national hospital Abuja, Nigeria: The epidemiology, injury severity and initial management options

Background

Trauma is the leading cause of death in individuals between the ages of 1 and 44 years and it is the third commonest cause of death regardless of age. Thoracic trauma is a relatively common cause of preventable death among trauma patients. The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. This study is intended to discuss the epidemiology, severity and initial management strategies in chest trauma patients, in a low income country.

Methods

A cross sectional retrospective study among chest trauma patients seen in the emergency room of National Hospital Trauma Centre, Abuja, Nigeria, from January 2015 to December 2017. Relevant patients' information was retrieved from the trauma registry kept in the trauma centre. Data processing and analysis was done using statistical package for social sciences (SPSS) version 24. Test of significance was done where applicable using chi square and student t test, using p value less than 0.05 as significant. Results are presented in tables and figures.

Results

A total of 637 patients, male to female ratio of 3.6 and mean age of 34.18 ± 11.34 were enrolled into the study. The most common mechanisms of injury were MVC (54.6%) and assault (23.5%). Blunt injuries were 3.5 times more frequent than the penetrating injuries. The RTS of 12 (76.3%) and the ISS of 1-15 category (52.3%) were the most common scores. Up to 98% of patients were managed non-operatively. Recovery rate was high (89%) with relatively low mortality rate of 4.2%.

Conclusion

Majority of thoracic trauma can be managed effectively by employing simple, non-operative procedures such as needle decompression and chest tube insertion. Efforts should be made to include these procedures in the skill set of every medical officer working in the emergency room, particularly in low and middle income countries where there is paucity of emergency physicians.

A rare case of migration of ballistic projectile from left to right main bronchus

A foreign body in the bronchus due to a ballistic projectile is very uncommon. A 45-year-old man presented to the hospital after being accidentally shot. The initial radiographic assessment found a bullet in his left thoracic cavity. With the help of an X-ray, an urgent left posterolateral thoracotomy was conducted, but no foreign body was found. The foreign body had migrated to the contralateral chest cavity, as determined by the C-arm. On the following day, a thorax computed tomography scan was conducted, and it was discovered that the foreign body had already migrated to the right lower bronchus. A right thoracotomy was then performed to remove the foreign body. He was moved to the intensive care unit and discharged with a stable condition. In conclusion, migration of a foreign body in the bronchus is rare. A thorough strategy is required to prevent the object from migrating even further.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Tension haemothorax from a bleeding branch of the renal artery following isolated penetrating thoracic trauma: a rare presentation

A 27-year-old man presented to a major trauma centre with two posterolateral thoracic stab injuries over the right scapula and thoracoabdominal junction. He was tachycardic and hypotensive with a chest X-ray revealing a large right-sided tension haemothorax, requiring insertion of two intercostal chest drains. A subsequent CT scan demonstrated a grade 4 right kidney laceration with active back bleeding from a renal artery branch, through a right diaphragmatic defect, into the pleural cavity. Embolisation of the feeding renal vessel controlled the bleeding and avoided the need for a nephrectomy. The patient required subsequent video-assisted thoracoscopic evacuation of the haemothorax and diaphragmatic repair, confirming that there was no associated lung or major vessel injury. A ureteric stent was ultimately inserted to manage a persistent urinary leak. This case highlights a rare cause for a common traumatic presentation and the need for a multidisciplinary approach in effective management of complex, multiorgan trauma.

Injuries caused by fragmenting rifle ammunition

INTRODUCTION

Although penetrating injuries are encountered on a regular basis in high volume trauma centres, most civilian trauma teams will be unfamiliar with the treatment of patients with injuries caused by fragmenting ammunition. The terrorist attacks in Norway on July 22, 2011 included a shooting spree causing 69 deaths and 60 injured. One of the weapons used was a semi-automatic rifle, calibre 5.56mm, with soft tip, short stop ammunition. The aim of the present study was to describe the characteristic injury patterns and lessons learned from the treatment of multiple patients admitted at the regional trauma centre with injuries from this type of ammunition.

METHODS

We undertook an observational study of patients admitted at Oslo University Hospital, Ulleval after the shooting spree at Utoya on July 22, 2011. Data on demographics, injuries, injury severity, surgical procedures and outcome were collected prospectively.

RESULTS

Of the 21 patients admitted after the shooting incident, 18 were identified with injuries caused by fragmenting ammunition and included in the study. Median age was 17 years (IQR 16, 19), median ISS 21 (IQR 12, 30) and 12 patients were female. They had been hit by a total of 38 projectiles, of which 32 were fragmenting bullets. Of the seven patients who sustained injuries to the head, neck and face, one patient required a craniotomy and one patient had a non-survivable head injury. Of the 11 patients with torso injuries, six of the eight patients with chest injuries had intra-thoracic injuries that could be treated with chest tubes only. One patient had cardiac tamponade, requiring thoracotomy. Six patients underwent laparotomy, four of them more than one. Of the 10 patients with extremity injuries, two had nerve injuries and six patients had fractures. Five amputations were performed within the first nine days. A total of 101 operations were required within the first four weeks. The majority of these were repeated soft tissue debridements due to progressive necrosis.

CONCLUSION

Knowledge about the specific challenges created by the progressive soft tissue necrosis caused by fragmenting ammunition should lead to planned, repeated debridements to reduce total tissue loss and complications.

Entrance and exit wounds of high velocity bullet: An autopsy analysis in the event of dispersing the mass rally in Bangkok Thailand, May 2010

Fatal mass casualties by high velocity bullets (HVBs) are rare events in peaceful countries. This study presents 27 forensic autopsy cases with 32 shots fired by 5.56×45mm. HVB (M-16 rifle bullets) during the dispersing the mass rally in Bangkok Thailand, May 2010. It was found that twenty-three (71.88%) typical entrance HVB wounds had round sizes less than the bullet diameters. Most entrance wounds had microtears but no collar abrasion since a HVB has a small streamlined spitzer tip and full metal jacket. For exit wounds, there were various sizes and shapes depending on which section of wound ballistics presented when the bullet exited the body. If a bullet exited in the section of temporally cavity formation, there would be a large size exit wound in accordance with the degree of bullet yaw. This is different from civilian bullets whereby the shape looks like a cylindrical round nose and at low velocity that causes entrance wounds with a similar size to the bullet diameter and is usually round or oval shape with collar abrasion. The temporary cavity is not as large as in a HVB so exit wounds are not quite as large and present a ragged border compared to a HVB. We also reported 9 out of 32 shots (28.13%) of atypical entrance wounds that had various characteristics depending on site of injury and destabilization of bullets. These findings may be helpful to forensic pathologists and to give physicians, who need to diagnose HVB wounds, more confidence.

Thoracoscopy in chest trauma: an update

The role of thoracoscopy in the management of patients with chest injuries is constantly being redefined as more reports on its use continue to emerge in the literature. As of today video-thoracoscopy has been used mainly as a diagnostic tool for certain occult injuries, such as of the diaphragm, as well as a minimally invasive management option in specific therapeutic situations including early evacuation of retained thoracic collections. It has the potential to replace open surgery in the management of more than 50% of civilian and military thoracic injuries previously considered candidates for open surgical management with all the benefits of minimally invasive surgery. In addition, it is a promising tool for earlier detection of missed injuries in patients otherwise managed nonoperatively. The procedure-related complication rate is low and there are only few contraindications for thoracoscopy, mainly haemodynamic instability and obliterated pleural space caused by previous infections or surgical interventions. However, the scientific evaluation of the global impact of thoracoscopy in the management of thoracic injuries is currently limited to descriptive series, some of them using historical controls, and a few non-randomized prospective studies. Until more well-designed, prospective, randomized studies emerge which compare thoracoscopy to standard management protocols in defined patient populations with thoracic injuries using relevant end points, the potential benefit of thoracoscopy in chest trauma remains unvalidated and its value is limited to isolated patients depending on individual surgeon’s preferences and skills.

Penetrating trauma

Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.

Repair of tracheobronchial injuries

Tracheobronchial injuries (TBIs) are caused by blunt, penetrating injury or by iatrogenic damage. Most injuries are life threatening and need early and skillful airway management. Bronchoscopy remains the gold standard of diagnosis. Penetrating TBI always needs blunt trauma, and iatrogenic TBI sometimes needs surgical exploration and reconstruction, which is performed after sparing debridement with primary repair and wound closure. Prognosis mainly depends on associated injuries and comorbidities in terms of tracheal membrane laceration.

Analytical review of 664 cases of penetrating buttock trauma

A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.

Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania

BACKGROUND

Chest injuries constitute a continuing challenge to the trauma or general surgeon practicing in developing countries. This study was conducted to outline the etiological spectrum, injury patterns and short term outcome of these injuries in our setting.

PATIENTS AND METHODS

This was a prospective study involving chest injury patients admitted to Bugando Medical Centre over a six-month period from November 2009 to April 2010 inclusive.

RESULTS

A total of 150 chest injury patients were studied. Males outnumbered females by a ratio of 3.8:1. Their ages ranged from 1 to 80 years (mean = 32.17 years). The majority of patients (72.7%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 50.7% of patients. Chest wall wounds, hemothorax and rib fractures were the most common type of injuries accounting for 30.0%, 21.3% and 20.7% respectively. Associated injuries were noted in 56.0% of patients and head/neck (33.3%) and musculoskeletal regions (26.7%) were commonly affected. The majority of patients (55.3%) were treated successfully with non-operative approach. Underwater seal drainage was performed in 39 patients (19.3%). One patient (0.7%) underwent thoracotomy due to hemopericardium. Thirty nine patients (26.0%) had complications of which wound sepsis (14.7%) and complications of long bone fractures (12.0%) were the most common complications. The mean LOS was 13.17 days and mortality rate was 3.3%. Using multivariate logistic regression analysis, associated injuries, the type of injury, trauma scores (ISS, RTS and PTS) were found to be significant predictors of the LOS (P < 0.001), whereas mortality was significantly associated with pre-morbid illness, associated injuries, trauma scores (ISS, RTS and PTS), the need for ICU admission and the presence of complications (P < 0.001).

CONCLUSION

Chest injuries resulting from RTCs remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce the incidence of chest injuries in this region.

Incidence of postoperative acute renal failure among violence-related cardiovascular trauma patients: a review of our experience in 117 cases

BACKGROUND

The purpose of this retrospective study was to determine the incidence of renal failure and hemodialysis (HD) in postoperative period after cardiovascular surgery associated with trauma.

METHODS

One hundred and seventeen cases of violence-related cardiovascular trauma patients had emergent surgery between 1996 and 2009. Cases were reviewed in three main groups: Cardiac trauma in 11 patients (Group A), vascular trauma in 78 patients (Group B), and cardiovascular trauma in 28 patients (Group C). Postoperative incidence of HD requirements with acute renal failure (ARF) was investigated in these groups of patients postoperatively.

RESULTS

Multiorgan deficiency developed in 10 patients from Group A, in 45 patients from Group B, and in 26 patients from Group C. Overall mortality was 81 cases in 117 patients. Total hospitalization periods were 21 +/- 2, 17 +/- 3, and 27 +/- 1 days for Group A, Group B, and Group C, respectively. HD administrations were indicated in 3 patients in Group A, 41 patients in Group B, and 9 patients in Group C. No statistically significant difference presented in any study parameter between groups.

CONCLUSIONS

Cardiovascular trauma is a common reason for emergent cardiovascular surgery. Postoperative renal failure occurs among these patients in a wide percentage. We strongly advocate a close and detailed follow-up of renal functions in these patients during the hospitalization period and immediate HD at indication.

Cardiac and Pulmonary Injury

Cardiac and pulmonary injuries present major challenges in diagnosis and treatment. Distinct differences between penetrating and blunt trauma of these organs exist. Outcomes for severe injuries are still grave. Organized trauma systems can provide optimal care by minimizing prehospital time, allowing easy access to imaging modalities, and offering state-of-the-art treatment strategies. A multidisciplinary approach, including surgeons, intensivists, and others, is absolutely necessary.

Penetrating chest wounds: 24 years experience

Thoracic and thoracoabdominal penetrating wounds are frequently encountered in urban medical centers in the United States. This study was undertaken to determine the clinical characteristics and in hospital outcome of these injuries. This was a longitudinal, nonblinded study using the established standard of care of patients with penetrating chest trauma. It consists of an analysis of a consecutive series of 3049 patients treated at one trauma center between April 1972 and March 1996. There were 1347 stab wounds and 1702 gunshot wounds. Antibiotic prophylaxis was administered to patients who underwent laparotomy or thoracotomy or who had lung contusion with hemoptysis (41.6%, 1296/3049). Of 3049 patients, 196 had cardiac injuries. All of them underwent thoracotomy, and the mortality was 21.9%. In contrast, among 2853 patients without cardiac injuries, only 257 (9%) required thoracotomy; the mortality in this group was 1.5%. Patients with thoracoabdominal injuries (899/3049) had a mortality of 4.3% compared to 2.1% among those who had isolated chest injuries. The overall mortality was 2.8%. Of 1702 patients with gunshot wounds, 85 (5%) sustained transaxial injuries, with an overall mortality of 36.5%. The complication rate among the survivors was 6% with only 2.5% being infectious. We conclude that the mortality for noncardiac penetrating injuries of the chest is low. The presence of associated abdominal injuries increases the mortality twofold. More than one-third of the patients with transaxial wounds die. Gunshot wounds of the heart result in higher mortality than stab wounds to the heart. The infection rate is low.

Penetrating chest injuries in the firearm era

BACKGROUND

firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury.

METHODS

records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed.

RESULTS

there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively.

CONCLUSIONS

patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.