Combat surgery: Status of tactical abbreviated surgical control

KABUL AIRPORT SUICIDE BOMBING ATTACK: MASS CASUALTY MANAGEMENT AT THE EMERGENCY'NGO HOSPITAL

BACKGROUND

Terrorist attacks with large numbers of civilian victims are not uncommon in war-torn countries, and present a unique challenge for health care facilities with limited resources. However, these events are largely under-reported and little is known about how the mass casualty events (MCE) are handled outside of a military setting.

METHODS

This study is a retrospective analysis of the MCE which ensued the Kabul Airport suicide attack (26th August 2021) at the Kabul EMERGENCY'NGO Hospital (Afghanistan).

RESULTS

Within six hours 93 causalities presented at our hospital. Out of them, 36 severe injured were admitted. Mean age was 30.8 years (SD 10.1). The most common injury mechanism was shell fragments. The most common injury site was head (63%; 23/36), followed by limbs (55.5%; 20/36) and thoracoabdominal region (30.5%; 11/36). Combined injuries occurred in 38.9% of cases. Patients receiving surgery presented more combined injuries in comparison with patients receiving only medical treatment (47.1% vs 31.6%). Thoraco-abdomen (25.0% vs 15.4%) and/or extremity injury (42.9% vs 28.6%) were more prevalent in the surgical group. Thirty major surgical procedures were carried out on 17 patients in the nine hours following the first arrival. The rate of Intensive Care Unit/High Dependency Unit admission was 36.1% and the 30-day in-hospital mortality was 16.6% (6/36). All deaths were recorded in the first 24 hours and none of them received surgery.

CONCLUSIONS

A large number of wounded patients must be anticipated after suicide bombing attacks. The authors report the challenges faced and key aspects of their management of MCEs.

LEVEL OF EVIDENCE

Retrospective analysis/incident management.

Combined thoracoabdomial injury: Case report

Introduction

Combined thoracoabdominal injuries are the most severe case in the medical practice. Bilateral injuries are rare case in patients and just few cases reported in literature. Diaphragm traumas and pneumothorax are defined as severe trauma leading to injuries of thoracic and abdominal organs. We are describing multiple injuries of abdominal tract and chest causing internal bleeding and hemothorax in patient. Surgical operation was carried out on the right side thoracotomy including revision of the pleural cavity and subphrenic space, closure of the wound, removal of the blood clot and drainage of the pleural with abdominal cavities.

Presentation of case

A 24-years old man was admitted in Emergency Department after penetrating knife wounds of abdominal cavity.

Discussion

X-ray of the tracheobronchial tree (bronchography) showed closed chest injuries, post traumatic hemopneumothorax of the right side.

Conclusion

Surgical repair was conducted by displacing of the organs in chest cavity with lamellar T-shaped retractor, and hemostatic Billroth, Kocher clamps to stop bleeding in the wound.

Terrorist attacks: common injuries and initial surgical management

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side

BACKGROUND

During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions.

METHODS

Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups.

RESULTS

Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05).

CONCLUSION

Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed.

LEVEL OF EVIDENCE

Basic science.

The evolution and impact of the "damage control orthopedics" paradigm in combat surgery: a review

The idea of damage control (DC) is grounded on a sequential therapeutic strategy that supports physiological restoration over anatomic repair in critically injured patients. This concept is firstly described as damage control surgery (DCS) for war-wounded patients with abdominal exsanguinating trauma. The goal was to avoid prolonged operative times and prevent the outset of the lethal cycle of hypothermia, acidosis and coagulopathy. Damage control orthopedics (DCO) is also based on this concept and it is applied in the treatment of some polytrauma patients with pelvic and long bones fractures as to avoid the "second hit" of a lengthy definitive operation and eliminate initial morbidity and mortality. It is in favor of primary fracture stabilization utilizing provisional external fixation. When the patient is in stable condition, conversion to definitive open reduction and intramedullary nailing can be done. This stepwise approach should be considered as a part of the resuscitation process, and it follows the saying "do no further harm".

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma

INTRODUCTION

The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience.

METHODS

All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0.

RESULTS

A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high.

CONCLUSION

Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.