Case-control analysis of prehospital death and prolonged field care survival during recent US military combat operations

BACKGROUND

Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning.

MATERIALS AND METHODS

Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy.

RESULTS

The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity.

CONCLUSION

Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment.

LEVEL OF EVIDENCE

Prognostic, Level III.

United States military fatalities during Operation New Dawn

BACKGROUND

Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care.

METHODS

A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement.

RESULTS

Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%).

CONCLUSION

Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery.

LEVEL OF EVIDENCE

Therapeutic, level V and epidemiological, level IV.

Severe Fireworks-Related Injuries: Demographic Characteristics, Injury Patterns, and Firework Types in 294 Consecutive Patients

OBJECTIVES

The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults.

METHODS

We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older.

RESULTS

Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died.

CONCLUSIONS

Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

Simulated Aeromedical Evacuation in a Polytrauma Rat Model

BACKGROUND: Hemorrhage and traumatic brain injury can be lethal if left unattended. The transportation of severely wounded combat casualties from the battlefield to higher level of care via aeromedical evacuation (AE) may result in unintended complications. This could become a serious concern at the time of evacuation of mass casualties or for prolonged field care scenarios with limited resources.METHODS: Following instrumentation (t1), anesthetized Sprague-Dawley rats were injured or not [75-kPa blast and 30% estimated blood-volume controlled hemorrhage] (t2). After 15 min, all rats were resuscitated with saline. During the simulated 3-h evacuation, 8000 ft (2440 m) vs. sea-level heart rate, temperature, and oxygenation (S_po₂) were continuously recorded. One group of rats was euthanized immediately after evacuation (t3) and another after a 72-h recovery period (t4). Hematology and metabolic levels were measured at t1, t2, t3, and t4.RESULTS: Survival was 100% in control-uninjured animals, 83% in injured animals under normobaria, and significantly reduced to 50% under hypobaria. This AE setting resulted in significantly lower hemodynamics, thermoregulation, and oxygenation parameters in the animals under hypobaria than those under normobaria. The initial lower mean arterial pressure (MAP) with the reduced oxygen level before AE were critical factors for the survival of injured animals. We observed a general increase of white blood cells and platelet ability to aggregate at t4 in all experimental groups.CONCLUSION: Physiological parameters were affected during aeromedical evacuation in all groups. This was worsened for injured animals with MAP less than 60 mmHg associated with low S_po₂ in a simulated aeromedical evacuation. This represented a high risk of mortality for severely polytraumatized animals.Arnaud F, Pappas G, Maudlin-Jeronimo E, Goforth C. Simulated aeromedical evacuation in a polytrauma rat model. Aerosp Med Hum Perform. 2019; 90(12):1016-1025.

Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat

BACKGROUND

The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss.

METHODS

The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed.

RESULTS

Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12).

CONCLUSIONS

The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ± 4.21 hours vs 3.77 ± 2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Lethal explosions in a non-terrorist civilian setting

A study was undertaken to investigate the range and nature of deaths that may result from explosions in a civilian population that has not been exposed to terrorist attacks or significant military activities. A search was conducted of autopsy files at Forensic Science SA, Adelaide, Australia, from July 2000 to June 2017 for all cases where death had been attributed to an explosion. Twenty cases were identified, consisting of 10 accidents, five suicides, two homicides, one murder-suicide with two decedents and one case where the manner of death was undetermined. Explosives were involved in nine deaths, petrol in seven and propane/butane/natural gas in a further four. Deaths caused by explosions were a rare event, with most cases being caused by accidents in a domestic or industrial environment. Although suicides formed the next most-common group, it is possible that explosions caused by petrol in cases of self-immolation were not intended.

From Northern Ireland to Afghanistan: half a century of blast injuries

Introduction

Throughout the last half century, blast injuries have been a common occurrence to UK military personnel during combat operations. This study investigates casualty data from three different military operations to determine whether survivability from blast injuries has improved over time and whether the tactics used could have influenced the injuries sustained.

Methods

Casualty data from operations in Northern Ireland, Iraq and Afghanistan were reviewed and found to contain a total of 2629 casualties injured by improvised explosive devices. The injury severities were examined and the suitability of comparison between conflicts was considered.

Results

The case fatality rate and mean severity score sustained remained consistent among the operations included in this study. Using the New Injury Severity Score, the probabilities of survival were calculated for each separate operation. The body regions injured were identified for both fatalities and survivors. Using this information, comparisons of injury severities sustained at an Abbreviated Injury Scale of 3 and above (identified as a threshold for fatal injury) were conducted between the different operations.

Conclusions

The data showed that as operations changed over time, survivability improved and the proportions of body regions injured also changed; however, this study also highlights how studying casualty data from different conflicts without taking account for the contextual differences may lead to misleading conclusions.

Air blast injuries killed the crew of the submarine H.L. Hunley

The submarine H.L. Hunley was the first submarine to sink an enemy ship during combat; however, the cause of its sinking has been a mystery for over 150 years. The Hunley set off a 61.2 kg (135 lb) black powder torpedo at a distance less than 5 m (16 ft) off its bow. Scaled experiments were performed that measured black powder and shock tube explosions underwater and propagation of blasts through a model ship hull. This propagation data was used in combination with archival experimental data to evaluate the risk to the crew from their own torpedo. The blast produced likely caused flexion of the ship hull to transmit the blast wave; the secondary wave transmitted inside the crew compartment was of sufficient magnitude that the calculated chances of survival were less than 16% for each crew member. The submarine drifted to its resting place after the crew died of air blast trauma within the hull.

Injury profile suffered by targets of antipersonnel improvised explosive devices: prospective cohort study

OBJECTIVE

To describe pattern 1 injuries caused by the antipersonnel improvised explosive device (AP-IED) in comparison to those previously described for antipersonnel mines (APM).

DESIGN

Prospective cohort study of 100 consecutive pedestrian victims of an AP-IED, with traumatic amputation without regard for gender, nationality or military status.

SETTING

Multinational Medical Unit at Kandahar Air Field, Afghanistan.

PARTICIPANTS

One hundred consecutive patients, all male, 6-44 years old.

MAIN OUTCOME MEASURES

The details of injuries were recorded to describe the pattern and characterise the injuries suffered by the target of AP-IEDs. The level of amputation, the level of soft tissue injury, the fracture pattern (including pelvic fractures) as well as perineal, gluteal, genital and other injuries were recorded.

RESULTS

Victims of AP-IED were more likely, compared with APM victims, to have multiple amputations (70.0% vs 10.4%; p<0.001) or genital injury (26% vs 13%; p=0.007). Multiple amputations occurred in 70 patients: 5 quadruple amputations, 27 triple amputations and 38 double amputations. Pelvic fracture occurred in 21 victims, all but one of whom had multiple amputations. Severe perineal, gluteal or genital injuries were present in 46 patients. Severe soft tissue injury was universal, with injection of contaminated soil along tissue planes well above entry sites. There were 13 facial injuries, 9 skull fractures and 3 traumatic brain injuries. Eleven eye injuries were seen; none of the victims with eye injuries were wearing eye protection. The casualty fatality rate was at least 19%. The presence of more than one amputation was associated with a higher rate of pelvic fracture (28.6% vs 3.3%; p=0.005) and perineal-gluteal injury (32.6% vs 11.1%; p=0.009).

CONCLUSION

The injury pattern suffered by the target of the AP-IED is markedly worse than that of conventional APM. Pelvic binders and tourniquets should be applied at the point of injury to patients with multiple amputations or perineal injuries.

[Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®]

BACKGROUND

Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive.

MATERIAL AND METHODS

A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed.

RESULTS

A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %).

CONCLUSION

This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data

INTRODUCTION

Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.

METHODS

The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ² and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.

RESULTS

We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).

CONCLUSION

Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

A descriptive analysis of injury triage, surge of medical demand, and resource use in an university hospital after 8.12 Tianjin Port Explosion, China

OBJECTIVE

The 8.12 Tianjin Port Explosion in 2015 caused heavy casualties. Pingjin Hospital, an affiliated college hospital in Tianjin, China participated in the rescue activities. This study aims to analyze the emergency medical response to this event and share experience with trauma physicians to optimize the use of medical resource and reduce mortality of critical patients.

METHODS

As a trauma centre at the accident city, our hospital treated 298 patients. We retrospectively analyzed the data of emergency medical response, including injury triage, injury type, ICU patient flow, and medical resource use.

RESULTS

There were totally 165 deaths, 8 missing, and 797 non-fatal injuries in this explosion. Our hospital treated 298 casualties in two surges of medical demand. The first one appeared at 1 h after explosion when 147 wounded were received and the second one at 4 h when 31 seriously injured patients were received, among whom 29 were transferred from Tianjin Emergency Center which was responsible for the scene injury triage. After reexamination and triage, only 11 cases were defined as critical ill patients. The over-triage rate reached as high as 62.07%. Seventeen patients underwent surgery and 17 patients were admitted to the intensive care unit.

CONCLUSIONS

The present pre-hospital system is incomplete and may induce two surges of medical demand. The first one has a much larger number of casualties than predicted but the injury level is mild; while the second one has less wounded but almost all of them are critical patients. The over-triage rate is high. The hospital emergency response can be improved by an effective re-triage and implementation of a hospital-wide damage control.

Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

OBJECTIVE

To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI).

MATERIAL AND METHODS

This retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n=69), in which the limb was salvaged and group II (n=21), in which the patients received amputation.

RESULTS

The overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p=0.042). They were also more likely to be injured as a result of an explosion (p=0.004). Along with the MESS (p<0.001), the duration of ischemia (DoI) (p<0.001) were higher in group II. The rate of bony fracture (p<0.001) and wound infection (p=0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p=0.011), nerve injury (OR: 136.23, p=0.004), DoI (OR: 2.03, p=0.003), vascular ligation (OR: 8.65, p=0.040) and explosive device injury (OR: 10.8, p=0.041) were significant. Although the DoI (p<0.001) and the MESS (p=0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p=1.0).

CONCLUSIONS

The DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS>7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.

A Compact Blast-Induced Traumatic Brain Injury Model in Mice

Blast-induced traumatic brain injury (bTBI) is a common injury on the battlefield and often results in permanent cognitive and neurological abnormalities. We report a novel compact device that creates graded bTBI in mice. The injury severity can be controlled by precise pressures that mimic Friedlander shockwave curves. The mouse head was stabilized with a head fixator, and the body was protected with a metal shield; shockwave durations were 3 to 4 milliseconds. Reflective shockwave peak readings at the position of the mouse head were 12 6 2.6 psi, 50 6 20.3 psi, and 100 6 33.1 psi at 100, 200, and 250 psi predetermined driver chamber pressures, respectively. The bTBIs of 250 psi caused 80% mortality, which decreased to 27% with the metal shield. Brain and lung damage depended on the shockwave duration and amplitude. Cognitive deficits were assessed using the Morris water maze, Y-maze, and open-field tests. Pathological changes in the brain included disruption of the blood-brain barrier, multifocal neuronal and axonal degeneration, and reactive gliosis assessed by Evans Blue dye extravasation, silver and Fluoro-Jade B staining, and glial fibrillary acidic protein immunohistochemistry, respectively. Behavioral and pathological changes were injury severity-dependent. This mouse bTBI model may be useful for investigating injury mechanisms and therapeutic strategies associated with bTBI.

Dismounted Complex Blast Injuries Including Invasive Fungal Infections

Large blast injuries during dismounted operations in southwest Afghanistan causing major limb amputations and perineal injuries associated with large blood volume resuscitation were associated with invasive fungal, primarily mold, infections. This article outlines the interventions undertaken to mitigate excess morbidity and mortality associated with invasive fungal infection. These interventions include defining the problem and associated risk with systemically collected and analyzed information, developing improved protective body armor for the thigh and perineal region, standardizing management through clinical practice guidelines that outlined risk, diagnostic and treatment recommendations with enhanced discussions on the weekly Theater Combat Casualty Care Conference that includes personnel from the combat zone, Germany, and the United States. The article concludes by explaining the key way forward with regarding an inner-war approach to sustained knowledge and skills.

Human Injury Criteria for Underwater Blasts

Underwater blasts propagate further and injure more readily than equivalent air blasts. Development of effective personal protection and countermeasures, however, requires knowledge of the currently unknown human tolerance to underwater blast. Current guidelines for prevention of underwater blast injury are not based on any organized injury risk assessment, human data or experimental data. The goal of this study was to derive injury risk assessments for underwater blast using well-characterized human underwater blast exposures in the open literature. The human injury dataset was compiled using 34 case reports on underwater blast exposure to 475 personnel, dating as early as 1916. Using severity ratings, computational reconstructions of the blasts, and survival information from a final set of 262 human exposures, injury risk models were developed for both injury severity and risk of fatality as functions of blast impulse and blast peak overpressure. Based on these human data, we found that the 50% risk of fatality from underwater blast occurred at 302±16 kPa-ms impulse. Conservatively, there is a 20% risk of pulmonary injury at a kilometer from a 20 kg charge. From a clinical point of view, this new injury risk model emphasizes the large distances possible for potential pulmonary and gut injuries in water compared with air. This risk value is the first impulse-based fatality risk calculated from human data. The large-scale inconsistency between the blast exposures in the case reports and the guidelines available in the literature prior to this study further underscored the need for this new guideline derived from the unique dataset of actual injuries in this study.

[Combined mechanical-cold and mechanical-burn injuries in patients injured in maritime disasters]

On the basis of analysis of 372 medical histories and total amount of victims (2691 people) of marine accidents it was revealed that 303 (83.1%) survivors suffered from combined mechanical-cold injuries, combined two-factor mechanical-burn injuries were diagnosed in 115 of wounded (15.7%), combined three-factor mechanical-cold-burn injuries were diagnosed in 162 of wounded (22.5%). It was established that in case of capsizing and shipwrecking chest and abdomen injuries prevail in wounded (22.4%). Pelvic fractures, injuries of the lower extremities and spine traumas prevail in wounded evacuated from the crash area after explosion and fire on the ships (43.3%). The above-mentioned injuries prevail due to mine-blast nature of injuries. Typical injuries in wounded survived in maritime disasters are in non-severe combined mechanical-cold, mechanical-burn, and mechanical-cold-burn injuries, minor and moderate hypothermia, mild burn injuries and mild carbon monoxide poisoning.

An objective index to estimate the survival rate of primary blast lung injury

To supply proper treatments to the primary blast lung injury (PBLI) patients, it is important to estimate the severity of the primary blast lung injury in accordance with the blast conditions. In this study, a blast-induced mechanical parameter (first principal stress) of lung was calculated using a finite element thorax model and the correlation between the survival rate of the subjects with blast-induced lung damage and an objective index that was related to the first principal stress of the lung model. This study propose the objective index for the estimation of the degree of PBLI. The results have a potential clinical application to improve the efficacy of treatment for blast injury patients.

The ins and outs of terrorist bus explosions: injury profiles of on-board explosions versus explosions occurring adjacent to a bus

BACKGROUND

Terrorist explosions occurring in varying settings have been shown to lead to significantly different injury patterns among the victims, with more severe injuries generally arising in confined space attacks. Increasing numbers of terrorist attacks have been targeted at civilian buses, yet most studies focus on events in which the bomb was detonated within the bus. This study focuses on the injury patterns and hospital utilisation among casualties from explosive terrorist bus attacks with the bomb detonated either within a bus or adjacent to a bus.

METHODS

All patients hospitalised at six level I trauma centres and four large regional trauma centres following terrorist explosions that occurred in and adjacent to buses in Israel between November 2000 and August 2004 were reviewed. Injury severity scores (ISS) were used to assess severity. Hospital utilisation data included length of hospital stay, surgical procedures performed, and intensive care unit (ICU) admission.

RESULTS

The study included 262 victims of 22 terrorist attacks targeted at civilian bus passengers and drivers; 171 victims were injured by an explosion within a bus (IB), and 91 were injured by an explosion adjacent to a bus (AB). Significant differences were noted between the groups, with the IB population having higher ISS scores, more primary blast injury, more urgent surgical procedures performed, and greater ICU utilisation. Both groups had percentages of nearly 20% for burn injury, had high percentages of injuries to the head/neck, and high percentages of surgical wound and burn care.

CONCLUSIONS

Explosive terrorist attacks detonated within a bus generate more severe injuries among the casualties and require more urgent surgical and intensive level care than attacks occurring adjacent to a bus. The comparison and description of the outcomes to these terrorist attacks should aid in the preparation and response to such devastating events.

Damage control surgery and open abdomen in trauma patients with exsanguinating bleeding

Acute coagulopathy with exsanguinating bleeding occurs in 2-5% of all trauma cases carrying mortality rate near 100% after conventional management. In the last few decades, the development of damage control surgery (DCS) in combination with the technique of open abdomen led to significantly improved survival among these patients.

MATERIAL AND METHODS

A descriptive study based on a retrospective analysis of 12 consecutive blast victims with exsanguinating bleeding underwent DCS and open abdomen management. All patients were soldiers injured during their deployment in Iraq and Afghanistan during 2002-2007, treated by our deployed surgical teams. Vacuum Assisted Closure (V.A.C., KCI) and vacuum pack (VP) was used for a temporary closure of abdomen. A cumulative analysis of all relevant series used these methods during the period 2000-2013 was performed.

RESULTS

DCS was applied in 12 of 114 consecutive blast victims (10.5%) with survival rate 66.7% (8/12). Eleven had open abdomen with temporary closure with V.A.C. in 6 and VP in 5. Four patients died before the definitive closure (36.4%). The survivors (n = 8) were with a mean age 28.5 years, suffered from a critical trauma with a mean Injury Severity Score 35.5. V.A.C was used in 4 of them, VP in 3. Primary closure of abdomen was achieved in 6 (85.7%) within 3.5 days and mean 1.3 dressing changes. Due to ACS, the abdomen was closed through skin suture only and a creation of planned ventral hernia in 1 patient treated with VP (1/7, 14.3%). Wound infection was observed in 1 case (14.3%).

CONCLUSION

Despite the small sample size, our series clearly demonstrate the benefits of DCS and open abdomen in trauma patients with exsangiunating bleeding. The survival rate is highly dependent on the rapid implementation of DCS in properly selected patients. V.A.C. and VP provide a high rate of primary fascial closure in trauma.

Internal fixation in a combat theater hospital

Limited data are available on the use of internal fixation in combat zone hospitals. The authors performed a retrospective review of 713 surgical cases during 2 Operation Enduring Freedom deployments to a Level III theater hospital in 2007 and 2009 to 2010. The epidemiology and short- to intermediate-term outcomes of patients treated with internal fixation devices were studied. The authors found that, with judicious use, internal fixation under a damage control protocol in a combat theater hospital can be performed with acceptable complication rates.

Backdraught deaths: a case of firecracker explosion

Backdraught is a type of explosion occurring in fire in closed spaces. The fire consumes all oxygen suddenly explodes when more oxygen is avaibable. Here a case is presented where death occurred as a consequence of backdraught related explosion. The inflammable substance in this case was firecrackers, which were stored in a closed room. The resultant blast was strong enough to sever both the upper limbs of one individual and cleave the other individual into two.

[The treatment of combat casualties today]

Most soldiers are wounded by an explosion and haemorrhaging is the main cause of death. From the first aid provided on the field of combat to repatriation to France, every stage in the treatment of injured soldiers is meticulously organised in order to save as many lives as possible.

The legacy of war: an epidemiological study of cluster weapon and land mine accidents in Quang Tri Province, Vietnam

The study examines the epidemiology of cluster weapon and land mine accidents in Quang Tri Province since the end of the Vietnam War. The province is located just south of the demarcation line and was the province most affected during the war. In 2009, a cross sectional household study was conducted in all nine districts of the province. During the study period of 1975-2009, 7,030 persons in the study area were exposed to unexploded ordnances (UXO) or land mine accidents, or 1.1% of the provincial population. There were 2,620 fatalities and 4,410 accident survivors. The study documents that the main problem is cluster weapons and other unexploded ordnances; only 4.3% of casualties were caused by land mines. The legacy of the war affects poor people the most; the accident rate was highest among villagers living in mountainous areas, ethnic minorities, and low-income families. The most common activities leading to the accidents were farming (38.6%), collecting scrap metal (11.2%), and herding of cattle (8.3%). The study documents that the people of the Quang Tri Province until this day have suffered heavily due to the legacy of war. Mine risk education programs should account for the epidemiological findings when future accident prevention programs are designed to target high-risk areas and activities.

Mass-Casualty Terrorist Bombings In Istanbul, Turkey, November 2003: Report of the Events and the Prehospital Emergency Response

Background:

This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.

Methods:

A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.

Results:

On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.

Conclusion:

The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

KAMEDO Report 90: Terrorist Attacks in Madrid, Spain, 2004

This is a descriptive study of the medical responses to the bombings by terrorists in Madrid on 11 March 2004. The nature of the event, the human damage, and the responses are described. It describes the: (1) nature and operations associated with the alarm; (2) assignment of responding units and personnel; (3) establishment and operations of casualty collection points; (4) medical transport and distribution of injured victims; (5) prioritization and command; (6) hospital care; (7) psychosocial care; (8) identification of the dead; and (9) police investigation and actions. Each of these descriptions is discussed in terms of what currently is known and the implications for future planning, preparedness, and response.

Anti-personnel Landmine Injuries during Peace: Experience in a European Country

Introduction:

The purpose of this study is to report the incidence of landmine injuries during peacetime in a European country.

Methods:

Forty victims of landmine explosions were admitted to Didimoticho General Hospital in Greece, from December 1988 to March 2003. A total of 19 people survived (47.5%) these events; all of the others were dead upon admission to the hospital. All of the victims were men, either suspected smugglers or migrants entering the country illegally, with an aver- age of 30 years (range: 15–56 years).

Results:

Most victims presented in groups, with multiple traumatic injuries, including lower extremity wounds. The mortality rate in the minefield prior to hospital admission was 52.5%, and the amputation rate for the survivors was 37%. There were no deaths of the patients admitted to the hospital.

Conclusions:

Landmines cause highenergy injuries with high mortality and amputation rates. Illegal migrants are the main victims of landmine explosions in Greece.

[The structure of non-combat injuries in survivors and victims of maritime disasters of warships in peace-time]

The structure of accidents and injuries in victims of major maritime disasters involving fires and explosions on warships from 1976-2011. It is established that the main damage of the injured are acute inhalation of carbon monoxide poisoning is mild, 33.3%, combined blast and mechanical trauma 25%, the combined mechanical and burn trauma-cold 21.2%, the combined mechanical-burn injury 13.4%, combined blast and cold injuries 5.3%, burns and chemical damage a 1.8%. The main causes of mortality were acute inhalation poisoning with carbon monoxide, severe burns of the upper respiratory tract bums, III and IV 12.4%. Bums I and II degree against carbon monoxide poisoning is mild with drowning as a major cause of death recorded 11.8%; combined mechanical-burn were travmy 19.2%, the combined mechanical-burn-cold injury was 9.4%, combined blast and mechanical trauma 26.3%, combined explosive, mechanical, and cold injuries 14.7%, and chemical burn of 6.2%.

[Blasting damage in manmade disasters and terrorist attacks]

In the present case of explosive injuries in peacetime, when suddenly there are usually accidental or intentional explosions methane in mines, tanks with gas or explosives, fuel tanks or gas content, gas tanks, gas pipelines, product pipelines, as well as the explosion of military ordnance--grenades, mines, fuses, shells, and accidentally found child or maliciously used by terrorists. Collected statistical data on manmade disasters in coal mines and explosive injuries in terrorist attacks, the physical parameters of which were able to identify only approximately and type of damage incurred,mostly multiple and combinative combined and presented significant challenges in health care. The reasons and circumstances of the explosion in peacetime, gave a detailed description of the damaging factors, mechanisms, and characteristics arise from injuries suffered in the blast injuries. We describe the pathogenesis of blast injury, basic and clinical manifestations of lesions in the explosions.

[Blast lung injuries]

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

[The disguised face of blast injuries: shock waves]

BACKGROUND

The increase in terrorist attacks has brought a profound and new knowledge of blast injuries. In order to improve our knowledge regarding the mechanisms of blast injuries, we analyzed the effects of shock waves.

METHODS

100 g TNT and 1000 g C4 were detonated and recorded by high-speed camera. Blast wind, shock wave and shrapnel speeds were calculated, and final condition of the target was examined.

RESULTS

A flash ball appeared first followed by the shock wave. Finally, blast wind occurred and shrapnel was distributed. The macroscopic structure of targets was not affected by the shock wave but was affected by shrapnel and blast wind. Shock waves created a transparent ballistic gel inside the target mat by changing its microscopic structure. The speed of the shock wave was 6482-7194 m/sn and shrapnel speed was 1420-1752 m/sn.

CONCLUSION

Shock waves especially affect the air-filled organs and cause lung injury, acute respiratory distress syndrome, and intestinal and eardrum perforation. Blast wind destroys targets due to its high speed and high density. The main cause of mortality is shrapnel injury. The high temperature created by the explosion causes thermal injuries. Being informed of the mechanisms of blast injuries will assist in providing better treatment. Additionally, consideration of all mechanisms of blast injuries will facilitate lower mortality and morbidity rates.

War surgical care--experience from Franciscan Hospital "dr. fra Mato Nikolić" in Nova Bila during conflict in Central Bosnia (1993-1994)

This report presents experience in treatment of war injuries in Franciscan hospital "dr. fra Mato Nikolić" in Nova Bila, during the war in Central Bosnia from 1993 to 1994, in conditions of encirclement and typhoid fever outbreak. Descriptive-retrospective analysis of organization, implementation and outcomes of surgical care for patients treated from January 1, 1993 till August 20, 1994. In this period, the hospital took care of 2500 wounded persons, 2286 (91.4%) of them male and 214 (8.6%) female, their the average age being 31.5 +/- 12.8. There were 1412 gunshot injuries (56.5%), 1022 explosive injuries (40.9%), and 66 blunt injuries (2.6%). There were 1250 injuries to extremities (50.0%), 349 injuries to head and neck (14%), 233 chest injuries (9.3%) and 193 injuries to abdomen (7.7%). There were also 475 multiple injuries (19%). Surgical operations were performed in 1498 patients (60%), with surgical mortality rate of 4.5%. Total hospital mortality rate was 11.4 percent (n = 286). Despite extremely difficult conditions of work and lack of doctors, we achieved a low hospital mortality rate. The hospital continued to work after the war. Today, it is a modern health institution in Lasva Valley, Central Bosnia.

Blast injury in a civilian trauma setting is associated with a delay in diagnosis of traumatic brain injury

High-pressure waves (blast) account for the majority of combat injuries and are becoming increasingly common in terrorist attacks. To our knowledge, there are no data evaluating the epidemiology of blast injury in a domestic nonterrorist setting. Data were analyzed retrospectively on patients admitted with any type of blast injury over a 10-year period at a busy urban trauma center. Injuries were classified by etiology of explosion and anatomical location. Eighty-nine cases of blast injury were identified in 57,392 patients (0.2%) treated over the study period. The majority of patients were male (78%) with a mean age of 40 +/- 17 years. The mean Injury Severity Score was 13 +/- 11 with an admission Trauma and Injury Severity Score of 0.9 +/- 0.2 and Revised Trauma Score of 7.5 +/- 0.8. The mean intensive care unit and hospital length of stay was 2 +/- 7 days and 4.6 +/- 10 days, respectively, with an overall mortality rate of 4.5 per cent. Private dwelling explosion [n = 31 (35%)] was the most common etiology followed by industrial pressure blast [n = 20 (22%)], industrial gas explosion [n = 16 (18%)], military training-related explosion [n = 15 (17%)], home explosive device [n = 8 (9%)], and fireworks explosion [n = 1 (1%)]. Maxillofacial injuries were the most common injury (n = 78) followed by upper extremity orthopedic (n = 29), head injury (n = 32), abdominal (n = 30), lower extremity orthopedic (n = 29), and thoracic (n = 19). The majority of patients with head injury [28 of 32 (88%)] presented with a Glasgow Coma Scale score of 15. CT scans on admission were initially positive for brain injury in 14 of 28 patients (50%). Seven patients (25%) who did not have a CT scan on admission had a CT performed later in their hospital course as a result of mental status change and were positive for traumatic brain injury (TBI). Three patients (11%) had a negative admission CT with a subsequently positive CT for TBI over the next 48 hours. The remaining four patients (14%) were diagnosed with skull fractures. All patients (n = 4) with an admission Glasgow Coma Scale score of less than 8 died from diffuse axonal injury. Blast injury is a complicated disease process, which may evolve over time, particularly with TBI. The missed injury rate for TBI in patients with a Glasgow Coma Scale score of 15 was 36 per cent. More studies are needed in the area of blast injury to better understand this disease process.

Consequence analysis to determine the damage to humans from vapour cloud explosions using characteristic curves

The aim of this paper is to provide a methodology to facilitate consequence analysis for vapour cloud explosions (VCE). Firstly, the main PROBIT equations to evaluate direct damage on humans from those accidents (eardrum rupture, death due to skull fracture, death due to whole body impact and lung damage) are discussed and the most suitable ones are selected. Secondly, a new methodology is developed to relate characteristic overpressure-impulse-distance curves for VCE, obtained in a previous paper (F. Diaz Alonso et al., Characteristic overpressure-impulse-distance curves for vapour cloud explosions using the TNO Multi-Energy model, J. Hazard. Mater. A137 (2006) 734-741) with the selected PROBIT equations. This methodology allows the determination of damage as a function of distance to the accident's origin in only one step, using explosion energy and VCE Multi-Energy charge strength as input parameters.

Key factors for civilian injuries and deaths from exploding landmines and ordnance

OBJECTIVE

To identify risk factors for death or injury from landmines and ordnance in Kabul City, Afghanistan, so programs can target preventive actions.

METHODS

Active surveillance in hospitals and communities for injuries and deaths from landmine and ordnance explosions in Kabul City.

RESULTS

Of the 571 people the authors identified during the 25-month period, 161 suffered a traumatic amputation and 94 were killed from a landmine or ordnance explosion. Of those asked, 19% of victims had received mine awareness education before the incident, and of those, the majority was injured while handling or playing with an explosive device. Most victims were young males with a few years of education. The occupation types most at risk were students and laborers, and unemployment was common among the victims. Collecting wood or paper and playing with or handling an explosive were the most frequent activities associated with injuries and deaths.

CONCLUSIONS

From May 1996 to July 1998, explosions from landmines and ordnance claimed 571 victims and were an important preventable cause of injury and death among people in Kabul City. Prevention strategies should focus on high-risk groups and changing risky behaviors, such as tampering with explosive devices.

Injuries in combat from 1982–2005 with particular reference to those to the head and neck: A review

The aim of this review was to examine the range of combat injuries with particular reference to those of the head and neck. We evaluated 10 retrospective studies selected from the period 1982-2005 that covered war injuries from Vietnam, Lebanon, Slovenia, Croatia, Iraq, Somalia, and Afghanistan. We found differences in the causes of injuries. Injuries from fragments were more common during the 90s than during the Vietnam War, where shooting injuries predominated. Injuries to the trunk were reduced in conflicts from 1991 onwards as military personal armour systems including protective vests were used. However, the mortality of wounded soldiers in all conflicts was consistently between 10% and 14%. There was a high incidence of injuries to the head and neck (up to 40%) though they affected only 12% of the body surface area. Though the data from the different military conflicts are not totally comparable, there are trends in the type of injuries and mortality, which may lead to changes in existing systems of medical care.

Terrorismus – Eine neue Dimension des Polytraumas

Bomb attacks on the civilian population are one of the primary instruments of global terrorism. Confronted as we are with the increasingly real threat in Europe too, we now have to be constantly prepared for the mass casualties and new injury patterns in trauma care that are caused by terrorist bombings. This is extraordinarily challenging, on both medical and logistical levels, for the hospitals involved. In this review the basic mechanisms of blast injuries are clarified. In addition, the fundamental principles of triage and the management of multiple trauma are presented; these are oriented on ATLS (advanced trauma life support) and DCS (damage control surgery) guidelines. These treatment concepts, which have proved their worth in both military and civilian environments, involve ongoing triage and constant situational assessment and are the basis of improved treatment results in the care of multiply traumatized victims of terrorist bombings.

Kriegschirurgische Verletzungsmuster

BACKGROUND

Epidemiological analysis of injury patterns and mechanisms help in identifying the expertise that military surgeons need in a combat setting and also in adjusting training requirements accordingly. This paper attempts to assess the surgical specialties and skills of particular importance in the management of casualties in crisis areas.

METHODS

MEDLINE (1949-2007) and Google search were used. Causes of death among casualties in Afghanistan and the Iraq war were analyzed.

RESULTS

The leading causes of injury were explosive devices, gunshot wounds, aircraft crashes, and terrorist attacks. Of the casualties, 55% died in hostile action and 45% in nonhostile incidents. Chest or abdominal injuries (40%) and brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq was approximately half as high as in the Vietnam War. In contrast, the amputation rate was twice as high. Approximately 8-15% of the deaths appeared to be preventable.

CONCLUSIONS

Military surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. It also is of vital importance to ensure the availability of sufficient medical evacuation capabilities. Furthermore, there is a need for a standardized registration system for all injuries similar to the German Trauma Registry.

Head injuries due to landmines

BACKGROUND

Landmine explosions cause most of the war injuries in the battlefield and pose a substantial public health risk. Although the lower limbs are usually affected, head injuries also occur. The aim of this study is to describe the types of head injuries caused by the explosion of landmines and the management of the victims.

PATIENTS AND METHOD

Fifteen patients who sustained a head injury due to a landmine explosion were treated in the Department of Neurosurgery between 2000 and 2006. The average age of the patients was 22.5 (range between 20 and 33). The Glasgow Coma Scale (GCS) score ranged between 3 and 15 and was 8 or less in 4. Shrapnel, stone and earth were the wounding agents. Four patients underwent neurosurgical treatment and 11, apart from simple scalp closure, had conservative treatment. Ten patients had associated lesions in the other parts of the body including thorax, upper and lower limbs, and the abdomen.

FINDINGS

Two patients died. At the time of admission, one had a GCS score of 3 and the other a score of 4. Infection was observed among 4 patients and a cerebrospinal fluid (CSF) fistula in 1 patient.

CONCLUSION

Landmines occasionally cause head injuries. Surgical intervention is seldom required and survival is likely unless the patient is in deep coma. Multidisciplinary approaches are required in case there are associated lesions in the other parts of the body.

Forensic findings from the Nairobi U.S. embassy terrorist bombing

BACKGROUND

The 1998 terrorist bombing of the US-Embassy in Nairobi resulted in the highest number of civilian deaths ever recorded from a single urban terrorist bombing in global history.

OBJECTIVE

To present forensic findings from the Nairobi terrorist bombing and discuss some contributory factors to the high-fatality witnessed.

DESIGN

Desriptive retrospective study.

SETTING

Office of the Chief Government Pathologist of Kenya.

RESULTS

A total of 211 persons were confirmed to have died as a direct result of the bomb blast. Out of the 201 cases examined in this paper, 198 (99%) died on the day of the blast. Sixty percent of the deceased were males and 85% were aged between 21 and 50 years. Most of the deceased were visually identified (95%). The rest required fingerprinting (3%), DNA testing (2%), and forensic odontology (1%). Ninety six percent of the victims (194 cases) had primary blast injuries. The typical triad of blast fragmentation injuries was found in only 47% of the cases. Eighty nine percent (179 cases) had injuries in multiple anatomical regions. The most common cause of death was head injury (30%).

CONCLUSION

The anatomical pattern of injuries and other pathological findings among fatalities from this terrorist bombing are similar to those recorded from other bombing incidents worldwide. Contributory factors to the high fatality include the collapse of a densely populated building, the TNT-equivalent force of the bomb, the confined site of detonation, and probably the lack of a proper disaster response system.

Fatal explosion injuries in Finland: a twenty-year nationwide survey

BACKGROUND AND AIMS

Expanding violence may necessitate treatment of explosion victims, requiring a broadening of existing medical skills and knowlegde of injury mechanisms. The aim of the study was to assess the number, nature and injury pattern of fatal explosion incidents in Finland.

MATERIAL AND METHODS

Retrospective analysis of explosion-related deaths from January 1985 to December 2004. Death certificates were obtained and reviewed.

RESULTS

Over the 20-year period from 1985 to 2004, only 61 inviduals died in Finland as a result of unintentional or unspecified explosion related events. A homemade bomb assault for unknown motives killed seven people in a suburb in 2002. The incidence was 5.7 cases per 10,000,000 person-years. Suicides using explosives were slightly more common; on average 4 cases per year (6.7 cases per 10,000,000 person-years). A small increase in the fatality trend was noticeable during the last years of the study period.

CONCLUSIONS

The incidence of fatal explosion injuries is a minor problem, but a small increase can be seen during the last few years. Victims of such injuries required only minimal hospital resources, because in most cases they died at the scene. Our results suggest that efforts to prevent fatalities related to explosives or corresponding devices, or to reduce their number, should focus on prevention of intentions.

Mass casualty management after a suicidal terrorist attack on a religious procession in Quetta, Pakistan

OBJECTIVE

To determine the effectiveness of hospital management, considering triage system, hospital staff response, medical resources availability, and surgical management depending upon the nature and pattern of injuries in a mass casualty incident.

DESIGN

Descriptive.

PLACE AND DURATION OF STUDY

Combined Military Hospital, Quetta, Pakistan in March 2004.

PATIENTS AND METHODS

All injured by gunshot or blast in a terrorist attack and reported to the hospital were included in this study. Patients were triaged by the triage team using "triage sieve" into priority I, II, III, and IV. Priority I patients were further triaged by using "trauma index" to prioritize for surgery. Phase I included life saving, Phase II limb saving surgery and Phase III for debridement. All data was recorded and analyzed.

RESULTS

Hospital received 161 casualties among whom 20 were brought in dead, and 141 patients were admitted to the hospital. Mean age was 26.63 +/- 13.97. The cases were categorized as Priority-I 22.7%, Priority-II 14.72%, Priority-III 50.31% and Priority-IV 12.27%. Maximum casualties reached within the first 2 hours. Eighty-eight patients had pre-dominantly splinter injuries and 53 patients had dominantly gunshot wound injuries. In priority I, the trauma index was 15.55 +/- 5.74. Six patients having trauma index 20 or above could not even be resuscitated. Seventy five percent of staff reported to the hospital within 15 minutes. Only 30% of reserve medical store was consumed. Total management cost to the hospital was Rs. 362,1856/- (British Pounds approx 32,052/-.) calculated by the hospital rates for treatment of non-entitled patients. Death rate in hospital survivors was 4%.

CONCLUSION

Mass casualty management in a terrorist act requires prompt hospital response, appropriate triage, efficient surgical approach, and dedicated postoperative care. A good response can help to decrease mortality rate in salvageable injuries.

In-hospital resource utilization during multiple casualty incidents

OBJECTIVE

To suggest guidelines for hospital organization during terror-related multiple casualty incidents (MCIs) based on the experience of 6 level I trauma centers.

SUMMARY BACKGROUND DATA

Most terror-related MCIs are bombings. The sporadic nature of these events complicates in-hospital preparation.

METHODS

Data were collected at all level I Trauma centers during/after MCIs for the Israel National Trauma registry. Patients were included if they were admitted or died in hospital following injury in suicide bombings (October 1, 2000 to June 30, 2003), which fulfilled Ministry of Health suggested criteria for MCIs (number of admissions, severity of injury).

RESULTS

Included were 325 casualties from 32 events, 34% of which had an Injury Severity Score >16. A third of the admissions arrived within 10 minutes and 65% within 30 minutes. Forty percent of the patients underwent CT scans directly from the ED. Operative procedures were performed on 60% of patients and 36% were transferred directly from the ED to the OR. Initiation of surgical procedures peaked at 1 to 1.5 hours, mainly multidisciplinary abdominal, thoracic, and vascular surgery. Orthopedic and plastic surgery predominated later. A third of the patients were admitted to ICUs, often (31%) directly from the ED.

CONCLUSIONS

High staffing demands for ED, OR, and ICU overlap. Anesthesiologists, general, thoracic, and vascular surgeons are in immediate demand. ICU admissions occur simultaneously with ongoing patient arrival to the ED. Most patients operated within the first 2 hours require multidisciplinary surgical teams. Demand for orthopedic and plastic surgery and anesthesiology services continues for >24 hours.

Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom

BACKGROUND

Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively.

STUDY DESIGN

A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test.

RESULTS

All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p < 0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors.

CONCLUSIONS

Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.