Ballistic thoracoabdominal injury: analysis of recent military experience in afghanistan

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.

Ten-year reduction in thoracic injury-related mortality among Israel Defense Forces soldiers

INTRODUCTION

This study aims to describe injury patterns, prehospital interventions and mortality rates of combat-related thoracic injuries during the past decade among Israel Defense Forces (IDF) soldiers before and after implementation of the 2012 IDF-Military Corps 'My Brother's Keeper' plan which included the publication of clinical practice guidelines (CPGs) for thoracic injuries, emphasis on adequate torso protection, introduction of modern life-saving procedures and encouragement of rapid evacuation.

METHODS

The IDF prehospital trauma registry was reviewed to identify all patients who sustained thoracic injuries from January 2006 to December 2017. IDF soldiers who were injured, died of wounds or killed in action (KIA) were included. These were cross-referenced with the Israel National Trauma Registry. The periods before and after the plan were compared.

RESULTS

458 (12.3%) of 3733 IDF soldiers wounded on the battlefield sustained combat-related thoracic injuries. The overall mortality was 44.3% before the CPG and 17.3% after (p<0.001). Most were KIA: 97% (95 of 98) died by 30 June 2012, and 83% (20 of 24) after (p<0.001). Casualties treated with needle thoracostomy before and after CPG were 6.3% and 18.3%, respectively (p=0.002). More tube thoracostomies were performed after June 2012 (16.1% vs 5.4%, p=0.001). Evacuation was faster after June 2012 (119.4 min vs 560.8 min, p<0.001), but the rates of casualties evacuated within 60 min were similar (21.1% vs 25%, p=0.617).

CONCLUSIONS

Among military casualties with thoracic injuries, the rate of life-saving interventions increased, evacuation time decreased and mortality dropped following the implementation of My Brother's Keeper plan.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

A systematic review of 3251 emergency department thoracotomies: is it time for a national database?

PURPOSE

Emergency department thoracotomy (EDT) is a potentially life-saving procedure, performed on patients suffering traumatic cardiac arrest. Multiple indications have been reported, but overall survival remains unclear for each indication. The objective of this systematic review is to determine overall survival, survival stratified by indication, and survival stratified by geographical location for patients undergoing EDT across the world.

METHODS

Articles published between 2000 and 2016 were identified which detailed outcomes from EDT. All articles referring to pre-hospital, delayed, or operating room thoracotomy were excluded. Pooled odds ratios (OR) were calculated comparing differing indications.

RESULTS

Thirty-seven articles, containing 3251 patients who underwent EDT, were identified. There were 277 (8.5%) survivors. OR demonstrate improved survival for; penetrating vs blunt trauma (OR 2.10; p 0.0028); stab vs gun-shot (OR 5.45; p < 0.0001); signs of life (SOL) on admission vs no SOL (OR 5.36; p < 0.0001); and SOL in the field vs no SOL (OR 19.39; p < 0.0001). Equivalence of survival was demonstrated between cardiothoracic vs non-cardiothoracic injury (OR 1.038; p 1.000). Survival was worse for USA vs non-USA cohorts (OR 1.59; p 0.0012).

CONCLUSIONS

Penetrating injury remains a robust indication for EDT. Non-cardiothoracic cause of cardiac arrest should not preclude EDT. In the absence of on scene SOL, survival following EDT is extremely unlikely. Survival is significantly higher in the non-USA publications; reasons for this are highly complex. A UK multicentre prospective study which collects standardised data on all EDTs could provide robust evidence for better patient stratification.

Emergency resuscitative thoracotomy performed in European civilian trauma patients with blunt or penetrating injuries: a systematic review

PURPOSE

Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure in selected patients. Indications are still being debated, but outcome in blunt trauma is believed to be poor. Recent reports from European populations, where blunt trauma predominates, have suggested favorable outcome also in blunt trauma. Our aim was to identify all European studies reported over the last decade and compare reported outcomes to existing knowledge.

METHODS

We performed a systematic literature search according to PRISMA guidelines (January 1st, 2004 to December 31st, 2014). The "grey literature" was included by searching Google Scholar. Qualitative comparison of studies and outcomes was done.

RESULTS

A total of 8 articles from Europe were included originating from Croatia, Norway (n = 2), Denmark, Iceland, the Netherlands, Scotland, and Switzerland. Of 376 resuscitative thoracotomies, 193 (51.3 %) were for blunt trauma. Male:female distribution was 3.5:1. The collectively reported overall survival was 42.8 % (n = 161), with 25.4 % (49 of 193) blunt trauma and 61.2 % (112 of 183) penetrating injuries. When strictly including those ERTs designated as done in the emergency department for blunt mechanism (n = 139) only, a total of 18 patients survived (12.9 %). Survival after EDTs for penetrating trauma was 41.6 % (37 of 89). Neurological outcome (reported in 5 of 8 studies) reported favorable neurological long-term outcome in the majority of survivors, even after blunt trauma. None referred to Glasgow Outcome Score. Heterogeneity in the studies prevented outcome analyses by formal quantitative meta-analysis.

CONCLUSION

The reported outcome after ERT in European civilian trauma populations is favorable, with one in every four ERTs in the ED surviving. Notably, outcome is at variance with previously reported collective data, in particular for blunt trauma. Multicenter, prospective, observational data are needed to validate the modern role of ERT in blunt trauma.

Basic data underlying clinical decision-making and outcomes in emergency department thoracotomy: tabular review

BACKGROUND

Emergency department thoracotomy (EDT) is a formidable and dramatic last attempt by the trauma surgeon to save the life of a patient in extremis. The aim of this report is to provide a benchmark for comparison with past results by reviewing all available published data since the American College of Surgeons Committee on Trauma review article in 2001, which reviewed literature from 1966 to 1999 regarding indications for and outcomes of EDT.

METHODS

A comprehensive literature search in MEDLINE Library databases was performed for EDT. Data were extracted by three independent reviewers.

RESULTS

We identified 37 papers with a total of 3466 patients. A total of 85.2% (1720 of the 2018) had penetrating trauma, 58.3% (372 of the 638) had cardiac injuries, 43.0% (251 of the 584) had thoracic injuries and 26.2% (143 of the 546) had abdominal injuries. The overall rate survival in this review was 8% (267 of the 3466, range 0-33.3%). Of 25 papers reporting cases of EDT for penetrating traumas, their survival rate was 9.8% (169 of the 1719, range 0-45.5); similarly, of 14 papers assessing EDT for blunt injuries, the survival rate was 5.2% (24 of the 460, range 0-12.2). Of 15 papers reporting neurological outcomes 84.6% (143 of the 169, range 50-100%) of patients returned to baseline. The survival outcome of EDT in US experience versus non-US experiences was 6.3% (164 of the 2612, range 0-14.9) versus 11.9% (89 of the 745, range 0-33.3) respectively.

CONCLUSION

The authors intend this review to serve as a practical and prompt literature search tool for all surgeons who encounter resuscitative thoracotomy in their practice.

Resuscitative thoracotomy following wartime injury

BACKGROUND

The evidence for resuscitative thoracotomy (RT) in trauma patients following wartime injury is limited; its indications and timings are less defined in battle injury. The aim of this study was to analyze survival as well as the causes and times of death in patients undergoing RT within the context of modern battlefield resuscitation.

METHODS

A retrospective cohort study was performed on consecutive admissions to a Field Hospital in Southern Afghanistan. All patients undergoing RT were identified using the UK Joint Theatre Trauma Registry. The primary outcome was 30-day mortality, and secondary outcomes included location of cardiac arrest, time from arrest to thoracotomy, and proportion achieving a return of spontaneous circulation.

RESULTS

Between April 2006 to March 2011, 65 patients underwent RT with 14 survivors (21.5%). Ten patients (15.4%) had an arrest in the field with no survivors, 29 (44.6%) had an arrest en route with 3 survivors, and 26 (40.0%) had an arrest in the emergency department with 11 survivors. There was no difference in Injury Severity Scores (ISSs) between survivors and fatalities (27.3 [7.6] vs. 36.0 [22.1], p = 0.636). Survivors had a significantly shorter time to thoracotomy than did fatalities (6.15 [5.8] minutes vs. 17.7 [12.63] minutes, p < 0.001).

CONCLUSION

RT following combat injury will yield survivors. Best outcomes are in patients who have an arrest in the emergency department or on admission to the hospital.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Difficult decisions in the surgical care of military casualties with major torso trauma

Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to "get it right, first time and every time" when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.