Emergency Treatment of Blast, Shell Fragment and Bullet Injuries to the Central Midface Complex

Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study

BACKGROUND

The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting.

METHODS

A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure.

RESULTS

During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05).

CONCLUSION

Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.

Patterns of War-Related Traumatic Brain Injuries and Predictors of Mortality Among Civilians During the Syrian Armed Conflict

BACKGROUND AND OBJECTIVES

High-velocity weapons were used against unshielded civilians during the Syrian armed conflict, leading to a variety of combat-related traumatic brain injuries with high fatality and morbidity. Because of the lack of data in the literature about the management and outcomes of similar injuries, we aimed in this study to characterize shrapnel and gunshot injuries in this vulnerable group and to describe the association between the mechanisms, site, and type of injury and the outcomes.

METHODS

This was a single-center retrospective cohort study on new traumatic brain injuries in civilians who presented alive to the neurosurgery department at Damascus Hospital between 2014 and 2017. The analyzed data included the mechanism of injury and its type and site based on computed tomography scans. We also studied the neurological status at admission, the major interventions applied, and outcomes including mortality and neurological deficits at discharge.

RESULTS

Shrapnel and gunshot injuries more likely affected the frontal and parietal lobes, respectively. While shrapnel led to injuries in multiple body parts, gunshots led to localized but more severe injuries. Despite that, mortality rates were comparable between the two mechanisms. Injuries to the right parietal and right frontal lobes were more fatal with odds ratios of 2.61 (1.23-5.52) and 2.12 (1.00-4.50), respectively. Moreover, mortality was also linked to the radiological findings of loss of brain material with an odds ratio of 3.73 (1.42-9.81), intracerebral hemorrhage with an odds ratio of 3.60 (1.67-7.80), intraventricular hemorrhage with an odds ratio of 5.49 (1.68-17.95), and subdural hemorrhage with an odds ratio of 6.35 (2.29-17.66).

CONCLUSION

The unfortunate nature of the Syrian armed conflict, wherein civilians were targeted during their daily routine, seems to manifest a heightened propensity to affect the parietal lobes, potentially resulting in higher morbidity. Although shrapnel and gunshot injuries showed no significant difference in mortality rates, injuries involving loss of brain tissue and intracranial hemorrhage emerged as independent predictors of mortality.

Composite grafts made of polycaprolactone fiber mats and oil-based calcium phosphate cement pastes for the reconstruction of cranial and maxillofacial defects

OBJECTIVES

Synthetic bone substitutes which can be adapted preoperatively and patient specific may be helpful in various bony defects in the field of oral- and maxillofacial surgery. For this purpose, composite grafts made of self-setting and oil-based calcium phosphate cement (CPC) pastes, which were reinforced with 3D-printed polycaprolactone (PCL) fiber mats were manufactured.

MATERIALS AND METHODS

Bone defect models were acquired using patient data from real defect situations of patients from our clinic. Using a mirror imaging technique, templates of the defect situation were fabricated via a commercially available 3D-printing system. The composite grafts were assembled layer by layer, aligned on top of these templates and fitted into the defect situation. Besides, PCL-reinforced CPC samples were evaluated regarding their structural and mechanical properties via X-ray diffraction (XRD), infrared (IR) spectroscopy, scanning electron microscopy (SEM), and 3-point-bending testing.

RESULTS

The process sequence including data acquisition, template fabrication, and manufacturing of patient specific implants proved to be accurate and uncomplicated. The individual implants consisting mainly of hydroxyapatite and tetracalcium phosphate displayed good processability and a high precision of fit. The mechanical properties of the CPC cements in terms of maximum force and stress load to material fatigue were not negatively affected by the PCL fiber reinforcement, whereas clinical handling properties increased remarkably.

CONCLUSION

PCL fiber reinforcement of CPC cements enables the production of very freely modelable three-dimensional implants with adequate chemical and mechanical properties for bone replacement applications.

CLINICAL RELEVANCE

The complex bone morphology in the region of the facial skull often poses a great challenge for a sufficient reconstruction of bony defects. A full-fledged bone replacement here often requires the replication of filigree three-dimensional structures partly without support from the surrounding tissue. With regard to this problem, the combination of smooth 3D-printed fiber mats and oil-based CPC pastes represents a promising method for fabricating patient specific degradable implants for the treatment of various craniofacial bone defects.

[Treatment of victims with mine-explosive injuries]

OBJECTIVE

To study the incidence and structure of combat gunshot surgical trauma received during the 2^nd Karabakh War and to analyze the results of treatment of these victims.

MATERIAL AND METHODS

We analyzed surgical treatment of 60 victims with combat gunshot surgical trauma received during the 2^nd Karabakh war. In 25 (41.7%) victims, injury occurred as a result of mine-explosive trauma. These victims were divided into 3 groups depending on mechanism of mine-explosive injury. The 1^st group included 7 (28%) patients who received mine-explosive injury due to indirect (propelling) effect of blast wave. The 2^nd group included 14 (56%) victims in whom mine-explosive injury was caused by non-contact (distant) impact of mine fragments. The 3^rd group consisted of 4 (16%) patients whose mine-explosive injuries were caused by direct impact of explosion factors on various anatomical areas. Patients were also ranked into 3 groups depending on the nature and severity of mine-explosive injury: wounded with isolated injuries (n=16, 64%), wounded with concomitant injuries (n=2.8%), wounded with combined and multiple injuries (n=7, 28%).

RESULTS

Most patients underwent organ-sparing procedures. Resections were performed only in 4 cases (splenectomy - 3, nephrectomy - 1). Postoperative complications developed in 23 (38.3%) wounded (suppuration of postoperative wounds - 13, post-traumatic pleuritis - 5, clotted hemothorax - 2, subphrenic abscess - 1, phlegmon of perineum and perianal region - 2). Mortality rate was 1.7%.

CONCLUSION

Timely sorting and evacuation of victims, early qualified surgical care and correct postoperative management with monitoring of vital functions can improve the results of treatment of victims with mine-explosive trauma. Autologous skin grafting for extensive defects and closure of colostomy with restoration of colon continuity were essential in rehabilitation of these patients.

Endoscopic management gunshot wound at the face: Fact or fiction?

Shrapnel or gunshot injuries in Maxillofacial Region are highly considered to be challenging which leads to death in most cases, and even in the case of no mortality, they will cause morbidity and appearance impairment due to complex injuries to bone and soft tissue. Herein, in a particular case, the patient was a person injured by a gunshot of a Kalashnikovs҆ bullet in his face; the bullet was located at the end of the medial wall of the maxillary sinus and was removed through the functional endoscopy of the nose and sinuses. The bullet was removed without causing any additional incisions on the face and further damage through endoscopic ligation of severe bleeding from the sphenopalatine artery. The clinical approach to patients with penetrating trauma from a bullet to head and face demands prompt action. Functional endoscopic nasal and sinus surgery can maintain the patient's face cosmetic appearance.