Cardiovascular and thoracic battle injuries in the Lebanon War

Epidemiology of adult injuries: A multi-center study in greater Beirut

INTRODUCTION

Injury accounts for nearly 4 million deaths and 63 million disabilities annually. The injury burden is disproportionally large in low- and middle-income countries (LMICs), including Lebanon. This study aims to examine the characteristics and patterns of adult injuries presenting at multiple emergency departments (ED) in Lebanon and further identifies factors associated with hospital admission.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted on adult patients (aged≥16) who presented with an injury to one of the five participating EDs from June 2017 to May 2018. Pan-Asia Trauma Outcomes Study (PATOS) variables were adopted for data collection. A descriptive analysis was performed, followed by bivariate and multivariate logistic regression to identify injury risk factors for hospital admission.

RESULTS

A total of 3,716 patients' records were included. Most injuries were sustained by males (62.7%), patients aged between 16 and 35 years (16-25: 28%; 26-35: 22.7%), and above 65 years (15.6%). Most injuries were unintentional (94.9%). Falls were highly prevalent across all age groups (38.8%), more proclaimed among the older adults' population (56-65:52.8%; ≥66:73.7%), followed by struck-by object (23.6%) and transport injuries (10.1%). Upper and lower extremity injuries were common across all ages. Most patients (80.9%) were treated and discharged at the ED, 11.4% were admitted to the hospital, 4.3% were transferred to other trauma care facilities, and 2 patients died in the ED. Factors positively associated with hospital admission included: older age (≥ 56 years); private insurance; spine and lower extremity injuries; fractures, cuts/open wounds, concussion, and organ injuries (p-value≤0.05; OR>1).

CONCLUSION

Injury is a neglected public health problem in many LMICs, including Lebanon. While youth and the elderly are most affected, injuries occur across all age groups. This study lays the foundation for establishing a population-based injury surveillance system, crucial for designing tailored injury prevention programs to reduce injury-related deaths and disabilities.

Changing pattern and outcome of pediatric chest injuries in urban Syria

Background Pediatric chest injuries were infrequent in our practice, but the outbreak of the Syrian crisis resulted in an increase in number and a change in the pattern of thoracic trauma incidents. We compared our experience of pediatric chest injuries before and during the crisis. Methods We reviewed the records of 256 children aged 12.8 ± 5 years who were admitted to our hospital with the diagnosis of chest trauma over a 12-year period. Collected data included mechanism of injury, associated injuries, method of management, length of hospital stay, complications, and mortality. Results The incidence of pediatric chest injuries increased significantly following the outbreak of the crisis, and penetrating injuries prevailed, mainly due to shrapnel, bullets, and stab wounds. Forty percent of patients with blunt injuries and 20% of those with penetrating injuries were managed conservatively, whereas urgent thoracotomies were indicated in 10%, mostly in patients with penetrating injuries. Associated injuries were more frequent in patients with blunt injuries and resulted in a longer hospital stay and an increased mortality rate. The overall mortality rate was 7.8% and it was higher in children younger than 7 years of age and in patients who had been subjected to blunt injuries. Conclusions There has been a recent substantial upsurge in the incidence of pediatric thoracic trauma, with a predominance of penetrating injuries. Most patients could be managed nonoperatively, but a small subset required an open thoracotomy. The presence of associated injuries constitutes the main determinant of prognosis in this group of patients.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles

INTRODUCTION

Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles.

METHODS

A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy.

RESULTS AND CONCLUSIONS

Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan

INTRODUCTION

Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries.

METHODS

The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included.

RESULTS

During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality.

CONCLUSIONS

Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.

Ballistic thoracoabdominal injury: analysis of recent military experience in afghanistan

BACKGROUND

Military surgery has seen the arrival of the critical care provision and cross-sectional imaging enjoyed by civilian trauma surgeons. Ballistic injury to the thoracoabdominal region is uncommon but potentially devastating. The aim of this study was to analyze recent military experience of managing this injury complex.

METHODS

The study is a retrospective analysis of patients, admitted over a 12-month period, to the British Military Hospital in Afghanistan with ballistic thoracoabdominal injuries.

RESULTS

In total, 27 patients sustained combined thoracoabdominal injury with a mean new injury severity score of 29±12, revised trauma score of 5.94±2.93 and predicted survival of 71.1%±39.1%. In all, 20 (74%) patients underwent immediate operation, and 7 (26%) were initially managed nonoperatively. Of those requiring surgery, 11 required laparotomy and tube thoracostomy, and 9 required thoraco-laparotomy. Of the seven casualties who were initially observed and/or further investigated, two required laparotomy following computed tomography scanning, and five were managed conservatively, two of whom required delayed surgery. There were nine fatalities, all within 16 days of being wounded. Four patients died from exsanguination, one from a traumatic brain injury, and four from multiorgan failure. Five patients presented with cardiac arrest, two of whom survived.

CONCLUSIONS

Exploration remains the default treatment. Resuscitative thoracotomy may yield unexpected survivors, even if subsequent laparotomy is required. Nonoperative management appears to be feasible in a small proportion of patients but requires careful selection supported by cross-sectional imaging.

Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center

BACKGROUND

Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality.

METHODS

A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded.

RESULTS

A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 9.33 (range, 15–54) years. The mean LOS was 10.65 8.30 (range, 5–65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 9.92 days; stab wound, 8.76 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 36.702 mm Hg) compared with those who survived (83.96 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% (n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds (p = 0.29). Concomitant abdominal injuries (p = 0.01), diaphragmatic injury (p = 0.01), ISS (p = 0.001), chest AIS score (p < 0.05), ongoing output (p = 0.001), blood transfusion volume (p < 0.01) and SBP (p = 0.001) were associated with mortality.

CONCLUSION

Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.

Increased Damage from Rifle Wounds of the Chest Caused By Bullets Striking Commonly Carried Military Equipment

BACKGROUND

The purpose of this study was to investigate the fragmentation effect of the bullet that passes through the radio or ammunition magazine, which are essential pieces of equipment for a soldier, in thoracic gunshot injuries.

METHODS

Twelve adult pigs were used. The pigs were separated into three groups (each group contained four pigs). The first group was shot without any obstacle between muzzle and subject. The second group was shot through a cartridge magazine placed in front of the subject's thoracic cage. The third group was shot with a radio in front of the subject's thoracic cage.

RESULTS

It was observed that there was a large bullet entrance and fragmentation in the pigs that were shot with a radio or magazine placed over them, and there was no fragmentation in those that were shot without any obstacle.

CONCLUSION

Metal equipment that soldiers carry causes bullet fragmentation. Fragmented bullets may cause excessive tissue disruption of intrathoracic vital organs.

[Thoracic ballistic traumatisms. Wounding agents and wound ballistic]

The adequate care of thoracic ballistic traumatisms implies a good preliminary knowledge of wounding agents, and of the principles governing lesion-based ballistic, in particular the role played by the meeting with an obstacle which modifies the ballistic behaviour of the projectile, with worsened wounding effects. Authors describe the principal types of involved projectiles and their wound profile applied to the thorax, while stressing the need to treat systematically the wound and not the weapon, and on the importance of the choice of the surgical exploration way of these lesions, which conditions, as from the initial stage, the later choices of the parietal closure and rebuilding methods. The importance of parietal disrepair is therefore an essential decisional factor in the assumption of responsibility and the definition of the therapeutic strategy of these casualties.

Injury of the pulmonary artery and its branches due to penetrating chest trauma

This study describes the treatment of seven wounds involving the pulmonary artery or its main branches in six men (36 +/- 12 years). Injury was associated with hemoptysis or massive hemothorax in four patients, three of whom had arrest on the way to the operating room. The mean interval between injury and admittance and between injury and surgery was 18 +/- 8 min and 39 +/- 14 min, respectively. Wounds were located on the left pulmonary artery in two cases, right pulmonary artery in two cases, intermediate branch of the pulmonary artery in one case and right upper mediastinal branch of the pulmonary artery in two cases. Injuries involved penetration of only one side of the vessel in three cases, transfixion of two sides of the vessel in one case, and complete disruption of the vessel in three cases. Treatment required pneumonectomy in two cases presenting complex lesions involving both vessels and lung structures. In the remaining five cases, arterial repair was achieved by resection-anastomosis (n = 2) and lateral suture (n = 3). Our results show that isolated injuries of the pulmonary artery are amenable to surgical repair and have a good prognosis. Mortality appears to be high in patients presenting complex lesions involving vascular and pulmonary structures that require pneumonectomy to achieve hemostasis and in patients presenting associated cardiovascular lesions.

Penetrating cardiothoracic war wounds

OBJECTIVE

Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of treatment for such injuries, and there are not many large series of such patients in recent literature.

METHODS

We analysed a group of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992.

RESULTS

There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac, wounds and in 10 (3.7%) patients both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and 1 patient which involved descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2 patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively).

CONCLUSIONS

Penetrating cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature, they can be treated successfully with relatively low mortality and morbidity.

Functional effects of decortication after penetrating war injuries to the chest

Decortication was performed in 32 persons with penetrating war injuries to the chest. The indications were acute and chronic post-traumatic empyema, incompletely evacuated hemothorax, chylothorax, and chronic pneumothorax. Decortications were done through a thoracotomy in 29 cases and by thoracoscopy in three cases. Results of overall lung function tests and blood gas analyses were studied in all patients before operation, after immediate postoperative recovery, and 6 months after operation. Significant improvement in lung function was observed after decortication in all patients, particularly after thoracoscopic decortication. Restrictive pattern decreased moderately (p < 0.01). Blood gas analyses did not show significant changes after operation. There were no intraoperative or postoperative deaths.

Chest tubes: indications, placement, management, and complications

Use of tube thoracostomy in intensive care units for evacuation of air or fluid from the pleural space has become commonplace. In addition to recognition of pathological states necessitating chest tube insertion, intensivists are frequently involved in placement, maintenance, troubleshooting, and discontinuation of chest tubes. Numerous advances have permitted safe use of tube thoracostomy for treatment of spontaneous or iatrogenic pneumothoracies and hydrothoracies following cardiothoracic surgery or trauma, or for drainage of pus, bile, or chylous effusions. We review current indications for chest tube placement, insertion techniques, and available equipment, including drainage systems. Guidelines for maintenance and discontinuation are also discussed. As with any surgical procedure, complications may arise. Appropriate training and competence in usage may reduce the incidence of complications.

Prospective study of the yield of physical examination compared with chest radiography in penetrating thoracic trauma

A prospective study was conducted on 102 patients (84 male), with a median age of 27 years, who had sustained a penetrating chest wound to evaluate the ability of physical examination in comparison with chest radiography to determine management of these injuries. Knife wounds accounted for 92% of the injuries. Fifty three patients had a small collection of air or fluid in their pleural cavity that was not drained. Fifty six hemithoraces had a large collection of fluid or air and were treated by tube thoracostomy. Physical examination at presentation detected large collections of air and fluid correctly and predicted appropriate management (sensitivity 96%, specificity 94%). Residual collections of air or fluid or both were also predicted correctly by clinical examination. Seven small collections increased in size and required intubation. Routine pre-extubation radiographs were found to be of little value in management and their routine use is not recommended. Four patients required late thoracotomy for decortication. By using a policy of selective intubation, frequent clinical reassessment, and chest radiography when relevant, experienced trauma surgeons can manage most penetrating pleural injuries with an acceptably low complication rate.

Pitfalls in the management of penetrating chest trauma

A prospective study designed specifically to analyze errors in management and iatrogenic complications was conducted on 234 consecutive patients with penetrating chest trauma. Eleven percent of penetrating pleural injuries were incorrectly diagnosed on initial physical and radiologic examination, but this led to wrong management decisions in only 4 percent. Decisions regarding intercostal tube drainage were particularly inaccurate when emergency intubation was required prior to chest radiography. Atypical clinical features of penetrating cardiac injuries caused delay in diagnosis and thoracotomy in 3 of 14 patients. Only two of four mediastinal vascular injuries were recognized on initial examination. Transdiaphragmatic injuries were initially missed in 5 of 14 patients. This resulted in management errors and delay in these patients. Awareness of atypical presentations and circumstances in which misjudgments and wrong decisions are prone to occur should help to avoid pitfalls and reduce mortality from penetrating chest trauma.

Penetrating wounds to the heart: a wartime experience

Forty-nine war casualties with penetrating cardiac wounds were treated at the Hôtel-Dieu de France University Hospital between April 1975 and December 1987. All the wounds were caused by high-velocity missiles. An aggressive approach was utilized. Emergency room thoracotomy was performed in 17 "lifeless" patients, 4 of whom survived. Twenty-seven of the 32 patients who were in stable enough condition to undergo initial repair in the operating room survived. Overall survival was 63% (31/49). No intracardiac injuries were diagnosed in survivors, and no cardiac reoperations were required. Careful analysis of the trajectory of the missile or missiles and a portable chest roentgenogram were the most important factors for diagnosing a penetrating wound to the heart and for predicting potential associated injuries.

Bullets retained within the heart: diagnosis and management in three cases

Three cases of gunshot wounds of the chest are reported, in each of which a bullet was retained within the heart. Although it is rare, the surgeon should consider this possibility if the missile overlies the cardiac silhouette on the plain chest radiograph. Fluoroscopy played an important part in confirming the diagnosis. Cardiopulmonary bypass was used in all cases and provides operating circumstances that improve the prospects of success.

Assessment of hospital workload in war surgery

The aim of treatment of casualties in war time is to offer a chance of survival to the greatest number of patients. This goal can be approached by selecting for treatment patients who have a real chance of survival and by reducing the duration of operations as much as possible. Should the operative time be limited to an assessed predetermined duration as proposed in certain armies? Conditions for the observation of war wounded were particularly favourable in the ICRC (International Committee of the Red Cross) Hospital in Peshawar (Pakistan) because all treatments were started and completed in the same place. During the summer of 1985, a major battle took place near the Pakistan border. Analysis of 212 operated patients, of whom 68 per cent arrived at the hospital less than 48 h after the injury, showed that the operations lasted 90 min on average. Abdominal procedures were the longest. Patients stayed in the hospital for an average of 4 weeks; those with lesions of the extremities stayed longer (5.8 weeks) than those with abdominal or thoracic lesions (4.3 and 3 weeks). The results show that the long duration of an operation has not been correlated either with an unfavourable outcome or with an increased postoperative workload. As far as possible, accelerating the turnover of operations by increasing the number of operating teams should be the objective rather than the selection of patients who require short operations. Such selection would have resulted in the death of most seriously wounded patients in this series.