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Sarber KM, O'Connor P, Weitzel EK, Stevens J, Aden JK, Breeze J. Local Effect of Ballistic Fragments Embedded Along the Carotid Sheath of a Porcine Animal Model. Mil Med 2023; 188:e1774-e1780. [PMID: 36173120 DOI: 10.1093/milmed/usac276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/14/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Energized ballistic fragments from improvised explosive devices were the most common cause of injury to coalition service personnel during conflicts in Iraq and Afghanistan. Surgical excision of retained fragments is not routinely performed unless there is a concern for injury to vital structures. However, no clear guidelines dictate when or if a fragment should be removed, reflecting a lack of objective evidence of their long-term effects. Using a porcine model, we aimed to evaluate changes to the carotid artery produced by retained fragments over time. MATERIALS AND METHODS Institutional Animal Care and Use Committee approval for all experiments was obtained before commencement of the study. Eighteen female swine (mean mass 62.0 ± 3.4 kg) were randomized into three study groups corresponding to the time of survival after implantation of ballistic fragments: 1, 6, and 12 weeks. Two animals from each group were randomly assigned to have one of the three different fragments implanted within the right carotid sheath in zones 1-3 of the neck. The left carotid served as the control. The vascular flow rate and arterial diameter were measured at each level before implantation and again after the survival interval. Baseline and interval angiograms were performed to identify gross vascular changes. RESULTS No abnormalities were identified on baseline or interval angiograms. No significant difference was found when the baseline was compared to interval measurements or when compared to the control side for all gross and physiological measures at 1 and 6 weeks (P = .053-.855). After 12 weeks, the flow and diameter changed significantly (P < .001-.03), but this significant change was found in both the control and affected carotid. CONCLUSIONS The lack of significant gross anatomical and physiological changes at 6 weeks postimplantation lends evidence toward the current policy that early removal of retained ballistic fragments around cervical vessels is not required. Changes were significant after 12 weeks which suggest that surveillance may be required; however, such changes could be explained by physiological animal growth.
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Affiliation(s)
- Kathleen M Sarber
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Otolaryngology-Head and Neck Surgery, 59th Medical Group, Lackland AFB, TX 78236, USA
| | - Peter O'Connor
- Department of Otolaryngology, Mid Coast Hospital - MaineHealth, Brunswick, ME 04011, USA
| | - Erik K Weitzel
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Operational Medicine, Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX 78236, USA
| | - Jayne Stevens
- Department of Otolaryngology-Head and Neck Surgery, 59th Medical Group, Lackland AFB, TX 78236, USA
| | - James K Aden
- Department of Graduate Medical Education, Brooke Army Medical Center, Ft Sam Houston, TX 78234, USA
| | - John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Level 2 Queen Elizabeth Hospital, Birmingham B15 2TH, UK
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Ponomarenko OV, Pysanko VV, Mialkovskyi DS, Tkachuk DV. THE MANAGEMENT OF THE VICTIMS WITH GUNSHOT WOUNDS OF THE EXTREMITIES WITH EXTENSIVE DEFECTS OF THE SOFT TISSUES AT THE LEVEL OF QUALIFIED MEDICAL CARE. CASE-SERIES. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1227-1232. [PMID: 37364077 DOI: 10.36740/wlek202305214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE The aim: To highlight the original experience of diagnosis and treatment of patients with gunshot wounds of the extremities with extensive defects of the soft tissues. PATIENTS AND METHODS Materials and methods: The total number of treated patients with massive gunshot wounds from February 2022 to March 2023 was 60 males. Basic labo¬ratory tests, X-rays of the affected limbs were performed to all patients. USS of the vessels with color Doppler was performed to those casualties who had no peripheral pulses on the wounded extremity. All injured persons underwent wound debridement and fasciotomy on the day of admission, 8 more casualties underwent surgical interventions on the major vessels and nerves. RESULTS Results: Good treatment outcomes for patients with extensive soft tissue injury were achieved by early surgical intervention to remove non-viable tissue. Limb preservation was achieved in 98.3% of cases. CONCLUSION Conclusions: The study's conclusion emphasizes the importance of a multidisciplinary approach to treating patients with gunshot wounds to the limbs with extensive soft tissue injury. Early surgical interventions with the removal of non-viable tissues are necessary for good outcomes. Revascularization of the affected limb is essential in case of major vessel injury if there is no thread to the life.
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Affiliation(s)
- Olena V Ponomarenko
- ZAPORIZHZHIA STATE MEDICAL AND PHARMACEUTICAL UNIVERSITY, ZAPORIZHZHIA, UKRAINE
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D’Souza EW, MacGregor AJ, Dougherty AL, Olson AS, Champion HR, Galarneau MR. Combat injury profiles among U.S. military personnel who survived serious wounds in Iraq and Afghanistan: A latent class analysis. PLoS One 2022; 17:e0266588. [PMID: 35385552 PMCID: PMC8985965 DOI: 10.1371/journal.pone.0266588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background The U.S. military conflicts in Iraq and Afghanistan had the most casualties since Vietnam with more than 53,000 wounded in action. Novel injury mechanisms, such as improvised explosive devices, and higher rates of survivability compared with previous wars led to a new pattern of combat injuries. The purpose of the present study was to use latent class analysis (LCA) to identify combat injury profiles among U.S. military personnel who survived serious wounds. Methods A total of 5,227 combat casualty events with an Injury Severity Score (ISS) of 9 or greater that occurred in Iraq and Afghanistan from December 2002 to July 2019 were identified from the Expeditionary Medical Encounter Database for analysis. The Barell Injury Diagnosis Matrix was used to classify injuries into binary variables by site and type of injury. LCA was employed to identify injury profiles that accounted for co-occurring injuries. Injury profiles were described and compared by demographic, operational, and injury-specific variables. Results Seven injury profiles were identified and defined as: (1) open wounds (18.8%), (2) Type 1 traumatic brain injury (TBI)/facial injuries (14.2%), (3) disseminated injuries (6.8%), (4) Type 2 TBI (15.4%), (5) lower extremity injuries (19.8%), (6) burns (7.4%), and (7) chest and/or abdominal injuries (17.7%). Profiles differed by service branch, combat location, year of injury, injury mechanism, combat posture at the time of injury, and ISS. Conclusion LCA identified seven distinct and interpretable injury profiles among U.S. military personnel who survived serious combat injuries in Iraq or Afghanistan. These findings may be of interest to military medical planners as resource needs are evaluated and projected for future conflicts, and medical professionals involved in the rehabilitation of wounded service members.
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Affiliation(s)
- Edwin W. D’Souza
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, United States of America
- Leidos, Inc., San Diego, California, United States of America
- * E-mail:
| | - Andrew J. MacGregor
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, United States of America
- Axiom Resource Management, Inc., San Diego, California, United States of America
| | - Amber L. Dougherty
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, United States of America
- Leidos, Inc., San Diego, California, United States of America
| | - Andrew S. Olson
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, United States of America
| | - Howard R. Champion
- Uniformed Services University of the Health Sciences, Annapolis, Maryland, United States of America
- Section of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Michael R. Galarneau
- Medical Modeling, Simulation, and Mission Support Department, Naval Health Research Center, San Diego, California, United States of America
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Yilmaz S, Ak R, Hokenek NM, Yilmaz E, Tataroglu O. Comparison of trauma scores and total prehospital time in the prediction of clinical course in a plane crash: Does timing matter? Am J Emerg Med 2021; 50:301-308. [PMID: 34425323 DOI: 10.1016/j.ajem.2021.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/10/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate how the total prehospital time (TPT), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and Trauma Score-Injury Severity Score (TRISS) affect the outcome of plane crash victims from anatomical, physiological and psychological perspectives. The accuracy or strength of these scores and TPT in predicting hospitalization and surgery, sequelae development and psychiatric complications [permanent temporary disability (PoTDs)] and PTSD can allow medical professionals to direct and prioritize management efforts of the victims of mass casualties in general. METHODS The study was designed as a single-center retrospective study. By examining the records of victims of a plane crash transferred to the ED, AIS, ISS, TRISS and TPT were calculated on admission. The clinical severity of the patients was determined by a joint decision of five clinicians. The performances of the trauma scores on hospitalization, surgery, PTSD and PoTDs were compared. The study data were analyzed via the Mann-Whitney U test and descriptive statistical methods. Pearson's chi-square test was used for the comparison of qualitative data, and ROC analyses were employed to determine cutoff levels. RESULTS The AIS, ISS, and TRISS scores of the victims with an indication for hospitalization, calculated on admission to the ED, were significantly higher than those of the other victims (p = 0.001). In addition, TPT, AIS, ISS, and TRISS scores were significantly higher in hospitalized patients than in outpatients (p < 0.05). The cutoff levels for AIS and ISS were ≥ 1.50 and ≥ 4.50, respectively, while they were ≥ 123.5 min for TPT with regard to hospitalization decisions. The AIS, ISS, and TRISS scores calculated on admission for the patients who underwent surgery were significantly higher than those who did not (p = 0.001). Cutoff levels for AIS and ISS were ≥ 2.50 and ≥ 11.50, respectively, while they were ≥ 135.5 min for TPT with respect to the decision to operate on the victims. CONCLUSIONS It is expected that everyone who practices medicine be equipped to handle multiple casualties. As the number of people involved in mass casualties increases, diagnostic tools, workups such as laboratory and radiological studies, and prognostic markers such as trauma scores should be simpler and more user-friendly.
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Affiliation(s)
- Sarper Yilmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Rohat Ak
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Nihat Mujdat Hokenek
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey.
| | - Erdal Yilmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Ozlem Tataroglu
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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O'Connell RL, Wakam GK, Siddiqui A, Williams AM, Graham N, Kemp MT, Chtraklin K, Bhatti UF, Shamshad A, Li Y, Alam HB, Biesterveld BE. Development of a large animal model of lethal polytrauma and intra-abdominal sepsis with bacteremia. Trauma Surg Acute Care Open 2021; 6:e000636. [PMID: 33537457 PMCID: PMC7852924 DOI: 10.1136/tsaco-2020-000636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022] Open
Abstract
Background Trauma and sepsis are individually two of the leading causes of death worldwide. When combined, the mortality is greater than 50%. Thus, it is imperative to have a reproducible and reliable animal model to study the effects of polytrauma and sepsis and test novel treatment options. Porcine models are more translatable to humans than rodent models due to the similarities in anatomy and physiological response. We embarked on a study to develop a reproducible model of lethal polytrauma and intra-abdominal sepsis, which was lethal, though potentially salvageable with treatment. Methods Our laboratory has a well-established porcine model that was used as the foundation. Animals were subjected to a rectus crush injury, long bone fracture, liver and spleen laceration, traumatic brain injury and hemorrhage that was used as a foundation. We tested various colon injuries to create intra-abdominal sepsis. All animals underwent injuries followed by a period of shock, then subsequent resuscitation. Results All animals had blood culture-proven sepsis. Attempts at long-term survival of animals after injury were ceased because of poor appetite and energy. We shifted to an 8-hour endpoint. The polytrauma injury pattern remained constant and the colon injury pattern changed with the intention of creating a model that was ultimately lethal but potentially salvageable with a therapeutic drug. An uncontrolled cecal injury (n=4) group resulted in very early deaths. A controlled cecal injury (CCI; n=4) group had prolonged time prior to mortality with one surviving to the endpoint. The sigmoid injury (n=5) produced a similar survival curve to CCI but no animals surviving to the endpoint. Conclusion We have described a porcine model of polytrauma and sepsis that is reproducible and may be used to investigate novel treatments for trauma and sepsis. Level of evidence Not applicable. Animal study.
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Affiliation(s)
- Rachel L O'Connell
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Glenn K Wakam
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ali Siddiqui
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron M Williams
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Graham
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael T Kemp
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kiril Chtraklin
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Umar F Bhatti
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alizeh Shamshad
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yongqing Li
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hasan B Alam
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ben E Biesterveld
- Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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