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Sinyuk M, Polishchuk V, Yuschak P, Burachok I. Management of war-related facial wounds in Ukraine: the Lviv military hospital experience. BMJ Mil Health 2023:e002527. [PMID: 38124117 DOI: 10.1136/military-2023-002527] [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: 07/30/2023] [Accepted: 11/12/2023] [Indexed: 12/23/2023]
Abstract
The Lviv Military Medical Centre is the main hospital responsible for the management of wounded military personnel in Western Ukraine. Since the full-scale invasion of our country in 2022, we have had to rapidly adapt our department to managing a large influx of complex facial battle injuries. These wounds are generally from large explosive fragments such as from shells and commonly produce avulsive defects of the facial bones and overlying soft tissues. Using representative cases, we aim to discuss management of these extensive injuries and guide the future direction of our service, particularly in surgical training such as microvascular anastomosis.
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Affiliation(s)
- Mikola Sinyuk
- Department of Oral and Maxillofacial Surgery, Lviv Military Medical Centre, Lviv, Ukraine
| | - V Polishchuk
- Department of Oral and Maxillofacial Surgery, Lviv Military Medical Centre, Lviv, Ukraine
| | - P Yuschak
- Department of Oral and Maxillofacial Surgery, Lviv Military Medical Centre, Lviv, Ukraine
| | - I Burachok
- Department of Oral and Maxillofacial Surgery, Lviv Military Medical Centre, Lviv, Ukraine
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Muacevic A, Adler JR, Gonçalves J, Almeida V. Airway Management for Penetrating Neck Trauma: A Case Report. Cureus 2023; 15:e33441. [PMID: 36751184 PMCID: PMC9899350 DOI: 10.7759/cureus.33441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/07/2023] Open
Abstract
Penetrating neck injuries comprise 5-10% of traumatic injuries in adults and can cause immediate life-threatening compromise. Performing awake fibreoptic intubation in cooperative patients when airway management is not time critical has been suggested as a method of securing these potentially complicated airways. We report a case of a male in his 20s who presented to the emergency service with neck trauma following a bicycle road accident. With the exception of a wound in the neck region, there were no alarming distress signs or symptoms of airway endangerment. Imagiological evaluation revealed a rupture of the right lateral tracheal wall. He was referred for urgent surgery. We performed intubation with video laryngoscopy assisted by a neck surgery team, keeping the patient breathing spontaneously and under deep sedation. After advancing the tube through the vocal cords, the surgeon explored the cervical wound, guiding the tube through the trachea. Keeping spontaneous ventilation and advancing the tracheal tube beyond the lesion under visualization is essential when managing a traumatized airway. Tracheal intubation using video laryngoscopy, assisted by a neck surgeon guiding the tube, and avoiding creation of a false passage can be a safe alternative to fibreoptic intubation in selected cases of tracheal laceration.
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Craniofacial Trauma on the Modern Battlefield: Initial Management and Techniques. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-021-00213-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Breeze J, Gensheimer WG, DuBose JJ. Penetrating Neck Injuries Treated at a U.S. Role 3 Medical Treatment Facility in Afghanistan During Operation Resolute Support. Mil Med 2020; 186:18-23. [PMID: 33007083 DOI: 10.1093/milmed/usaa252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/24/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
Introduction
Military trauma registries can identify broad epidemiological trends from neck wounds but cannot reliably demonstrate temporal casualty from clinical interventions or differentiate penetrating neck injuries (PNI) from those that do not breach platysma.
Materials and Methods
All casualties presenting with a neck wound to a Role 3 Medical Treatment Facility in Afghanistan between January 1, 2016 and September 15, 2019 were retrospectively identified using the Emergency Room database. These were matched to records from the Operating Room database, and computed tomography (CT) scans reviewed to determine damage to the neck region.
Results
During this period, 78 casualties presented to the Emergency Room with a neck wound. Forty-one casualties underwent surgery for a neck wound, all of whom had a CT scan. Of these, 35/41 (85%) were deep to platysma (PNI). Casualties with PNI underwent neck exploration in 71% of casualties (25/35), with 8/25 (32%) having surgical exploration at Role 2 where CT is not present. Exploration was more likely in Zones 1 and 2 (8/10, 80% and 18/22, 82%, respectively) compared to Zone 3 (2/8, 25%).
Conclusion
Hemodynamically unstable patients in Zones 1 and 2 generally underwent surgery before CT, confirming that the low threshold for exploration in such patients remains. Only 25% (2/8) of Zone 3 PNI were explored, with the high negative predictive value of CT angiography providing confidence that it was capable of excluding major injury in the majority of cases. No deaths from PNI that survived to treatment at Role 3 were identified, lending evidence to the current management protocols being utilized in Afghanistan.
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Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD, 20762, USA
| | - Joseph J DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
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Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities. J Trauma Acute Care Surg 2020; 88:696-703. [PMID: 32068717 PMCID: PMC7182242 DOI: 10.1097/ta.0000000000002625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental digital content is available in the text. The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.
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Breeze J, Gensheimer W, DuBose JJ. Combat Facial Fractures Sustained During Operation Resolute Support and Operation Freedom’s Sentinel in Afghanistan. Mil Med 2020; 185:414-416. [DOI: 10.1093/milmed/usaa159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Facial fractures sustained in combat are generally unrepresentative of those commonly experienced in civilian practice. In the US military, acute trauma patient care is guided by the Joint Trauma System Clinical Practice Guidelines but currently none exists for facial trauma.
Materials and methods
All casualties that underwent surgery to facial fractures between January 01, 2016 and September 15, 2019 at a US deployed Military Treatment Facility in Afghanistan were identified using the operating room database. Surgical operative records and outpatient records for local Afghan nationals returning for follow-up were reviewed to determine outcomes.
Results
55 casualties underwent treatment of facial fractures; these were predominantly from explosive devices (27/55, 49%). About 46/55 (84%) were local nationals, of which 32 (70%) were followed up. Length of follow-up ranged between 1 and 25 months. About 36/93 (39%) of all planned procedures developed complications, with the highest being from ORIF mandible (18/23, 78%). About 8/23 (35%) casualties undergoing ORIF mandible developed osteomyelitis, of which 5 developed nonunion. Complications were equally likely to occur in those procedures for “battlefield type” events such as explosive devices and gunshot wounds (31/68, 46%) as those from “civilian type” events such as falls or motor vehicle collisions (5/11, 45%).
Conclusions
Complications Rates from facial fractures were higher than that reported in civilian trauma. This likely reflects factors such as energy deposition, bacterial load, and time to treatment. Load sharing osteosynthesis should be the default modality for fracture fixation. External fixation should be considered in particular for complex high-energy or infected mandible fractures where follow-up is possible.
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Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, University Hospitals Birmingham, Birmingham, B15 2TH, UK
| | - William Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland 20762
| | - Joseph J DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, Maryland 21201
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Breeze J, Bowley DM, Harrisson SE, Dye J, Neal C, Bell RS, Armonda RA, Beggs AD, DuBose J, Rickard RF, Powers DB. Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts. J Neurol Neurosurg Psychiatry 2020; 91:359-365. [PMID: 32034113 PMCID: PMC7147183 DOI: 10.1136/jnnp-2019-321723] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/14/2019] [Accepted: 01/12/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes. METHODS The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables. RESULTS 15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×104, 95% CI 1.61×104 to 110.6×104, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001). CONCLUSIONS Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Douglas M Bowley
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Stuart E Harrisson
- Department of Neurosurgery, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Justin Dye
- Department of Neurosurgery, Loma Linda University, Loma Linda, California, USA
| | - Christopher Neal
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Randy S Bell
- National Capital Neurosurgery Consortium, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University Medical Center, Washington, DC, USA
| | - Andrew D Beggs
- Surgical Research Laboratory, University of Birmingham, Birmingham, UK
| | - Jospeh DuBose
- Center for the Sustainment of Trauma and Readiness Skills, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - David Bryan Powers
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Breeze J, Bowley DM, Combes JG, Baden J, Rickard RF, DuBose J, Powers DB. Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study. BMJ Open 2019; 9:e033557. [PMID: 31772107 PMCID: PMC6887033 DOI: 10.1136/bmjopen-2019-033557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. SETTING The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011. PARTICIPANTS US and UK military personnel, local police, local military and civilians. PRIMARY AND SECONDARY OUTCOME MEASURES An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables. RESULTS Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066). CONCLUSIONS The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.
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Affiliation(s)
- John Breeze
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Douglas M Bowley
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James G Combes
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - James Baden
- Royal Centre for Defence Medicine, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - David B Powers
- Duke University Medical Center, Durham, North Carolina, USA
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Owston H, Jones C, Groom P, Mercer SJ. The anaesthetic management of the airway after blunt and penetrating neck injury. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408619886216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hazel Owston
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Clinton Jones
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Peter Groom
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Simon J Mercer
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth 2018; 117 Suppl 1:i49-i59. [PMID: 27566791 DOI: 10.1093/bja/aew193] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns. METHODS A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763). RESULTS A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns. CONCLUSIONS The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.
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Affiliation(s)
- S J Mercer
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Defence Medical Services, Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK Postgraduate School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, UK
| | - C P Jones
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - M Bridge
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - E Clitheroe
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
| | - B Morton
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK Honorary Research Fellow, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - P Groom
- Anaesthetic Department, Aintree University Hospital NHS Foundation Trust, Longmoor Lane, Aintree, Liverpool L9 7AL, UK
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Breeze J, Blanch R, Baden J, Monaghan AM, Evriviades D, Harrisson SE, Roberts S, Gibson A, MacKenzie N, Baxter D, Gibbons AJ, Heppell S, Combes JG, Rickard RF. Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement. J ROY ARMY MED CORPS 2018; 164:133-138. [DOI: 10.1136/jramc-2017-000881] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
IntroductionThe evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons.MethodA systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management.ResultsHead, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair.ConclusionsThe identification of those skill sets required for deployment is in keeping with the General Medical Council’s current drive towards credentialing consultants, by which a consultant surgeon’s capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.
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Girod S, Schvartzman SC, Gaudilliere D, Salisbury K, Silva R. Haptic feedback improves surgeons' user experience and fracture reduction in facial trauma simulation. ACTA ACUST UNITED AC 2018; 53:561-570. [PMID: 27898160 DOI: 10.1682/jrrd.2015.03.0043] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 10/29/2015] [Indexed: 11/05/2022]
Abstract
Computer-assisted surgical (CAS) planning tools are available for craniofacial surgery, but are usually based on computer-aided design (CAD) tools that lack the ability to detect the collision of virtual objects (i.e., fractured bone segments). We developed a CAS system featuring a sense of touch (haptic) that enables surgeons to physically interact with individual, patient-specific anatomy and immerse in a three-dimensional virtual environment. In this study, we evaluated initial user experience with our novel system compared to an existing CAD system. Ten surgery resident trainees received a brief verbal introduction to both the haptic and CAD systems. Users simulated mandibular fracture reduction in three clinical cases within a 15 min time limit for each system and completed a questionnaire to assess their subjective experience. We compared standard landmarks and linear and angular measurements between the simulated results and the actual surgical outcome and found that haptic simulation results were not significantly different from actual postoperative outcomes. In contrast, CAD results significantly differed from both the haptic simulation and actual postoperative results. In addition to enabling a more accurate fracture repair, the haptic system provided a better user experience than the CAD system in terms of intuitiveness and self-reported quality of repair.
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Affiliation(s)
- Sabine Girod
- Departments of Surgery, Oral Medicine & Maxillofacial Surgery Section, and
| | | | - Dyani Gaudilliere
- Departments of Surgery, Oral Medicine & Maxillofacial Surgery Section, and
| | | | - Rebeka Silva
- San Francisco Department of Veterans Affairs Health Care System, Dental Service, San Francisco, CA
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Duwat A, Travers S, Deransy R, Langeron O, Tourtier JP. Cricothyroïdotomie par technique SMS (Scalpel, Mandrin long béquillé, Sonde d’intubation) : une alternative à connaître en situation d’exception et d’afflux massif de victimes. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0775-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Breeze J, Tong D, Gibbons A. Contemporary management of maxillofacial ballistic trauma. Br J Oral Maxillofac Surg 2017; 55:661-665. [DOI: 10.1016/j.bjoms.2017.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
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Optimising ballistic facial coverage from military fragmenting munitions: a consensus statement. Br J Oral Maxillofac Surg 2016; 55:173-178. [PMID: 27836236 DOI: 10.1016/j.bjoms.2016.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/21/2016] [Indexed: 11/22/2022]
Abstract
VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.
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Lorenz KJ, Böckers A, Fassnacht U, Wilde F, Wegener M. Implementation of a miniaturised navigation system in head and neck surgery for the detection and removal of foreign bodies. Eur Arch Otorhinolaryngol 2016; 274:553-559. [PMID: 27430225 DOI: 10.1007/s00405-016-4212-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
The removal of embedded blast-generated fragments from soft tissue is very difficult, especially in the head and neck regions. First, because many retained foreign materials are non-metallic and can, therefore, not be detected by fluoroscopy, and second, because a broad exploration of the soft tissue is not possible in the facial area for functional and cosmetic reasons. Intraoperative navigation computer-assisted surgery (CAS) may facilitate the retrieval of foreign bodies and reduce exploration trauma. In a blind trial, five test specimens of different materials (glass, metal, wood, plastic, and stone) were inserted on the left and right sides of the head and neck of ten body donors through an intraoral incision. A second physician then detected and removed the foreign bodies from one side of the body without and from the other side of the body with navigation. We measured the duration of surgery, the extent of tissue trauma caused during surgery, the time it took to remove the foreign bodies, and the subjective evaluation of the usefulness of navigation. With the aid of the navigation system, the various foreign bodies were detected after an average of 26.7 (±35.1) s (p < 0.0001) and removed after an average of 79.1 (±66.2) s (p = 0.0239), with an average incision length of 10.0 (±3.5) mm. Without the navigation system, the foreign bodies were located after an average of 86.5 (±77.7) s and removed after an average of 74.1 (±45.9) s, with an average incision length of 13.0 mm (±3.6) mm (=0.0007). Intraoperative navigation systems are a valuable tool for removing foreign bodies from the soft tissue of the face and neck. Both the duration of surgery and the incision length can be reduced using navigation systems. Depending on the material of the foreign bodies and the signal intensity in the CT/MRI scanner, however, the detection reliability varies. All in all, navigation is considered to be a useful tool.
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Affiliation(s)
- K J Lorenz
- Department of Otorhinolaryngology, German Armed Forces Hospital, Ulm, Germany.
| | - A Böckers
- Institute of Anatomy and Cell Biology, University Ulm, Ulm, Germany
| | - U Fassnacht
- Institute of Anatomy and Cell Biology, University Ulm, Ulm, Germany
| | - F Wilde
- Department of Maxillo-facial Surgery, German Armed Forces Hospital, Ulm, Germany
| | - M Wegener
- Department of Maxillo-facial Surgery, German Armed Forces Hospital, Ulm, Germany
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Hung BP, Naved BA, Nyberg EL, Dias M, Holmes CA, Elisseeff JH, Dorafshar AH, Grayson WL. Three-Dimensional Printing of Bone Extracellular Matrix for Craniofacial Regeneration. ACS Biomater Sci Eng 2016; 2:1806-1816. [PMID: 27942578 DOI: 10.1021/acsbiomaterials.6b00101] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tissue-engineered approaches to regenerate bone in the craniomaxillofacial region utilize biomaterial scaffolds to provide structural and biological cues to stem cells to stimulate osteogenic differentiation. Bioactive scaffolds are typically comprised of natural components but often lack the manufacturability of synthetic materials. To circumvent this trade-off, we 3D printed materials comprised of decellularized bone (DCB) matrix particles combined with polycaprolactone (PCL) to create novel hybrid DCB:PCL scaffolds for bone regeneration. Hybrid scaffolds were readily printable at compositions of up to 70% bone by mass and displayed robust mechanical properties. Assessments of surface features revealed both collagenous and mineral components of bone were present. Qualitative and quantitative assessments showed increased surface roughness relative to that of pure PCL scaffolds. These findings correlated with enhanced cell adhesion on hybrid surfaces relative to that on pure surfaces. Human adipose-derived stem cells (hASCs) cultured in DCB:PCL scaffolds without soluble osteogenic cues exhibited significant upregulation of osteogenic genes in hybrid scaffolds relative to pure PCL scaffolds. In the presence of soluble phosphate, hybrid scaffolds resulted in increased calcification. The hASC-seeded scaffolds were implanted into critical-sized murine calvarial defects and yielded greater bone regeneration in DCB:PCL scaffolds compared to that in PCL-only at 1 and 3 months post-transplantation. Taken together, these results demonstrate that 3D printed DCB:PCL scaffolds might be effective for stimulating bone regeneration.
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Affiliation(s)
- Ben P Hung
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States; Translational Tissue Engineering Center, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States
| | - Bilal A Naved
- Fischell Department of Biomedical Engineering, University of Maryland, College Park, Maryland 21231, United States
| | - Ethan L Nyberg
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States; Translational Tissue Engineering Center, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States
| | - Miguel Dias
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States; Translational Tissue Engineering Center, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States
| | - Christina A Holmes
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore 21231, Maryland, United States
| | - Jennifer H Elisseeff
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States; Translational Tissue Engineering Center, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States
| | - Amir H Dorafshar
- Department of Plastic Surgery, The Johns Hopkins Hospital, Baltimore 21231, Maryland, United States
| | - Warren L Grayson
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States; Translational Tissue Engineering Center, The Johns Hopkins University School of Medicine, Baltimore 21231, Maryland, United States
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Carr D, Lindstrom AC, Jareborg A, Champion S, Waddell N, Miller D, Teagle M, Horsfall I, Kieser J. Development of a skull/brain model for military wound ballistics studies. Int J Legal Med 2014; 129:505-10. [PMID: 25194710 DOI: 10.1007/s00414-014-1073-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 08/28/2014] [Indexed: 11/29/2022]
Abstract
Reports on penetrating ballistic head injuries in the literature are dominated by case studies of suicides; the penetrating ammunition usually being .22 rimfire or shotgun. The dominating cause of injuries in modern warfare is fragmentation and hence, this is the primary threat that military helmets protect the brain from. When helmets are perforated, this is usually by bullets. In combat, 20% of penetrating injuries occur to the head and its wounding accounts for 50% of combat deaths. A number of head simulants are described in the academic literature, in ballistic test methods for helmets (including measurement of behind helmet blunt trauma, BHBT) and in the 'open' and 'closed' government literature of several nations. The majority of these models are not anatomically correct and are not assessed with high-velocity rifle ammunition. In this article, an anatomically correct 'skull' (manufactured from polyurethane) and 'brain' (manufactured from 10%, by mass, gelatine) model for use in military wound ballistic studies is described. Filling the cranium completely with gelatine resulted in a similar 'skull' fracture pattern as an anatomically correct 'brain' combined with a representation of cerebrospinal fluid. In particular, posterior cranial fossa and occipital fractures and brain ejection were observed. This pattern of injury compared favourably to reported case studies of actual incidents in the literature.
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Affiliation(s)
- Debra Carr
- Impact and Armour Group, Centre for Defence Engineering, Cranfield Defence and Security, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, Wiltshire, SN6 8LA, UK,
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Mercer SJ, Tarmey N, Mahoney PF. Military experience of human factors in airway complications. Anaesthesia 2013; 68:1081-2. [DOI: 10.1111/anae.12417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - N. Tarmey
- Queen Alexandra Hospital; Portsmouth; UK
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Breeze J, Baxter D, Carr D, Midwinter MJ. Defining combat helmet coverage for protection against explosively propelled fragments. J ROY ARMY MED CORPS 2013; 161:9-13. [DOI: 10.1136/jramc-2013-000108] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jeevaratnam JA, Pandya AN. One year of burns at a Role 3 Medical Treatment Facility in Afghanistan. J ROY ARMY MED CORPS 2013; 160:22-6. [DOI: 10.1136/jramc-2013-000100] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Brennan J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope 2013; 123:2411-7. [PMID: 23553408 DOI: 10.1002/lary.24096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/19/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objectives are to compare and contrast the head and neck trauma experience in Iraq and Afghanistan and to identify trauma lessons learned that are applicable to civilian practice. STUDY DESIGN A retrospective review of one head and neck surgeon's operative experience in Iraq and Afghanistan was performed using operative logs and medical records. METHODS The surgeon's daily operative log book with patient demographic data and operative reports was reviewed. Also, patient medical records were examined to identify the preoperative and postoperative course of care. RESULTS The head and neck trauma experiences in Iraq and Afghanistan were very different, with a higher percentage of emergent cases performed in Iraq. In Iraq, only 10% of patients were pretreated at a facility with surgical capabilities. In Afghanistan, 93% of patients were pretreated at such facilities. Emergent neck exploration for penetrating neck trauma and emergent airway surgery were more common in Iraq, which most likely accounted for the increased perioperative mortality also seen in Iraq (5.3% in Iraq vs. 1.3% in Afghanistan). Valuable lessons regarding soft tissue trauma repair, midface fracture repair, and mandible fracture repair were learned. CONCLUSION The head and neck trauma experiences in Iraq and Afghanistan were very different, and the future training for mass casualty trauma events should reflect these differences. Furthermore, valuable head and neck trauma lessons learned in both war zones are applicable to the civilian practice of trauma. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Joseph Brennan
- Department of Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
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Developmental framework to validate future designs of ballistic neck protection. Br J Oral Maxillofac Surg 2013; 51:47-51. [DOI: 10.1016/j.bjoms.2012.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 03/04/2012] [Indexed: 11/20/2022]
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Rajguru R. Role of ENT Surgeon in Managing Battle Trauma During Deployment. Indian J Otolaryngol Head Neck Surg 2013; 65:89-94. [PMID: 24381930 PMCID: PMC3585560 DOI: 10.1007/s12070-012-0598-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 11/10/2012] [Indexed: 10/27/2022] Open
Abstract
With technological improvements in body armour and increasing use of improvised explosive devices, it is the injuries to head, face and neck are the cause for maximum fatalities as military personnel are surviving wounds that would have otherwise been fatal. The priorities of battlefield surgical treatment are to save life, eyesight and limbs and then to give the best functional and aesthetic outcome for other wounds. Modern day battlefields pose unique demands on the deployed surgical teams and management of head and neck wounds demands multispecialty approach. Optimal result will depend on teamwork of head and neck trauma management team, which should also include otolaryngologist. Data collected by various deployed HFN surgical teams is studied and quoted in the article to give factual figures. Otorhinolaryngology becomes a crucial sub-speciality in the care of the injured and military otorhinolaryngologists need to be trained and deployed accordingly. The otolaryngologist's clinical knowledge base and surgical domain allows the ENT surgeon to uniquely contribute in response to mass casualty incident. Military planners need to recognize the felt need and respond by deploying teams of specialist head and neck surgeons which should also include otorhinolaryngologists.
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Affiliation(s)
- Renu Rajguru
- Institute of Aerospace Medicine, Near HAL Airport, Vimanapura, Bangalore, 560017 India
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Abstract
INTRODUCTION Accurately determining the entry location of penetrating eye and face wounds and relating that to mortality and long-term morbidity is of vital importance in the design of future personal protective equipment. METHOD Hospital and post mortem records for all UK servicemen sustaining penetrating battle injuries to the face or eye during the period 01 January 2005 to 31 December 2009 were analysed. RESULTS Face and eye injuries were found in 391/1187 (33%) and 113/1187 (10%) of all battle-injured servicemen respectively. 27% of eye wounds from explosions resulted in blindness and a further 17% in significant permanently reduced visual acuity (<6/12). Those servicemen that chose not to wear Combat Eye Protection (CEP) were 36 times more likely to sustain an eye injury from explosive fragmentation than those that did. However only 36% of servicemen chose to wear CEP. 7 deaths could potentially have been prevented had the serviceman chosen to wear their CEP. The lower third of the face was most commonly injured (60%) followed by the upper third (24%). CEP reduced facial injuries as a whole (bone and soft tissue) by 15% (p<0.01). Potentially changing the existing material used for chinstrap and helmet covers to that with ballistic protection would further reduce this incidence by up to 9%. CONCLUSIONS Although the lower third of the face remains poorly protected, the incidence of lower facial wounds could be further reduced by the use of ballistic visors by servicemen in exposed positions in vehicles (which represented 16% of facial injuries). Such a visor could potentially have prevented 17 deaths. A rigid attachment to the front of a ballistic helmet would allow either a visor, a high visibility LED lamp or a night vision goggle to clip in and we believe this capability should be investigated through future human factor trials.
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Breeze J, Masterson L, Banfield G. Outcomes from penetrating ballistic cervical injury. J ROY ARMY MED CORPS 2012; 158:96-100. [PMID: 22860497 DOI: 10.1136/jramc-158-02-05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Ballistic cervical injury has become a significant source of both morbidity and mortality for the deployed UK soldier. The aim of this paper was to document a case series of ballistic cervical wounds to describe the pattern of these injuries and relate them to outcome. METHODS The records of all UK service personnel sustaining wounds to the neck in Iraq or Afghanistan between 01 August 2004 and 01 January 2008 were analysed following identification by the Joint Theatre Trauma Registry. Blunt or thermal injuries were excluded. RESULTS The records of 75/76 service personnel sustaining penetrating cervical injury during this period were available for analysis. 56/75 (75%) were due to explosive fragmentation and the remainder due to gunshot wounds (GSW). 33/75 (44%) of soldiers sustained vascular injury, 32/75 (43%) injury to the spine or spinal cord, 29/75 (39%) injury to the larynx or trachea and 11/75 (15%) injury to the pharynx or oesophagus. 14/75 (19%) patients in this series underwent surgery in a hospital facility for treatment of potentially life threatening cervical injuries, with a survival rate after surgery of 12/14 (86%). The overall mortality from this series of battlefield penetrating neck injury was 63%. CONCLUSIONS Penetrating cervical ballistic injury is a significant source of injury to deployed UK service personnel, predominantly due to neurovascular damage. Neck collars if worn would likely prevent many of the injuries in this case series but such protection is uncomfortable and may interfere with common military tasks. Newer methods of protecting the neck should be investigated that will be acceptable to the deployed UK soldier.
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Affiliation(s)
- J Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine
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