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Kiriu N, Saitoh D, Sekine Y, Yamamura K, Fujita M, Mizukaki T, Tomura S, Kiyozumi T. Effectiveness of Body Armor Against Shock Waves: Preventing Blast Injury in a Confined Space. Cureus 2024; 16:e57568. [PMID: 38707053 PMCID: PMC11069021 DOI: 10.7759/cureus.57568] [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: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Blast injuries in modern society often occur owing to terrorist attacks in confined spaces, particularly in urban settings, indoors, and in vehicles, leading to significant damage. Therefore, it is important to focus on blast injuries in confined spaces rather than in conventional open-field experiments. Materials and methods We used an air-driven shock wave generator (blast tube) established indoors in 2017 and conducted basic research to potentially save the lives of patients with blast injuries. Under general anesthesia, pigs were divided into with body armor (BA) and without BA groups. The pigs were fixed in the measurement chamber with their dorsal chest directly exposed to the shock wave. The driving pressure was set at 3.0 MPa to achieve a mortality rate of approximately 50%. A generated shock wave was directly applied to the pigs. Comparisons were made between the groups with respect to cardiac arrest and survival, as well as apnea, bradycardia, and hypotension, which are the triad of blast lung. Autopsies were performed to confirm the extent of the organ damage. Statistical analysis was performed using Fisher's exact test, and statistical significance was set at p<0.05. The animal experimentation was conducted according to the protocol reviewed and approved by the Animal Ethics Committee of the National Defense Medical College Hospital (approval number 19041). Results Eight pigs were assigned to the BA group and seven pigs to the non-BA group. In the non-BA group, apnea was observed in four of seven cases, three of which resulted in death. None of the eight pigs in the BA group had respiratory arrest; notably, all survived. Hypotension was observed in some pigs in each group; however, there were no cases of bradycardia in either group. Statistical analysis showed that wearing BA significantly reduced the occurrence of respiratory and cardiac arrest (p=0.026) but not survival (p=0.077). No significant differences were found in other vital signs. Conclusions Wearing BA with adequate neck and chest protection reduced mortality and it was effective to reduce cardiac and respiratory arrest against shock wave exposure. Mortality from shock wave injury appears to be associated with respiratory arrest, and the avoidance of respiratory arrest may lead to survival.
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Affiliation(s)
- Nobuaki Kiriu
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, JPN
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, JPN
| | - Daizoh Saitoh
- Graduate School of Emergency Medical System, Kokushikan University, Tokyo, JPN
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, JPN
| | - Yasumasa Sekine
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, JPN
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, JPN
| | - Koji Yamamura
- Department of Oral Surgery, National Defense Medical College, Saitama, JPN
| | - Masanori Fujita
- Division of Environmental Medicine, Research Institute, National Defense Medical College, Saitama, JPN
| | - Toshiharu Mizukaki
- Department of Aeronautics and Astronautics, School of Engineering, Tokai University, Kanagawa, JPN
| | - Satoshi Tomura
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, JPN
| | - Tetsuro Kiyozumi
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Saitama, JPN
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2
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Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. High risk and low prevalence diseases: Blast injuries. Am J Emerg Med 2023; 70:46-56. [PMID: 37207597 DOI: 10.1016/j.ajem.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries. OBJECTIVE This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential. CONCLUSIONS An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Josh Bukowski
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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3
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Peng YY, Lu XM, Li S, Tang C, Ding Y, Wang HY, Yang C, Wang YT. Effects and mechanisms of extremely cold environment on body response after trauma. J Therm Biol 2023; 114:103570. [PMID: 37344028 DOI: 10.1016/j.jtherbio.2023.103570] [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: 11/21/2022] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 06/23/2023]
Abstract
With the outbreak of the Ukrainian crisis, extremely cold environment warfare has once again become the focus of international attention. People exposed to extremely cold environments may suffer from cold damage, further aggravate trauma, trigger high disability and mortality rates, and even cause serious sequelae. To declare the effects and mechanisms of the extremely cold environment on the body after trauma, this paper reviews, firstly, physiological reaction of human body in an extremely cold environment. Then, the post-traumatic body response in an extremely cold environment was introduced, and finally, the sequelae of trauma in extremely cold environment was further summarized in the paper. The results indicated that extremely cold environment can cause a series of damage to the body, especially the body after trauma. The extremely cold factor is a double-edged sword, showing a favorable and unfavorable side in different aspects. Moreover, in addition to the trauma suffered by the body, the subsequent sequelae such as cognitive dysfunction, anxiety, depression and even post-traumatic stress disorder may also be induced. The paper summarizes the human body's physiological response in an extremely cold environment, and declares the effects and mechanisms of the extremely cold environment on the body after trauma, which may provide a theoretical basis for effectively improving the level of combat trauma treatment in extremely cold regions.
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Affiliation(s)
- Yu-Yuan Peng
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China; College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Xiu-Min Lu
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Sen Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Can Tang
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Yang Ding
- College of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, 400054, China
| | - Hai-Yan Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Ce Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Yong-Tang Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China.
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4
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Simovic MO, Yang Z, Jordan BS, Fraker TL, Cancio TS, Lucas ML, Cancio LC, Li Y. Immunopathological Alterations after Blast Injury and Hemorrhage in a Swine Model of Prolonged Damage Control Resuscitation. Int J Mol Sci 2023; 24:ijms24087494. [PMID: 37108656 PMCID: PMC10139120 DOI: 10.3390/ijms24087494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Trauma-related hemorrhagic shock (HS) remains a leading cause of death among military and civilian trauma patients. We have previously shown that administration of complement and HMGB1 inhibitors attenuate morbidity and mortality 24 h after injury in a rat model of blast injury (BI) and HS. To further validate these results, this study aimed to develop a swine model and evaluate BI+HS-induced pathophysiology. Anesthetized Yucatan minipigs underwent combined BI and volume-controlled hemorrhage. After 30 min of shock, animals received an intravenous bolus of PlasmaLyte A and a continuous PlasmaLyte A infusion. The survival rate was 80% (4/5), and the non-survivor expired 72 min post-BI. Circulating organ-functional biomarkers, inflammatory biomarkers, histopathological evaluation, and CT scans indicated evidence of multiple-organ damage, systemic innate immunological activation, and local tissue inflammation in the injured animals. Interestingly, a rapid and dramatic increase in plasma levels of HMGB1 and C3a and markedly early myocarditis and encephalitis were associated with early death post-BI+HS. This study suggests that this model reflects the immunopathological alterations of polytrauma in humans during shock and prolonged damage control resuscitation. This experimental protocol could be helpful in the assessment of immunological damage control resuscitation approaches during the prolonged care of warfighters.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Zhangsheng Yang
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Bryan S Jordan
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Tamara L Fraker
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Tomas S Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Michael L Lucas
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
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5
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Shock in Trauma. Emerg Med Clin North Am 2023; 41:1-17. [DOI: 10.1016/j.emc.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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6
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Arnold S, Watts S, Kirkman E, Page CP, Pitchford SC. Single and Multiplex Immunohistochemistry to Detect Platelets and Neutrophils in Rat and Porcine Tissues. Methods Protoc 2022; 5:mps5050071. [PMID: 36136817 PMCID: PMC9498441 DOI: 10.3390/mps5050071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Abstract
Platelet–neutrophil complexes (PNCs) occur during the inflammatory response to trauma and infections, and their interactions enable cell activation that can lead to tissue destruction. The ability to identify the accumulation and tissue localisation of PNCs is necessary to further understand their role in the organs associated with blast-induced shock wave trauma. Relevant experimental lung injury models often utilise pigs and rats, species for which immunohistochemistry protocols to detect platelets and neutrophils have yet to be established. Therefore, monoplex and multiplex immunohistochemistry protocols were established to evaluate the application of 22 commercially available antibodies to detect platelet (nine rat and five pig) and/or neutrophil (four rat and six pig) antigens identified as having potential selectivity for porcine or rat tissue, using lung and liver sections taken from models of polytrauma, including blast lung injury. Of the antibodies evaluated, one antibody was able to detect rat neutrophil elastase (on frozen and formalin-fixed paraffin embedded (FFPE) sections), and one antibody was successful in detecting rat CD61 (frozen sections only); whilst one antibody was able to detect porcine MPO (frozen and FFPE sections) and antibodies, targeting CD42b or CD49b antigens, were able to detect porcine platelets (frozen and FFPE and frozen, respectively). Staining procedures for platelet and neutrophil antigens were also successful in detecting the presence of PNCs in both rat and porcine tissue. We have, therefore, established protocols to allow for the detection of PNCs in lung and liver sections from porcine and rat models of trauma, which we anticipate should be of value to others interested in investigating these cell types in these species.
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Affiliation(s)
- Stephanie Arnold
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
| | - Sarah Watts
- CBR Division, Defence Science and Technology Laboratory, Salisbury SP4 0JQ, UK
| | - Emrys Kirkman
- CBR Division, Defence Science and Technology Laboratory, Salisbury SP4 0JQ, UK
| | - Clive P. Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
| | - Simon C. Pitchford
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
- Correspondence:
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7
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Tollman J, Ahmed Z. Ventilating the blast lung: Exploring ventilation strategies in primary blast lung injury. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221080020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Primary blast lung injury (PBLI) is the most common and fatal of all primary blast injuries. The majority of those with PBLI will require early intubation and mechanical ventilation, and thus, ventilation strategy forms a crucial part of any management plan. Methods: A comprehensive, but not systematic, PubMed and Google Scholar database search identified articles that contribute to our current understanding of ventilation strategies in PBLI for a narrative educational review. Results A PBLI ventilation strategy must strive to minimise all four of ventilator-associated lung injury (VALI), volutrauma, barotrauma and biotrauma. The three main ventilation strategies available are conventional low tidal volume (LTV) ventilation, airway pressure release ventilation (APRV) and high frequency oscillatory ventilation (HFOV). Conventional LTV ventilation together with a variable positive end-expiratory pressure (PEEP) and permissive hypercapnia has demonstrated reduced inflammation and mortality with a greater number of ventilator-free days. APRV has the potential to reduce dynamic strain, PaO2/FiO2 ratios, levels of applied mechanical power and extravascular lung water while encouraging spontaneous breathing. HFOV is able to effectively avoid VALI while curbing inflammation and histological lung injury, though not necessarily mortality. Conclusions: Presently, PBLI should largely be managed with conventional LTV ventilation alongside a variable PEEP and permissive hypercapnia with APRV and HFOV reserved as rescue strategies for where conventional LTV ventilation fails. Clinicians should additionally consider supplementing their strategy with adjunctive therapies such as prone positioning, inhaled nitric oxide and extracorporeal membrane oxygenation that may further reduce mortality and combat severe respiratory and/or cardiac failure.
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Affiliation(s)
- Jaden Tollman
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, UK
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8
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Bergmann-Leitner ES, Bobrov AG, Bolton JS, Rouse MD, Heyburn L, Pavlovic R, Garry BI, Alamneh Y, Long J, Swierczewski B, Tyner S, Getnet D, Sajja VS, Antonic V. Blast Waves Cause Immune System Dysfunction and Transient Bone Marrow Failure in a Mouse Model. Front Bioeng Biotechnol 2022; 10:821169. [PMID: 35392409 PMCID: PMC8980552 DOI: 10.3389/fbioe.2022.821169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
Explosive devices, either conventional or improvised, are common sources of injuries during combat, civil unrest, and terror attacks, resulting in trauma from exposure to blast. A blast wave (BW), a near-instantaneous rise in pressure followed by a negative pressure, propagates through the body in milliseconds and can affect physiology for days/months after exposure. Epidemiological data show that blast-related casualties result in significantly higher susceptibility to wound infections, suggesting long-lasting immune modulatory effects from blast exposure. The mechanisms involved in BW-induced immune changes are poorly understood. We evaluated the effects of BW on the immune system using an established murine model. Animals were exposed to BWs (using an Advanced Blast Simulator), followed by longitudinally sampling for 14 days. Blood, bone marrow, and spleen were analyzed for changes in the 1) complete blood count (CBC), and 2) composition of bone marrow cells (BMC) and splenocytes, and 3) concentrations of systemic cytokines/chemokines. Our data demonstrate that BW results in transient bone marrow failure and long-term changes in the frequency and profile of progenitor cell populations. Viability progressively decreased in hematopoietic stem cells and pluripotent progenitor cells. Significant decrease of CD4+ T cells in the spleen indicates reduced functionality of adaptive immune system. Dynamic changes in the concentrations of several cytokines and chemokines such as IL-1α and IL-17 occurred potentially contributing to dysregulation of immune response after trauma. This work lays the foundation for identifying the potential mechanisms behind BW’s immunosuppressive effects to inform the recognition of this compromised status is crucial for the development of therapeutic interventions for infections to reduce recovery time of wounded patients injured by explosive devices.
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Affiliation(s)
- Elke S. Bergmann-Leitner
- Biologics Research and Development, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
| | - Alexander G. Bobrov
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Jessica S. Bolton
- Biologics Research and Development, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Michael D. Rouse
- Wound Infections Department, Naval Research Medical Center, Silver Spring, MD, United States
- Henry M. Jackson Foundation, Rockville, MD, United States
| | - Lanier Heyburn
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Radmila Pavlovic
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brittany I. Garry
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Yonas Alamneh
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Joseph Long
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brett Swierczewski
- Bacterial Disease Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Stuart Tyner
- Military Infectious Diseases Research Program, Frederick, MD, United States
| | - Derese Getnet
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Venkatasivasai S. Sajja
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
| | - Vlado Antonic
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
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9
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Lewis K, Stoll A, Watts S, Kirkman E. Relating Ventilatory Support and Drug Treatment Strategies to the Fundamental Pathophysiology in COVID-19 Illness. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This article relates the current pathophysiologic and radiologic findings to the fundamental idea of acute lung epithelial infection, alveolar inflammation causing leak into the interstitial space, and subsequent secondary or concurrent endothelial infection and dysfunction. Understanding the mechanisms and timings of alveolar damage can better inform the types of ventilatory support required and timing of targeted pharmacotherapies.
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Affiliation(s)
- Keir Lewis
- Department of Medicine, Prince Philip Hospital, Llanelli, UK; College of Human and Health Sciences, University of Swansea, Swansea, UK
| | - Alexander Stoll
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Sarah Watts
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Emrys Kirkman
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
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10
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Lewis KE, Stoll A, Watts S, Kirkman E. Relating Ventilatory Support and Drug Treatment Strategies to the Fundamental Pathophysiology in COVID-19 Illness. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This article relates the current pathophysiologic and radiologic findings to the fundamental idea of acute lung epithelial infection, alveolar inflammation causing leak into the interstitial space, and subsequent secondary or concurrent endothelial infection and dysfunction. Understanding the mechanisms and timings of alveolar damage can better inform the types of ventilatory support required and timing of targeted pharmacotherapies.
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Affiliation(s)
- Keir E. Lewis
- Department of Medicine, Prince Philip Hospital, Llanelli, UK; College of Human and Health Sciences, University of Swansea, Swansea, UK
| | - Alexander Stoll
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Sarah Watts
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
| | - Emrys Kirkman
- CBR Division, Defence Science and Technology Laboratory, Salisbury, UK
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McCabe JT, Tucker LB. Sex as a Biological Variable in Preclinical Modeling of Blast-Related Traumatic Brain Injury. Front Neurol 2020; 11:541050. [PMID: 33101170 PMCID: PMC7554632 DOI: 10.3389/fneur.2020.541050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022] Open
Abstract
Approaches to furthering our understanding of the bioeffects, behavioral changes, and treatment options following exposure to blast are a worldwide priority. Of particular need is a more concerted effort to employ animal models to determine possible sex differences, which have been reported in the clinical literature. In this review, clinical and preclinical reports concerning blast injury effects are summarized in relation to sex as a biological variable (SABV). The review outlines approaches that explore the pertinent role of sex chromosomes and gonadal steroids for delineating sex as a biological independent variable. Next, underlying biological factors that need exploration for blast effects in light of SABV are outlined, including pituitary, autonomic, vascular, and inflammation factors that all have evidence as having important SABV relevance. A major second consideration for the study of SABV and preclinical blast effects is the notable lack of consistent model design—a wide range of devices have been employed with questionable relevance to real-life scenarios—as well as poor standardization for reporting of blast parameters. Hence, the review also provides current views regarding optimal design of shock tubes for approaching the problem of primary blast effects and sex differences and outlines a plan for the regularization of reporting. Standardization and clear description of blast parameters will provide greater comparability across models, as well as unify consensus for important sex difference bioeffects.
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Affiliation(s)
- Joseph T McCabe
- Pre-clinical Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, IL, United States.,Department of Anatomy, Physiology & Genetics, F.E. Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Laura B Tucker
- Pre-clinical Studies Core, Center for Neuroscience and Regenerative Medicine, Bethesda, IL, United States.,Department of Anatomy, Physiology & Genetics, F.E. Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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12
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Li N, Geng C, Hou S, Fan H, Gong Y. Damage-Associated Molecular Patterns and Their Signaling Pathways in Primary Blast Lung Injury: New Research Progress and Future Directions. Int J Mol Sci 2020; 21:ijms21176303. [PMID: 32878118 PMCID: PMC7504526 DOI: 10.3390/ijms21176303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Primary blast lung injury (PBLI) is a common cause of casualties in wars, terrorist attacks, and explosions. It can exist in the absence of any other outward signs of trauma, and further develop into acute lung injury (ALI) or a more severe acute respiratory distress syndrome (ARDS). The pathogenesis of PBLI at the cellular and molecular level has not been clear. Damage-associated molecular pattern (DAMP) is a general term for endogenous danger signals released by the body after injury, including intracellular protein molecules (HMGB1, histones, s100s, heat shock proteins, eCIRP, etc.), secretory protein factors (IL-1β, IL-6, IL-10, TNF-α, VEGF, complements, etc.), purines and pyrimidines and their derived degradation products (nucleic acids, ATP, ADP, UDPG, uric acid, etc.), and extracellular matrix components (hyaluronic acid, fibronectin, heparin sulfate, biglycan, etc.). DAMPs can be detected by multiple receptors including pattern recognition receptors (PRRs). The study of DAMPs and their related signaling pathways, such as the mtDNA-triggered cGAS-YAP pathway, contributes to revealing the molecular mechanism of PBLI, and provides new therapeutic targets for controlling inflammatory diseases and alleviating their symptoms. In this review, we focus on the recent progress of research on DAMPs and their signaling pathways, as well as the potential therapeutic targets and future research directions in PBLI.
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Affiliation(s)
- Ning Li
- Institute of Disaster Medicine, Tianjin University, Tianjin 300072, China; (N.L.); (C.G.); (S.H.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Chenhao Geng
- Institute of Disaster Medicine, Tianjin University, Tianjin 300072, China; (N.L.); (C.G.); (S.H.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Shike Hou
- Institute of Disaster Medicine, Tianjin University, Tianjin 300072, China; (N.L.); (C.G.); (S.H.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Haojun Fan
- Institute of Disaster Medicine, Tianjin University, Tianjin 300072, China; (N.L.); (C.G.); (S.H.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
- Correspondence: (H.F.); (Y.G.)
| | - Yanhua Gong
- Institute of Disaster Medicine, Tianjin University, Tianjin 300072, China; (N.L.); (C.G.); (S.H.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
- Correspondence: (H.F.); (Y.G.)
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13
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McDonald Johnston A, Alderman JE. Thoracic Injury in Patients Injured by Explosions on the Battlefield and in Terrorist Incidents. Chest 2019; 157:888-897. [PMID: 31605701 DOI: 10.1016/j.chest.2019.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 09/02/2019] [Accepted: 09/05/2019] [Indexed: 11/25/2022] Open
Abstract
Thoracic injury is common on the battlefield and in terrorist attacks, occurring in 10% to 70% of patients depending on the type of weapons used. Typical injuries seen include bullet, blast, and fragment injuries to the thorax, which are often associated with injuries to other parts of the body. Initial treatment prehospital and in the ED is carried out according to the principles of Tactical Combat Casualty Care or other standard trauma management systems. Immediately life-threatening problems including catastrophic hemorrhage are dealt with rapidly, and early consideration is given to CT scanning or rapid surgical intervention where appropriate. All patients should be given lung-protective ventilation. Treatment of these patients in the critical care unit is complicated by the severity of associated injuries and by features specific to combat trauma including blast lung injury, a high incidence of delirium, unusual infections such as colonization with multidrug-resistant Acinetobacter baumannii complex, and sometimes invasive fungal infections. A minority of patients with blast lung injury in published series have been successfully treated with prolonged respiratory support with high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. The role of newer treatment options such as resuscitative endovascular balloon occlusion of the aorta is not yet known. In this article we review the relatively sparse literature on this group of patients and provide practical advice based on the literature and our institution's extensive experience of managing battlefield casualties.
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Affiliation(s)
- Andrew McDonald Johnston
- Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research, University of Birmingham, Birmingham, UK; Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Joseph Edward Alderman
- Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research, University of Birmingham, Birmingham, UK
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Liu Y, Liu YE, Tong CC, Cong PF, Shi XY, Shi L, Jin XH, Wang Q. CD28 deficiency attenuates primary blast-induced renal injury in mice via the PI3K/Akt signalling pathway. BMJ Mil Health 2019; 166:e66-e69. [PMID: 31129646 DOI: 10.1136/jramc-2019-001181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/19/2019] [Accepted: 04/30/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Primary blast affects the kidneys due to direct shock wave damage and the production of proinflammatory cytokines without effective treatment. CD28 has been reported to be involved in regulating T cell activation and secretion of inflammatory cytokines. The aim of this study was to investigate the influence of primary blast on the kidney and the effect of CD28 in mice. METHODS A mouse model of primary blast-induced kidney injury was established using a custom-made explosive device. The severity of kidney injury was investigated by H&E staining. ELISA was applied to study serum inflammation factors' expression. Western blot assays were used to analyse the primary blast-induced inflammatory factors' expression in the kidney. Immunofluorescence analysis was used to examine the PI3K/Akt signalling pathway. RESULTS Histological examination demonstrated that compared with the primary blast group, CD28 deficiency caused a significant decrease in the severity of the primary blast-induced renal injury. Moreover, ELISA and western blotting revealed that CD28 deficiency significantly reduced the levels of interleukin (IL)-1β, IL-4 and IL-6, and increased the IL-10 level (p<0.05). Finally, immunofluorescence analysis indicated that PI3K/Akt expression also changed. CONCLUSIONS CD28 deficiency had protective effects on primary blast-induced kidney injury via the PI3K/Akt signalling pathway. These findings improve the knowledge on primary blast injury and provide theoretical basis for primary blast injury treatment.
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Affiliation(s)
- Ying Liu
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - Y E Liu
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - C C Tong
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - P F Cong
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - X Y Shi
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - L Shi
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - X H Jin
- Emergency Medicine Department of General Hospital of Northern Theater Command, Laboratory of Rescue Center of Severe Wound and Trauma PLA, Shenyang, China
| | - Q Wang
- Nuclear Medicine Department of General Hospital of Northern Theater Command, Shenyang, China
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Trauma Hemostasis and Oxygenation Research Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation. J Trauma Acute Care Surg 2019; 84:S3-S13. [PMID: 29799823 DOI: 10.1097/ta.0000000000001856] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network's opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation.The THOR Network's consensus statement is, "In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock".
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Smith JE, Watts S, Spear AM, Wilson C, Kirkman E. Nebulised recombinant activated factor VII (rFVIIa) does not attenuate the haemorrhagic effects of blast lung injury. J ROY ARMY MED CORPS 2018; 165:51-56. [PMID: 30420554 PMCID: PMC6581091 DOI: 10.1136/jramc-2018-001029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 01/19/2023]
Abstract
Introduction Primary blast lung injury causes intrapulmonary haemorrhage. A number of case reports have suggested the efficacy of recombinant activated factor VII (rFVIIa) in the treatment of diffuse alveolar haemorrhage from a range of medical causes, but its efficacy in blast lung is unknown. The aim of this study was to investigate whether nebulised rFVIIa attenuates the haemorrhagic effects of blast lung injury in an animal model. Methods Terminally anaesthetised rabbits subjected to blast lung injury were randomised to receive either rFVIIa or placebo via a nebuliser. The primary outcome was the level of blood iron–transferrin complex, a marker of the extent of blast lung injury, analysed using low temperature electron paramagnetic resonance spectroscopy. Results Blast exposure led to a significant fall in iron-bound transferrin in both groups of animals (p<0.001), which remained depressed during the study. There were no significant differences in iron–transferrin between the rFVIIa and placebo treatment groups over the duration of the study (p=0.081), and there was no trend towards elevated iron–transferrin in the rFVIIa-treated group once drug treatment had started. There was suggestive evidence of systemic absorption of rFVIIa given via the inhaled route. Conclusion A single dose of nebulised rFVIIa did not attenuate pulmonary haemorrhage in a rabbit model of blast lung injury. As there was some evidence of systemic absorption, the inhaled route does not avoid the concern about potential thromboembolic complications from administration of rFVIIa.
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Affiliation(s)
- Jason E Smith
- CBR Division, Dstl Porton Down, Salisbury, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - S Watts
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - A M Spear
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - C Wilson
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - E Kirkman
- CBR Division, Dstl Porton Down, Salisbury, UK
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Distinguishing the Unique Neuropathological Profile of Blast Polytrauma. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:5175249. [PMID: 28424745 PMCID: PMC5382305 DOI: 10.1155/2017/5175249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 02/28/2017] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury sustained after blast exposure (blast-induced TBI) has recently been documented as a growing issue for military personnel. Incidence of injury to organs such as the lungs has decreased, though current epidemiology still causes a great public health burden. In addition, unprotected civilians sustain primary blast lung injury (PBLI) at alarming rates. Often, mild-to-moderate cases of PBLI are survivable with medical intervention, which creates a growing population of survivors of blast-induced polytrauma (BPT) with symptoms from blast-induced mild TBI (mTBI). Currently, there is a lack of preclinical models simulating BPT, which is crucial to identifying unique injury mechanisms of BPT and its management. To meet this need, our group characterized a rodent model of BPT and compared results to a blast-induced mTBI model. Open field (OF) performance trials were performed on rodents at 7 days after injury. Immunohistochemistry was performed to evaluate cellular outcome at day seven following BPT. Levels of reactive astrocytes (GFAP), apoptosis (cleaved caspase-3 expression), and vascular damage (SMI-71) were significantly elevated in BPT compared to blast-induced mTBI. Downstream markers of hypoxia (HIF-1α and VEGF) were higher only after BPT. This study highlights the need for unique therapeutics and prehospital management when handling BPT.
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Scott T, Kirkman E, Haque M, Gibb I, Mahoney P, Hardman J. Primary blast lung injury - a review. Br J Anaesth 2017; 118:311-316. [DOI: 10.1093/bja/aew385] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Roberts SAG, Toman E, Belli A, Midwinter MJ. Decompressive craniectomy and cranioplasty: experience and outcomes in deployed UK military personnel. Br J Neurosurg 2016; 30:529-35. [DOI: 10.1080/02688697.2016.1208807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Wang JM, Chen J. Damage of vascular endothelial barrier induced by explosive blast and its clinical significance. Chin J Traumatol 2016; 19:125-8. [PMID: 27321288 PMCID: PMC4908223 DOI: 10.1016/j.cjtee.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/24/2016] [Accepted: 03/01/2016] [Indexed: 02/04/2023] Open
Abstract
In recent years, injuries induced by explosive blast have got more and more attention owing to weapon development and frequent terrorist activities. Tear, bleeding and edema of tissues and organs are the main manifestations of blast shock wave damage. Vascular endothelial barrier is the main defense of tissues and organs' integrity. This article aims to discuss possible mechanisms of endothelial barrier damage induced by explosive blast and main manifestations of blood brain barrier, bloodeair barrier, and intestinal vascular barrier impairments. In addition, the main regulatory factors of vascular permeability are also summarized so as to provide theoretical basis for prevention and cure of vascular endothelial barrier damage resulting from explosive blast.
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Affiliation(s)
- Jian-Min Wang
- State Key Laboratory of Trauma, Burn and Combined Injury, Research Institute of Surgery/Daping Hospital, Third Military Medical University, Chongqing 400042, China
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Eftaxiopoulou T, Barnett-Vanes A, Arora H, Macdonald W, Nguyen TTN, Itadani M, Sharrock AE, Britzman D, Proud WG, Bull AMJ, Rankin SM. Prolonged but not short-duration blast waves elicit acute inflammation in a rodent model of primary blast limb trauma. Injury 2016; 47:625-32. [PMID: 26838938 DOI: 10.1016/j.injury.2016.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/06/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blast injuries from conventional and improvised explosive devices account for 75% of injuries from current conflicts; over 70% of injuries involve the limbs. Variable duration and magnitude of blast wave loading occurs in real-life explosions and is hypothesised to cause different injuries. While a number of in vivo models report the inflammatory response to blast injuries, the extent of this response has not been investigated with respect to the duration of the primary blast wave. The relevance is that explosions in open air are of short duration compared to those in confined spaces. METHODS Hindlimbs of adult Sprauge-Dawley rats were subjected to focal isolated primary blast waves of varying overpressure (1.8-3.65kPa) and duration (3.0-11.5ms), utilising a shock tube and purpose-built experimental rig. Rats were monitored during and after the blast. At 6 and 24h after exposure, blood, lungs, liver and muscle tissues were collected and prepared for histology and flow cytometry. RESULTS At 6h, increases in circulating neutrophils and CD43Lo/His48Hi monocytes were observed in rats subjected to longer-duration blast waves. This was accompanied by increases in circulating pro-inflammatory chemo/cytokines KC and IL-6. No changes were observed with shorter-duration blast waves irrespective of overpressure. In all cases, no histological damage was observed in muscle, lung or liver. By 24h post-blast, all inflammatory parameters had normalised. CONCLUSIONS We report the development of a rodent model of primary blast limb trauma that is the first to highlight an important role played by blast wave duration and magnitude in initiating acute inflammatory response following limb injury in the absence of limb fracture or penetrating trauma. The combined biological and mechanical method developed can be used to further understand the complex effects of blast waves in a range of different tissues and organs in vivo.
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Affiliation(s)
| | | | - Hari Arora
- Department of Bioengineering, Imperial College London, UK.
| | | | | | - Mako Itadani
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Anna E Sharrock
- National Heart and Lung Institute, Imperial College London, UK.
| | - David Britzman
- Department of Bioengineering, Imperial College London, UK.
| | | | | | - Sara M Rankin
- National Heart and Lung Institute, Imperial College London, UK.
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Mathews ZR, Koyfman A. Blast Injuries. J Emerg Med 2015; 49:573-87. [PMID: 26072319 DOI: 10.1016/j.jemermed.2015.03.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/04/2015] [Accepted: 03/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Blast injuries in the United States and worldwide are not uncommon. Partially due to the increasing frequency of both domestic and international terrorist bombing attacks, it is prudent for all emergency physicians to be knowledgeable about blasts and the spectrum of associated injuries. OBJECTIVE Our aim was to describe blast physiology, types of blast injuries associated with each body system, and manifestations and management of each injury. DISCUSSION Blast injuries are generally categorized as primary to quaternary injuries. Primary injuries result from the effect of transmitted blast waves on gas-containing structures, secondary injuries result from the impact of airborne debris, tertiary injury results from transposition of the entire body due to blast wind or structural collapse, and quaternary injuries include almost everything else. Different body systems are affected and managed differently. Despite previous dogma, multiple studies now show that tympanic membrane perforation is a poor predictor of other blast injury. CONCLUSIONS Blast events can produce a myriad of injuries affecting any and every body system. All emergency physicians should be familiar with the presentation and management of these injuries. This knowledge may also be incorporated into triage and discharge protocols guiding management of mass casualty events.
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Affiliation(s)
- Zara R Mathews
- Department of Emergency Medicine, Mount Sinai Medical Center, New York, New York
| | - Alex Koyfman
- Division of Emergency Medicine, University of Texas Southwestern Medical Center/Parkland Memorial Hospital, Dallas, Texas
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Abstract
Trauma is the leading cause of death during the first four decades of life in the developed countries. Its haemodynamic response underpins the patient's initial ability to survive, and the response to treatment and subsequent morbidity and resolution. Trauma causes a number of insults including haemorrhage, tissue injury (nociception) and, predominantly, in military casualties, blast from explosions. This article discusses aspects of the haemodynamic responses to these insults and subsequent treatment. 'Simple' haemorrhage (blood loss without significant volume of tissue damage) causes a biphasic response: mean arterial blood pressure (MBP) is initially maintained by the baroreflex (tachycardia and increased vascular resistance, Phase 1), followed by a sudden decrease in MAP initiated by a second reflex (decrease in vascular resistance and bradycardia, Phase 2). Phase 2 may be protective. The response to tissue injury attenuates Phase 2 and may cause a deleterious haemodynamic redistribution that compromises blood flow to some vital organs. In contrast, thoracic blast exposure augments Phase 2 of the response to haemorrhage. However, hypoxaemia from lung injury limits the effectiveness of hypotensive resuscitation by augmenting the attendant shock state. An alternative strategy ('hybrid resuscitation') whereby tissue perfusion is increased after the first hour of hypotensive resuscitation by adopting a revised normotensive target may ameliorate these problems. Finally, morphine also attenuates Phase 2 of the response to haemorrhage in some, but not all, species and this is associated with poor outcome. The impact on human patients is currently unknown and is the subject of a current physiological investigation.
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Affiliation(s)
- E Kirkman
- Biomedical Sciences Department, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - S Watts
- Biomedical Sciences Department, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
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Hu Q, Chai J, Hu S, Fan J, Wang HW, Ma L, Duan HJ, Liu L, Yang H, Li BL, Wang YH. Development of an Animal Model for Burn-Blast Combined Injury and Cardiopulmonary System Changes in the Early Shock Stage. Indian J Surg 2014; 77:977-84. [PMID: 27011494 DOI: 10.1007/s12262-014-1095-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/27/2014] [Indexed: 01/23/2023] Open
Abstract
The purposes of this study were to establish an animal model for burn-blast combined injury research and elaborate cardiopulmonary system changes in the early shock stage. In this study, royal demolition explosive or RDX (hexagon, ring trimethylene nitramine) was used as an explosive source, and the injury conditions of the canine test subjects at various distances to the explosion (30, 50, and 70 cm) were observed by gross anatomy and pathology to determine a larger animal model of moderate blast injury. The canines were then subjected to a 35 % total body surface area (TBSA) full-thickness flame injury using napalm, which completed the development of a burn-blast combined injury model. Based on this model, the hemodynamic changes and arterial blood gas analysis after the burn-blast combined injury were measured to identify the cardiopulmonary system characteristics. In this research, RDX explosion and flame injury were used to develop a severe burn-blast injury animal model that was stable, close to reality, and easily controllable. The hemodynamic and arterial blood gas changes in the canine subjects after burn-blast injury changed distinctly from the burn and blast injuries. Blood pressure and cardiac output fluctuated, and the preload was significantly reduced, whereas the afterload significantly increased. Meanwhile, the oxygen saturation (SO2) decreased markedly with carbon dioxide partial pressure (PCO2), and lactic acid (Lac) rose, and oxygen partial pressure (PO2) reduced. These changes suggested that immediate clinical treatment is important during burn-blast injury both to stabilize cardiac function and supply blood volume and to reduce the vascular permeability, thereby preventing acute pneumonedema or other complications.
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Affiliation(s)
- Quan Hu
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Jiake Chai
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Sen Hu
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Jun Fan
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Hong-Wei Wang
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Li Ma
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Hong-Jie Duan
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Lingying Liu
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Hongming Yang
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Bai-Ling Li
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
| | - Yi-He Wang
- Department of Burn and Plastic Surgery, Burns Institute, The First Affiliated Hospital of PLA General Hospital, 100048 Beijing, China
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Behrsing HP, Furniss MJ, Davis M, Tomaszewski JE, Parchment RE. In vitro exposure of precision-cut lung slices to 2-(4-amino-3-methylphenyl)-5-fluorobenzothiazole lysylamide dihydrochloride (NSC 710305, Phortress) increases inflammatory cytokine content and tissue damage. Toxicol Sci 2012; 131:470-9. [PMID: 23143926 DOI: 10.1093/toxsci/kfs319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The anticancer drug (2-[4-amino-3-methylphenyl]-5-fluorobenzothiazole lysylamide dihydrochloride) (NSC 710305, Phortress) is a metabolically activated prodrug that causes DNA adduct formation and subsequent toxicity. Preclinically, it was found that hepatic, bone marrow, and pulmonary toxicity presented challenges to developing this drug. An ex vivo precision-cut lung slice (PCLS) model was used to search for concentration dependent effects of NSC 710305 (10, 25, 50, and 100 µM) on cytokine content, protein content, and immuno/histological endpoints. Preparation and culture of PCLS caused an initial spike in proinflammatory cytokine expression and therefore treatment with NSC 710305 was delayed until 48 h after initiating the slice cultures to avoid confounding the response to slicing with any drug response. PCLSs were evaluated after 24, 48, and 72 h exposures to NSC 710305. Reversibility of toxicity due to the 72-h treatment was evaluated after a 24-h recovery period. NSC 710305 caused a concentration-dependent cytokine response, and only the toxicity caused by a 72-h exposure to 25 µM reversed during the 24-h recovery period. Immuno/histological examination and quantitation of tissue protein levels indicated that tissue destruction, ED-1 (activated macrophage) staining, and protein levels were associated with the levels of proinflammatory cytokines in the tissue. In conclusion, the concentration- and time-dependent inflammatory response of PCLS to NSC 710305 preceded relevant tissue damage by a few days. The no-observable adverse effect level (NOAEL) for 24, 48, and 72 h exposures was established as 10 µM NSC 710305.
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Affiliation(s)
- Holger P Behrsing
- Laboratory of Investigative & Screening Toxicology, LHTP, SAIC-Frederick, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland 21702, USA.
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Abstract
Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.
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Affiliation(s)
- Adrian A Maung
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT, USA
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Housden S. Blast injury: A case study. Int Emerg Nurs 2012; 20:173-8. [DOI: 10.1016/j.ienj.2011.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 09/05/2011] [Accepted: 09/06/2011] [Indexed: 11/29/2022]
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Pun PBL, Kan EM, Salim A, Li Z, Ng KC, Moochhala SM, Ling EA, Tan MH, Lu J. Low level primary blast injury in rodent brain. Front Neurol 2011; 2:19. [PMID: 21541261 PMCID: PMC3083909 DOI: 10.3389/fneur.2011.00019] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/15/2011] [Indexed: 01/21/2023] Open
Abstract
The incidence of blast attacks and resulting traumatic brain injuries has been on the rise in recent years. Primary blast is one of the mechanisms in which the blast wave can cause injury to the brain. The aim of this study was to investigate the effects of a single sub-lethal blast over pressure (BOP) exposure of either 48.9 kPa (7.1 psi) or 77.3 kPa (11.3 psi) to rodents in an open-field setting. Brain tissue from these rats was harvested for microarray and histopathological analyses. Gross histopathology of the brains showed that cortical neurons were “darkened” and shrunken with narrowed vasculature in the cerebral cortex day 1 after blast with signs of recovery at day 4 and day 7 after blast. TUNEL-positive cells were predominant in the white matter of the brain at day 1 after blast and double-labeling of brain tissue showed that these DNA-damaged cells were both oligodendrocytes and astrocytes but were mainly not apoptotic due to the low caspase-3 immunopositivity. There was also an increase in amyloid precursor protein immunoreactive cells in the white matter which suggests acute axonal damage. In contrast, Iba-1 staining for macrophages or microglia was not different from control post-blast. Blast exposure altered the expression of over 5786 genes in the brain which occurred mostly at day 1 and day 4 post-blast. These genes were narrowed down to 10 overlapping genes after time-course evaluation and functional analyses. These genes pointed toward signs of repair at day 4 and day 7 post-blast. Our findings suggest that the BOP levels in the study resulted in mild cellular injury to the brain as evidenced by acute neuronal, cerebrovascular, and white matter perturbations that showed signs of resolution. It is unclear whether these perturbations exist at a milder level or normalize completely and will need more investigation. Specific changes in gene expression may be further evaluated to understand the mechanism of blast-induced neurotrauma.
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Affiliation(s)
- Pamela B L Pun
- Combat Care Laboratory, Defence Medical and Environmental Research Institute, DSO National Laboratories Singapore
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