TERRORISM AND BLAST EXPLOSIONS: LESSONS FOR THE AUSTRALIAN SURGICAL COMMUNITY

Blast-Induced Traumatic Brain Injuries: Experience from the Deadliest Double Suicide Bombing Attack in Iraq

INTRODUCTION

Blast-induced traumatic brain injuries (bTBIs) are increasingly frequent in civilian settings. We present the first study of individuals with bTBI in Iraq. The study focuses on one of the deadliest suicide car bomb attacks in Iraq and uses it to show the devastating nature of bTBIs.

METHODS

This study was conducted at the Neurosurgery Teaching Hospital in Baghdad, Iraq. A retrospective chart analysis of patients with bTBI admitted to the Neurosurgery Teaching Hospital was performed. Measured parameters included patients' demographics, initial presentation, injury patterns, hospital course, surgical management, and outcomes.

RESULTS

A total of 75 patients with bTBI were included in this study, 19 of whom died in the emergency room. The remaining 56 patients were admitted to the hospital. Of those patients, 68.6% (n = 39) underwent surgery, and 30.4% were managed conservatively. A modified, tailored triaging system was implemented. All surgery was guided by the principles of damage control neurosurgery. In addition, 76.9% and 46.2% of patients underwent corticectomy and decompressive craniectomy, respectively. Dural venous sinus repair was performed in 17.9% of patients, and 30.7% of the operations entailed additional steps to control major (arterial) cerebrovascular bleeding. The net bTBI-related complication rate was 76%. The total mortality was 48%. Of survivors, 10.7% (n = 8) were discharged with a severe disability. Overall, good outcomes were achieved in 41.3% of the patients.

CONCLUSIONS

This study sheds light on the devastating nature of bTBIs. Neurosurgeons worldwide need to be mindful of the unique triaging, diagnostic, and management requirements of these injuries.

AN ANATOMICALLY-RELEVANT COMPUTATIONAL MODEL FOR PRIMARY BLAST EFFECTS ON THE HUMAN LOWER EXTREMITY

Explosions pose serious threats to US soldiers and civilians, often resulting in disability and death. Due to its direct contact with the ground, the lower extremity is commonly injured, and the blast loading often results in traumatic amputations and soft tissue rupture. The exact overpressure signatures that induce these primary blast injuries are still unknown. A high fidelity FE model of the lower extremity blast condition is thus essential to reveal the underlying injury mechanism. In this study, we created an anatomically-relevant lower extremity model and analyzed several different blast cases using Abaqus/Explicit. Pressures, impulses, stresses, and maximum principal strains were evaluated and compared to previous results in the literature. Our FE model and simulation were able to capture the detailed structural responses to a blast wave in the lower extremity; moreover, we showed that the injury patterns could be correlated to biomechanical metrics that may have incited pathologies such as amputations and compartment syndrome. The lower extremity FE model developed in this project allows for a cost-effective and reproducible analysis of blast events and has the potential to improve injury metrics and personal protective equipment design by accurately evaluating the damage imposed on the lower extremity.

Preparedness for treating victims of terrorist attacks in Australia: Learning from recent military experience

The Australian health system is generally well prepared for mass casualty events. Fortunately, there have been very few terrorist attacks and these have involved low numbers of casualties compared with events overseas. Nevertheless, Australian health professionals need to be prepared to treat mass casualties with blast and ballistic trauma. The US military and its allies including Australia have had extensive experience with mass casualty management in the Middle East and Afghanistan wars for more than a decade. To define their experience, they developed the Tactical Combat Casualty Care Guidelines that have saved many lives. It is now prudent to incorporate this knowledge and experience into civilian practice in Australia.

Bomb blast, mild traumatic brain injury and psychiatric morbidity: a review

Traumatic brain injury (TBI) arising from blast exposure during war is common, and frequently complicated by psychiatric morbidity. There is controversy as to whether mild TBI from blast is different from other causes of mild TBI. Anxiety and affective disorders such as Post-traumatic Stress Disorder (PTSD) and depression are common accompaniments of blast injury with a significant overlap in the diagnostic features of PTSD with post-concussive syndrome (PCS). This review focuses on this overlap and the effects of mild TBI due to bomb blast. Mild TBI may have been over diagnosed by late retrospective review of returned servicemen and women using imprecise criteria. There is therefore a requirement for clear and careful documentation by health professionals of a TBI due to bomb blast shortly after the event so that the diagnosis of TBI can be made with confidence. There is a need for the early recognition of symptoms of PCS, PTSD and depression and early multi-disciplinary interventions focussed on expected return to duties. There also needs to be a continued emphasis on the de-stigmatization of psychological conditions in military personnel returning from deployment.

Australian experience with frozen blood products on military operations

Historically, the Australian Defence Force (ADF) has sourced all its blood supplies from the Australian Red Cross Blood Service. Recent ADF operations in the Middle East have highlighted a need to rely on other nations' blood supply systems. In 2008, the ADF embedded a surgical and intensive care team into the Netherlands-led forward health facility at the Uruzgan Medical Centre at Tarin Kowt in Afghanistan. To date, three teams have provided 2-month rotations as part of the North Atlantic Treaty Organization International Security Assistance Force in Afghanistan. The Netherlands armed forces use a sophisticated system for supply of liquid and frozen blood products (frozen red cells, plasma and platelets). We review Australian experience with the Dutch system of supplying blood products for major trauma resuscitation in Afghanistan.

Improvised explosive devices and traumatic brain injury: the military experience in Iraq and Afghanistan

OBJECTIVE

The current conflicts in Iraq and Afghanistan have seen frequent use of improvised explosive devices resulting in thousands of casualties, with traumatic brain injuries particularly common. The recent literature is reviewed to provide information to clinicians on the management of this condition.

METHOD

A Medline search from 2001-2008, using the terms Afghanistan, blast injury, improvised explosive devices, Iraq and traumatic brain injury, was performed.

RESULTS

The United States military experience predominates in the literature. The use of body armour and other advances has led to improved survival rates among blast injury victims. Resultant neuropsychiatric injuries, in particular traumatic brain injuries, are discussed. There is debate about the prevalence of traumatic brain injuries. The diagnosis, management, relationship with posttraumatic stress disorder and prognosis of traumatic brain injury are reviewed.

CONCLUSIONS

Traumatic brain injury has been described as the 'signature wound' of the current conflicts in Iraq and Afghanistan. While this term is highly debatable and probably unhelpful, clinicians need to know about this condition to provide the best management.

Missile injuries in head - neck and maxillo-facial region - an experience in eastern nepal

Ballistic injuries to head-neck and maxillofacial region is quite common problem nowadays. Most of the time the injuries seem to be dreadful but the mechanism of the injuries caused by ballistics and the anatomical conditions of maxillofacial and head-neck region mitigate the severity of the injuries. Proper primary management followed by reconstruction and management of associated injuries decreases the mortality and morbidity of missile injuries in head-neck and maxillofacial region. Eleven cases of missile injuries in head-neck and maxillofacial region are included in the present study. The mechanism of the injury and the ideal management strategy for the ballistics injuries in the region has been discussed in the article.

A case of death from the explosion of a 66mm M72 High Explosive Anti-Tank rocket

A 53-year-old male died from an explosion of a 66 mm M72 High Explosive Anti-Tank (HEAT) rocket. He had collected various cast-off military weapons and was selling them. There were numerous explosive injuries on the anterior side of the body, thus especially bilateral hands, left toe and right knee were severely crushed and fractured. The location and severity of the injuries suggest that he was down on his left knee and was manipulating the weapon with both hands at the moment of detonation. We consider that 66 mm M72 HEAT rocket accidentally detonated during his handling. Very rarely are civilians killed by a military weapon, except during wartime. Appropriate investigation of various explosive injuries provide not only evidence of the cause of death, but also the position and posture of the body.