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Satanovsky A, Gilor Y, Benov A, Chen J, Shlaifer A, Talmy T, Radomislensky I, Siman-Tov M, Peleg K, Weil YA, Eisenkraft A. Combat Injury Profile in Urban Warfare. Mil Med 2024; 189:973-979. [PMID: 36454618 DOI: 10.1093/milmed/usac366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/19/2022] [Accepted: 11/07/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield. MATERIALS AND METHODS IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part. RESULTS Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group. CONCLUSIONS The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.
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Affiliation(s)
- Alexandra Satanovsky
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel
| | - Yuval Gilor
- The Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 91120, Israel
| | - Avi Benov
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Jacob Chen
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
- Deputy Director General of the medical center, Meir Medical Center, Kfar Saba 4428163, Israel
| | - Amir Shlaifer
- The Israel Defense Force Medical Corps Headquarters, Ramat Gan 5262000, Israel
| | - Tomer Talmy
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
| | - Maya Siman-Tov
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
- The Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Kobi Peleg
- The Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel HaShomer, Ramat Gan 5266202, Israel
- The Department of Emergency Management and Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
| | - Yoram A Weil
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel
| | - Arik Eisenkraft
- The Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Force Medical Corps, Jerusalem 91120, Israel
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Hostetler ZS, Gayzik FS. Lower Extremity Injury Risk Curve Development for a Human Body Model in the Underbody Blast Environment. J Biomech Eng 2024; 146:031006. [PMID: 37682582 DOI: 10.1115/1.4063349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
Computational human body models (HBMs) provide the ability to explore numerous candidate injury metrics ranging from local strain based criteria to global combined criteria such as the Tibia Index. Despite these efforts, there have been relatively few studies that focus on determining predicted injury risk from HBMs based on observed postmortem human subjects (PMHS) injury data. Additionally, HBMs provide an opportunity to construct risk curves using measures that are difficult or impossible to obtain experimentally. The Global Human Body Models Consortium (GHBMC) M50-O v 6.0 lower extremity was simulated in 181 different loading conditions based on previous PMHS tests in the underbody blast (UBB) environment and 43 different biomechanical metrics were output. The Brier Metric Score were used to determine the most appropriate metric for injury risk curve development. Using survival analysis, three different injury risk curves (IRC) were developed: "any injury," "calcaneus injury," and "tibia injury." For each injury risk curve, the top three metrics selected using the Brier Metric Score were tested for significant covariates including boot use and posture. The best performing metric for the "any injury," "calcaneus injury" and "tibia injury" cases were calcaneus strain, calcaneus force, and lower tibia force, respectively. For the six different injury risk curves where covariates were considered, the presence of the boot was found to be a significant covariate reducing injury risk in five out of six cases. Posture was significant for only one curve. The injury risk curves developed from this study can serve as a baseline for model injury prediction, personal protective equipment (PPE) evaluation, and can aid in larger scale testing and experimental protocols.
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Affiliation(s)
- Zachary S Hostetler
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC 27101
| | - F Scott Gayzik
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC 27101
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Pandelani T, Carpanen D, Masouros SD. Evaluating Pelvis Response During Simulated Underbody Blast Loading. J Biomech Eng 2024; 146:024501. [PMID: 38071487 DOI: 10.1115/1.4064214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Indexed: 12/21/2023]
Abstract
In recent conflicts, blast injury from landmines and improvised explosive devices (IEDs) has been the main mechanism of wounding and death. When a landmine or IED detonates under a vehicle (an under-body blast), the seat acceleration rapidly transmits a high load to the pelvis of the occupants, resulting in torso and pelvic injury. Pelvic fractures have high mortality rates, yet their injury mechanism has been poorly researched. Three (3) fresh-frozen male pelvic specimens were tested under axial impact loading. The pelvis was impacted mounted upside down by dropping a 12 kg mass at target impact velocities ranging from 1 to 8.6 m/s with time to peak velocity ranging from 3.8 to 5.8 ms. Resulting fractures were broadly categorized as involving a bilateral pubis rami fracture, a bilateral ischium fracture, and sacroiliac joint disruption. The study provides insights into the type and severity of pelvic injury that may occur over a range of under-body blast (UBB)-relevant loading profiles.
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Affiliation(s)
- Thanyani Pandelani
- Unisa Biomechanics Research Lab, Department of Mechanical Engineering, School of Engineering, College of Science Engineering and Technology, University of South Africa, Pretoria 0184, South Africa; Department of Bioengineering, Imperial College London, London SW7 2BX, UK
| | | | - Spyros D Masouros
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
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Gibb I, Delaney R, Murphy D, Hunt N. Post-mortem computed tomography in the investigation of conflict and terrorist related deaths: UK military experience of developing a multidisciplinary service. Clin Radiol 2023; 78:804-811. [PMID: 36031431 DOI: 10.1016/j.crad.2022.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 11/21/2022]
Abstract
This paper discusses the introduction, development and utility of post-mortem imaging relating specifically to conflict-related and terrorist-related deaths and considers the use of computed tomography (CT) in the investigations. We demonstrate how a multi-disciplinary approach involving direct communication between forensic pathologist and radiologist can maximise evidential yield, reduce the need for unnecessary dissection and further our understanding of such injuries. This summarises our shared experience of hundreds of cases, each having been individually discussed and reviewed, and has helped shape our understanding of conflict injury as well as contributing to the development of mitigation strategies and adaptations to protective equipment. A series of clinical cases are presented to demonstrate some of the strengths and weaknesses of the process.
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Affiliation(s)
- I Gibb
- Centre for Blast Injury Studies, Imperial College London, London, UK; Centre for Defence Radiology, c/o HMS Nelson, Portsmouth, Hampshire, UK.
| | - R Delaney
- South West Forensic Pathology Group Practice
| | - D Murphy
- Metropolitan Police Force, New Scotland Yard, London, SW1A 2JL, UK
| | - N Hunt
- Home Office Registered Forensic Pathologist (Retired)
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Jakob DA, Müller M, Jud S, Albrecht R, Hautz W, Pietsch U. The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:37. [PMID: 37550763 PMCID: PMC10405424 DOI: 10.1186/s13049-023-01107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies. METHODS This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI). RESULTS Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group. CONCLUSION Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.
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Affiliation(s)
- Dominik A Jakob
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Sebastian Jud
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Roland Albrecht
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Urs Pietsch
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
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Howe TJ, Claireaux H, Fox H, Morgan G, McMenemy L, Masouros SD, Ramasamy A. Mechanical assessment of proprietary and improvised pelvic binders for use in the prehospital environment. BMJ Mil Health 2023:e002398. [PMID: 37541678 DOI: 10.1136/military-2023-002398] [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: 04/15/2023] [Accepted: 07/07/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION Pelvic fractures often result from high-energy trauma and are associated with a 10% mortality rate and significant morbidity. Pelvic binders are applied in suspected pelvic injury to stabilise fractured bone, decrease bleeding and potentiate tamponade. A binder must hold the pelvis with sufficient force for this effect to be achieved. This study aims to quantify the ability of proprietary and improvised pelvic binders to hold a target tensile force over time. METHODS The ability of three proprietary and three improvised binders to hold a binding force for 2 hours was tested. A uniaxial materials testing machine was used to tension each binder to 150 N and then hold the displacement for 2 hours; the drop in tension over time was recorded for each binder. The ability to hold tension above 130 N after 2 hours was set as the metric of binder performance. RESULTS The median tension at 2 hours was above 130 N for the SAM Pelvic Sling II and T-POD Pelvic Stabilisation Device and was below 130 N for the Prometheus Pelvic Splint, field-expedient pelvic splint (FES) and the Personal Clothing System-Multi-Terrain Pattern Combat Trousers binders. The tension in the improvised FES after 2 hours was approximately at the target 130 N; however, in 40% of the tests, it held above 130 N. CONCLUSIONS Binders varied in their ability to maintain sufficient tension to treat a pelvic fracture over the 2-hour testing period. The FES performed well under our testing regime; with relatively low cost and weight, it represents a good alternative to proprietary binders for the austere environment.
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Affiliation(s)
- Thomas John Howe
- Department of Bioengineering, Imperial College London, London, UK
- Army Medical Service 16 Medical Regiment, Colchester, UK
| | - H Claireaux
- Department of Bioengineering, Imperial College London, London, UK
- Army Medical Service, Camberley, Surrey, UK
| | - H Fox
- Department of Bioengineering, Imperial College London, London, UK
| | - G Morgan
- Department of Bioengineering, Imperial College London, London, UK
| | - L McMenemy
- Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - S D Masouros
- Department of Bioengineering, Imperial College London, London, UK
| | - A Ramasamy
- Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Shakargy JD, Gendler S, Talmy T, Shushan G, Radomislensky I, Tsur AM, Almog O, Avital G, Benov A, Gelikas S. Blast Injury Patterns Among Israel Defense Forces Fatalities. Mil Med 2023; 188:e1788-e1794. [PMID: 36205252 DOI: 10.1093/milmed/usac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/03/2022] [Accepted: 09/09/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The incidence of blast injuries on the battlefield has risen over the last several decades. In order to improve prevention and treatment, it is essential to understand the severity and bodily distribution of these injuries. This study aims to characterize blast injury patterns among IDF fatalities. MATERIALS AND METHODS This is a descriptive, retrospective study on postmortem reports of military-blast fatalities between the years 1982 and 2021. Body regions injured according to the Abbreviated Injury Scale (AIS) were described. The frequency of body region injury combinations was mapped, and the correlation between injured body regions was calculated using Pearson's coefficient. Analysis of a subgroup with a postmortem computed tomography (CT-PM) or autopsy was performed, describing severe (AIS ≥ 3) injury patterns. RESULTS Overall, 222 fatalities suffered from blast injury, with most injuries affecting the upper and lower extremities (63.7% and 66.5%, respectively), followed by the head (57.1%) and the thorax (56.6%). The median number of injured body regions was 4 (interquartile range, 2-5). The most frequent injury combinations were the upper and lower extremities (51%), the upper extremities and the thorax (45%), and the lower extremities and the thorax (41%). In all, 47/222 (21.2%) fatalities had a documented autopsy or CT-PM report. Among the fatalities with CT-PM or autopsy, the head (63.8%) and the thorax (57.4%) were most frequently severely injured (AIS ≥ 3). CONCLUSIONS Among blast fatalities in the military setting, the extremities were most commonly injured. However, data suggest that the head and thorax are more likely to sustain severe blast injuries resulting in mortality. Blast injuries in this cohort were characterized by concomitant involvement of several regions. Development of protective gear to minimize the multisystem injuries inflicted by blast injuries is warranted and should be focused on distinct types and anatomical distribution of severe blast injuries as reported in this study. LEVEL OF EVIDENCE Level III, Retrospective analysis.
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Affiliation(s)
- Josef Daniel Shakargy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Sami Gendler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Tomer Talmy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Shushan
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Ground forces Technology Unit, Tel-Hashomer, Israel Defense Forces, Ramat Gan 02149, Israel
| | - Irina Radomislensky
- The Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute of Epidemiology and Health Policy Research, Tel Aviv 5262000, Israel
| | - Avishai M Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Ofer Almog
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem 91120, Israel
| | - Guy Avital
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Division of Anesthesia, Intensive Care & Pain Management, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel
| | - Avi Benov
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Shaul Gelikas
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan 02149, Israel
- Sheba Medical Center Hospital-Tel-Hashomer, Ramat Gan 5262000, Israel
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Balkert LS, Thomsen AH, Knudsen PJT. Danish military fatalities in international operations 2002-2018. BMJ Mil Health 2022:e002164. [PMID: 36581500 DOI: 10.1136/military-2022-002164] [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: 05/24/2022] [Accepted: 12/12/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION This study describes deaths among Danish soldiers in international operations 2002-2018. Having been part of UN and later NATO forces in ex-Yugoslavia, in 2002 the first Danish contingent took part in the International Security Assistance Force mission in Afghanistan as well as Iraq. The changing role of the Danish military in international operations meant casualties, in numbers that had not yet been experienced, and necessitated a review of our procedures for handling fatalities in the military. METHODS The study is a retrospective review of autopsy reports, Military Police reports and medical reports, and the purpose is to examine all Danish fatalities in international operations in 2002-2018 to identify potential areas of improving treatment and protection and to review the contribution of the autopsies. The mechanism of injury, the fatal injuries and causes of death and the time of death within the chain of evacuation were identified. Casualties dying at any time from site of injury until definitive care were included. RESULTS A total of 53 soldiers died from injuries during international operations in the years 2002-2018. The majority of these (43) died from combat injuries and 10 from accidents. Four of the victims with combat injuries were not autopsied. The majority (36) of the combat deaths were caused by blast/explosions (improvised explosive devices, rocket propelled grenades, fragments), while 7 were caused by bullets. 39 combat victims died instantly on the site or at the arrival to the field hospital, 4 were treated in field hospital and 2 of these were transported back to Denmark. CONCLUSIONS Most combat fatalities result from fragmentation and blast injury. Forensic autopsies provide valuable information regarding injuries, weaponry, the efficiency of protective equipment and the quality of medical intervention in military fatalities and are recommended in all military fatalities in order to prevent avoidable casualties in the future.
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Affiliation(s)
- Lise Skyttegaard Balkert
- Institue of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Defense Medical Command, Brabrand, Denmark
| | - A H Thomsen
- Department of Forensic Medicine, University of Aarhus, Aarhus, Denmark
| | - P J T Knudsen
- Institute of Forensic Medicine, University of Southern Denmark, Odense, Denmark
- Danish Defence Medical Command, Brabrand, Denmark
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Hostetler ZS, Caffrey J, Aira J, Gayzik FS. Lower Extremity Validation of a Human Body Model for High Rate Axial Loading in the Underbody Blast Environment. STAPP CAR CRASH JOURNAL 2022; 66:99-142. [PMID: 37733823 DOI: 10.4271/2022-22-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
While the use of Human Body Models (HBMs) in the underbody blast (UBB) environment has increased and shown positive results, the potential of these models has not been fully explored. Obtaining accurate kinematic and kinetic response are necessary to better understand the injury mechanisms for military safety applications. The objective of this study was to validate the Global Human Body Models Consortium (GHBMC) M50 lower extremity using a combined objective rating scheme in vertical and horizontal high-rate axial loading. The model's lower extremity biomechanical response was compared to Post Mortem Human Subjects (PMHS) subjects for vertically and horizontally-applied high rate axial loading. Two distinct experimental setups were used for model validation, comprising a total of 33 distinct end points for validation. A combined Correlation and Analysis (CORA) score that incorporates CORA, time-to-peak (TTP) and peak magnitude of the experimental signals and ISO TS 18571 was used to evaluate the model response. For the horizontal impacts, the combined CORA scores were 0.80, 0.84, and 0.81 for compression, force, and strain respectively. For the vertical impacts combined CORA scores for the knee Z force, compression and heel Z displacement ranged from 0.70-0.81, 0.87-0.91, and 0.82-0.99 respectively. The GHBMC lower extremity model showed good agreement with PMHS experimental data in the horizontal and vertical loading environment in 33 unique tests. The accuracy is demonstrated by using the ISO TS 18571 standard and a combined CORA score that takes into consideration the peak and time to peak of the signal. The results of this study show that GHBMC v 6.0 HBM lower extremity can be used for kinetic and kinematic predictions in the UBB environment.
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Affiliation(s)
| | | | - Jazmine Aira
- Wake Forest School of Medicine- Biomedical Engineering
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Influence of Ball Bearing Size on the Flight and Damage Characteristics of Blast-Driven Ball Bearings. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This paper presents insights into the influence of ball size on the flight characteristics and damage of a ball bearing embedded in a rear detonated cylindrical charge. It includes results from a post-test damage analysis of ball bearings from previously reported experiments. Computational simulations using Ansys Autodyn were used to provide extra information about the velocity variation during flight and the damage sustained by the ball bearings during the blast event. The influence of bearing size (diameter and mass) was investigated using the validated simulation models to extend the dataset beyond the initial experimental work. The peak bearing velocity is influenced by the charge mass to ball bearing mass ratio and the aspect ratio of the charge. Larger ball bearings require extra momentum to accelerate them to higher velocities, but their higher surface area means a greater portion of the explosive charge is involved in transferring kinetic energy to the projectile. Tensile spalling was to be the major damage mechanism within the ball bearings. The charge aspect ratio also influenced the hydrostatic pressure propagation within the ball bearing itself, affecting the location and degree of internal cracking within the bearings. These findings will prove valuable to blast protection engineers considering the effects of embedded projectiles in improvised explosive devices.
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Verification of High-Rate Vertical Loading Laboratory Skeletal Fractures by Comparison with Theater Injury Patterns. Ann Biomed Eng 2021; 49:3080-3090. [PMID: 34654980 DOI: 10.1007/s10439-021-02873-1] [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: 01/05/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
For the current study, an existing theater injury data set was compared to component and whole body experiments meant to replicate the theater high rate vertical loading environment. The theater injury data set was derived from real world events that were within the design range of the Warrior Injury Assessment Manikin. A qualitative and quantitative assessment of the whole body fracture patterns was developed to determine whether the laboratory loading was correctly representing the resulting injuries seen in theater Underbody Blast (UBB) events. Results indicated that most of the experimental test fracture patterns were similar to the theater injuries for Abbreviated Injury Scale body regions of interest (lower extremities, pelvis, and spine); however, some of the body regions had higher similarity scores compared to others. Whole body fracture distribution was less similar than the component tests because of differences in injury distributions. The lower extremity whole body similarity was lower than spine and pelvis similarity. This analysis was able to identify some experimental tests that might not represent theater loading. In conclusion, this analysis confirmed that some laboratory testing produced skeletal injury patterns that are seen in comparable theater UBB events.
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Lewison G, Roe P, Sullivan R, Bricknell M. The spin-off to civilian medical practice in the UK and USA from medical research developed during conflict. Scientometrics 2020. [DOI: 10.1007/s11192-020-03738-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality. METHODS The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded. RESULTS One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73). CONCLUSION Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden. LEVEL OF EVIDENCE Prognostic, level III.
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McMenemy L, Ramasamy A, Sherman K, Mistlin A, Phillip R, Evriviades D, Kendrew J. Direct Skeletal Fixation in bilateral above knee amputees following blast: 2 year follow up results from the initial cohort of UK service personnel. Injury 2020; 51:735-743. [PMID: 31932040 DOI: 10.1016/j.injury.2020.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/31/2019] [Accepted: 01/04/2020] [Indexed: 02/02/2023]
Abstract
AIMS The aim of the study is to evaluate the clinical outcome and complications from the initial cohort of blast injured bilateral lower limb, above knee amputees who underwent Direct Skeletal Fixation (DSF). PATIENTS AND METHODS We undertook a retrospective analysis of a prospective data base identifying patients who had undergone implantation with the Australian Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL) prosthesis, with minimum 24 months follow up. Patient demographics, injury profile, and polymicrobial colonisation status were recorded. Physical functional performance measures recorded were the 6 minute Walk Test (6-MWT) and patient reported outcome measures were the Short Form Health Survey-36 (SF-36). Post operatively, complications including infection, re-operation, and fracture were recorded. RESULTS 7 patients (14 femora) were identified (mean age 29.8yrs), all injured by dismounted blast. Mean follow up was 46 months. All were polytrauma patients and all had previous polymicrobial colonisation. Following surgery, all patients mobilised with significant improvement in 6-minute walk time, with a mean improvement of 154 m (248 m vs 402 m, p = 0.018). The physical component score for the SF-36 demonstrated a statistically significant improvement from 34.65 to 54.5 (p = 0.018) and the mental component score demonstrated a similar improvement (41.55-58.19 p = 0.018). At follow up, no patient required explantation of the implant. Each had been prescribed a minimum of 1 course of antibiotics with no evidence of deep infection. CONCLUSION DSF is an option for amputees who, due to the nature of their injuries, may not be able to tolerate traditional suspension socket prostheses and have exhausted all other treatment options. At a minimum of 2 year follow up, the absence of significant infective complications suggests DSF may be utilised in the blast injured despite chronic polymicrobial colonisation. Longer term surveillance of these patients is required to assess the long-term suitability of this technique in this cohort of patients.
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Affiliation(s)
- Louise McMenemy
- Centre for Blast Injury Studies, Bessemer Building, Imperial College London, South Kensington Campus, Exhibition Road, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK.
| | - Arul Ramasamy
- Centre for Blast Injury Studies, Bessemer Building, Imperial College London, South Kensington Campus, Exhibition Road, London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK.
| | - Kate Sherman
- Defence Medical Rehabilitation Centre, Stanford Hall, Stanford on Soar, Loughborough LE12 5QW, UK.
| | - Alan Mistlin
- Defence Medical Rehabilitation Centre, Stanford Hall, Stanford on Soar, Loughborough LE12 5QW, UK.
| | - Rhodri Phillip
- Defence Medical Rehabilitation Centre, Stanford Hall, Stanford on Soar, Loughborough LE12 5QW, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK.
| | | | - Jon Kendrew
- Centre for Blast Injury Studies, Bessemer Building, Imperial College London, South Kensington Campus, Exhibition Road, London, UK; Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2TH, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK.
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15
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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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16
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Affiliation(s)
- Cpt D C Covey
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, California
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17
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Ratnayake A, Bala M, Worlton TJ. International perspective of tourniquet use in extremity vascular trauma: a commentary from the Sri Lankan civil war experience. Eur J Trauma Emerg Surg 2019; 46:1195-1196. [PMID: 31486850 DOI: 10.1007/s00068-019-01211-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Amila Ratnayake
- Military Hospital Narahenpita, 08 Elvitigala Mawatha, Colombo, 00800, Sri Lanka
| | - Miklosh Bala
- Hadassah Medical Center, Kiryat Hadassah, POB 12000, 91120, Jerusalem, Israel
| | - Tamara Jean Worlton
- Department of General Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20889, USA.
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18
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Restricting Lower Limb Flail is Key to Preventing Fatal Pelvic Blast Injury. Ann Biomed Eng 2019; 47:2232-2240. [PMID: 31147806 PMCID: PMC6838040 DOI: 10.1007/s10439-019-02296-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/23/2019] [Indexed: 11/21/2022]
Abstract
Pelvic vascular injury in the casualty of an explosive insult is a principal risk factor for increased mortality. The mechanism of injury has not previously been investigated in a physical model. In this study, a small-animal model of pelvic blast injury with a shock-tube mediated blast wave was utilised and showed that lower limb flail is necessary for an unstable pelvic fracture with vascular injury to occur. One hundred and seventy-three cadaveric mice underwent shock-tube blast testing and subsequent injury analysis. Increasingly displaced pelvic fractures and an increase in the incidence of pelvic vascular injury were seen with increasing lower limb flail; the 50% risk of vascular injury was 66° of lower limb flail out from the midline (95% confidence intervals 59°–75°). Pre-blast surgical amputation at the hip or knee showed the thigh was essential to result in pelvic displacement whilst the leg was not. These findings, corroborated by clinical data, bring a paradigm shift in our understanding of the mechanism of blast injury. Restriction of lower limb flail in the human, through personal protective equipment, has the potential to mitigate the effects of pelvic blast injury.
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19
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Pearce AP, Clasper J. Improving survivability from blast injury: 'shifting the goalposts' and the need for interdisciplinary research. J ROY ARMY MED CORPS 2019; 165:5-6. [PMID: 29769370 PMCID: PMC6581150 DOI: 10.1136/jramc-2018-000968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2018] [Indexed: 01/07/2023]
Affiliation(s)
- A Phill Pearce
- The Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering,, Imperial College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Jon Clasper
- The Royal British Legion Centre for Blast Injury Studies, Department of Bioengineering,, Imperial College London, London, UK
- Defence Medical Group South East, Frimley Park, Frimley, UK
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20
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Webster CE, Clasper J, Gibb I, Masouros SD. Environment at the time of injury determines injury patterns in pelvic blast. J ROY ARMY MED CORPS 2018; 165:15-17. [PMID: 30580283 DOI: 10.1136/jramc-2018-000977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/12/2018] [Accepted: 06/13/2018] [Indexed: 11/04/2022]
Abstract
The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and loss of life, on a very large scale. The environment at the time of detonation is known to result in different injury patterns in casualties exposed to blast, which is highly relevant to injury mitigation analyses. We describe differences in pelvic injury patterns in relation to different environments, from casualties that presented to the deployed UK military hospitals in Iraq and Afghanistan. A casualty on foot when injured typically sustains an unstable pelvic fracture pattern, which is commonly the cause of death. These casualties die from blood loss, meaning treatment in these should focus on early pelvic haemorrhage control. In contrast, casualties injured in vehicle present a different pattern, possibly caused by direct loading via the seat, which does not result in pelvic instability. Fatalities in this cohort are from injuries to other body regions, in particular the head and the torso and who may require urgent neurosurgery or thoracotomy as life-saving interventions. A different strategy is therefore required for mounted and dismounted casualties in order to increase survivors.
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Affiliation(s)
| | - J Clasper
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - I Gibb
- Radiology, HMS Nelson, Portsmouth, UK
| | - S D Masouros
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
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21
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Danelson K, Watkins L, Hendricks J, Frounfelker P, Pizzolato-Heine K, Valentine R, Loftis K. Analysis of the Frequency and Mechanism of Injury to Warfighters in the Under-body Blast Environment. STAPP CAR CRASH JOURNAL 2018; 62:489-513. [PMID: 30609005 DOI: 10.4271/2018-22-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
During Operation Iraqi Freedom and Operation Enduring Freedom, improvised explosive devices were used strategically and with increasing frequency. To effectively design countermeasures for this environment, the Department of Defense identified the need for an under-body blast-specific Warrior Injury Assessment Manikin (WIAMan). To help with this design, information on Warfighter injuries in mounted under-body blast attacks was obtained from the Joint Trauma Analysis and Prevention of Injury in Combat program through their Request for Information interface. The events selected were evaluated by Department of the Army personnel to confirm they were representative of the loading environment expected for the WIAMan. A military case review was conducted for all AIS 2+ fractures with supporting radiology. In Warfighters whose injuries were reviewed, 79% had a foot, ankle or leg AIS 2+ fracture. Distal tibia, distal fibula, and calcaneus fractures were the most prevalent. The most common injury mechanisms were bending with probable vehicle contact (leg) and compression (foot). The most severe injuries sustained by Warfighters were to the pelvis, lumbar spine, and thoracic spine. These injuries were attributed to a compressive load from the seat pan that directly loaded the pelvis or created flexion in the lumbar spine. Rare types of injuries included severe abdominal organ injury, severe brain injury, and cervical spine injury. These typically occurred in conjunction with other fractures. Mitigating the frequently observed skeletal injuries using the WIAMan would have substantial long-term benefits for Warfighters.
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22
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Rama Rao KV, Iring S, Younger D, Kuriakose M, Skotak M, Alay E, Gupta RK, Chandra N. A Single Primary Blast-Induced Traumatic Brain Injury in a Rodent Model Causes Cell-Type Dependent Increase in Nicotinamide Adenine Dinucleotide Phosphate Oxidase Isoforms in Vulnerable Brain Regions. J Neurotrauma 2018; 35:2077-2090. [PMID: 29648986 PMCID: PMC6098412 DOI: 10.1089/neu.2017.5358] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Blast-induced traumatic brain injury (bTBI) is a leading cause of morbidity in soldiers on the battlefield and in training sites with long-term neurological and psychological pathologies. Previous studies from our laboratory demonstrated activation of oxidative stress pathways after blast injury, but their distribution among different brain regions and their impact on the pathogenesis of bTBI have not been explored. The present study examined the protein expression of two isoforms: nicotinamide adenine dinucleotide phosphate (NADPH) oxidase 1 and 2 (NOX1, NOX2), corresponding superoxide production, a downstream event of NOX activation, and the extent of lipid peroxidation adducts of 4-hydroxynonenal (4HNE) to a range of proteins. Brain injury was evaluated 4 h after the shock-wave exposure, and immunofluorescence signal quantification was performed in different brain regions. Expression of NOX isoforms displayed a differential increase in various brain regions: in hippocampus and thalamus, there was the highest increase of NOX1, whereas in the frontal cortex, there was the highest increase of NOX2 expression. Cell-specific analysis of changes in NOX expression with respect to corresponding controls revealed that blast resulted in a higher increase of NOX1 and NOX 2 levels in neurons compared with astrocytes and microglia. Blast exposure also resulted in increased superoxide levels in different brain regions, and such changes were reflected in 4HNE protein adduct formation. Collectively, this study demonstrates that primary blast TBI induces upregulation of NADPH oxidase isoforms in different regions of the brain parenchyma and that neurons appear to be at higher risk for oxidative damage compared with other neural cells.
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Affiliation(s)
- Kakulavarapu V Rama Rao
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Stephanie Iring
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Daniel Younger
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Matthew Kuriakose
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Maciej Skotak
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Eren Alay
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
| | - Raj K Gupta
- 2 Department of Defense Blast Injury Research Program Coordinating Office, United States Army Medical Research and Materiel Command , Fort Detrick, Maryland
| | - Namas Chandra
- 1 Center for Injury Biomechanics, Materials, and Medicine, Department of Biomedical Engineering, New Jersey Institute of Technology , Newark, New Jersey
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23
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Nguyen TT, Pearce AP, Carpanen D, Sory D, Grigoriadis G, Newell N, Clasper J, Bull A, Proud WG, Masouros SD. Experimental platforms to study blast injury. J ROY ARMY MED CORPS 2018; 165:33-37. [PMID: 29794172 PMCID: PMC6581094 DOI: 10.1136/jramc-2018-000966] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 11/21/2022]
Abstract
Injuries sustained due to attacks from explosive weapons are multiple in number, complex in nature, and not well characterised. Blast may cause damage to the human body by the direct effect of overpressure, penetration by highly energised fragments, and blunt trauma by violent displacements of the body. The ability to reproduce the injuries of such insults in a well-controlled fashion is essential in order to understand fully the unique mechanism by which they occur, and design better treatment and protection strategies to alleviate the resulting poor long-term outcomes. This paper reports a range of experimental platforms that have been developed for different blast injury models, their working mechanism, and main applications. These platforms include the shock tube, split-Hopkinson bars, the gas gun, drop towers and bespoke underbody blast simulators.
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Affiliation(s)
- Thuy-Tien Nguyen
- Department of Bioengineering, Imperial College London, London, UK
| | - A P Pearce
- Department of Bioengineering, Imperial College London, London, UK.,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Carpanen
- Department of Bioengineering, Imperial College London, London, UK
| | - D Sory
- Institute of Shock Physics, Imperial College London, London, UK
| | - G Grigoriadis
- Department of Bioengineering, Imperial College London, London, UK
| | - N Newell
- Department of Bioengineering, Imperial College London, London, UK
| | - J Clasper
- Department of Bioengineering, Imperial College London, London, UK.,Department of Orthopaedics and Trauma, Frimley Park, Frimley, UK
| | - A Bull
- Department of Bioengineering, Imperial College London, London, UK
| | - W G Proud
- Institute of Shock Physics, Imperial College London, London, UK
| | - S D Masouros
- Department of Bioengineering, Imperial College London, London, UK
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24
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Stewart SK, Pearce AP, Clasper JC. Fatal head and neck injuries in military underbody blast casualties. J ROY ARMY MED CORPS 2018; 165:18-21. [PMID: 29680818 PMCID: PMC6581151 DOI: 10.1136/jramc-2018-000942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
Abstract
Introduction Death as a consequence of underbody blast (UBB) can most commonly be attributed to central nervous system injury. UBB may be considered a form of tertiary blast injury but is at a higher rate and somewhat more predictable than injury caused by more classical forms of tertiary injury. Recent studies have focused on the transmission of axial load through the cervical spine with clinically relevant injury caused by resultant compression and flexion. This paper seeks to clarify the pattern of head and neck injuries in fatal UBB incidents using a pragmatic anatomical classification. Methods This retrospective study investigated fatal UBB incidents in UK triservice members during recent operations in Afghanistan and Iraq. Head and neck injuries were classified by anatomical site into: skull vault fractures, parenchymal brain injuries, base of skull fractures, brain stem injuries and cervical spine fractures. Incidence of all injuries and of each injury type in isolation was compared. Results 129 fatalities as a consequence of UBB were identified of whom 94 sustained head or neck injuries. 87 casualties had injuries amenable to analysis. Parenchymal brain injuries (75%) occurred most commonly followed by skull vault (55%) and base of skull fractures (32%). Cervical spine fractures occurred in only 18% of casualties. 62% of casualties had multiple sites of injury with only one casualty sustaining an isolated cervical spine fracture. Conclusion Improvement of UBB survivability requires the understanding of fatal injury mechanisms. Although previous biomechanical studies have concentrated on the effect of axial load transmission and resultant injury to the cervical spine, our work demonstrates that cervical spine injuries are of limited clinical relevance for UBB survivability and that research should focus on severe brain injury secondary to direct head impact.
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Affiliation(s)
- Sarah K Stewart
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - A P Pearce
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.,Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Jon C Clasper
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK.,Department of Trauma and Orthopaedics, Frimley Park Hospital, Frimley, UK
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25
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Basma A, Melek M, Anis R, Hejer D, Jamel Z, Ridha M. Myélite aiguë par effet blast. Presse Med 2018; 47:174-178. [DOI: 10.1016/j.lpm.2017.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 11/01/2017] [Accepted: 11/27/2017] [Indexed: 11/16/2022] Open
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26
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Pearce AP, Bull AMJ, Clasper JC. Mediastinal injury is the strongest predictor of mortality in mounted blast amongst UK deployed forces. Injury 2017; 48:1900-1905. [PMID: 28750794 DOI: 10.1016/j.injury.2017.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blast injury has been the most common cause of morbidity and mortality encountered by UK forces during recent conflicts. Injuries sustained by blast are categorised by the injuring component of the explosion and depend upon physical surroundings. Previous work has established that head injuries and intra cavity haemorrhage are the major causes of death following exposure to under body (mounted) blast but has yet to explore the precise nature of these torso injuries nor the effect of particular injuries upon survival. This study examines the patterns of torso injury within the mounted blast environment in order to understand the effect of these injuries upon survivability. METHODS This retrospective study examined the UK Joint Theatre Trauma Registry to determine precise injury patterns of mounted blast casualties within a 13year period of UK military deployments. Survival rates of individual injuries were compared and a multivariable logistic regression model was developed in order to assess the effect that each injury had upon likelihood of death. RESULTS 426 mounted casualties were reviewed of whom 129 did not survive. Median NISS and ISS for non-survivors was found to be 75. Torso injuries were significantly more common amongst non-survivors than survivors and high case fatality rates were associated with all haemorrhagic torso injuries. Multivariable analysis shows that mediastinal injuries have the largest odds ratio for mortality (20.4) followed by lung laceration and head injury. CONCLUSIONS Non-compressible torso haemorrhage is associated with mortality amongst mounted blast. Of this group, mediastinal injury is the strongest predictor of death and could be considered as a surrogate marker of lethality. Future work to link blast loading characteristics with specific injury patterns will inform the design of mitigating strategies in order to improve survivability of underbody blast.
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Affiliation(s)
- A Phillip Pearce
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, UK.
| | - Jonathon C Clasper
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
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27
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Kulla M, Maier J, Bieler D, Lefering R, Hentsch S, Lampl L, Helm M. [Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®]. Unfallchirurg 2017; 119:843-53. [PMID: 26286180 DOI: 10.1007/s00113-015-0046-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive. MATERIAL AND METHODS A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed. RESULTS A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %). CONCLUSION This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.
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Affiliation(s)
- M Kulla
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - J Maier
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs-, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - R Lefering
- Institut für Forschung in der Operativen Medizin, Universität Witten-Herdecke, Witten, Deutschland
| | - S Hentsch
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs-, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - L Lampl
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - M Helm
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
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Barnard EBG, Morrison JJ, Madureira RM, Lendrum R, Fragoso-Iñiguez M, Edwards A, Lecky F, Bouamra O, Lawrence T, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. Emerg Med J 2016; 32:926-32. [PMID: 26598631 PMCID: PMC4717355 DOI: 10.1136/emermed-2015-205217] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Introduction Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown. Methods We conducted a population based analysis of 2012–2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded. Results During 2012–2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type. Conclusions This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.
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Affiliation(s)
- Edward Benjamin Graham Barnard
- Institute of Naval Medicine, Gosport, Hampshire, UK Office of the Chief Scientist, 59th Medical Wing, Joint Base San Antonio, United States Air Force, San Antonio, Texas, USA
| | - Jonathan James Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Academic Unit of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Robbie Lendrum
- Department of Anaesthetics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Fiona Lecky
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK EMRiS Group, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK
| | - Thomas Lawrence
- Trauma Audit and Research Network, Hope Hospital, Manchester, UK
| | - Jan Olaf Jansen
- Departments of Surgery and Intensive Care Medicine, Aberdeen Royal Infirmary, Aberdeen, UK Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Edwards DS, Guthrie HC, Yousaf S, Cranley M, Rogers BA, Clasper JC. Trauma-related amputations in war and at a civilian major trauma centre-comparison of care, outcome and the challenges ahead. Injury 2016; 47:1806-10. [PMID: 27287739 DOI: 10.1016/j.injury.2016.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 02/02/2023]
Abstract
The Afghanistan conflict has resulted in a large number of service personnel sustaining amputations. Whilst obvious differences exist between military and civilian trauma-related amputations both settings result in life changing injuries. Comparisons offer the potential of advancement and protection of the knowledge gained during the last 12 years. This paper compares the military and civilian trauma-related amputee cohorts' demographics, management and rehabilitation outcomes measures. The UK military Joint Theatre Trauma Registry and a civilian major trauma centre database of trauma-related amputees were analysed. 255 military and 24 civilian amputees were identified. A significant difference (p>0.05) was seen in median age (24, range 18-43, vs. 48, range 24-87 years), mean number of amputations per casualty (1.6±SD 0.678 vs. 1±SD 0.0), mean ISS (22±SD 12.8 vs. 14.7±SD 15.7) and gender (99% males vs. 78%). Rehabilitation outcome measures recorded included the Special Interest Group in Amputee Medicine score where the military group demonstrated significantly better scores (91% Grade E+ compared to 19%). Differences in patients underlying physiology and psychology, the military trauma system and a huge sustained investment in rehabilitation are all contributing factors for these differing outcomes. However the authors also believe that the use of a consultant-led MDT and central rehabilitation have benefited the military cohort in the acute rehabilitation stage and is reflected in the good short-term outcomes.
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Affiliation(s)
- D S Edwards
- The Royal Centre for Defence Medicine, Birmingham, UK; The Royal British Legion Centre for Blast Injury Studies, Imperial College, London, UK.
| | - H C Guthrie
- The Royal Centre for Defence Medicine, Birmingham, UK; Brighton and Sussex University Hospitals, Sussex, UK; Defence Medical Rehabilitation Centre, Headley Court, UK
| | - S Yousaf
- Brighton and Sussex University Hospitals, Sussex, UK; University of Brighton, Sussex, UK
| | - M Cranley
- Defence Medical Rehabilitation Centre, Headley Court, UK
| | - B A Rogers
- Brighton and Sussex University Hospitals, Sussex, UK; University of Brighton, Sussex, UK
| | - J C Clasper
- The Royal British Legion Centre for Blast Injury Studies, Imperial College, London, UK; Defence Medical Group (South East), Frimley Park, UK
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Bennett RA. Ethics surrounding the medical evacuation of catastrophically injured individuals from an operational theatre of war. J ROY ARMY MED CORPS 2016; 162:321-323. [DOI: 10.1136/jramc-2015-000574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 12/15/2015] [Indexed: 11/04/2022]
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Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps. J Trauma Acute Care Surg 2015; 79:S204-9. [DOI: 10.1097/ta.0000000000000720] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Breeze J, Lewis EA, Fryer R, Hepper AE, Mahoney PF, Clasper JC. Defining the essential anatomical coverage provided by military body armour against high energy projectiles. J ROY ARMY MED CORPS 2015; 162:284-90. [PMID: 26272950 DOI: 10.1136/jramc-2015-000431] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/05/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles. METHODS A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy. RESULTS AND CONCLUSIONS Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK Biomedical Sciences Department, Dstl Porton Down, Salisbury, Wiltshire, UK
| | - E A Lewis
- Defence Equipment and Support, Ministry of Defence Abbey Wood, Bristol, UK
| | - R Fryer
- Land Battlespace Systems Department, Defence Science & Technology Laboratory, Fareham, Hampshire, UK
| | - A E Hepper
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, Wiltshire, UK
| | - Peter F Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Jon C Clasper
- The Royal British Legion Centre for Blast Injury Studies at Imperial College London, London, UK
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Breeze J, Fryer R, Lewis EA, Clasper J. Defining the minimum anatomical coverage required to protect the axilla and arm against penetrating ballistic projectiles. J ROY ARMY MED CORPS 2015; 162:270-5. [DOI: 10.1136/jramc-2015-000453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/02/2015] [Indexed: 11/03/2022]
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Rigelsford JM, Al-Azzawi BF, Davenport CJ, Novodvorsky P. A passive biodegradable implant for subcutaneous soft-tissue trauma monitoring. IEEE J Biomed Health Inform 2015; 19:901-9. [PMID: 25826811 DOI: 10.1109/jbhi.2015.2417754] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In-body medical devices can play an important role in clinical monitoring and diagnosis of diseases. Wireless devices implanted within a patient have to be physically small, and must overcome the challenges of having a little or no onboard electrical power and the highly attenuating electromagnetic propagation environment which is the human body. In this paper, we investigate the use of biodegradable implant to monitor the healing of soft-tissue trauma and to allow early stage diagnosis of infection. The implantable tag is designed to degrade in a predetermined and controlled method, the stage of which can be measured from outside the body without the need for further surgical intervention. The speed of degradation of the tag depends on the temperature and acidity of the subcutaneous tissue in which the tag is implanted. We show that as the electrical length of the tag pattern increases due to degradation, the resonant frequency changes significantly, and this change in resonant frequency can be detected from outside the patient. Results are presented showing the tag's performance at normal and oblique incidence, and techniques for miniaturizing and enhancing the tag's response sensitivity are given. As the entire tag is biodegradable, there is no need for further postoperative surgery to remove it from the patient at the end of its useful life.
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Elder GA, Gama Sosa MA, De Gasperi R, Stone JR, Dickstein DL, Haghighi F, Hof PR, Ahlers ST. Vascular and inflammatory factors in the pathophysiology of blast-induced brain injury. Front Neurol 2015; 6:48. [PMID: 25852632 PMCID: PMC4360816 DOI: 10.3389/fneur.2015.00048] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 02/23/2015] [Indexed: 11/13/2022] Open
Abstract
Blast-related traumatic brain injury (TBI) has received much recent attention because of its frequency in the conflicts in Iraq and Afghanistan. This renewed interest has led to a rapid expansion of clinical and animal studies related to blast. In humans, high-level blast exposure is associated with a prominent hemorrhagic component. In animal models, blast exerts a variety of effects on the nervous system including vascular and inflammatory effects that can be seen with even low-level blast exposures which produce minimal or no neuronal pathology. Acutely, blast exposure in animals causes prominent vasospasm and decreased cerebral blood flow along with blood-brain barrier breakdown and increased vascular permeability. Besides direct effects on the central nervous system, evidence supports a role for a thoracically mediated effect of blast; whereby, pressure waves transmitted through the systemic circulation damage the brain. Chronically, a vascular pathology has been observed that is associated with alterations of the vascular extracellular matrix. Sustained microglial and astroglial reactions occur after blast exposure. Markers of a central and peripheral inflammatory response are found for sustained periods after blast injury and include elevation of inflammatory cytokines and other inflammatory mediators. At low levels of blast exposure, a microvascular pathology has been observed in the presence of an otherwise normal brain parenchyma, suggesting that the vasculature may be selectively vulnerable to blast injury. Chronic immune activation in brain following vascular injury may lead to neurobehavioral changes in the absence of direct neuronal pathology. Strategies aimed at preventing or reversing vascular damage or modulating the immune response may improve the chronic neuropsychiatric symptoms associated with blast-related TBI.
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Affiliation(s)
- Gregory A Elder
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA ; Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Miguel A Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA
| | - Rita De Gasperi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA
| | - James Radford Stone
- Department of Radiology and Medical Imaging, University of Virginia , Charlottesville, VA , USA ; Department of Neurosurgery, University of Virginia , Charlottesville, VA , USA
| | - Dara L Dickstein
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Fatemeh Haghighi
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center , Bronx, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Patrick R Hof
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Fishberg Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Stephen T Ahlers
- Department of Neurotrauma, Operational and Undersea Medicine Directorate, Naval Medical Research Center , Silver Spring, MD , USA
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Pasquier P, Dubost C, Boutonnet M, Chrisment A, Villevieille T, Batjom E, Bordier E, Ausset S, Puidupin M, Martinez JY, Bay C, Escarment J, Pons F, Lenoir B, Mérat S. Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service. Injury 2014; 45:1307-11. [PMID: 24952973 DOI: 10.1016/j.injury.2014.05.037] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To improve the mortality rate on the battlefield, and especially the potentially survivable pre-Medical Treatment Facility deaths, Tactical Combat Casualty Care (TCCC) is now considered as a reference for management of combat casualty from the point of injury to the first medical treatment facility. TCCC comprises of a set of trauma management guidelines designed for use on the battlefield. The French Military Health Service also standardised a dedicated training programme, entitled "Sauvetage au Combat" (SC) ("forward combat casualty care"), with the characteristic of forward medicalisation on the battlefield, the medical team being projected as close as possible to the casualty at the point of injury. The aim of our article is to describe the process and the result of the SC training. MATERIALS AND METHODS Records from the French Military Health Service Academy - École du Val-de-Grâce administration, head of the SC teaching programme, defining its guidelines, and supporting its structure and its execution, were examined and analyzed, since the standardisation of the SC training programme in 2008. The total number of trainees was listed following the different courses (SC1, SC2, SC3). RESULTS At the end of 2013, every deployed combatant underwent SC1 courses (confidential data), 785 health-qualified combatants were graduated for SC2 courses and 672 Role 1 physician-nurse pairs for SC3 courses. CONCLUSION The SC concept and programmes were defined in France in 2007 and are now completely integrated into the predeployment training of all combatants but also of French Military Health Service providers. Finally, SC teaching programmes enhance the importance of teamwork in forward combat medicalisation settings.
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Affiliation(s)
- Pierre Pasquier
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Clément Dubost
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Mathieu Boutonnet
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Anne Chrisment
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Thierry Villevieille
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Emmanuel Batjom
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Emmanuel Bordier
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Marc Puidupin
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - Jean-Yves Martinez
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - Christian Bay
- Tactical Care Training Department, French Military Health Service Academy - École du Val-de-Grâce, Paris, France.
| | - Jacques Escarment
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - François Pons
- French Military Health Service Academy - École du Val-de-Grâce, Paris, France.
| | - Bernard Lenoir
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Stéphane Mérat
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
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Radiologic Features of Injuries From the Boston Marathon Bombing at Three Hospitals. AJR Am J Roentgenol 2014; 203:235-9. [DOI: 10.2214/ajr.14.12549] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Russell R, Hunt N, Delaney R. The Mortality Peer Review Panel: a report on the deaths on operations of UK Service personnel 2002–2013. J ROY ARMY MED CORPS 2014; 160:150-4. [DOI: 10.1136/jramc-2013-000215] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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