Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020

Qualitative assessment of combat-related injury patterns and injury prevention in Ukraine since the Russian invasion

INTRODUCTION

The ongoing invasion of Ukraine by the Russian Federation represents one of the largest ongoing conventional military engagements in the last 20 years. Since the start of the war, an estimated 210 000 Ukrainian soldiers have been injured or killed as a result of combat. This experience could help prognosticate the nature of large-scale combat operations for modern militaries. The aim of this study was to assess current patterns of injuries among military combatants in Ukraine and identify prevention and mitigation methods.

METHODS

We conducted a series of key informant interviews during the ongoing conflict using an expanded version of the global trauma system evaluation tool. We focused the analysis on injury patterns and prevention of combat-related injuries.

RESULTS

We interviewed 36 participants from June 2023 to February 2024. Respondents described complex polytrauma as representing the injury norm, with prominent battle injuries, including blast wounds to the extremities, traumatic brain injuries and spinal cord trauma. The primary source of injury prevention on the battlefield remains combat body armour. Military commanders and the Ministry of Defence were identified as principal bodies for the authorising equipment and tactical changes. Most respondents stated there was no formal process for using data to inform injury prevention initiatives.

CONCLUSION

The current conflict in Ukraine is characterised by a high prevalence of devastating combat-related injury, with limited measures for battlefield injury prevention. We believe that the provision of additional protective gear could mitigate the severity of some combat-related injuries, while the creation of a trauma registry would provide greater insight into prevention, wounding patterns, treatment and outcomes.

Delayed reconstruction of the combat-related mandibular defects with non-vascularized iliac crest grafts: Defining the optimal conditions for a positive outcome in the retrospective study

BACKGROUND

Reconstruction of mandibular defects caused by combat injuries is challenging for clinicians due to soft tissue defects and high complication risk. This study evaluated the outcomes of mandibular continuous defects reconstruction with non-vascularized iliac crest graft (NVICG) in patients with combat injuries.

MATERIAL AND METHODS

Patients with continuous mandibular defects acquired by high-velocity agents, who received NVICG reconstruction with or without microvascular-free soft tissue or regional flaps, were included in the study. The outcome variable was graft loss due to postoperative complications or full (more than 90 %) resorption. The primary predictor variable was soft tissue defect in the recipient area. The secondary predictor variable was the length of the defect. Variables related to patients, defect site, surgery, and other complications were also evaluated. Statistical analysis was performed with the usage of independent sample t-test, Pearson's chi-squared and Fisher's exact tests with a significance level of P < 0.05 RESULTS: The study included 24 patients with 27 mandibular defects. Overall, the general success rate of reconstructions was 59.3 %. Soft tissue defects were significantly associated with graft failure and other complications (p < 0.05), which were mostly related to soft tissue defects. The graft success rate was only 14.3 % even in minor soft tissue defects. In turn, in reconstructions with sufficient soft tissue coverage, the graft survived in 75.0 % of the cases. In addition, patients with more delayed reconstruction had significantly fewer graft failures than those with earlier surgery (p < 0.05). No associations were found between defect size and complications.

CONCLUSION

The sufficient soft tissue coverage is essential in the reconstruction of mandibular defects caused by combat injuries. Also, minor soft tissue defects should be covered with soft tissue flaps to avoid complications and graft loss in these specific injuries. Even large defects can be reconstructed with NIVICG if the soft tissue coverage is sufficient.

Assault rifle injuries in civilians: ballistics of wound patterns, assessment and initial management

PURPOSE

Wounds from assault rifles and their commercial offspring have been encountered with increasing frequency in civilian practice. Our aim is to summarize wound ballistics related to the main injury patterns that can also affect management strategies.

METHODS

An online search of the PubMed was conducted for research and review articles published after 2000 in English, using the MeSH terms "gunshot wounds", "mass casualty incidents", "war-related injuries", "soft tissue injuries", "vascular system injuries", "colon injuries", "wound infection", "antibiotic prophylaxis", "debridement", "hemorrhage", "penetrating head injuries", "pneumothorax" and additional free-text terms. Other academic databases were also searched for relevant articles and book chapters.

RESULTS

Consensus regarding recognition of high energy wounds from assault rifle projectiles is largely based on war experience. Studies of such wounds inflicted by expanding projectiles suggest that their wounding effects significantly increase tissue damage and adverse outcomes following injury, as a result of the temporary cavity and bullet fragmentation. The use of assault rifles in mass shootings has prompted utilization of tourniquet for control of life-threatening hemorrhage, also derived from military experience, while limited evidence indicates that tension pneumothorax rather than extremity wounds is the leading cause of potentially preventable death in these incidents.

CONCLUSIONS

Wound ballistics provides a system for evaluation of injuries from assault rifles and risk analysis of shooting incidents. Lessons learned from armed conflicts can improve the management of victims, with due consideration given to characteristics of civilian injuries. Further research is required to define the impact on survival by key life-saving procedures in the prehospital setting, in order to prioritize these interventions.

A rare case of endoscopic removal of the metal fragment from the segmental bronchus after gunshot injury to the chest in combat patient injured in the war in Ukraine

INTRODUCTION AND IMPORTANCе: Russo-Ukrainian war is associated with severe injuries to the chest. Isolated chest injuries are associated with high mortality or advanced invalidization due to the severity of the trauma. The aim of the study was to demonstrate the experience and the challenges in diagnosis and management of the combat patient with gunshot injury to the lungs with subsequent migration of the shrapnel projectile to the segmental bronchus and its bronchoscopic removal by using forceps.

CASE PRESENTATION

A male patient 44 years of age was injured at an artillery strike in East Ukraine. The patient was evacuated to the Forward Surgical Team (Role 1) facility within one hour after the injury. The bronchoscopy was performed and to our surprise, the metal fragment in the lumen of the right segmental S2 bronchi was visualized at bronchoscopy, indicating its migration from the first place. The decision was made to attempt to remove the metal fragment endoscopically. At bronchoscopy, the metal fragment was caught by the endoscopic forceps and therefore removed endoscopically. The time of endoscopic removal of the metal fragment was 8 min.

CLINICAL DISCUSSION

Removal of a foreign body (metal fragment) of gunshot origin from the lumen of a segmental bronchus by using bronchoscopy with endoscopic forceps is a rare phenomenon.

CONCLUSIONS

The use of minimally invasive technologies in the treatment of gunshot blind penetrating wounds of the chest contributes to the reduction of operative trauma and shortens the time of operative treatment.

Addressing abdominal trauma from conflict and warfare in under-resourced regions: A critical narrative review

Introduction

The prevalence of abdominal injuries in war and conflict zones, particularly in low- and middle-income countries (LMICs), presents a significant healthcare challenge. These injuries, often resulting from explosive devices, firearms, and shrapnel, lead to high morbidity and mortality rates due to delayed diagnoses, inadequate medical infrastructure, and limited access to specialised care. This review aims to summarise the literature on conflict-related abdominal injuries in LMICs, highlighting the impact of such trauma on healthcare systems and patient outcomes, and suggesting strategies for improvement.

Methods

A comprehensive narrative review was conducted, focusing on studies from contemporary and historical conflict-ridden nations. Databases such as PubMed, EMBASE, Google Scholar, the Cochrane Library, and Scopus were searched using specific keywords. Inclusion criteria encompassed various study designs and both paediatric and adult populations, with studies providing raw data prioritised. Exclusions included non-English articles, non-peer-reviewed studies, and those not reporting outcomes or involving high-income countries.

Results

The review identified significant challenges in managing war-related abdominal trauma in LMICs, including a shortage of healthcare personnel and infrastructure, socio-political barriers, and research gaps. Clinical implications of such injuries include elevated mortality rates, with surgical and nonsurgical management outcomes varying significantly. Positive advancements in diagnostics and surgical techniques have improved survival rates, yet the need for further infrastructural and workforce enhancements remains critical.

Conclusion

Abdominal trauma in conflict-affected LMICs necessitates focused efforts to improve healthcare delivery, including targeted funding for infrastructure and equipment, development of training programs for trauma specialists, and increased humanitarian aid. Bridging research gaps and fostering collaborative efforts are essential for advancing the management of abdominal trauma and enhancing patient outcomes in these challenging environments.

Lessons learned from the war in Ukraine for the anesthesiologist and intensivist: A scoping review

BACKGROUND

The war in Ukraine provides purposefully anesthesiologists and intensivists with important data for improving the management of trauma patients. This scoping review aims to investigate the specific management of war-related trauma patients, during the war in Ukraine, through an objective and comprehensive analysis.

METHODS

A comprehensive search of the Embase, Medline, and Open Grey databases from 2014 to February 2024 yielded studies focusing on anesthesia and surgery. These studies were assessed by PRISMA and STROBE criteria and needed to discuss anesthesiology and surgical procedures.

RESULTS

Of the 519 studies identified, 21 were included, with a low overall level of evidence. The studies covered 11,622 patients and 2470 surgical procedures. Most patients were Ukrainian men, 25-63 years old, who had sustained severe injuries from high-energy weapons, such as multiple rocket systems and combat drones. These injuries included major abdominal, facial, and extremity traumas. The surgical procedures varied from initial debridement to complex reconstructions. Anesthesia management faced significant challenges, including resource scarcity and the need for quick adaptability. Evacuations of casualties were lengthy, complex, and often involved rail transportation. Hemorrhage control with tourniquets was critical but associated with many complications. The very frequent presence of multi-resistant organisms required dedicated preventive measures and appropriated treatments. The need for qualified human resources underscored the importance of civilian-military cooperation.

CONCLUSION

This scoping review provides original and relevant insights on the lessons learned from the ongoing war in Ukraine, which could be useful for anesthesiologists and intensivists.

Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war

BACKGROUND

Russo-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90-100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava.

CASE PRESENTATION

A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars' explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the "golden hour" principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent second-look surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava.

CONCLUSIONS

Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies.

Management of thoracoabdominal gunshot injuries by using minimally invasive surgery at role 2 deployed field hospitals in Ukraine

The Russia-Ukraine war is associated with critical and severe thoracoabdominal injuries. A more specific approach to treating patients with thoracoabdominal injury should also include minimally invasive technologies. It remains unclear about the utility of using video-assisted thoracoscopic surgery (VATS) and laparoscopy in patients with thoracoabdominal injury. The aim of this study was to investigate and evaluate the utility of video-assisted thoracoscopic surgery, laparoscopy as well as magnetic tool applications for the management of severe thoracoabdominal injury in combat patients injured in the ongoing war in Ukraine and treated in the Role 2 deployed hospital. Patients and methods 36 male combat patients thoracoabdominal injury were identified for the study during the first 100 days from February, 24 2022. These individuals were diagnosed with thoracoabdominal GSW in the Role 2 hospital (i.e. deployed military hospital) of the Armed Forces of Ukraine. Video-assisted thoracoscopy surgery (VATS) and laparoscopy with application of surgical magnetic tools were applied with regards to the damage control resuscitation and damage control surgery. Results In 10 (28%) patients, VATS was applied to remove the metal foreign body fragments. Both thoracotomy and laparotomy were performed in 20 (56%) hemodynamically unstable patients. Of these 20 patients, the suturing of the liver was performed in 8 (22%) patients, whereas peri-hepatic gauze packing in 12 (33%) patients. Massive injury to the liver and PI 2.0-3.0 were diagnosed in 2 (6%) patients. Lethal outcome was in 1 (2.8%) patient. Conclusions Thoracoabdominal gunshot injuries might be managed at Role 2 hospitals by using video-assisted thoracoscopy (VATS) and laparoscopy accompanied by surgical magnetic tools. Damage control surgery and damage control resuscitation must be applied for patients in critical and severe conditions.

Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war

INTRODUCTION

Russo-Ukrainian war is associated with application of high-energy weapon, causing severe multifragmental injuries to the bones an associating with severe bone defects. The aim of the study was to evaluate various methods to treat combat patients with severe defects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war.

PATIENTS AND METHODS

A 24 patients were active-duty military personnel of Armed Forces of Ukraine. These patients were diagnosed with severe humerus defects due to gunshot injury in battlefield zone in various areas of Ukraine. Data was collected within period between February, 24th 2022 till January, 01st 2023. The following approaches were applied to replace bone defect: preoperative 3D printing with polyetheretherketone (PEEK) as orthobiological material; closed reduction, percutaneous lag screw and Ilizarov external fixation; vascularized fibula grafting.

RESULTS

Data analyses of the segmental defects of humerus showed 5 cm defect in 3 (13 %) patients, from 5 to 10 cm in 4 (17 %) patients, over 10 cm in 17 (71 %) patients. Analyses were performed in these 17 (71 %) patients, showing 5 patients treated with 3D-printed PEEK implants, 6 patients with vascular-pedicle graft of fibula, 6 patients with closed reduction, percutaneous lag screw, Ilizarov external fixation. Osteomyelitis was diagnosed in one case (20 %) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for patients treated with 3D-printed PEEK implants.

CONCLUSIONS

Closed reduction, percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severe humerus defect due to gunshot injury. 3D printing and PEEK implants could also be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.

Renal injuries in conflict zones: a 6-year study of traumatic cases in Afghanistan

PURPOSE

During hostilities, gunshot wounds are the most common cause of penetrating injuries. In 8-10% of abdominal injuries kidneys are involved. The treatment method include surgical or conservative treatment (fluids + blood components).

METHODS

Of 1266 combat trauma cases treated during 6 to 14 rotation of the Polish Military Contingent in Afghanistan, we extracted a subgroup of 44 kidney injuries. Corelation of trauma mechanism, PATI score, treatment methods, and outcomes was evaluated.

RESULTS

Out of the 41 renal injuries, 20 considered left, 18 right, and 3 both kidneys. There were no statistical significancy in injury lateralization (p = 0.669), and no differences regarding side of a trauma and quantity of blood component used for the treatment (p = 0.246). Nephrectomy was performed on 17 patients (13 left vs. 4 right). A significant correlation between PATI score and the need for a nephrectomy (p = 0.027) was confirmed. Penetrating trauma recquired higher number of blood components comparing to blunt trauma (p < 0.001). The renal salvage rate was in study group was 61.36%. The overall survival (OS) rate was 90.25% - 4 patients died due to trauma.

CONCLUSIONS

The damage side does not result in a statistically significant increase in the need for blood transfusions or differences in the PATI score. The mechanism of trauma does, however, affect the number of blood components required for treatment, particularly in cases of penetrating trauma. With the introduction of proper treatment, the overall survival rate exceeds 90%, even when opting for conservative treatment.

A new approach for reconstruction of the gunshot defect of the flexor surface of the ungual (distal) phalanx by the proper transverse branch of the digital artery: a case report of combat patient injured in the Russo-Ukrainian war

BACKGROUND

Gunshot injury to the hand is severe trauma, requiring complicated reconstruction surgery for the damaged anatomic site to restore all the hand functions. The aim of this study was to show the example of the distal phalanx reconstruction by using a flap with distal transverse digital artery (DTDA) blood supply as well as to demonstrate the utility of the audio Doppler application at the reconstruction stage in the combat patient injured in the Russo-Ukrainian war.

CASE PRESENTATION

In this report, we present a case of a 26-year-old service member of the Ukrainian Armed Forces delivered to the Military Medical Clinical Centre on the fourth day after the gunshot gutter shrapnel wound of the distal flexor of the 2nd digit with a gunshot fracture of the ungula (distal) and middle phalanges of the 2nd digit of the right hand along with a bone deficiency of the osseous structure of the distal and middle phalanges, volar soft tissues. The dorsal metacarpal artery (DMCA) flap is a universal variant among the tools of the reconstructive plastic surgeon engaged in reconstructing defects of the digital dorsum and flexors with a limited range of flaps. We consider this to be a key that conforms with the majority of the reconstructive principles, such as 'analog replacement', and which is simple, adequate, and easy for operating with a minimal sequela of the donor site.

CONCLUSIONS

The distal transverse digital artery (DTDA) could be considered for hand reconstructive surgery for repairing defects of the flexor surface of the digit injury and hands after severe gunshot injury.

Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool: a case report of combat patient injured in the war in Ukraine

BACKGROUND

Gunshot wounds injury to the thorax is common in armed conflicts or war, including the war of Russia against Ukraine. Injury to the chest is associated with a high mortality or physical disability due to damage to the lungs, heart, and major vessels. The aim of this report is to demonstrate a case of successful management of severe gunshot injury to the lungs using video-assisted thoracoscopic surgery and magnetic tool for a combat patient injured in the war in Ukraine.

CASE PRESENTATION

A 51-year-old soldier of the Armed Forces of Ukraine received a gunshot injury due to shelling from artillery strikes in the Donbas battlefield area. After evacuation to Level II, a forward surgical team performed primary surgical debridement. Two hours after the injury, the patient was evacuated to the Level IV of medical care (Kharkiv). At Level IV, a CT scan showed penetrating gunshot wounds to the left part of the chest with injury to the upper lobe of the left lung with the presence of the 2 metal fragments of the artillery projectile with the size of 2.5 × 2.0 cm and 1.0 × 1.0 cm. These two fragments were removed by using video-assisted thoracoscopic surgery (VATS) using the inlet gunshot hole in the left lateral chest area, as well as the assistance of a magnetic tool.

CONCLUSIONS

VATS and magnetic technologies should be considered for hemodynamically stable combat patients with a gunshot injury to the lungs in the ongoing war. Each combat patient could be treated by individualized approach such as using the wound canal as a scope port after primary surgical debridement of the wound and antibiotic prophylaxis.