A trauma expert consensus: Capabilities are required early to improve survivability from traumatic injury.

BACKGROUND: Mortality reviews examine US military fatalities resulting from traumatic injuries during combat operations. These reviews are essential to the evolution of the military trauma system to improve individual, unit, and system-level trauma care delivery and inform trauma system protocols and guidelines. This study identifies specific prehospital and hospital interventions with the potential to provide survival benefits. METHODS: US Special Operations Command fatalities with battle injuries deemed potentially survivable (2001-2021) were extracted from previous mortality reviews. A military trauma review panel consisting of trauma surgeons, forensic pathologists, and prehospital and emergency medicine specialists conducted a methodical review to identify prehospital, hospital, and resuscitation interventions (e.g., laparotomy, blood transfusion) with the potential to have provided a survival benefit. RESULTS: Of 388 US Special Operations Command battle-injured fatalities, 100 were deemed potentially survivable. Of these (median age, 29 years; all male), 76.0% were injured in Afghanistan, and 75% died prehospital. Gunshot wounds were in 62.0%, followed by blast injury (37%), and blunt force injury (1.0%). Most had a Maximum Abbreviated Injury Scale severity classified as 4 (severe) (55.0%) and 5 (critical) (41.0%). The panel recommended 433 interventions (prehospital, 188; hospital, 315). The most recommended prehospital intervention was blood transfusion (95%), followed by finger/tube thoracostomy (47%). The most common hospital recommendations were thoracotomy and definitive vascular repair. Whole blood transfusion was assessed for each fatality: 74% would have required ≥10 U of blood, 20% would have required 5 to 10 U, 1% would have required 1 to 4 U, and 5% would not have required blood products to impact survival. Five may have benefited from a prehospital laparotomy. CONCLUSION: This study systematically identified capabilities needed to provide a survival benefit and examined interventions needed to inform trauma system efforts along the continuum of care. The determination was that blood transfusion and massive transfusion shortly after traumatic injury would impact survival the most. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level V.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury.

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Injury scoring systems for blast injuries: a narrative review.

Injury scoring systems can be used for triaging, predicting morbidity and mortality, and prognosis in mass casualty incidents. Recent conflicts and civilian incidents have highlighted the unique nature of blast injuries, exposing deficiencies in current scoring systems. Here, we classify and describe deficiencies with current systems used for blast injury. Although current scoring systems highlight survival trends for populations, there are several major limitations. The reliable prediction of mortality on an individual basis is inaccurate. Other limitations include the saturation effect (where scoring systems are unable to discriminate between high injury score individuals), the effect of the overall injury burden, lack of precision in discriminating between mechanisms of injury, and a lack of data underpinning scoring system coefficients. Other factors influence outcomes, including the level of healthcare and the delay between injury and presentation. We recommend that a new score incorporates the severity of injuries with the mechanism of blast injury. This may include refined or additional codes, severity scores, or both, being added to the Abbreviated Injury Scale for high-frequency, blast-specific injuries; weighting for body regions associated with a higher risk for death; and blast-specific trauma coefficients. Finally, the saturation effect (maximum value) should be removed, which would enable the classification of more severe constellations of injury. An early accurate assessment of blast injury may improve management of mass casualty incidents.

United States military fatalities during Operation New Dawn.

BACKGROUND: Military operations vary by scope, purpose, and intensity, each having unique forces and actions to execute a mission. Evaluation of military operation fatalities guides current and future casualty care. METHODS: A retrospective study was conducted of all US military fatalities from Operation New Dawn in Iraq, 2010 to 2011. Data were obtained from autopsies and other records. Population characteristics, manner of death, cause of death, and location of death were analyzed. All fatalities were evaluated for concomitant evidence of underlying atherosclerosis. Nonsuicide trauma fatalities were also reviewed for injury severity, mechanism of death, injury survivability, death preventability, and opportunities for improvement. RESULTS: Of 74 US military Operation New Dawn fatalities (median age, 26 years; male, 98.6%; conventional forces, 100%; prehospital, 82.4%) the leading cause of death was injury (86.5%). The manner of death was primarily homicide (55.4%), followed by suicide (17.6%), natural (13.5%), and accident (9.5%). Fatalities were divided near evenly between combatants (52.7%) and support personnel (47.3%), and between battle injury (51.4%) and disease and nonbattle injury (48.6%). Natural and suicide death was higher (p < 0.01, 0.02) among support personnel who were older (p = 0.05) with more reserve/national guard personnel (p = 0.01). Total population prevalence of underlying atherosclerosis was 18.9%, with more among support personnel (64.3%). Of 46 nonsuicide trauma fatalities, most died of blast injury (67.4%) followed by gunshot wound (26.1%) and multiple/blunt force injury (6.5%). The leading mechanism of death was catastrophic tissue destruction (82.6%). Most had nonsurvivable injuries (82.6%) and nonpreventable deaths (93.5%). CONCLUSION: Operation New Dawn fatalities were exclusively conventional forces divided between combatants and support personnel, the former succumbing more to battle injury and the latter to disease and nonbattle injury including self-inflicted injury. For nonsuicide trauma fatalities, none died from a survivable injury, and 17.4% died from potentially survivable injuries. Opportunities for improvement included providing earlier blood products and surgery. LEVEL OF EVIDENCE: Therapeutic, level V and epidemiological, level IV.

Case-control analysis of prehospital death and prolonged field care survival during recent US military combat operations.

BACKGROUND: Quantification of medical interventions administered during prolonged field care (PFC) is necessary to inform training and planning. MATERIALS AND METHODS: Retrospective cohort study of Department of Defense Trauma Registry casualties with maximum Abbreviated Injury Scale (MAIS) score of 2 or greater and prehospital records during combat operations 2007 to 2015; US military nonsurvivors were linked to Armed Forces Medical Examiner System data. Medical interventions administered to survivors of 4 hours to 72 hours of PFC and nonsurvivors who died prehospital were compared by frequency-matching on mechanism (explosive, firearm, other), injury type (penetrating, blunt) and injured body regions with MAIS score of 3 or greater. Covariates for adjustment included age, sex, military Service, shock, Glasgow Coma Scale, transport team, MAIS and Injury Severity Score (ISS). Sensitivity analysis focused on US military subgroup with AIS/ISS assigned to nonsurvivors after autopsy. RESULTS: The total inception cohort included 16,202 casualties (5,269 US military, 10,809 non-US military), 64% Afghanistan, 36% Iraq. Of US military, 734 deaths occurred within 30 days, nearly 90% occurred within 4 hours of injury. There were 3,222 casualties (1,111 US military, 2,111 non-US military) documented for prehospital care and died prehospital (691) or survived 4 hours to 72 hours of PFC (2,531). Twenty-five percent (815/3,222) received advanced airway, 18% (583) ventilatory support, 9% (281) tourniquet. Twenty-three percent (725) received blood transfusions within 24 hours. Of the matched cohort (1,233 survivors, 490 nonsurvivors), differences were observed in care (survivors received more warming, intravenous fluids, sedation, mechanical ventilation, narcotics, antibiotics; nonsurvivors received more intubations, tourniquets, intraosseous fluids, cardiopulmonary resuscitation). Sensitivity analysis focused on US military (732 survivors, 379 nonsurvivors) showed no significant differences in prehospital interventions. Without autopsy information, the ISS of nonsurvivors significantly underestimated injury severity. CONCLUSION: Tourniquets, blood transfusion, airway, and ventilatory support are frequently required interventions for the seriously injured. Prolonged field care should direct resources, technology, and training to field technology for sustained resuscitation, airway, and breathing support in the austere environment. LEVEL OF EVIDENCE: Prognostic, Level III.

Severe Fireworks-Related Injuries: Demographic Characteristics, Injury Patterns, and Firework Types in 294 Consecutive Patients.

OBJECTIVES: The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults. METHODS: We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older. RESULTS: Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died. CONCLUSIONS: Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

A review of deadly accidents involving fireworks in Denmark.

The aim of this study was to describe the circumstances surrounding firework-related deaths in Denmark, locate similarities and compare findings to the other known literature. Autopsy files, including police reports, located through searches in the archives of the three Danish institutes of forensic medicine were accessed. Data describing the age, gender, toxicology findings, circumstances of the accident, cause of death, autopsy findings and type of fireworks were examined. Eight cases involving firework-related deaths matched the search criteria, two of which occurred on New Year's Eve. An unknown number of cases that had not been autopsied were confirmed to exist. Data from the included cases suggested that using illegal fireworks, being male and handling fireworks directly played a key role in deaths. Most notably, illegal fireworks account for few injuries overall but caused the most deaths found in this study. Firework-related deaths are a rare occurrence. Autopsy findings often reveal blast wave injury to be the cause of death. Only one of the eight decedents included in this study were intoxicated with alcohol. Thus it can be assumed that powerful illegal fireworks are, by themselves, a risk factor for a deadly accident, independent of alcohol intoxication.

United States Special Operations Command fatality study of subcommands, units, and trends.

BACKGROUND: Death from injury occurs predominantly in prehospital settings. Injury prevention and prehospital care of military forces is the responsibility of combatant commanders. Medical examiner and trauma systems should routinely study fatalities and inform commanders of mortality trends. METHODS: Data reported on US Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018, were reevaluated to compare subcommands, units, and trends. Injury was assessed by mechanism, severity, operational posture, and survivability. Death was assessed by manner, cause, classification, mechanism, and preventability. RESULTS: Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%), 67.6% occurred in the Army command, of which 49.2% occurred in the Special Forces command. Battle injury accounted for 60.1% of USSOCOM fatalities. Most battle-injured fatalities in each subcommand had nonsurvivable injuries and nonpreventable deaths. For each subcommand except Marine Corps, fatalities with nonsurvivable injuries sustained injuries primarily while mounted. By subcommand, the primary cause of death for fatalities with nonsurvivable injuries was blast for Army (57.6%), multiple/blunt force for Navy (60.0%), gunshot wound for Air Force (55.6%), and split between blast (50.0%) and gunshot wound (50.0%) for Marine Corps. For each subcommand except Air Force, fatalities with potentially survivable-survivable injuries sustained injuries primarily while dismounted, and the mechanism of death was primarily hemorrhage plus other mechanism or hemorrhage alone. Hemorrhage only mechanism of death was surpassed over time by complex multimechanism death. Potential for injury survivability and death preventability was greatest during early and later years of conflict. CONCLUSION: Organizational differences in mortality characteristics and trends were identified from which commanders can refine efforts to prevent and treat injury and improve survival. Fatality analyses inform operational risk matrices and advance casualty prevention and response efforts. Prevention, assessment, and treatment strategies must evolve to reduce death from hemorrhage plus coexisting mechanisms. LEVEL OF EVIDENCE: Performance Improvement and Epidemiological, level IV.

Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat.

BACKGROUND: The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss. METHODS: The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed. RESULTS: Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12). CONCLUSIONS: The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

Innocent Children in the Syrian Civil War.

INTRODUCTION: Our aim is to present the clinical and surgical characteristics of the children affected by the Syrian civil war. MATERIALS AND METHODS: Medical records were reviewed retrospectively for Syrian war victims between the ages of 0 and 18 who were brought to the emergency department of the Education and Research Hospital between March 2011 and March 2019. Each patient was evaluated with respect to demographic data (gender, age), type of injury, history of operations in Syria, injured organ(s), accompanying traumas and the mortality and trauma score. RESULTS: The majority of our study population of 147 patients were male (108/147, 73.46%), and 39 of the total were girls (26.53%). The mean age of the patients was 9 (7.5 ± 4). The mean age of the girls was 8.5 (range: 7 months to 16 years), and the mean age of the boys was 9.2 (4 months to 17 years). Seventeen patients who had abdominal surgery in Syria were operated on again after clinical and radiological observations. A total of 83 patients were operated on in Turkey. For 66 of those patients, the operation in Turkey was their first surgery on their war injuries. Seventeen patients were operated on in Syria but needed surgery again in Turkey. CONCLUSION: War affects not only the battlefield, but also the neighboring countries in many aspects such as medical, social, and economic. Hollow organ injuries are the most common intraabdominal pathologies. Delayed intervention is associated with increase mortality and morbidity.

Simulated Aeromedical Evacuation in a Polytrauma Rat Model.

BACKGROUND: Hemorrhage and traumatic brain injury can be lethal if left unattended. The transportation of severely wounded combat casualties from the battlefield to higher level of care via aeromedical evacuation (AE) may result in unintended complications. This could become a serious concern at the time of evacuation of mass casualties or for prolonged field care scenarios with limited resources.METHODS: Following instrumentation (t1), anesthetized Sprague-Dawley rats were injured or not [75-kPa blast and 30% estimated blood-volume controlled hemorrhage] (t2). After 15 min, all rats were resuscitated with saline. During the simulated 3-h evacuation, 8000 ft (2440 m) vs. sea-level heart rate, temperature, and oxygenation (Spo2) were continuously recorded. One group of rats was euthanized immediately after evacuation (t3) and another after a 72-h recovery period (t4). Hematology and metabolic levels were measured at t1, t2, t3, and t4.RESULTS: Survival was 100% in control-uninjured animals, 83% in injured animals under normobaria, and significantly reduced to 50% under hypobaria. This AE setting resulted in significantly lower hemodynamics, thermoregulation, and oxygenation parameters in the animals under hypobaria than those under normobaria. The initial lower mean arterial pressure (MAP) with the reduced oxygen level before AE were critical factors for the survival of injured animals. We observed a general increase of white blood cells and platelet ability to aggregate at t4 in all experimental groups.CONCLUSION: Physiological parameters were affected during aeromedical evacuation in all groups. This was worsened for injured animals with MAP less than 60 mmHg associated with low Spo2 in a simulated aeromedical evacuation. This represented a high risk of mortality for severely polytraumatized animals.Arnaud F, Pappas G, Maudlin-Jeronimo E, Goforth C. Simulated aeromedical evacuation in a polytrauma rat model. Aerosp Med Hum Perform. 2019; 90(12):1016-1025.

The unexpected effect of Syrian civil war in Turkey: Change of forensic postmortem case pattern.

In the last decade, the whole world has witnessed a chaotic process characterized by uprisings, revolutions, and wars in the Middle East. The Syrian civil war, with its local and global consequences, is the most destructive of these events. Social and economic aspects of the effects of the Syrian civil war were discussed in detail. However, the change in forensic postmortem case pattern of neighboring countries remains unclear. Here, we aim to discuss the effects of the Syrian civil war on forensic postmortem case patterns in Turkey as a neighboring country, with possible causes and suggestions. The postmortem case patterns of the 5-year period before the beginning of the Syrian war (2006-2011) and the next 5-year period after the start of the war (2012-2016) were investigated retrospectively. This aims to reveal the possible effects of the Syrian civil war on forensic postmortem case pattern of Turkey in relation to the assault deaths of statistics of Turkey. We found that explosion-related and firearm-related death cases significantly increased after the Syrian civil war. The dramatic increase in the explosion-related deaths can be attributed to terrorist attacks. Wounded civilians during the civil war were admitted to health units and hospitals in the south and southeast parts of Turkey, which consequently result in a crisis in the application of health services. There was no significant difference in Turkish death statistics, however forensic case pattern was affected.

A descriptive study of US Special Operations Command fatalities, 2001 to 2018.

BACKGROUND: Studies of fatalities from injury and disease guide prevention and treatment efforts for populations at risk. Findings can inform leadership and direct clinical practice guidelines, research, and personnel, training, and equipment requirements. METHODS: A retrospective review and descriptive analysis was conducted of United States Special Operations Command (USSOCOM) fatalities who died while performing duties from September 11, 2001, to September 10, 2018. Characteristics analyzed included subcommand, military activity, operational posture, and manner of death. RESULTS: Of 614 USSOCOM fatalities (median age, 30 years; male, 98.5%) the leading cause of death was injury (97.7%); specifically, multiple/blunt force injury (34.5%), blast injury (30.7%), gunshot wound (GSW; 30.3%), and other (4.5%). Most died outside the United States (87.1%), during combat operations (85.3%), in the prehospital environment (91.5%), and the same day of insult (90.4%). Most fatalities were with the US Army Special Operations Command (67.6%), followed by the Naval Special Warfare Command (16.0%), Air Force Special Operations Command (9.3%), and Marine Corps Forces Special Operations Command (7.2%). Of 54.6% who died of injuries incurred during mounted operations, most were on ground vehicles (53.7%), followed by rotary-wing (37.3%) and fixed-wing (9.0%) aircrafts. The manner of death was primarily homicide (66.0%) and accident (30.5%), followed by natural (2.1%), suicide (0.8%), and undetermined (0.7%). Specific homicide causes of death were GSW (43.7%), blast injury (42.2%), multiple/blunt force injury (13.8%), and other (0.2%). Specific accident causes of death were multiple/blunt force injury (80.7%), blast injury (6.4%), GSW (0.5%), and other (12.3%). Of accident fatalities with multiple/blunt force injury, the mechanism was mostly aircraft mishaps (62.9%), particularly rotary wing (68.4%). CONCLUSION: Most USSOCOM fatalities died abroad from injury in the prehospital setting. To improve survival from military activities worldwide, leaders must continue to optimize prehospital capability and develop strategies that rapidly connect patients to advanced resuscitative and surgical care. LEVEL OF EVIDENCE: Epidemiological, level IV; Therapeutic level IV.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries.

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ±â€Š4.21 hours vs 3.77 ±â€Š2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Management of Major Burns in 37 Casualties of a Colored Powder Explosion: Experience of the Linkou Burn Center in Taiwan.

BACKGROUND: On June 27, 2015, a colored powder explosion occurred in Taiwan. As a result, 499 people were injured, and over 200 people were in critical condition because of severe burns. Forty-nine casualties were transported to the Chang Gung Memorial Hospital. METHODS: We undertook a single-center retrospective observational study using clinical data for 37 patients with major burns with more than 20% total burn surface area (TBSA). We describe the experience of managing patients with acute burn injuries in these patients. Patient-specific data were analyzed and expressed as mean ± standard deviation. RESULTS: Thirty-seven major burn patients were admitted to our hospital. The mean ± SD age was 22.5 ± 5 years. The mean ± SD TBSA was 48.9% ± 20%. All patients were stabilized within 6 hours after admission, and no patient experienced hypothermia or hypovolemia. We performed 95 debridement procedures and 88 skin grafts. A mean of 5.6 surgeries were performed for each patient. The mean ± SD hospital stay was 62 ± 32 days. The ratio for hospital days/%TBSA was 1.36, and hospital charges/hospital days ratio was US $973 a day for surviving patients. Two mortalities (2/37, 5.4%) were reported: one was related to cardiac insult, and another was caused by sepsis. CONCLUSIONS: We share our experience in managing 37 major burn patients in a colored powder explosion to improve the holistic care in modern mass burn casualties. Aggressive early debridement and skin grafting reduced hospital stay and costs.

Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort.

OBJECTIVE: Vascular injury is a leading cause of death and disability in military and civilian settings. Most wartime and an increasing amount of civilian vascular trauma arises from penetrating mechanisms of injury due to gunshot or explosion. The objective of this study was to provide a comprehensive examination of penetrating lower extremity arterial injury and to characterize long-term limb salvage and differences related to mechanisms of injury. METHODS: The military trauma registries of the United States and the United Kingdom were analyzed to identify service members who sustained penetrating lower limb arterial injury (2001-2014). Treatment and limb salvage data were studied and comparisons made of patients whose penetrating vascular trauma arose from explosion (group 1) vs gunshot (group 2). Standardized statistical testing was used, with Bonferroni corrections for multiple comparisons. RESULTS: The cohort consisted of 568 combat casualties (mean age, 25.2 years) with 597 injuries (explosion, n = 416; gunshot, n = 181). Group 1 had higher Injury Severity Score (P < .05) and Mangled Extremity Severity Score (P < .0001), required more blood transfusion (P < .05), and had more tibial (P < .01) and popliteal (P < .05) arterial injuries; group 2 had more profunda femoris injuries (P < .05). Initial surgical management for the whole cohort included vein interposition graft (33%), ligation (31%), primary repair with or without patch angioplasty (16%), temporary vascular shunting (15%), and primary amputation (6%). No difference in patency of arterial reconstruction was found between group 1 and group 2, although group 1 had a higher incidence of primary (13% vs 2%; P < .05) and secondary (19% vs 9%; P < .05) amputation. Similarly, longer term freedom from amputation was lower for group 1 than for group 2 (68% vs 89% at 5.5 years; Cox hazard ratio, 0.30; P < .0001), as was physical functioning (36-Item Short Form Health Survey data; mean, 39.80 vs 43.20; P < .05). CONCLUSIONS: The majority of wartime lower extremity arterial injuries result from an explosive mechanism that preferentially affects the tibial vasculature and results in poorer long-term limb salvage compared with those injured with firearms. The mortality associated with immediate limb salvage attempts is low, and delayed amputations occur weeks later, affording the patient involvement in the decision-making and rehabilitation planning. We recommend assertive attempts at vascular repair and limb salvage for service members injured by explosive and gunshot mechanisms.

From Northern Ireland to Afghanistan: half a century of blast injuries.

INTRODUCTION: Throughout the last half century, blast injuries have been a common occurrence to UK military personnel during combat operations. This study investigates casualty data from three different military operations to determine whether survivability from blast injuries has improved over time and whether the tactics used could have influenced the injuries sustained. METHODS: Casualty data from operations in Northern Ireland, Iraq and Afghanistan were reviewed and found to contain a total of 2629 casualties injured by improvised explosive devices. The injury severities were examined and the suitability of comparison between conflicts was considered. RESULTS: The case fatality rate and mean severity score sustained remained consistent among the operations included in this study. Using the New Injury Severity Score, the probabilities of survival were calculated for each separate operation. The body regions injured were identified for both fatalities and survivors. Using this information, comparisons of injury severities sustained at an Abbreviated Injury Scale of 3 and above (identified as a threshold for fatal injury) were conducted between the different operations. CONCLUSIONS: The data showed that as operations changed over time, survivability improved and the proportions of body regions injured also changed; however, this study also highlights how studying casualty data from different conflicts without taking account for the contextual differences may lead to misleading conclusions.

One hundred years (and counting) of blast-associated traumatic brain injury.

Blast-associated traumatic brain injury (TBI) has become one of the signature issues of modern warfare and is increasingly a concern in the civilian population due to a rise in terrorist attacks. Despite being a recognised feature of combat since the introduction of high explosives in conventional warfare over a century ago, only recently has there been interest in understanding the biology and pathology of blast TBI and the potential long-term consequences. Progress made has been slow and there remain remarkably few robust human neuropathology studies in this field. This article provides a broad overview of the history of blast TBI and reviews the pathology described in the limitedscientific studies found in the literature.

Fatal head and neck injuries in military underbody blast casualties.

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.