Injury modelling for strategic planning in protecting the national infrastructure from terrorist explosive events.

Terrorist events in the form of explosive devices have occurred and remain a threat currently to the population and the infrastructure of many nations worldwide. Injuries occur from a combination of a blast wave, energised fragments, blunt trauma and burns. The relative preponderance of each injury mechanism is dependent on the type of device, distance to targets, population density and the surrounding environment, such as an enclosed space, to name but a few. One method of primary prevention of such injuries is by modification of the environment in which the explosion occurs, such as modifying population density and the design of enclosed spaces. The Human Injury Predictor (HIP) tool is a computational model which was developed to predict the pattern of injuries following an explosion with the goal to inform national injury prevention strategies from terrorist attacks. HIP currently uses algorithms to predict the effects from primary and secondary blast and allows the geometry of buildings to be incorporated. It has been validated using clinical data from the '7/7' terrorist attacks in London and the 2017 Manchester Arena terrorist event. Although the tool can be used readily, it will benefit from further development to refine injury representation, validate injury scoring and enable the prediction of triage states. The tool can assist both in the design of future buildings and methods of transport, as well as the situation of critical emergency services required in the response following a terrorist explosive event. The aim of this paper is to describe the HIP tool in its current version and provide a roadmap for optimising its utility in the future for the protection of national infrastructure and the population.

Encouraging Firework Safety Through Public Service Announcements.

A dramatic increase in firework-related blast injuries to the hand and upper extremity resulted in record-setting numbers at our institution over the July 4, 2018, holiday. This led our hand and upper extremity department to create a public service announcement (PSA) campaign regarding firework safety and injury prevention. This PSA was broadcast in advance of the next July 4 holiday via several media platforms including television, radio, and the internet. The following year only 4 patients required surgery for firework-related blast injuries to the hand and upper extremity over the same 10-day period, including the weekends before and after the July 4, 2019, holiday. This represented a considerable reduction compared with the 14 patients seen within the same time frame in 2018. The purpose of this article was to outline the process and report the impact of creating and disseminating a public service announcement for firework-related blast injury prevention.

Comparing the medical coverage provided by four contemporary military combat helmets against penetrating traumatic brain injury.

INTRODUCTION: Modern military combat helmets vary in their shapes and features, but all are designed to protect the head from traumatic brain injury. Recent recommendations for protection against energised projectiles that are characteristic of secondary blast injury is to ensure coverage of both the brain and brainstem. METHOD: Graphical representations of essential coverage of the head (cerebral hemispheres, cerebellum and brainstem) within an anthropometrically sized model were superimposed over two standard coverage helmets (VIRTUS helmet, Advanced Combat Helmet (ACH)) and two 'high-cut' helmets (a Dismounted Combat Helmet (DCH)) and Combat Vehicle Crewman (CVC) helmet), both of which are designed to be worn with communications devices. Objective shotline coverage from representative directions of projectile travel (-30 to +30 degrees) was determined using the Coverage of Armour Tool (COAT). RESULTS: VIRTUS and ACH demonstrated similar overall coverage (68.7% and 69.5%, respectively), reflecting their similar shell shapes. ACH has improved coverage from below compared with VIRTUS (23.3% vs 21.7%) due to its decreased standoff from the scalp. The 'high-cut' helmets (DCH and CVC) had reduced overall coverage (57.9% and 52.1%), which was most pronounced from the side. CONCLUSIONS: Both the VIRTUS and ACH helmets provide excellent overall coverage of the brain and brainstem against ballistic threats. Coverage of both would be improved at the rear by using a nape protector and the front using a visor. This is demonstrated with the analysis of the addition of the nape protector in the VIRTUS system. High-cut helmets provide significantly reduced coverage from the side of the head, as the communication devices they are worn with are not designed to provide protection from ballistic threats. Unless absolutely necessary, it is therefore recommended that high-cut helmets be worn only by those users with defined specific requirements, or where the risk of injury from secondary blast is low.

Medicinal plants in traumatic brain injury: Neuroprotective mechanisms revisited.

Traumatic brain injury (TBI) is the most prevalent health problem affecting all age groups, and leads to many secondary problems in other organs especially kidneys, gastrointestinal tract, and heart function. In this review, the search terms were TBI, fluid percussion injury, cold injury, weight drop impact acceleration injury, lateral fluid percussion, cortical impact injury, and blast injury. Studies with Actaea racemosa, Artemisia annua, Aframomum melegueta, Carthamus tinctorius, Cinnamomum zeylanicum, Crocus sativus, Cnidium monnieri, Curcuma longa, Gastrodia elata, Malva sylvestris, Da Chuanxiong Formula, Erigeron breviscapus, Panax ginseng, Salvia tomentosa, Satureja khuzistanica, Nigella sativa, Drynaria fortune, Dracaena cochinchinensis, Polygonum cuspidatum, Rosmarinus officinalis, Rheum tanguticum, Centella asiatica, and Curcuma zedoaria show a significant decrease in neuronal injury by different mechanisms such as increasing superoxide dismutase and catalase activities, suppressing nuclear factor kappa B (NF-κB), interleukin 1 (IL-1), glial fibrillary acidic protein, and IL-6 expression. The aim of this study was to evaluate the neuroprotective effects of medicinal plants in central nervous system pathologies by reviewing the available literature.

Using the Haddon matrix to explore medical response strategies for terrorist subway bombings.

BACKGROUND: Since the 1970s, terrorist bombings in subways have been frequently occurring worldwide. To cope with this threat and to provide medical response countermeasures, we analyzed the characteristics of subway bombing terrorist attacks and used the Haddon matrix to explore medical response strategies. METHODS: First, we analyzed 111 subway bombings from 1970 to 2017 recorded in the Global Terrorism Database to provide a reference for the strategy exploration. Then, we convened an expert panel to use the Haddon matrix to explore the medical response strategies to subway bombings. RESULTS: In recent decades, at least one bombing attack occurs every 3 years. Summarized by the Haddon matrix, the influencing factors of medical responses to conventional subway bombings include the adequacy of first-aid kits and the medical evacuation equipment, the traffic conditions affecting the evacuation, the continuity and stability of communication, as well as the factors exclusively attributed to dirty bomb attacks in subways, such as ionizing radiation protection capabilities, the structure of the radiation sickness treatment network based on the subway lines, and the disposal of radioactive sewage. These factors form the basis of the strategy discussion. CONCLUSION: Since subway bombings are long-term threats, it is necessary to have proper medical response preparation. Based on the Haddon matrix, we explored the medical response strategies for terrorist subway bombings, especially dirty bomb attacks. Haddon matrix can help policymakers systematically find the most important factors, which makes the preparations of the response more efficient.

Protection of the lung from blast overpressure by stress wave decouplers, buffer plates or sandwich panels.

INTRODUCTION: This paper outlines aspects of UK Ministry of Defence's research and development of blast overpressure protection technologies appropriate for use in body armour, with the aim of both propagating new knowledge and updating existing information. METHODS: Two simple models are introduced not only to focus the description of the mechanism by which the lungs can be protected, but also to provide a bridge between fields of research that may hold the key to further advances in protection technology and related body armour. RESULTS: Protection can be provided to the lungs by decoupling the stress wave transmission into the thorax by managing the blast energy imparted through the protection system. CONCLUSIONS: It is proposed that the utility of the existing 'simple decoupler' blast overpressure protection is reviewed in light of recent developments in the treatment of those sustaining both overpressure and fragment injuries. It is anticipated that further advances in protection technology may be generated by those working in other fields on the analogous technologies of 'buffer plates' and 'sandwich panels'.

Unexploded Ordnance Management.

The purpose of this Clinical Practice Guide is to provide details on the procedures to safely remove unexploded ordnance from combat patients, both loose and impaled, to minimize the risks to providers and the medical treatment facility while ensuring the best outcome for the patient. Military ordnance, to include bullets, grenades, flares, and explosive ordnance, retained by a patient can be a risk to all individuals and equipment along the continuum of care. This is especially true from the point of injury to the first treatment facility. Management of patients with unexploded ordnance either on or in their body is a rare event during combat surgery. Loose munitions are usually noted and easily removed prior to the patient receiving medical treatment. However, impaled munitions provide a significant challenge. These are usually caused by large caliber, high-velocity projectiles. Patients who survive to arrive at a treatment facility must be triaged safely and simultaneously treated appropriately to ensure both the survival of the patient and the treatment team. Between WWII and the Somalia conflict, there have been 36 reported cases of unexploded ordnance from U.S. soldiers. Since 2005, there have been six known cases during the U.S. wars in Afghanistan and Iraq and one additional case in Pakistan. Optimal outcomes require a basic knowledge of explosives and triggering mechanisms, as well as adherence to basic principles of trauma resuscitation and surgery.

Is There a Threat Towards Medical Institutions, and What to Do?

Unfortunately the reality of today is that a terrorist threat in Europe has become evident. With increasing frequency we are confronted with attacks all across Europe, at least this is the perception. So is there a Threat? If look at the paper of Wolf et al (1), this describes an increase of terrorist attacks from 1999- 2006, the amount of victims due to these attacks increased exponentially. This means the attacks are getting more effective. The perpetrators are getting better and are learning how to injure or kill more victims. The techniques are getting more sophisticated. For example if we look at the Bali Bombing in 2002, here a second hit technique is used. The terrorist placed first a small bomb in a tourist area, knowing that this eventually will attract many people who rush in to help the victims. Then a second hit was done with a much larger bomb killing and wounding even a larger group of people. This is the goal of the terrorist, introducing terror, shocking the world, introduce fear. If we look at the attack in Nice, South France. They used a truck driving through a large tourist crowd, knowing that there would be many children and young people. This is their ultimate goal, shock the world. With that mindset, just imagine how shocking would it be to primary attack a medical institution. Our weakness as medical people is that we want to help people, In fact we gave a Hippocratic oath that we will always help other people, that is our job. We find it hard to believe that medical relief institutions will be attacked. If we look at the London bombing in 2005, one of the terrorists detonated the bomb in a bus. By coincidence this happened right in front of the British Medical Association with many doctors in the building at that time. All of them immediately went to the exploded bus to provide medical relieve, did they even think for a second that there maybe would be a second hit? We are to nice, and the terrorists know this. Historyhas proven to us that medical institutions are a potential goal. 2008 a terror attack in Mumbai, eight series of attacks were done between 26-29th of November. Eventually the terrorist where heading for the CAMA hospital. However because the hospital was alerted and were able to perform a complete lock down they were able to prevent additional casualties in the hospital itself. Are these rare incidents?

Chest response assessment of post-mortem swine under blast loadings.

To better protect soldiers from blast threat, that principally affect air-filled organs such a lung, it is necessary to develop an adapted injury criterion and, prior to this, to evaluate the response of a biological model against that threat. The objective of this study is to provide some robust data to quantify the chest response of post-mortem swine under blast loadings. 7 post-mortem swine (54.5 ±â€¯2.6 kg), placed side-on to the threat and against the ground, were exposed to 5 shock-waves of increasing intensities. Their thorax were instrumented with a piezo-resistive pressure sensor, an accelerometer directly exposed to the shock-wave and a target was mounted on the latter in order to track the chest wall displacement. For incident impulses ranging from 47 kPa ms±2% to 173 kPa ms ±6%, the measured maximum of linear chest wall acceleration (Γmax) goes from 5800 m/s2 ±16% to 41,000 m/s2 ±â€¯8%, with a duration of 0.8 ms. Chest wall displacements ranging from 5 mm ±â€¯20% to 20 mm ±â€¯15%, with a duration of 9 ms, are reached. These reproducible data were used to find simple relations (linear, 2nd and 3rd order polynomials) between the kinematic parameters (plus the viscous criterion) and the incident and reflected impulses. Correlating the new reproducible data with the prediction from the Bowen curves showed a lung injury threshold in terms of Γmax similar to that of Cooper (10,000 m/s2). However, the limits defined for the viscous criterion in the automobile field and for non-lethal weapons seems not adapted for the blast threat.

Firework-related injury in the Top End: a 16-year review.

BACKGROUND: On July 1st on 'Territory Day', the public in the Northern Territory are permitted to purchase and operate consumer fireworks without a licence. Serious permanent injuries from fireworks are well described, leading to their banning in many other jurisdictions. This study describes those seriously injured by fireworks in the Top End of the Northern Territory, with the aim of identifying opportunities for prevention and harm minimization. METHODS: This is a retrospective audit of all admitted patients with an injury from fireworks at the Royal Darwin Hospital between 2000 and 2015. The variables collected included demographic data and the circumstances around injury (operator versus bystander, alcohol involvement and day of device operation). The consequences such as injuries, operating theatre visits, length of stay and outpatient visits are described. RESULTS: Fifty-five patients (including 17 children) suffered 67 injuries over the study period, resulting in 68 operating theatre visits, 322 hospital days and 380 outpatient appointments. Burns, hand and eye injuries predominate. Females (P = 0.000) and children (P = 0.029) were more likely to be injured as bystanders. Injuries on a day other than Territory Day were more likely to have alcohol involvement (P = 0.01), and occur in the operator (P = 0.017). CONCLUSION: Consumer firework usage results in a small number of life altering injuries annually. Previous prevention campaigns focusing on device user safety should be expanded to include the safety of bystanders and children and reduce firework usage outside of the Territory Day.

Pirotecnia: lesiones graves de mano asociadas a explosión de un tipo de dispositivo (megapetardo/superbomba) / Pyrotechnics: severe hand lesions associated to the explosion of a certain device (megafirecrackers/superbombs)

Resumen Introducción: el uso de fuegos artificiales y dispositivos de pirotecnia forma parte de celebraciones y espectáculos públicos en todo el mundo. En Uruguay, su uso se encuentra concentrado en los meses estivales en eventos públicos y privados. Hay normativas para su uso, la importación y venta está regulada. En el verano de 2014-2015 hubo cuatro niños con lesiones graves de mano producidas por explosivos. Todas en circunstancias similares, compartieron el mismo mecanismo lesional y vinculados a un único dispositivo. En el año 2016 hubo más niños con iguales injurias. Objetivo: comunicar una serie de niños con injurias provocadas por un tipo de explosivo de pirotecnia con un patrón diferente al conocido previamente. Resultados: n=6. Todos varones, cinco adolescentes. Los seis presentaron lesiones severas en manos con amputación de uno o varios dedos, determinando secuelas estéticas y funcionales. Discusión: se identifica los dispositivos con alto contenido en pólvora y el mal uso de los mismos como factores asociados a las lesiones graves de mano. Se realizó una campaña desde la Sociedad Uruguaya de Pediatría, el Departamento de Emergencia Pediátrica, el Ministerio de Salud y otras autoridades para abordar este problema. Se prohíbe la venta de ese dispositivo. Conclusiones: la utilización de dispositivos de pirotecnia con alto contenido de pólvora como el megapetardo o superbomba puede determinar lesiones graves de mano, mutilantes y secuelas permanentes. No se recomienda la manipulación de fuegos artificiales por parte de los niños. El cumplimiento de las normativas vigentes y el correcto uso de los mismos podrían contribuir a disminuir estas injurias.

Summary Introduction: the use of fireworks and pyrotechnic devices are ways of public entertainment and celebration around the world. In Uruguay, they are more frequently used during summer-time in public and private events. Usage, import and sales are regulated by law. In summer 2014-2015 four children presented severe hand injuries caused by blasts, all of which occurred under similar conditions, shared the same injury mechanism and were linked to a specific device. In 2016 there were more children with similar lesions. Objective: to report a series of children with hand lesions caused by a certain type of pyrotechnic device with a pattern that was different from the one previously known. Results: n=6. All of them males 5 adolescents. The 6 children studied presented severe lesions in hands with amputation of 1 or several fingers, which resulted in aesthetic and functional sequelae. Discussion: devices with a high dose of gunpowder and their incorrect use are identified as factors associated to severe lesions. The Uruguayan Society of Pediatrics, the Pediatrics Emergency Department and the Ministry of Health, among other authorities, conducted a campaign to address this issue. The sale of this device is prohibited. Conclusions: the use of pyrotechnic devices with a high dose of gunpowder such as mega firecrackers or superbombs can result in severe hand lesions, mutilation and permanent sequelae. The handling of fireworks by children is not recommended. Fulfillment of updated regulations and the correct use of fireworks might contribute to diminishing these injuries.

Erythropoietin either Prevents or Exacerbates Retinal Damage from Eye Trauma Depending on Treatment Timing.

PURPOSE: Erythropoietin (EPO) is a promising neuroprotective agent and is currently in Phase III clinical trials for the treatment of traumatic brain injury. The goal of this study was to determine if EPO is also protective in traumatic eye injury. METHODS: The left eyes of anesthetized DBA/2J or Balb/c mice were exposed to a single 26 psi overpressure air-wave while the rest of the body was shielded. DBA/2J mice were given intraperitoneal injections of EPO or buffer and analyses were performed at 3 or 7 days post-blast. Balb/c mice were given intramuscular injections of rAAV.EpoR76E or rAAV.eGFP either pre- or post-blast and analyses were performed at 1 month post-blast. RESULTS: EPO had a bimodal effect on cell death, glial reactivity, and oxidative stress. All measures were increased at 3 days post-blast and decreased at 7-days post-blast. Increased retinal ferritin and NADPH oxygenases were detected in retinas from EPO-treated mice. The gene therapy approach protected against axon degeneration, cell death, and oxidative stress when given after blast, but not before. CONCLUSIONS: Systemic, exogenous EPO and EPO-R76E protects the retina after trauma even when initiation of treatment is delayed by up to 3 weeks. Systemic treatment with EPO or EPO-R76E beginning before or soon after trauma may exacerbate protective effects of EPO within the retina as a result of increased iron levels from erythropoiesis and, thus, increased oxidative stress within the retina. This is likely overcome with time as a result of an increase in levels of antioxidant enzymes. Either intraocular delivery of EPO or treatment with non-erythropoietic forms of EPO may be more efficacious.

A Novel Classification System for Injuries After Electronic Cigarette Explosions.

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study.

BACKGROUND: Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries. METHODS: We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups. RESULTS: Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries. CONCLUSION: The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Novel method for comparing coverage by future methods of ballistic facial protection.

The wearing of eye protection by United Kingdom soldiers in Afghanistan has reduced the morbidity caused by explosive fragments. However, the remaining face remains uncovered because there is a lack of evidence to substantiate the procurement of methods to protect it. Using a new computerised tool we entered details of the entry sites of surface wounds caused by explosive fragments in all UK soldiers who were injured in the face between 1 January 2010 and 31 December 2011. We compared clinical and predicted immediate and long term outcomes (as defined by the Abbreviated Injury Score (AIS) and the Functional Capacity Index (pFCI), respectively). We also used the tool to predict how additional protection in the form of a visor and mandible guard would affect outcomes. A soldier wearing eye protection was 9 times (1.03/0.12) less likely to sustain an eye injury than one without. However, 38% of soldiers in this series were not wearing eye protection at the time of injury. There was no significant difference between the AIS and pFCI scores predicted by the tool and those found clinically. There is limited evidence to support the use of a mandible guard; its greatest asset is better protection of the nose, but a visor would be expected to reduce long-term morbidity more than eye protection alone, and we recommend future trials to assess its acceptability to users. We think that use of this novel tool can help in the selection of future methods of ballistic facial protection.

Defining combat helmet coverage for protection against explosively propelled fragments.

INTRODUCTION: Prevention against head wounds from explosively propelled fragments is currently the Mark 7 general service combat helmet, although only limited evidence exists to define the coverage required for the helmet to adequately protect against such a threat. The Royal Centre for Defence Medicine was tasked by Defence Equipment and Support to provide a framework for determining the optimum coverage of future combat helmets in order to inform the VIRTUS procurement programme. METHOD: A systematic review of the literature was undertaken to identify potential solutions to three components felt necessary to define the ideal helmet coverage required for protection against explosively propelled fragments. RESULTS: The brain and brainstem were identified as the structures requiring coverage by a helmet. No papers were identified that directly defined the margins of these structures to anatomical landmarks, nor how these could be related to helmet coverage. CONCLUSIONS: We recommend relating the margins of the brain to three identifiable anatomical landmarks (nasion, external auditory meatus and superior nuchal line), which can in turn be related to the coverage provided by the helmet. Early assessments using an anatomical mannequin indicate that the current helmet covers the majority of the brain and brainstem from projectiles with a horizontal trajectory but not from ones that originate from the ground. Protection from projectiles with ground-originating trajectories is reduced by helmets with increased stand-off from the skin. Future helmet coverage assessments should use a finite element numerical modelling approach with representative material properties assigned to intracranial anatomical structures to enable differences in projectile trajectory and helmet coverage to be objectively compared.

Demonstrating the effectiveness of body armour: a pilot prospective computerised surface wound mapping trial performed at the Role 3 hospital in Afghanistan.

INTRODUCTION: Modern body armour clearly reduces injury incidence and severity, but evidence to actually objectively demonstrate this effect is scarce. Although the Joint Theatre Trauma Registry (JTTR) alone cannot relate injury pattern to body armour coverage, the addition of computerised Surface Wound Mapping (SWM) may enable this utility. METHOD: Surface wound locations of all UK and NATO coalition soldiers, Afghan National Army and Police and local nationals injured by explosively propelled fragments and treated in the Role 3 UK-led Field Hospital in Camp Bastion, Afghanistan, between 8 July and 20 October 2012 were prospectively recorded. The Abbreviated Injury Scores (AIS) and relative risk of casualties sustaining injuries under a type of body armour were compared with those that did not wear that armour. RESULTS: Casualties wearing a combat helmet were 2.7 times less likely to sustain a fragmentation wound to the head than those that were unprotected (mean AIS of 2.9 compared with 4.1). Casualties wearing a body armour vest were 4.1 times less likely to sustain a fragmentation wound to the chest or abdomen than those that were unprotected (mean AIS of 2.9 compared with 3.9). Casualties wearing pelvic protection were 10 times less likely to sustain a fragmentation wound to the pelvis compared with those that were unprotected (mean AIS of 3.4 compared with 3.9). DISCUSSION: Computerised SWM has objectively demonstrated the ability of body armour worn on current operations in Afghanistan to reduce wound incidence and severity. We recognise this technique is limited in that it only records the surface wound location and may be specific to this conflict. However, gathering electronic SWM at the same time as recording injuries for the JTTR was simple, required little extra time and therefore we would recommend its collection during future conflicts.

Using computerised surface wound mapping to compare the potential medical effectiveness of Enhanced Protection Under Body Armour Combat Shirt collar designs.

INTRODUCTION: Protecting the neck from explosively propelled fragments has traditionally been achieved through a collar attached to the ballistic vest. An Enhanced Protection Under Body Armour Combat Shirt (EP-UBACS) collar has been identified as an additional method of providing neck protection but limited evidence as to its potential medical effectiveness exists to justify its procurement. METHOD: Entry wound locations and resultant medical outcomes were determined using Abbreviated Injury Scale (AIS) for all fragmentation neck wounds sustained by UK soldiers between 01 January 2010 and 31 December 2011. Data were prospectively entered into a novel computerised tool base and comparisons made between three EP-UBACS neck collar designs in terms of predicted reduction in AIS scores. RESULTS: All collars reduced AIS scores, with the greatest reduction provided by designs incorporating increased standoff from the neck and an additional semi-circle of ballistic material underneath the collar at the front and back. DISCUSSION: This technique confirms that reinforcing the neck collar of an EP-UBACS would be expected to reduce injury severity from neck wounds. However, without knowledge of entry wound locations for injuries to other body areas as well as the use of AIS scores without clinical or pathological verification its further use in the future may be limited. The ability to overlay any armour design onto a standardised human was potentially the most useful part of this tool and we would recommend developing this technique using underlying anatomical structures and not just the skin surface.

The past and present of blast injury research in China.

With the increasing incidence of blast injury, the research on its mechanisms and protective measures draws more and more attention. Blast injury has many characteristics different from general war injuries or trauma. For example, soldiers often have various degrees of visceral injury without significant surface damage, combined injuries and arterial air embolism. Researchers in China began to investigate blast injury later than the United States and Sweden, but the development is so fast that lots of achievements have been gained, including the development of biological shock tube, the mechanisms and characteristics of blast injury in various organs, as well as protective measures under special environments. This article reviews the past and current situation of blast injury research in China.