[Ballistic injury, decaying wounds: the nurse at the heart of the long rehabilitation process]. / Lésion balistique, plaies délabrantes : l'infirmier au cœur du long parcours de réhabilitation.

Ballistic injuries are disabling. Its functional impact is determined by its trajectory. Whether the injury affects a limb that could jeopardize its preservation, visceral lesions or craniocerebral and vertebro-medullary wounds, the nurse is at the heart of multidisciplinary care to limit and compensate for the after-effects. Directed healing, appropriate analgesia, settling in, technical training for this new, modified body (stoma, self-catheterization, appliances, etc.) and support in accepting the injury are all part of the nurse's role in helping the injured person rebuild his or her life.

Psychosocial care for hospitalized young survivors after the terror attack on Utøya Island: A qualitative study of the survivors' experiences.

OBJECTIVE: The objective of the study was to explore hospitalized youths' experiences with psychosocial care in the hospital after the shooting on Utøya Island, Norway, in 2011. METHODS: 17 hospitalized youths were interviewed face-to-face 30-31 months after the attack. The interviews were analysed using interpretative phenomenological analysis (IPA). The initial reading and coding of the interviews was carried out inductively. To explore the emphasis placed on everyday conversation and ordinary interaction detected during the initial reading, the text was re-read while bearing in mind concepts from the research field of sociology concerning the therapeutic potential in commonplace conversations and situations. RESULTS: The youths highlighted the need for health care workers to embrace essential aspects of their past, present and future. Therefore, three overarching categories emerged related to 1) Remembering the past, 2) Dealing with the present and 3) Preparing for the future. For each temporal category, two related subcategories were identified: Past:Engaging in the trauma narrative; Understanding the trauma reminders; Present: Bringing back normalcy; Being there; Future: Supporting confidence; Instilling trust. CONCLUSIONS: For the youths in the current study, talking with the hospital staff about their traumatic experiences was mostly perceived as positive and linked to various helpful outcomes. In addition to engaging in the trauma narrative, the staff needed to comprehend and address how the traumatic experiences and the hospitalization resulted in the survivors' extended fear and changed appraisals about the world and themselves. Having the time to stay physically and mentally close to the youths and engage in everyday interaction was crucial in rebuilding their sense of safety and bringing back normalcy. The hospital staff played a significant role in strengthening the survivors' confidence in own capabilities and trust in others. The different professionals in the hospital contributed to various aspects of psychosocial care, and both trauma-focused interventions and commonplace conversations and actions were emphasized as important and meaningful approaches.

Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation.

OBJECTIVEThere are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).METHODSThis study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.RESULTSA total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.CONCLUSIONSGood functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.

[Successful treatment and rehabilitation of severe, penetrating brain injury].

Penetrating brain injuries due to gunshots are rare in Denmark. This is a case report of the successful treatment of a 31-year-old man who was shot in the right frontal region of the head. The bullet went through his brain without damaging the large intracranial vessels. On admission he had a GCS of 9. Haematoma removal and bifrontal craniectomy was performed to obtain lowering of the intracranial pressure. One year after the incidence the patient was able return to work. This case report illustrates the importance of early prehospital and neurointensive treatment with lowering of the intracranial pressure and highly specialised rehabilitation.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

INTRODUCTION: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Characteristics of Firearm Brain Injury Survivors in the Traumatic Brain Injury Model Systems (TBIMS) National Database: A Comparison of Assault and Self-Inflicted Injury Survivors.

OBJECTIVE: To characterize and compare subgroups of survivors with assault-related versus self-inflicted traumatic brain injuries (TBIs) via firearms at the time of inpatient rehabilitation and at 1-, 2-, and 5-year follow-up. DESIGN: Secondary analysis of data from the Traumatic Brain Injury Model Systems National Database (TBIMS NDB), a multicenter, longitudinal cohort study. SETTING: Retrospective analyses of a subset of individuals enrolled in the TBIMS NDB. PARTICIPANTS: Individuals 16 years and older (N=399; 310 via assault, 89 via self-inflicted injury) with a primary diagnosis of TBI caused by firearm injury enrolled in the TBIMS NDB. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability Rating Scale, Glasgow Outcome Scale-Extended, sociodemographic variables (sex, age, race, marital status), injury-related/acute care information (posttraumatic amnesia, loss of consciousness, time from injury to acute hospital discharge), and mental health variables (substance use history, psychiatric hospitalizations, suicide history, incarcerations). RESULTS: Individuals who survived TBI secondary to a firearm injury differed by injury mechanism (assault vs self-inflicted) on critical demographic, injury-related/acute care, and mental health variables at inpatient rehabilitation and across long-term recovery. Groups differed in terms of geographic area, age, ethnicity, education, marital status, admission Glasgow Coma Scale score, and alcohol abuse, suicide attempts, and psychiatric hospitalizations at various time points. CONCLUSIONS: These findings have implications for prevention (eg, mental health programming and access to firearms in targeted areas) and for rehabilitation planning (eg, by incorporating training with coping strategies and implementation of addictions-related services) for firearm-related TBI, based on subtype of injury.

Removable Partial Denture After Gunshot Injury: Five Year Follow-Up.

The aim of this study was to report a patient of rehabilitation with removable partial denture retained by implants in-patient who suffered injury after firearm shooting. A 19-year-old man presented to the hospital of the Val Paraíso city after being hit by a bullet in the right on the face, affecting the teeth 12 to 16. The surgery to remove the shards of teeth, and bullet was performed. Surgical team opted for installation of implants without bone grafts; however, due to extensive loss of alveolar bone, only 3 tilted implants (2 Ø3.75 × 8.5 mm and 1 Ø3.75 × 10 mm) were installed. After recovery, the patient was referred to the Araçatuba Dental School-UNESP for the rehabilitation on the affected region. The difficulty of rehabilitation with conventional fixed prostheses was verified during the prosthetic phase. This way, it was opted for rehabilitation with removable partial dentures associated with dental implant. Two attachment system ERA (ERA, Sterngold) were positioned in the bar to make the removable partial denture. After 5 years of follow-up, the authors can conclude that the use of removable partial denture retained by implants is effective for functional and aesthetic rehabilitation, favoring socialization and self-esteem of the patient.

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan.

INTRODUCTION: The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan. METHODS: Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013. RESULTS: 566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK. CONCLUSIONS: The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.

Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: A systematic approach of three cases.

Gunshot injuries are always known to cause severe morbidity and mortality when head and neck are involved. They vary in morbidity, which can occur in civilian surroundings. The wound largely depends on the type of weapon, mass and velocity of the bullet, and the distance from where it has been shot. Close-range gunshot wounds in the head and neck region can result in devastating aesthetic and functional impairment. The complexity in facial skeletal anatomy cause multiple medical and surgical challenges to an operating surgeon, demanding elaborate soft and hard tissue reconstruction. Here we presented the successful management of three patients shot by short-range pistol with basic life support measures, wound management, reconstruction and rehabilitation.

Overutilization of bracing in the management of penetrating spinal cord injury from gunshot wounds.

OBJECTIVE Penetrating gunshot wounds (GSWs) to the spinal column are stable injuries and do not require spinal orthoses or bracing postinjury. Nonetheless, a high number of GSW-related spinal cord injury (SCI) patients are referred with a brace to national rehabilitation centers. Unnecessary bracing may encumber rehabilitation, create skin breakdown or pressure ulcers, and add excessive costs. The aim of this study was to confirm the stability of spinal column injuries from GSWs and quantify the overutilization rate of bracing based on long-term follow-up. METHODS This retrospective cohort study was performed at a nationally renowned rehabilitation center. In total, 487 GSW-related SCI patients were transferred for rehabilitation and identified over the last 14 years. Retrospective chart review and telephone interviews were conducted to identify patients who were braced at the initial treating institution and determine if late instability, deformity, or neurological deterioration resulted in secondary surgery or intervention. In addition, 396 unoperated patients were available for analysis after 91 patients were excluded for undergoing an initial destabilizing surgical dissection or laminectomy, thereby altering the natural history of the injury. All of these 396 patients who presented with a brace had bracing discontinued upon reaching the facility. RESULTS In total, 203 of 396 patients were transferred with a spinal brace, demonstrating an overutilization rate of 51%. No patients deteriorated neurologically or needed later surgery for spinal column deformity or instability attributable to the injury. All patients had stable injuries. The patterns of injury and severity of neurological injury did not vary between patients who were initially braced or unbraced. The average follow-up was 7.8 years (range 1-14 years) and the average age was 25 years (range 10-62 years). CONCLUSIONS The incidence of brace overutilization for penetrating GSW-related SCI was 51%. Long-term follow-up in this study confirmed that these injuries were stable and thus did not require bracing. No patients deteriorated neurologically, whether or not they were initially braced. The unnecessary use of spinal orthoses increases costs and patient morbidity. Reeducation and dissemination of this information is warranted.

Collaborative Establishment of an Integrated Orthotic and Rehabilitation Pathway.

Returning to active military duty and to recreational activities has been difficult for service members sustaining combat-related high-energy lower extremity trauma (HELET). The Return to Run (RTR) clinical pathway was introduced in 2009 with favorable results in returning active duty service members to running, sports participation, active duty, and deployments. The RTR pathway was introduced at a second institution in 2011 to determine if the pathway could be reproduced at a different institution. In this study, a series of patients is presented who underwent limb salvage procedures after sustaining HELET at an outside military treatment facility and subsequently participated in the authors' RTR protocol. They received a novel orthotic device from the San Antonio Military Medical Center and returned to their home institution for rehabilitation. In this cohort, an improvement in functional capability was obtained in nearly all patients. In conclusion, successful translation of the integrated orthotic and rehabilitation initiative to outside institutions is possible.

Penetrating brain injury: a case report.

BACKGROUND: Gunshot wounds as a result of attempted suicide, criminality or warfare comprise a significant group among penetrating injuries of the brain. A prognosis in such cases is based mainly on an initial score on the Glasgow Coma Scale (GCS). According to the literature, the mortality rate among patients with initial GCS ranging from 3 to 5 points is very high, up to 98.5%. Although there are also many other prognostic factors for high mortality, such as damage to the ventricular system or the involvement of two or more lobes, GCS score seems to be the most important determinant. The treatment in an ICU which is focused on decreasing the risk of secondary brain damage can significantly improve the prognosis and final outcome. CASE REPORT: The authors present the case of a 27-year-old man who suffered a gunshot wound to the right temporal region, self-inflicted from an air-gun. On admission to the intensive care unit he received a score of 3 points on the GCS. There were also other negative prognostic factors - the pellet penetrated two lobes and damaged the third ventricle. Despite the serious prognosis, the appropriate multiprofile treatment and rehabilitation resulted in unexpectedly good recovery. Two years after the trauma the patient was conscious, maintained logical verbal contact, and was able to walk using a walking-aid. CONCLUSION: Rapid transport to a major trauma center is essential for patients with penetrating brain injury. Among all interventions it seems essential to provide the prevention of posttraumatic nervous tissue damage and associated neurological dysfunction.

Manejo de lesión traumática de arteria femoral con injerto autólogo de vena safena en zona de operaciones / Management of traumatic injury of femoral artery with autologous saphenous vein graft in area of operations

Tanto en el ámbito civil como en el militar, las lesiones vasculares de las extremidades inferiores son frecuentes y potencialmente mortales. Las medidas de soporte iniciales para combatir el shock, una actitud quirúrgica técnicamente correcta encaminada a reparar precozmente la vascularización del miembro y un control postoperatorio estricto y continuo son los pilares básicos del tratamiento. En condiciones óptimas, las tasas de amputación y de mortalidad se hallan por debajo del 10 y del 4%, respectivamente. Presentamos a continuación un caso de un militar afgano con una lesión con pérdida de substancia de la arteria femoral en el que se consiguió una revascularización inicial con un shunt temporal. Tras ser estabilizado y evacuado al ROLE 2 de Herat, se realizó un injerto autólogo de la vena safena contralateral

In both the military and civilian settings, traumatic vascular extremity trauma is an uncommon but potentially fatal injury. Principles of treatment involve correcting shock, rapid surgical restoration of blood flow, and strict postoperative surveillance. Under optimal conditions for these injuries, the rate of amputation and mortality are below 10% and 4%, respectively. We present a case of an Afghan soldier who suffered a major traumatic extremity injury in an austere environment. Early revascularization was temporized with an arterial shunt. After his condition stabilized, he was evacuated to the next echelon of care, where a definitive an autologous reverse saphenous vein bypass was performed

Reconstructive and rehabilitation challenges following a cranio-orbital gunshot wound.

We present a case of a 26-year-old man who sustained a close-range gunshot wound to the head. His injuries included significant left orbital injury resulting in a ruptured, blind eye and severely comminuted fractures of the left orbital roof, superior and inferior orbital rims, and orbital floor. Associated injuries included left frontal lobe injury, anterior and posterior table fractures of the left frontal sinus, and a comminuted left zygomaticomaxillary complex fracture. We employed an interdisciplinary surgical approach with collaboration among the Otolaryngology, Neurosurgery, and Oculoplastic Surgery services performed in two stages. Management of such extensive craniofacial injuries can be challenging and requires a coordinated, interdisciplinary approach.

Zygomatic implants as a rehabilitation approach for a severely deficient maxilla.

A gunshot injury is one of the main trauma injuries that affect the head and neck region. Severe esthetic, functional, and psychologic deficiencies are consequences of gunshot injuries. The use of implants anchored in the zygomatic bone has been advocated as an approach to the prosthetic rehabilitation of a severely deficient maxilla. This approach provides the patient with an immediate, high-quality, esthetic, and functional complete fixed prosthesis and eliminates the need for bone grafting. In this case report, a patient with a severely deficient maxilla caused by a gunshot injury was rehabilitated by placement of four zygomatic and two pterygomaxillary implants, which were immediately loaded with a complete fixed all-acrylic resin interim prosthesis. The definitive CM Prosthesis (CM Prosthetics) was constructed using computer-aided design/computer-assisted manufacture (CAD/CAM) technology.

Rehabilitation of a patient with gunshot injury through the iliac graft and implant-retained restorations with a 3-year follow-up: a brief clinical study.

Trauma is one of the most common causes of teeth loss. Assault with a gunshot and bullet shot is life threatening, and for patients who survive the injury, it results in hard and soft tissue loss in the tissues and organs crossed by the bullet. The tissue loss results in the loss of structure and function. Rehabilitation of these patients to function and aesthetics requires surgical and prosthodontic procedures over time. This report is of a 24-year-old male patient who had a bullet injury resulting in hard and soft tissue deficiency. The ridge deficiency was augmented with iliac bone graft, and 3 months later, implants were placed. Five months later, hybrid prosthesis was delivered. At 3-year follow-up visit, the hybrid prosthesis was replaced with porcelain fused to a metal bridge. The bone levels on all the implants were stable.

Maxillary reconstruction using microvascular free flaps.

OBJECTIVE: Loss of all or part of the maxilla as a result of tumor ablation has both functional and aesthetic consequences. Reconstruction of the maxilla remains a challenge despite the availability of several flaps and the skills of the prosthodontist. We have analyzed a series of maxillary resections that underwent flap reconstruction to guide planning of the rehabilitation of patients with such defects. STUDY DESIGN: The authors present 83 patients with various types of maxillary defects that were reconstructed with different microvascular free flaps. All clinical data, including data on the functional and aesthetic outcome, are analyzed. RESULTS: Flap transfer was successful in 80 of 83 patients who underwent maxillary reconstruction. Separation of the oral and nasal cavities was achieved in all cases. Flap compromise occurred in 6 cases, which made revision necessary. Three of these flaps were salvaged and 3 flaps failed. In 10 of 28 patients with transferred bone, osseointegrated implants were inserted and dentally rehabilitated with excellent functional and aesthetic results. CONCLUSION: Various types of maxillary defects can be reconstructed successfully using different microvascular free flaps. This procedure is challenging because of the anatomical site of reconstruction creating a steep learning curve. If the reconstruction is successful, both facial appearance and oral function can be improved. Microvascular flaps containing bone of the fibula, scapula, or iliac crest facilitate complete dental rehabilitation.

Prosthodontic rehabilitation of a shotgun injury: a patient report.

This report describes the prosthodontic rehabilitation of a shotgun patient traumatized in the maxillary, mandibular, and nasal areas resulting in severe problems in her esthetics, phonetics, and mastication. The patient was treated with removable partial prostheses using tooth, soft tissue, and implant support.