[The Koblenz algorithm for thoracoabdominal wounds in a military hospital]. / Pervoe primenenie «koblentsskogo algoritma¼ v lechenii patsientov s torakoabdominal'nymi raneniyami v usloviyakh voennogo gospitalya. Klinicheskii sluchai.

Despite available armored personal protection in troops, the incidence of abdominal wounds in modern wars is 6.6-9.0%. Of these, penetrating abdominal injuries comprise 75-80%. Thoracoabdominal injuries occupy a special place with incidence up to 88%. We present the first case of the "Koblenz algorithm" in the treatment of a patient with mine explosion wound, combined injury of the head, limbs, thoracoabdominal trauma, widespread peritonitis, small intestinal obstruction and septic shock in a military hospital. This algorithm was implemented under import substitution considering the peculiarities of abdominal adhesive process in a patient with thoracoabdominal wound. This case demonstrates the advantage of this algorithm for patients with severe combined wounds of the chest and abdomen complicated by diffuse purulent peritonitis. Clinical status of these patients does not allow not only open laparostomy, but also "classical" redo laparotomies.

Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center.

Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.

[Features of otosurgery in children after blast injuries]. / Osobennosti rekonstruktivnoi otokhirurgii u detei posle minno-vzryvnykh ranenii.

An explosion is a process that rapidly releases a huge amount of energy in the form of heat, kinetic energy, and high-pressure shock waves. Since the organ of hearing is most susceptible to pressure changes, damage to the sound-conducting or sound-receiving systems is inevitable in case of an explosive injury. This article examines the mechanism of formation of explosive injuries of the middle and inner ear in children and adolescents, the features of diagnosis and tactics of surgical reconstructive treatment of explosive ear injuries based on the data available in the scientific literature and their own experience.

Periarticular blast wounds without fracture a prospective case series.

BACKGROUND: During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture. METHODS: The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement. RESULTS: Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01). CONCLUSION: Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Re-implantation of a degloving amputation of distal index finger caused by fireworks: a case report and literature review / Re-implantación de una amputación por desguantamiento de un dedo índice distal causada por fuegos artificiales: Reporte de caso y revisión de la literatura

Amputations associated with fireworks are customarily treated by stump revision resulting in permanent disability. In this case report, we present an eight-year old boy who suffered an amputation of his right distal index finger at the level of the epiphyseal disk with degloving injury of the amputated finger caused by fireworks. Successful re-implantation was achieved. Two-year follow-up revealed fair cosmesis and acceptable functional and aesthetic recovery though the free distal phalanx had been absorbed completely. Re-implantation of a degloving amputation finger caused by fireworks is possible and can provide good distal soft tissue coverage and recovery ofsensory and motor functions.

Las amputaciones relacionadas con fuegos artificiales son tratadas habitualmente por revisión de muñón, lo que trae como resultado una discapacidad permanente. En este reporte de caso, presentamos a un niño de 8 años que sufrió una amputación de su dedo índice derecho distal a nivel del disco epifisario con lesión por desguantamiento del dedo amputado causada por fuegos artificiales. Se logró una re-implantación exitosa. Los dos años de seguimiento revelaron una corrección quirúrgica cosmética satisfactoria, así como una recuperación funcional y estética aceptable, aunque la falange distal libre había sido absorbida completamente. La re-implantación de un dedo amputado por desguantamiento causado por fuegos artificiales es posible y puede proporcionar buena cobertura de tejido suave distal y recuperación de las funciones sensoriales y motoras.

Atención a las víctimas por ataque terrorista con explosivos / Clinical management of terrorist bomb explosions

El 11 de marzo de 2004 se produjo en Madrid un atentado terrorista haciendo explosionar 10 bombas en cuatro vagones de ferrocarril. De forma inmediata fallecieron 177 personas sumándose 14 fallecimientos posteriores en el ámbito hospitalario. Nuestro objetivo es mostrar nuestra experiencia en este tipo de incidentes. La mayoría de las víctimas llegaron al Servicio de Urgencias entre las 8:00 y las 11:00 h. De un total de 312 pacientes atendidos en nuestro Centro, 12 casos fueron asistidos en el Hospital Infantil. La edad media de los pacientes fue de 16 años (rango = 14-21). Diez pacientes fueron hospitalizados. Dos pacientes fueron considerados críticos precisando ingreso en la unidad de cuidados intensivos (presentaban un ITP de 5). Las diferentes lesiones detectadas fueron: perforaciones timpánicas (81%), lesiones de partes blandas con cuerpos extraños (36%), lesiones oculares (27%), lesiones musculoesqueléticas (27%) traumatismos torácicos (18%), traumatismo craneoencefálico severo en un caso y contusión pulmonar bilateral (blust lung injury) más traumatismo abdominal en otro. Todos los pacientes sobrevivieron, si bien presentaron secuelas traumatológicas, oculares, auditivas y todos precisaron apoyo psiquiátrico postatentado. Del análisis de estos resultados se desprende que las lesiones más frecuentes son las derivadas de la onda expansiva en un compartimiento cerrado siendo las lesiones timpánicas, oculares y de partes blandas las más frecuentes. La logística hospitalaria así como el entrenamiento personal y de grupos en los programas de asistencia al trauma pediátrico (AITP) son cruciales para enfrentarse a situaciones excepcionales de múltiples víctimas (AU)

At 07:39 on 11 March 2004 terrorist bomb explosions ocurred in 4 trains in Madrid killing 177 people instantly and 14 more later in the hospital. This report describes the organization, clinical management and patterns of injuries in casualties who were taken to our chilren patients were taken to the Gregorio Marañon hospital and 12 to the children´s one. The mean age was 16 years (14-21), Two of them were critically ill and needed intensive care (ITP 5). Tympanic perforations occurred in 81% victims with moderate to severe trauma, shrapnel wounds in 36% and eye lesions in 27%. Among critically ill patients blast lung injury, cranial and abdominal trauma were the most important lesions. Training in AITP courses and hospital logistics were essential in clinical management of these casualties (AU)

Area quirúrgica Introducción / Surgical Area Introduction

Se revisan los tipos de lesiones habituales en los atentados por ex-plosiones y los principios generales de actuación para su correcto tratamiento. Asimismo se describe la dotación del Departamento de Cirugía General y especialidades quirúrgicas del Hospital General Universitario Gregorio Marañón como introducción general a los artículos específicos de cada área quirúrgica. Además se explica la capacidad quirúrgica del centro, tanto en lo que se refiere a dotación de personal como de quirófanos (AU)

We review the most common types of lesion produced by terrorist blasts and the general principles of their treatment. We also describe the resources of the General Surgery Department and surgical specialties of the Gregorio Marañón University Hospital as a general introduction to the specific resources of each surgical area. The center's surgical capacity, in terms of both staffing and operating rooms, is also described (AU)

Cirugía General / General Surgery

Las explosiones terroristas con múltiples víctimas provocan situaciones de catástrofe que ponen a prueba la capacidad de respuesta de los sistemas de salud. El Hospital Gregorio Marañón atendió en unas pocas horas a más de 300 víctimas, la mayoría con lesiones moderadas o leves, aunque 29 pacientes llegaron en estado grave o crítico. Durante las primeras 24 h se realizaron 37 intervenciones quirúrgicas mayores en 34 pacientes, y en 7 de ellos fueron laparotomías. Dos de éstas resultaron negativas y otra no fue terapéutica. Falleció un paciente durante una reintervención para control de daños. Se realizaron 3 embolizaciones angiográficas por hemorragia de la arteria intercostal, hepática y hepatosplénica, respectivamente, y en todos los casos se consiguió la hemostasia. Las lesiones encontradas con más frecuencia, y las viscerales en particular, reproducen lo referido en situaciones similares. Se hacen algunas reflexiones a la luz de la experiencia vivida y los datos de la bibliografía (AU)

Terrorist explosions with multiple victims produce disaster situations that test health systems' ability to respond. The Gregorio Marañón University Hospital attended more than 300 victims within a few hours. Most of these victims had mild or moderate lesions, although 29 patients arrived in a serious or critical condition. In the first 24 hours, 37 major surgical interventions were performed in 34 patients. Of these, patients 7 underwent laparotomy, 2 of which were negative and one was non-therapeutic. One patient died during reintervention for damage limitation. Three angiographic embolizations were performed for bleeding of the intercostal artery, liver and liver-spleen, respectively and hemostasis was achieved in all three patients. The most common lesions and visceral injuries in particular were similar to those described in previous reports of similar situations. We reflect on our experience and discuss data from the literature (AU)

Cirugía Maxilofacial / Maxillo-facial Surgery

Presentamos la experiencia del Servicio de Cirugía Maxilofacial del Hospital Universitario Gregorio Marañón en la asistencia a las víctimas del atentado terrorista del 11 de marzo de 2004 en Madrid. Se describen los tipos más importantes de traumatismo craneomaxilofacial atendidos ese día y sus mecanismos de producción, así como la organización del departamento con el objetivo de atender a un elevado número de casos en un corto espacio de tiempo. Analizamos, asimismo, la evolución de la casuística atendida en los días posteriores al atentado (AU)

We describe the experience of the Maxillofacial Surgery Service of the Gregorio Marañón University Hospital in attending the victims of the terrorist attack of 11 March, 2004 in Madrid. The most important types of cranio-maxillofacial injury treated that day, their mechanisms of production, and the organization of the department to attend a large number of patients in a short space of time are described. The outcomes of the casuistics attended in the days after the attack are described (AU)

Neurocirugía / Neurosurgery

De los pacientes ingresados en este centro, un 14,44% (n = 26) requirió valoración por el Servicio de Neurocirugía. De éstos, un 29,63% (n = 7) necesitó intervención quirúrgica en las primeras 8 h y un 7,69% a lo largo de las siguientes 48 h. En días sucesivos los pacientes ingresados presentaron síntomas neurológicos (AU)

Of the patients admitted to our center, 14.44% (26 patients) required evaluation by the Neurosurgery Department. Of these, 29.63% (7 patients) required surgery within 8 hours and 7.69% within the following 48 hours. During the days after the attack, neurological symptoms developed in hospitalized patients (AU)

Cirugía Torácica / Thoracic Surgery

Nuestro servicio trató a 32 pacientes con traumatismo torácico por onda expansiva que no necesitaban soporte ventilatorio invasivo. Se analizan el Injury Severity Score (mediana de 13), la relación presión parcial de oxígeno/fracción inspiratoria de oxígeno (mediana de 350) y la gravedad de la lesión pulmonar observada (mediana de 1,25 en el índice de Murray). La clínica, dominada por el dolor torácico, dependió de la intensidad del barotrauma y del distrés respiratorio. Todas las lesiones aparecieron en las primeras 24 h y la mayoría de los pacientes (75%) presentaban contusión pulmonar. Aunque los pacientes con contusión pulmonar presentan mayor comorbilidad, intra y extratorácica, las diferencias no son significativas respecto a los que no la tienen, salvo en la estancia hospitalaria (13 frente a 5,5 días; p = 0,008). Aparecieron fracturas costales en 12 pacientes (37%), la mayoría en las 3 primeras costillas y en el 60% de los casos con disminución del contorno torácico superior (toracoplastia traumática apical). La evolución ha sido satisfactoria, sin mortalidad (AU)

Thirty-two patients with shock wave lesions to the chest who did not require invasive ventilatory support were treated. The Injury Severity Score (median 13), the pO2/FiO2 ratio (350) and lung injury severity (Murray score 1.25) were analyzed. Symptoms, mainly chest pain, depended on the severity of barotrauma and respiratory distress. All the lesions developed in the first 24 hours and most patients (75%) presented lung contusion. Although patients with lung contusion had greater intra- and extrathoracic comborbidity, differences in comparison with those without lung contusion were not significant, except in length of hospital stay (13 days vs 5.5 days; p = 0.008). Costal fractures were found in 12 patients (37%), mostly in the first 3 ribs and 60% of the patients had reduction of the upper thoracic contour (traumatic apical thoracoplasty). Outcomes were satisfactory with no mortality (AU)

Otorrinolaringología / Otorhinolaryngology

El atentado del 11 de marzo ocasionó en un alto porcentaje de pacientes lesiones otológicas. La onda expansiva provoca alteraciones tanto del oído externo como del oído medio e interno. La perforación timpánica es la más frecuente de las consecuencias. En nuestro caso, realizamos un primer estudio con otoscopia, acumetría, audiometría tonal y exploración vestibular, estudio que se repitió a los 2 y 3 meses. En la mayoría de los casos se comprobó una correlación entre el grado de lesión del oído medio y el daño auditivo. De los pacientes con rotura timpánica, la mayor parte presentaban perforación total o subtotal. Un determinado porcentaje de casos puede cerrar espontáneamente, pero suele estar en relación con el tamaño de la lesión inicial. Así, en perforaciones timpánicas de más del 50% es difícil que se produzca un cierre espontáneo (AU)

The terrorist attack on 11 March caused a high percentage of patients with ear injuries. Shock waves provoke alterations to the external ear as well as to the middle and inner ear. The most frequent lesion is tympanic membrane perforation. Initial evaluation with otoscopy, acoumetry, tonal audiometry and vestibular examination was performed and was repeated after 2 and 3 months. In most patients there was a correlation between the grade of middle ear lesion and auditory damage. In most patients with tympanic rupture, the perforation was total or subtotal. Spontaneous closure can occur in some patients but is usually related to the size of the initial lesion. Thus in tympanic perforations of more than 50%, spontaneous closure is unlikely (AU)

Lesión musculoesquelética masiva por acción de la onda expansiva / Musculoskeletal masssive injury due to action of the expansive wave

Las lesiones musculoesqueléticas masivas causadas por la acción de la onda expansiva constituyen eventos graves para el paciente que las recibe y difíciles para el médico que las atiende. Se incluyeron aspectos sobre la fisiopatología de las lesiones por onda expansiva y algunos elementos que deben caracterizar al cirujano que presta atención a lesionados graves. Se concluyó que la atención al lesionado complejo precisa de una buena organización e incluye una atención prehospitalaria eficaz para comenzar la resucitación, y el cirujano asistente requiere de un alto nivel de competencia y desempeño

Lesión musculoesquelética masiva por acción de la onda expansiva / Musculoskeletal masssive injury due to action of the expansive wave

Las lesiones musculoesqueléticas masivas causadas por la acción de la onda expansiva constituyen eventos graves para el paciente que las recibe y difíciles para el médico que las atiende. Se incluyeron aspectos sobre la fisiopatología de las lesiones por onda expansiva y algunos elementos que deben caracterizar al cirujano que presta atención a lesionados graves. Se concluyó que la atención al lesionado complejo precisa de una buena organización e incluye una atención prehospitalaria eficaz para comenzar la resucitación, y el cirujano asistente requiere de un alto nivel de competencia y desempeño(AU)