Characteristics of burn casualties treated at role 2 in Afghanistan.

BACKGROUND: Role 2 medical treatment facilities (MTFs) are frequently located in austere settings and have limited resources. A dedicated assessment of burn casualties treated at this level of care has not been performed. Therefore, the objective of this study was to characterize burn casualties presenting to role 2 MTFs in Afghanistan, along with the procedures they required, complications, and mortality to begin understanding the resources consumed by their care. METHODS: We identified burn casualties from the Department of Defense Trauma Registry (DODTR). The inclusion criteria were (1) experienced burn injuries in Afghanistan between October 2005 and April 2018 and (2) had documentation of treatment at role 2 in the DODTR. We excluded casualties with only first-degree burns, not otherwise specified burns, or only corneal burns. Casualty demographics, injury characteristics, procedures, and outcomes were reported. RESULTS: We identified 453 burn casualties with a median (interquartile range) Injury Severity Score of 10 (4-22) and percent total body surface area burned of 11 (5-30). There were 123 casualties (27.2%) with inhalation injury, and the casualties experienced 3,343 additional traumatic injuries and needed 2,530 procedures. Casualties with documentation of resuscitation information received a median (interquartile range) of 1.9 (0.7-3.7) L of crystalloid fluids. Complications were documented in 53 casualties (11.7%). Final mortality was reported in 36 casualties (8.0%), and mortality at role 2 MTFs was reported in 7 casualties (1.5%). CONCLUSION: Burn casualties had many injuries and needed many procedures, including those related to airway management, resuscitation, and wound care. Given the urgency of these procedures, ensuring that there is enough equipment and supplies will be important in the future. Although infrequent, some casualties experienced complications. Factors that may influence resuscitation include injury severity, concomitant traumatic injuries, and available supplies. Obtaining more contextual information on the patient care environment will be useful going forward. LEVEL OF EVIDENCE: Epidemiological, level III.

Impact of World War I on brain mapping.

Although much tragedy was experienced during World War I (WWI), the nature of the war and the advancements of weaponry led to a change in the quality and quantity of injuries which were conducive for study. This paper discusses how trauma during WWI led to advances in brain mapping from occipital injuries. Gordon Holmes was a British neurologist who was able to create a retinotopic map of the visual cortex from studying more than 400 cases of occipital injuries; his work has contributed immensely to our understanding of visual processing. There have been many extensions from Holmes' work in regard to how we analyze other sensory modalities and in researching how the brain processes complex stimuli such as faces. Aside from the scholastic benefit, brain mapping also has functional use and can be used for neurosurgical planning to preserve important structures. With the advent of more advanced modalities for analyzing the brain, there have been initiatives in total brain mapping which has added significantly to the body of work started by Holmes during WWI. This paper reviews the history during WWI that led to advances in brain mapping, the lasting scholastic and functional impact from these advancements, and future improvements.

Comparison of military and civilian burn patients admitted to a single center during 12 years of war.

OBJECTIVE: The current conflicts in Iraq and Afghanistan resulted in an increased incidence of burn injury in the military population. We sought to compare the characteristics and outcomes of this population to a civilian cohort cared for at the same burn center over the same time-period. METHODS: A retrospective review was performed to examine differences in the demographics, etiology, mortality, and functional status over a 12-year period. Descriptive analyses were performed. Logistic regression was used to calculate the likelihood of mortality. RESULTS: A total of 3814 patients were included in this analysis; 1069 were military casualties. When compared to civilians, military patients were younger, had a higher incidence of flame-induced burn injury, mean total body surface area burned (% TBSA), rate of inhalation injury, and lower mortality. Civilian patients presented with a higher Baux score. Although most military patients had a full functional recovery, they had a greater incidence of severe disability. In a univariate model, likelihood of mortality was higher in civilians. No difference in mortality between the two cohorts was found after adjusting for age, inhalation injury, gender, % TBSA and percent full-thickness burn. CONCLUSIONS: Military patients exhibited improved survival and functional recovery over their civilian counterparts. However, mortality did not differ between civilian and military patients after controlling for known covariates. Further studies are needed to improve functional outcomes in civilian patients, who may not have the inherent advantages of younger age and healthier physical status found in military patients.

Can functional emotion regulation protect children's mental health from war trauma? A Palestinian study.

Effective emotion regulation (ER) is expected to protect mental health in traumatic stress. We first analysed the protective (moderator) function of different ER strategies and the associations between ER and mental health. Second, we tested gender differences in the protective function of ER and the associations between ER strategies and mental health. Participants were 482 Palestinian children (girls 49.4%; 10-13 years, M = 11.29, SD = .68) whose ER was assessed by the Emotion Regulation Questionnaire and mental health by post-traumatic stress (Children's Impact Event Scale), depressive, and psychological distress (Strengths and Difficulties Questionnaire) symptoms, and by psychosocial well-being (Mental Health Continuum-Short Form). War trauma involved 42 events. Results showed, first, that none of the ER strategies could protect a child's mental health from negative impact of war trauma, but self-focused ER was associated with low depressive symptoms, and other-facilitated ER with high psychological well-being. However, controlling of emotions formed a comprehensive risk for children's mental health. Second, gender differences were found in the protective role of ER, as self-focused and distractive ER formed a vulnerability among boys. The results are discussed in the context of emotional and regulative demands of war and life-threat.

Acute high-altitude exposure shortens survival after uncontrolled hemorrhagic shock in rats.

BACKGROUND: Uncontrolled hemorrhage (UH) remains the most common cause of death on the battlefield. This study examined the pathophysiological characteristics of UH in rats acutely exposed to high altitude. MATERIAL AND METHODS: Rats raised at sea level were randomly divided into two groups. Rats in the high-altitude group were exposed to hypobaric hypoxia in a hypobaric chamber (simulating 4000 m above sea level) for 2 d and then were performed a hemorrhagic shock protocol in the hypobaric chamber. Rats that underwent the same hemorrhage procedure at sea level were used as control. Anesthetized rats were bled to maintain their mean arterial pressure at 45 mmHg for 1 h. The distal quarter of the tail was amputated to allow free blood loss. After 1 h, the tail cut was ligated to induce hemostasis. mean arterial pressure, acid-base balance, blood loss, and survival were recorded. Rats were killed, and tissues were obtained for histological analysis. RESULTS: Rats in the high-altitude group suffered less uncontrolled blood loss, more severe acidosis (lower pH and base excess), and inferior tissue oxygen supply (lower oxygen saturation and higher arterial lactate concentration) during the hemorrhage periods compared with the control group. Survival rates were significantly lower in the high-altitude group than those in the control group (P < 0.05), which was consistent with the results of pathological tissue injury. CONCLUSIONS: In this rat model of hemorrhagic shock, acute high-altitude exposure resulted in decreased UH but more serious hemorrhagic shock injuries than that at sea level.

[DISTANT CONSEQUENCES AND THE QUALITY OF LIFE OF PATIENTS WITH MILITARY-RELATED CRANIOCEREBRAL TRAUMA].

The purpose of the study was to determine appropriate diagnostic, therapeutic and rehabilitation treatments of patients with military-related craniocereberal trauma. We have examined 180 male patients: 100 participant of operations in the Democratic Republic Afghanistan (1979-1989) and 80 - participants of conflict in the east of Ukraine (from 2014 until present) with military-related craniocereberal trauma of varying severity. We used clinical-neurological, instrumental (craniography of skull, magnetic resonance imaging, ultrasonic doppler sonography of the main vessels of the head and neck), biochemical, statistical methods of a research, and also questionnaire scale SF-36. It was found that the quality of life of patients with military-related craniocereberal trauma depends on the severity of the wound and the period after trauma. In the early period after military-related craniocereberal trauma of light or average severity, the psychological components are more strongly manifested. Patients with severe military-related craniocereberal trauma have serious physical, psychological and social problems at different periods after trauma. The results of the research show that the quality of life depends on the severity of functional disorders and have impact on adaptive potential of the organism.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq.

BACKGROUND: Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival. METHODS: A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival. RESULTS: For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01). CONCLUSION: Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan. LEVEL OF EVIDENCE: Performance improvement and epidemiological, level IV.

Two cases with giant pseudo-aneurysm of vertebral artery secondary to shrapnel injury.

INTRODUCTION: Due to their locations, vertebral arteries (VA) are structures that are rarely injured after traumas. Formation of vertebral pseudo-aneurysm (PA) because of pieces of shrapnel is also rare. It causes clinical findings like cervical mass after the injury CASES PRESENTATION: Two Syrian 12- and 17-year-old male patients were admitted to the Department of Ear, Nose and Throat with the complaint of swelling in the left lower cervical region. In their USG examination which was ordered to investigate the cervical lesion, a lesion consistent with PA which shows a prominently thick wall structure due to circumferential thrombus formation and fibrotic tissue, chaotic flow, and ying-yang appearance in the centrally located cavity of the lesion in a color Doppler examination was detected. Later, multi-detector computed tomography angiography (MDCTA) was planned to demonstrate pseudo-aneurysms (PAs). CONCLUSION: Because there was no report on the development of giant pseudo-aneurysms secondary to shrapnel injury to date and because we thought these cases are demonstrative, we found the cases suitable for presenting as case reports.

Characterization and Comparison of Combat-Related Injuries in Women During OIF and OEF.

Although historically restricted from combat roles, women suffer from combat-related injuries, especially in recent conflicts where asymmetrical warfare erases distinctions between forward and rear operating areas. U.S. servicewomen who sustained combat-related injury in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) between January 2003 and May 2014 were identified from the Expeditionary Medical Encounter Database. Injuries were characterized using Abbreviated Injury Scale and International Classification of Diseases, 9th Revision codes. Of the 844 combat-related injury episodes in women, 51% (n = 433) were OIF injuries and 49% (n = 411) were OEF injuries. Blast events were responsible for 90% of injuries. The average Injury Severity Score was 3, with no statistical difference in means between OIF and OEF. Of significance were increased head injuries in OEF compared with OIF (80% vs. 48%; p < 0.001). Although the majority of combat-related injuries suffered by women were mild, some women suffered life-threatening injuries, and nearly 65% of the injury episodes resulted in more than one injury. More research is needed as the roles of women in the military continue to expand. Future studies will investigate quality of life outcomes and gender differences in combat-related injuries.

[Experience of the treatment of gunshot wounds and pancreas traumas during domestic armed conflict in the North Caucasus (1994-1996, 1999-2002)].

Experience of the treatment of gunshot wounds and pancreas traumas during domestic armed conflict in the North Caucasus (1994-1996, 1999-2002). The paper presents our own experience of surgical treatment of gunshot wounds, and pancreatic damage. Pathophysiological mechanisms of development of fire pancreatitis are presented. Tasks for surgery and their solutions are defined. The reasons for reoperation are analysed. It was found that the surgical approach depends on the nature and localization of pancreatic damage. The features of the surgical intervention are shown.

Beta-amyloid deposition in chronic traumatic encephalopathy.

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease associated with repetitive mild traumatic brain injury. It is defined pathologically by the abnormal accumulation of tau in a unique pattern that is distinct from other tauopathies, including Alzheimer's disease (AD). Although trauma has been suggested to increase amyloid ß peptide (Aß) levels, the extent of Aß deposition in CTE has not been thoroughly characterized. We studied a heterogeneous cohort of deceased athletes and military veterans with neuropathologically diagnosed CTE (n = 114, mean age at death = 60) to test the hypothesis that Aß deposition is altered in CTE and associated with more severe pathology and worse clinical outcomes. We found that Aß deposition, either as diffuse or neuritic plaques, was present in 52 % of CTE subjects. Moreover, Aß deposition in CTE occurred at an accelerated rate and with altered dynamics in CTE compared to a normal aging population (OR = 3.8, p < 0.001). We also found a clear pathological and clinical dichotomy between those CTE cases with Aß plaques and those without. Aß deposition was significantly associated with the presence of the APOE ε4 allele (p = 0.035), older age at symptom onset (p < 0.001), and older age at death (p < 0.001). In addition, when controlling for age, neuritic plaques were significantly associated with increased CTE tauopathy stage (ß = 2.43, p = 0.018), co-morbid Lewy body disease (OR = 5.01, p = 0.009), and dementia (OR = 4.45, p = 0.012). A subset of subjects met the diagnostic criteria for both CTE and AD, and in these subjects both Aß plaques and total levels of Aß1-40 were increased at the depths of the cortical sulcus compared to the gyral crests. Overall, these findings suggest that Aß deposition is altered and accelerated in a cohort of CTE subjects compared to normal aging and that Aß is associated with both pathological and clinical progression of CTE independent of age.

[COMPLEX OF THE TREATMENT MEASURES IN A SYSTEM OF THE MEDICAL CARE DELIVERY TO WOUNDED PERSONS WITH THE GUN-SHOT AND MINE-EXPLOSIVE INJURIES OF THE FOOT].

Complex of the treatment measures, conducted in 302 wounded persons, suffering the gun-shot and mine-explosive injuries of the foot in 2014 - 2015 yrs, was analyzed. Primary surgical processing of the wound was conducted in all injured persons, secondary surgical processing--in 64.6%, the foot bones osteosynthesis--in 13.9%, primary immobilization, using improvised tire--in 77.8%, secondary immobilization, using the plaster splint--in 48.1%, llizarov's spokes--in 35.2%, Ilizarov's apparatus--in 18.5%, the rods apparatuses of external fixation--in 16.7%. For improvement of functioning of a modern system for the treatment-evacuation provision it is necessary, to reduce the quantity of levels of the medical help provision maximally.

[Peculiarities of surgical treatment of wounded with combined thermomechanical injuries of the lower extremities under conditions of counter-terrorist operation].

Peculiarities of surgical treatment of wounded with combined thermomechanical injuries of the lower extremities under conditions of counter-terrorist operation. The authors analysed results of treatment of 67 wounded with injuries of the extremities, combined with burns. Two therapeutic approaches to surgical treatment were used. The first therapeutic approach (Early total Care - ETC) involved providing of a complete surgical care (the whole body is examined) during the first emergency operation and was used in 24 (35,8%) injured. The second therapeutic approach implied a differentiated approach to the treatment of wounded and treatment of injuries and was used in 43 (64,2%) patients. If arterial blood pressure was above 90 mm Hg, ETC approach was used in 19 (28,4%) wounded. If systolic blood pressure was less than 90 mm Hg programmable surgical approach Damage Control Surgery (DCS) was used in 24 (35,8%) patients. The use of differential surgical approach has led to increase in the number of complications from 45,8 to 55,8% (p=0,044) and decrease in mortality c 12,5 to 9,3% (p=0,039) compared with the group of wounded, where was used only traditional approach of single-stage treatment.