Blast Injury Research Articles

Multicenter assessment of impairments and disabilities associated with Beirut blast injuries: a retrospective review of hospital medical records

ObjectivesThis study aims to describe the injury patterns of the Beirut blast victims and assess hospitals’ disaster management and preparedness during the 2020 Beirut port blast.MethodsA cross-sectional retrospective multicenter study...

Diagnosis and Surgical Treatment of a Gunshot Fragment Wound of the Heart with a Threat of Coronary Artery Perforation

Each case of fragment heart damage is unique and requires careful preparation for surgical intervention. Complexity of such operations is explained by the probability of unwanted complications associated with technical measures and aimed at extracting fragments of the most diverse localization.
 The aim. To demonstrate the possibilities of effective diagnosis and optimal surgical treatment of a gunshot fragment wound of the heart with the threat of coronary artery perforation.
 Material and methods. The article presents a case of diagnosis and surgical treatment of a fragment heart damage with intramyocardial damage of the left ventricular wall with localization under the circumflex branch of the left coronary artery with the threat of its perforation. One day has passed since a mine blast injury. Diagnosis was based on the use of contrast enhanced computed tomography (CT) and coronary angiography.
 Results. During the diagnostic process, the need to use a CT scan with mandatory contrast media arose, which made it possible to confirm the presence of a fragment in the immediate vicinity of the coronary artery. Coronarography provided additional information which revealed contact of the fragment with the coronary artery with the threat of its perforation. Immediate surgery with artificial blood circulation with stepwise application of magnets of increasing power allowed safe removal of the fragment, avoiding damage to the coronary artery.
 Conclusions. The most accurate topical diagnosis of fragment localization in heart damage requires CT diagnosis with mandatory contrast media and, if possible, with 3D reconstruction, which allows for surgical intervention with a minimal risk of intraoperative complications. Location of the fragments near the coronary vessels may threaten their damaging during removal and requires careful manipulation to prevent injury to the heart vessels. Detection and removal of sharp fragments located near the coronary vessels require stepwise application of magnets of increasing power to bring the fragment to a safe zone with its subsequent extraction.

Reduction of epinephrine in the lumbar spinal cord following repetitive blast-induced traumatic brain injury in rats.

Abstract Traumatic brain injury-induced unfavorable outcomes in human patients have independently been associated with dysregulated levels of monoamines, especially epinephrine, although few preclinical studies have examined the epinephrine level in the central nervous system after traumatic brain injury. Epinephrine has been shown to regulate the activities of spinal motoneurons as well as increase the heart rate, blood pressure, and blood flow to the hindlimb muscles. Therefore, the purpose of the present study was to determine the impact of repeated blast-induced traumatic brain injury on the epinephrine levels in several function-specific central nervous system regions in rats. Following three repeated blast injuries at three-day intervals, the hippocampus, motor cortex, locus coeruleus, vestibular nuclei, and lumbar spinal cord were harvested at post-injury day eight and processed for epinephrine assays using a high-sensitive electrochemical detector coupled with high-performance liquid chromatography. Our results showed that the epinephrine levels were significantly decreased in the lumbar spinal cord tissues of blast-induced traumatic brain injury animals compared to the levels detected in age- and sex-matched sham controls. In other function-specific central nervous system regions, although the epinephrine levels were slightly altered following blast-induced traumatic brain injury, they were not statistically significant. These results suggest that blast injury-induced significant downregulation of epinephrine in the lumbar spinal cord could negatively impact the motor and cardiovascular function. This is the first report to show altered epinephrine levels in the spinal cord following repetitive mild blast-induced traumatic brain injury.

Temporal Changes in Functional and Structural Neuronal Activities in Auditory System in Non-Severe Blast-Induced Tinnitus.

Background and Objectives: Epidemiological data indicate that blast exposure is the most common morbidity responsible for mild TBI among Service Members (SMs) during recent military operations. Blast-induced tinnitus is a comorbidity frequently reported by veterans, and despite its wide prevalence, it is also one of the least understood. Tinnitus arising from blast exposure is usually associated with direct structural damage that results in a conductive and sensorineural impairment in the auditory system. Tinnitus is also believed to be initiated by abnormal neuronal activities and temporal changes in neuroplasticity. Clinically, it is observed that tinnitus is frequently accompanied by sleep disruption as well as increased anxiety. In this study, we elucidated some of the mechanistic aspects of sensorineural injury caused by exposure to both shock waves and impulsive noise. The isolated conductive auditory damage hypothesis was minimized by employing an animal model wherein both ears were protected. Materials and Methods: After the exposure, the animals' hearing circuitry status was evaluated via acoustic startle response (ASR) to distinguish between hearing loss and tinnitus. We also compared the blast-induced tinnitus against the well-established sodium salicylate-induced tinnitus model as the positive control. The state of the sensorineural auditory system was evaluated by auditory brainstem response (ABR), and this test helped examine the neuronal circuits between the cochlea and inferior colliculus. We then further evaluated the role of the excitatory and inhibitory neurotransmitter receptors and neuronal synapses in the auditory cortex (AC) injury after blast exposure. Results: We observed sustained elevated ABR thresholds in animals exposed to blast shock waves, while only transient ABR threshold shifts were observed in the impulsive noise group solely at the acute time point. These changes were in concert with the increased expression of ribbon synapses, which is suggestive of neuroinflammation and cellular energy metabolic disorder. It was also found that the onset of tinnitus was accompanied by anxiety, depression-like symptoms, and altered sleep patterns. By comparing the effects of shock wave exposure and impulsive noise exposure, we unveiled that the shock wave exerted more significant effects on tinnitus induction and sensorineural impairments when compared to impulsive noise. Conclusions: In this study, we systematically studied the auditory system structural and functional changes after blast injury, providing more significant insights into the pathophysiology of blast-induced tinnitus.

A Descriptive Study ofCasualties Evacuated Out ofAfghanistan by Critical Care Air Transport Teams During the Withdrawal ofU.S. Troops.

The War in Afghanistan ended in August 2021. Evacuation from the country was a large effort during the last days of the conflict. During evacuation efforts at Kabul Hamid Karzai International Airport, a suicide bombing occurred necessitating emergent medical care for many injured troops and civilians. The U.S. Air Force Critical Care Air Transport Teams (CCATTs) played a role in the medical care provided during the operations in Afghanistan. We report on in-flight events and interventions that took place during the final days of the Afghanistan withdrawal. We performed a retrospective chart review of patients requiring aeromedical evacuation from the Afghanistan theater of operations by CCATT from July 1 to August 30, 2021. From the CCATT patient care record, data abstractors collected patient characteristics, flight information, vital signs, laboratory values, in-flight interventions, and in-flight events in a study-specific electronic database. We performed descriptive analyses of patient characteristics and in-flight interventions. This study was approved by the San Antonio Institutional Review Board. Nine patients were included in this analysis. Seven out of nine patients were foreign nationals; the remaining two were U.S. Marines. Five patients suffered penetrating injuries from gunshot wounds and four suffered blast injuries. Six received intravenous narcotic analgesia. Four received intravenous sedatives, and four received antibiotics in flight. Two patients required chest tube management. One patient received blood. Three patients were in acute respiratory distress. Severe injuries were sustained during the withdrawal efforts at the end of the War in Afghanistan. Critical Care Air Transport Teams played a role in the care and evacuation of patients out of theater during this unique and unprecedented time. Even given the limitations associated with retrospective studies and a small sample size, information reported in this study can help inform future decisions, and aid in preparatory efforts for future operations, that may require medical care by CCATT.

Mild blast injury: vertigo complaints analysis

The data about vestibular disorders resulting from blast injury are contradictory. To disclose the problem of vestibular disorder as the consequence of blast injury, we have done present investigation. One hundred and nine patients were examined: 65 Anti-Terroristic Operation (ATO) participants, who survived mild and moderate blast injury without cranial trauma, and 44 non-ATO patients (rhinitis, pharyngitis, otitis). Questionnaire “Types of dizziness” has been used according to the International Clinical Protocol on Vestibular Disorders (Dizziness). Complaints of dizziness (distortion of perception of space, movement and time) have been revealed in 70.77 % (46) ATO and 43.18 % (19) non-ATO patients: F-test = 0.51, T-test = 0.004, thus, showing that this complaint is not specific for mild traumatic brain injury (mTBI). Objective vertigo (sensation of subjects moving around the patient) met in 26.15 % (17) ATO and 11.56 % (5) non-ATO patients: F-test = 0.027, T-test = 0.046. So, we have two different qualitative groups. Тhese complaints are specific for the patients, who survived blast injury. Complaints of vertigo are also typical for the patients, who survived blast injury. Complaints of giddiness are specific for the patients, who survived blast injury. Imbalance and drop attacks are not typical for ATO patients. Complaints of kinetosis are specific for the patients, who survived blast injury. Orthostatics (discomfort sensations that appear after sudden standing up) has been revealed in 76.92 % (50) ATO and 47.73 % (21) non-ATO patients, this complaint is not specific for mTBI. Vestibular system organizes space orientation tetrad: vestibular, somatosensory, visual and hearing information to percept, orient and interact with environment. Acro-, nycto- and ascendophobia have appeared to be of no importance. Agoraphobia (Greek αγωρα — market, supermarket syndrome, discomfort in open, public places or crowds) has been detected in 33.85 % (22) ATO and 15.91 % (7) non-ATO patients. This complaint is not specific for mTBI. Claustrophobia (discomfort appearing in small, closed spaces) is met in 20.00 % (13) ATO and 9.09 % (4) non-ATO patients: F-test = 0.024, T-test = 0.10. Thus, we have two different qualitative groups. This is also interesting case, when we reveal qualitative difference without quantitative one. This is the argument to use F-test in our study. So, complaints of claustrophobia are specific for the patients, who survived blast injury. The same situation is with descendophobia (discomfort during walking down the hill or descending the staircase, patients note the necessity of visual control. It has been shown that among other signs, there is a positive correlation with age, imbalance, ascendophobia and dyspnea). The results are discussed from the point of view of the severe vestibular impairment due to the blast injury. Conclusions. 1. MBTI from blast injury is accompanied by severe stress, objective and subjective vertigo, giddiness and kinetosis, which are considered to be the symptoms of vestibular damage. 2. Dizziness, orthostatics and agoraphobia are quantitatively significantly increased in mBTI, but it might not be considered specific for blast injury consequences. 3. Giddiness, claustrophobia and descendophobia in ATO patients have no quantitative changes compared to the ENT patients, but are specific for mBTI after blast injury. 4. It is important to use matrix Fisher test in statistical examinations.

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry

BackgroundPelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014–2019 in order to better understand the need of organized and dedicated personnel and infrastructures.MethodsThis retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients’ Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution’s catchment area; and (5) any document attesting the patient’s will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient’s will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors’ level I trauma center, no inferential statistics were computed.ResultsThe incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures.ConclusionsThese observations bring better knowledge about pseudo-lockdown’s impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures.

Landmine Injury Resulting inComminuted Lumbar Facet Fracture as a Cause ofLumbar Stenosis andSpondylolisthesis.

Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.

Delivering Traumatic Brain Injury to Larval Zebrafish.

We describe a straightforward, scalable method for administering traumatic brain injury (TBI) to zebrafish larvae. The pathological outcomes appear generalizable for all TBI types, but perhaps most closely model closed-skull, diffuse lesion (blast injury) neurotrauma. The injury is delivered by dropping a weight onto the plunger of a fluid-filled syringe containing zebrafish larvae. This model is easy to implement, cost-effective, and provides a high-throughput system that induces brain injury in many larvae at once. Unique to vertebrate TBI models, this method can be used to deliver TBI without anesthetic or other metabolic agents. The methods simulate the main aspects of traumatic brain injury in humans, providing a preclinical model to study the consequences of this prevalent injury type and a way to explore early interventions that may ameliorate subsequent neurodegeneration. We also describe a convenient method for executing pressure measurements to calibrate and validate this method. When used in concert with the genetic tools readily available in zebrafish, this model of traumatic brain injury offers opportunities to examine many mechanisms and outcomes induced by traumatic brain injury. For example, genetically encoded fluorescent reporters have been implemented with this system to measure protein misfolding and neural activity via optogenetics.

Low-intensity open-field blast exposure effects on neurovascular unit ultrastructure in mice

Mild traumatic brain injury (mTBI) induced by low-intensity blast (LIB) is a serious health problem affecting military service members and veterans. Our previous reports using a single open-field LIB mouse model showed the absence of gross microscopic damage or necrosis in the brain, while transmission electron microscopy (TEM) identified ultrastructural abnormalities of myelin sheaths, mitochondria, and synapses. The neurovascular unit (NVU), an anatomical and functional system with multiple components, is vital for the regulation of cerebral blood flow and cellular interactions. In this study, we delineated ultrastructural abnormalities affecting the NVU in mice with LIB exposure quantitatively and qualitatively. Luminal constrictive irregularities were identified at 7 days post-injury (DPI) followed by dilation at 30 DPI along with degeneration of pericytes. Quantitative proteomic analysis identified significantly altered vasomotor-related proteins at 24 h post-injury. Endothelial cell, basement membrane and astrocyte end-foot swellings, as well as vacuole formations, occurred in LIB-exposed mice, indicating cellular edema. Structural abnormalities of tight junctions and astrocyte end-foot detachment from basement membranes were also noted. These ultrastructural findings demonstrate that LIB induces multiple-component NVU damage. Prevention of NVU damage may aid in identifying therapeutic targets to mitigate the effects of primary brain blast injury.

The Superficial Circumflex Iliac Artery Perforator Flap for Devastating Hand Injuries in the Obese.

Blast injuries to the hand, such as those from fireworks, are debilitating and life altering. Often, because of the nature of the injury, there is a need for soft tissue and skin coverage. However, in the increasingly obese American population, free flaps often are too bulky for functional hand coverage. In this study, we present a series of 7 patients who underwent the superficial circumflex iliac artery perforator (SCIP) flap for upper extremity reconstruction with improvement in cosmesis, including a primarily repaired donor site, as well as an overwhelmingly high return to work with minimal revision surgery necessary. All patients who underwent a SCIP for hand injuries from a blast were included. Flaps were harvested based on previously described methods. A single attending surgeon performed all surgeries. All patients were followed for at least 6 months. Preoperative and postoperative characteristics were described. A total of 7 patients were included in this study. Ages ranged from 16 to 58 years and body mass index from 19 to 48 kg/m2. More than half of the patients had a body mass index greater than 30 kg/m2. All donor sites were primarily closed. Five patients returned to their preinjury work. Three patients had neurotized flaps with return of protective sensation. Three patients required revision surgery; all 3 had liposuction, and 1 had additional flap advancement surgery. The SCIP flap is a versatile flap that can be used in hand reconstruction in blast injuries with good functional outcome and improved cosmesis compared with other perforator flaps for the upper extremity.

Bilateral anterolateral thigh free flap in a flow-through chimeric pattern for a extensively large defect reconstruction: a case of an elderly patient under spinal-epidural anesthesia

An 83-year-old male patient presented with a Marjolin’s ulcer on his lower leg, which developed 60 years after a bomb blast injury. The lesion was a 24×12-cm2 chronic ulcer located circumferentially around the mid-third lower leg. Considering the patient’s age, vessel status, and the extent of the defect after wide excision, which included a section of the tibia, reconstruction utilizing bilateral anterolateral thigh free flaps in a flow-through pattern under spinal-epidural anesthesia was planned. The operative time was 9 hours, and the patient fully recovered without any complications. The patient was able to walk without any orthosis, and no evidence of recurrence was found during a 3-year postoperative follow-up period.

Development of an experimental method for well-controlled blast induced traumatic limb fracture in rats

Heterotopic ossification (HO) is a consequence of traumatic bone and tissue damage, which occurs in 65% of military casualties with blast-associated amputations. However, the mechanisms behind blast-induced HO remain unclear. Animal models are used to study blast-induced HO, but developing such models is challenging, particularly in how to use a pure blast wave (primary blast) to induce limb fracture that then requires an amputation. Several studies, including our recent study, have developed platforms to induce limb fractures in rats with blast loading or a mixture of blast and impact loading. However, these models are limited by the survivability of the animal and repeatability of the model. In this study, we developed an improved platform, aiming to improve the animal’s survivability and injury repeatability as well as focusing on primary blast only. The platform exposed only one limb of the rat to a blast wave while providing proper protection to the rest of the rat’s body. We obtained very consistent fracture outcome in the tibia (location and pattern) in cadaveric rats with a large range of size and weight. Importantly, the rats did not obviously move during the test, where movement is a potential cause of uncontrolled injury. We further conducted parametric studies by varying the features of the design of the platform. These factors, such as how the limb is fixed and how the cavity through which the limb is placed is sealed, significantly affect the resulting injury. This platform and test setups enable well-controlled limb fracture induced directly by pure blast wave, which is the fundamental step towards a complete in vivo animal model for blast-induced HO induced by primary blast alone, excluding secondary and tertiary blast injury. In addition, the platform design and the findings presented here, particularly regarding the proper protection of the animal, have implications for future studies investigating localized blast injuries, such as blast induced brain and lung injuries.

Peculiarities of paravulvar microcirculation in skin and muscle in blast wound in variants of early local injection of reparative active agent

Introduction. A promising method of correcting microcirculatory disorders in the area of soft tissue injury is the use of agents with antihypoxant action, which include deproteinized calf-blood hemoderivate.The aim of the work was to reveal the peculiarities of subcutaneous and intramuscular local injection of deproteinized calfblood hemoderivate on the changes of microcirculation in the skin and muscles in the experimental blast wound area.Materials and methods. The experiments were performed on 90 male Wistar rats weighing (320±20) g in compliance with international rules of work with laboratory animals. Modeling of an explosive wound of the soft tissues of the femur with mild degree of blood loss was carried out according to the original author’s method (Patent RU No. 2741238 dated 22.01.2021). After primary surgical treatment was performed paravulnarly, deproteinized calf-blood hemoderivate was injected intramuscularly, intramuscularly and subcutaneously (Actovegin drug) once in six points with an insulin syringe. Microcirculation in the skin and muscles of the injured area was assessed by laser Doppler flowmetry using the device LAKK-M (Russia). To determine the normal values of microcirculation, data obtained from healthy animals were used.Results. Local intramuscular injection into the paravular area resulted in an increase of the constant perfusion component (M) by 24.1−35.9 % (p < 0.05) and by 18.0−56.4 % (p < 0.05) in the skin and muscles during all periods of observation, an increase of the variable perfusion component (σ) in the skin by 31.4−38.0 % (p < 0.05) during 28 days and in muscles by 8.8−58.7 % (p < 0.05) during the first 14 days only, increase of Kv ratio in skin by 12.4 % (p = 0.01) early after injury (7 days) and decrease in muscles by 18.3−20.8% (p < 0.05) at 14−28 days. Local combined administration (intramuscularly and subcutaneously) of the drug around the wound promoted the increase of the constant perfusion component (M) in the skin by 23.8 % (p = 0.005) and 6.9 % (p = 0.01) at the 7th and 28th days of observation, increase of σ index in skin by 14.2−45.1 % (p < 0.007) on the 7−14 days and its decrease in muscles by 15.7 % (p = 0.009) by the end of the 7th day of observation in comparison with animals after only intramuscular injection only. Also, the coefficient of variation (Kv) with the combined route of injection was increased in the skin by 8.8−23.8 % (p < 0.009) in the first 14 days and decreased in the muscles by 15.7 % (p = 0.008) in the early period after injury (7 days) relative to its values in animals with intramuscular injection.Discussion. The results of the study allow noting the stimulating effect of deproteinized calf-blood hemoderivate on neovasculogenesis in the damaged tissues, which can be judged by the increase in the constant perfusion component (M). In addition, we can conclude that the direct endothelium-protective effect of the drug consists in the modulation of microcirculatory flow, which confirms the significant increase in the variable perfusion component (σ) throughout the experiment.Conclusion. Local paravular administration of deproteinized calf-blood hemoderivate in experimental blast wound promotes microcirculation increase in the soft tissues of the injury area. Combined (intramuscular and subcutaneous) local paravular injection of the drug allows more effective stimulation of microcirculation in the skin and muscles of the injury area.

A critical review of experimental analyses performed on animals, post-mortem human subjects, and substitutes to explore primary blast-induced Traumatic Brain Injuries

Although blast-induced Traumatic Brain Injury (bTBI) has become a signature wound of conflict, its cause is not yet fully understood. Regarding primary blast injuries, i.e., those caused by the propagation of shock waves in the body, four direct and two indirect injury mechanisms have been mainly proposed in the literature. Since numerous authors have exposed instrumented animals, Post-Mortem Human Subjects (PMHS), and head substitutes to blast conditions, the aim of this review is to classify them in terms of threat, instrumentation, and investigated mechanisms. In the first part, data are collected from 6 studies on PMHS, 1 on primates, 11 on rodents, and 6 on swine for comparison purposes. Peak amplitudes of reflected pressures, intracranial pressures and cranial strains are extracted and analyzed to establish trends. Despite the small number of comparable studies, several similarities can be highlighted. Indeed, the analyses revealed a dose-response effect for most measurements. The results also depend on the orientation of the subject (forward, backward, and sideways) for the PMHS, primates, and swine. The second goal of this review is to evaluate the behavior of substitutes developed to replace PMHS experiments. Shell strains and internal pressures are thus collected on 19 geometric and anthropomorphic substitutes to assess whether they faithfully represent a human head. The results showed that these substitutes are for the most part not properly designed and therefore cannot yet reliably replace PMHS experimental data.

Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study

Background Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. Methods Retrospective study of the IDF-MC Trauma Registry between 1997–2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. Results Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19–27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. Conclusion The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

Blast Lung Injury in Children: Injury Patterns and Associated Organ Injuries.

Bombings are the most common cause of civilian deaths in wars, and unfortunately, a large proportion of civilian victims are children. This study aimed to evaluate the frequency of blast lung injury (BLI), to evaluate lung injury patterns on tomographic images, and to document the relationship between blast lung and mortality in children exposed to the blast effect. Thirty-six children (25.3% of pediatric patients brought to our hospital with blast injury) with BLI were included in the study. The pediatric trauma score evaluations made in the emergency department in the first admission were recorded. Lung injury findings in the computed tomography images of the patients were examined, and injuries detected in other systems were recorded. The most common lung injury pattern was contusion (right: 69.4%, left: 80.6%). The incidence of brain damage (52.4%) and intra-abdominal injury (76.2%) in children with low pediatric trauma score value was statistically significantly higher ( P = 0.049, P = 0.017, respectively). There was no statistically significant correlation between the presence of lung injury, injury patterns, and mortality. The incidence of brain damage in deceased patients (61.5%) was statistically significantly higher than the incidence of brain damage in surviving patients (26.1%) ( P = 0.036). Low pediatric trauma score was observed in 11 (84.6%) of the deceased children and in 10 (43.5%) of the survivors ( P = 0.016). The mean age of children with hemothorax in the right lung was statistically significantly lower than those without ( P = 0.014). Our findings revealed that pediatric BLI is common after a blast, that it is associated with other system injuries, and that a multimodal radiological approach is required in child victims.

Developing a Blast Injury Modeling Capability: Application of Concepts from the Defense M&S Domain

Increases in computational power have contributed to growing interest in using modeling and simulation (M&S) to better understand and address blast injury for US service members. The development of an M&S capability that can comprehensively simulate human injury, lethality, and impairment due to blast injury threats in the military environment requires a large, coordinated integration of many models and simulations. This contribution describes how various lessons learned from the defense M&S domain were used to support the future development of an envisioned Modeling Capability for blast injury by providing simulation functionality for simulation-based experimentation. It first addresses conceptually the interoperability challenges when more than one simulation can be or must be applied and possibly composed for the experiment. This leads to the development of a proposed concept of operations for the application of the Modeling Capability and the development of a framework of services needed to allow the identification of an applicable simulation solution, selecting the subset of those simulations, composing them for the experiment, and assessing the results. As a nascent endeavor, anticipated challenges for implementing these concepts are discussed, leveraging lessons learned regarding interoperability, composability, use of services, repositories, and development of simulation compositions to conduct simulation-based experiments.

The use of Thiocetam in the complex therapy of combat-related brain contusion

Each patient presents a unique set of characteristics and challenges when it comes to acute cerebral ischemia resulting from craniocerebral injury. The aim of this study is to investigate the utilization of Thiocetam as part of a comprehensive treatment approach for combat-related cerebral contusion and to assess the therapeutic effects of Thiocetam in patients with mild and moderate closed combat craniocerebral trauma in comparison to standard basic therapy. Materials and methods. 79 patients with mild and moderate closed combat craniocerebral trauma were examined. Among them, 76 patients experienced craniocerebral trauma due to an explosive blast injury, which included conditions such as brain concussion, mild cerebral contusion, and cranial vault fractures. All patients were admitted to the department during the acute period of their injuries. During the study, various clinical and functional methods were employed to assess the condition of the central nervous system. These methods were used to evaluate the effects of the complex treatment administered to the patients. Results. The administration of Thiocetam to the patients did not result in an increase in excitability, nervousness, or sleep disturbances. Furthermore, the examination of autonomic reactivity following Thiocetam treatment revealed that the indicator of normal autonomic reactivity increased to 60 % in the treated group, whereas it only increased to 42 % in the control group. Additionally, the patients with initially heightened vegetative reactions experienced a decrease from 42.8 % to 17.9 % in the treated group, while the control group saw a decrease from 38.5 % to 23.1 %. In terms of clinical outcomes, a positive effect was observed in 94 % of patients in the Thiocetam-treated group within the first 5 days. In comparison, the control group showed a positive clinical effect in 76 % of cases. This improvement was evident both in the clinical field and based on indicators of autonomic reactivity in EEG data, as well as cognitive function assessed by the MMSE cognitive function test scale. Conclusions. The utilization of Thiocetam during the acute phase of mild and moderate closed combat craniocerebral trauma enhances the neuroprotective effects of basic therapy. The combined drug Thiocetam, which possesses both nootropic and neuroprotective effects, offers the advantage of reducing or even avoiding the side effects commonly associated with traditional racetam nootropics.

Causes and Characteristics of Traumatic Tympanic Membrane Perforation in a Tertiary Care Hospital

Background: Due to human violence, perforation of the tympanic membrane is a frequent occurrence all over the world. The abrupt increase in air pressure in the external auditory canal is the pathophysiology of traumatic tympanic membrane perforation. Objective: To assess the causes and characteristics of traumatic Tympanic Membrane perforation in a tertiary care hospital Methodology: The current study was cross sectional study, conducted at the ENT Department of Sahara Medical College Narowal from January 2022 to July 2022. All the patients were examined by a sing ENT specialist and data was recorded on a pre-designed performa. All the analysis of data was done by IBM SPSS version 23. Results: In the current study, totally 80 patients were enrolled. There were 50 (62.5%) male patients while female patients were 30 (37.5%). The mean age in our study was 28 (4.29) years. The most common type of tympanic membrane perforation was slap in 56 (70%) patients followed by blast injury in 8 (10%) patients. On left side of ear, perforation of the Tympanic membrane was observed in 39 (48.75%) patients. Based on number of perforation, single perforation was observed in 72 (90%) patients while multiple perforations were observed in 8 (10%) patients. Conductive hearing loss was observed in 62 (77.5%) patients and Mild Hearing Loss was observed in 44 (55%) patients. Conclusion: Young males, particularly those between the ages of 18 and 30, often have traumatic tympanic membrane perforation. The most frequent cause of traumatic perforation was slap, which affects the left ear more frequently than the right ear. The most common type of hearing loss was conductive, and mild. Keywords: Causes; characteristics; Tympanic Membrane perforation