Missile Injuries Research Articles

Missile Fragment Embolism of the Coronary Artery in a Patient with Coronary Artery Disease

A 51-year-old war veteran referred to us with typical chest pain and dyspnea on exertion. He had a history of hypertension from several years before, for which he had been prescribed anti-hypertensive medications. He also gave a history of missile fragment injury to his chest from the Iran-Iraq war, for which he had been hospitalized, but had received conservative medical treatment only. After admission and initial workup, echocardiography revealed mild left ventricular dysfunction with an ejection fraction of 45% and a metallic fragment at the diaphragmatic surface of the right ventricle. Coronary angiography showed significant stenosis at the LAD – Diagonal bifurcation, as well as a metallic fragment occluding the PDA branch of the right coronary artery. Coronary artery bypass surgery was performed successfully and the patient was discharged uneventfully. To the best of our knowledge, this is the first report of an embolized missile fragment to the coronary artery found incidentally in a patient undergoing surgery for coronary artery disease.

Complications, outcomes, and management strategies of non-missile penetrating head injuries.

While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors. Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed. One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18-58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge. The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Missile War Injuries of the Craniofacial Region

Many factors govern the nature, severity, and outcome of missile war injuries and associated soft tissue damages. Managements of primary phase and trauma care have improved significantly. Many of these injured victims survived and require immediate care for primary phase management. Secondary phase was achieved by reconstruction of soft tissue by local, regional flaps, and bony defect by bone grafting.There is no consensus on timing of treatment of bone and soft tissue of missile war injuries.Currently, in Iraq, anti-government's protestors' movement for the last 3 months mainly unemployed young people demanding for human rights has resettled in 22,000 people being injured. This includes more than 600 young men who were assassinated by unknown killers through confrontation with security and police men using tear gas canisters and sound bombs. The demonstrators used mini cars (Tuck Tuck) for attacking policemen and security people and used them for transferring injured demonstrators as ambulance to a special tent in the Tahrir Square for receiving first aid.

Book Review: Missile Injuries of the Brain, Spine, and Peripheral Nerves, Second Edition

Neurosurgery: March 2020 - Volume 86 - Issue 3 - p E343-E344 doi: 10.1093/neuros/nyz497

An Unusual Case of Penetrating Injury Skull with Metallic RCC Rod in A Child – A Rare Case Scenario with Review of Literature

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, and motor vehicle or occupational accidents (nails, screw-drivers). Penetrating head injuries in children constitute even a smaller part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. A 6-year-old female presented in casualty with an iron rod penetrating into the skull.

The priorities and emergency treatments of multisystem injuries associated with maxillofacial traumas

Background: The purpose of this study is to evaluate the care of multiple trauma victims with maxillofacial injuries in terms of epidemiological distributions, types of injuries, the related different modalities of surgical treatments delivered, and their complications. Materials and Methods: This prospective study was performed on 50 patients with multiple traumas including maxillofacial injuries, caused by different etiological factors, who were brought first to the surgical emergencies department of the Medical City then referred to the Maxillofacial unit in the Specialized Surgeries Hospital, Baghdad, Iraq, during the period from April 2007 to April 2008. Information was documented prospectively from the time of the emergency call to discharge (or death). Results: the age range was from 6 to 63 years, with the most frequent age group for injury being ranged between 21-30 years. The male to female ratio was 6:1. The missile injuries accounted for 90% of multiple traumas with maxillofacial injuries, while civilian injuries accounted for 10% of the cases. The mechanisms of injury, concerning war injuries, were gunshot injuries 46% and blast injuries 44%, while concerning civilian injuries: road traffic accidents 8% and stabbing injuries 2%. Among 50 people injured, 3 (6%) died. Conclusion: The priority during initial treatment is the achievement of patent airway, hemostasis, and the maintenance of vital tissues oxygenation.

Penetrating Wooden Injury : Wooden Stick

Background : Accidental penetrating brain injury is relatively uncommon representing about 0.4% of all head injuries. Penetrating brain injury (PBI) were divided into Missile and Non missile penetrating head injuries (NPHIs). Non missile penetrating head injuries (NPHIs) are relatively rare compared with missile injuries. Wooden Penetrating Brain Injury is one of Non missile penetrating head injuries (NPHIs)&#x0D; Case Report : 20-year-old male presented with Decreased of Conciousness. History revealed that he was riding motorcycle and had an crash injury with other motorcycle rider from a head. He fell down and a broken wooden stick entered into his skull. Airway was clear, Breathing was spontan and respiratory rate 26 per minutes, Circulatory finding were warm skin, pulse rate of 118 per minute and blood pressure of 140/80 mm Hg, Glasgow Coma Scale (GCS) score on admission was E3M5V4. Radiology Imaging finding a foreign body in Left Frontal Lobe.&#x0D; Discussion : Wooden Penetrating Brain Injury was Nonmissile penetrating head injuries (NPHIs). The pathophysiology is similar to closed head injuries causing cerebral contusion or intracranial hemorrhage, but there is more chance of infection. Primary survey and stabilization of the patient with regard to the airway, breathing, cervical spine, and circulation including external hemorrhage. Computed tomography (CT) scanning of the head is primary modality . MRI can be a useful neuroradiologic modality if a penetrating object is a wood. Patient was performed Craniectomy Debridement and was treated with triple antibiotic regiment.&#x0D; Conclusion : The management of PBI differs considerably from nonpenetrating brain injury because of the unique mechanism of injury and pathophysiology involved in this type of trauma In this patient surgical treatment was undergoing after 12 h. Patient was treated with triple antibiotic regiment and was discharged on 7th day post operation. The recovery of the patient went uneventfull. Patient gained back his conciousness without any neurological deficit.&#x0D; Key words : Penetrating Brain Injury, Nonmissile, Wooden stick&#x0D; &#x0D;

Isolated Retrodental Epidural Hematoma Without Dens Fracture.

Traumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being<1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma. A 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.

Letter to the Editor Regarding “Traumatic Brain Injury Caused by Missile Wounds in the North of Palestine: A Single Institution's Experience with 520 Consecutive Civilian Patients”

Letter to the Editor Regarding “Traumatic Brain Injury Caused by Missile Wounds in the North of Palestine: A Single Institution's Experience with 520 Consecutive Civilian Patients”

In Reply to the Letter to the Editor Regarding “Traumatic Brain Injury Caused by Missile Wounds: Are These Results a Mirror for Most Developing Countries?”

In Reply to the Letter to the Editor Regarding “Traumatic Brain Injury Caused by Missile Wounds: Are These Results a Mirror for Most Developing Countries?”

Visual and Anatomic Outcomes in Perforating Ocular Injuries.

This article reports the presentation, management, and outcomes in patients suffering perforating ocular injuries. A retrospective review was conducted at a single ophthalmology Level 1 trauma center. Patients with evidence of traumatic ocular perforation, with surgical intervention attended by a single vitreoretinal surgeon (W.F.M.), were reviewed between 2009 and 2017. Six eyes from 6 patients with perforating ocular injuries were studied. All patients were male, between ages 11 and 56 years. Perforation was the result of gunshots (3), other accidental injury (2), or surgical complication (1). Varying degrees of retinal detachments were seen in all 6 patients. Pars plana vitrectomy, with endolaser around posterior entry or exit wounds, was performed on average 21.7 ± 8.9 days from the time of injury (range, 0-58 days). In all cases with intraorbital foreign bodies, the foreign bodies were left in place. The most recent postoperative visual acuity ranged from 20/25 to counting fingers. Missile injuries tended to have poorer vision. All cases achieved full anatomic attachment at most recent follow-up. There have been no orbital complications related to retained intraorbital foreign bodies, including endophthalmitis, orbital infections, or mechanical strabismus. This study demonstrates successful anatomic outcomes of 6 cases of perforating ocular injuries. Visual outcomes were variable, though missile injuries demonstrated worse prognosis, whereas several nonmissile macula-involving cases achieved quite favorable results. Although traumatic perforating injuries generally have guarded visual prognoses, favorable results may be achieved in select scenarios.

Guns and Kids: Treatment of Pediatric Firearm and Air Gun Missile Injuries in the Emergency Department

Guns and Kids: Treatment of Pediatric Firearm and Air Gun Missile Injuries in the Emergency Department

Guns and Kids: Treatment of Pediatric Firearm and Air Gun Missile Injuries in the Emergency Department

Background: A recent inpatient data analysis found 16 US children are hospitalized with firearm-related injuries each day. We hypothesized a higher number children are treated in the emergency department (ED). Therefore we sought to examine the incidence and outcomes of pediatric firearm injuries treated in the ED. Methods: All pediatric (age, 0-18 years) firearm-related injuries were identified from the most …

Sniper-induced sciatic nerve injury

Missile injuries of the sciatic nerve are frequently encountered in military practice.[1 2][1] As part of a Reconstructive Surgery Project established in Amman, Jordan, 116 civilian war casualties of Middle...

Clinical profile and outcome of chest trauma: a four year retrospective analysis at a tertiary care centre

Background: Chest trauma comprises about 10-15% of all traumas and 25% of all deaths from traumatic injury. Chest injuries are cause by blunt mechanisms such as road traffic accidents or penetrating mechanisms such as stab and missile injuries. Traumatic chest injuries are the most common cause of preventive mortality and morbidity.Methods: A retrospective study of all patients with chest injury presenting to Emergency Department of SKIMS Medical College, Srinagar was done. Records of all the patients were retrieved. A complete data regarding age, gender, mode/type of injury, extra thoracic injuries, mode of management and outcome was gathered.Results: A total number of 1429 trauma patients presented to AE of which 160 patients (11.2%) had chest trauma. Majority of the patients (51.87%, n=83) were of age group of 21-40 years. A male preponderance was observed. Road traffic accidents were major causes of blunt chest injury, while gunshot injury was the major causes of penetrating chest injuries. Head and neck injuries were the most common associated injuries. Tube thoracostomy was the commonest modality of management (65%) and (28%) patients were managed conservatively. Severity of chest trauma and associated injuries coupled with prompt diagnosis and treatment were important factors in efficient management of chest injuries.Conclusions: Chest trauma resulting from road traffic accidents remains the major mechanism of injury. Preventive measures aimed at educating the common masses about traffic rules and strictly implementing them is indispensable to reduce the incidence of chest injuries.

Missile Injury of the Sciatic Nerve: Observational Study Supporting Early Exploration and Direct Suture With Flexed Knee.

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.

Fatal atypical missile injuries

The missile injuries predominately occur by explosive devices and firearms, but sometimes these injuries occur by high velocity objects such as stones and metallic articles, which may cause fatal injuries resulting in death. Boththe cases presented here are rare and uniquewith reference to the dramatic, sudden and unforeseen incidences, manner of causation of injury and limited availability in literature. In this article we have presented two cases, in which death has occurred due to penetration of non-ballistic missile objects propelled by wheels of high speed running train. Accidental injuries due to missile objects are rare, but severe nature of such injuries may lead to death. In both the cases high speed objects propelled by train had caused severe damage to internal organs causing death. Eventhough the incidences are very much uncertain and unforeseen to take preventive measures but awareness should be made among the peoples. Saving a ‘single life ’by such a step will achieve the purpose of this article, because every single life is important.

Missile injuries of the brain, spine and peripheral nerves

Missile injuries of the brain, spine and peripheral nerves

Penetrating Brain Injuries at Assiut University Hospital: One Year Study

AbstractBackground: Penetrating Brain Injury (PBI) is defined as head traumain which a projectile breaches the cranium and dura matter. It is one of the most fatal forms of trauma and many cases die at the site of trauma. For those who survive till hospitalization, the management of penetrating brain injury represents great challenges to medical and surgical providers. Penetrating brain injuries are classified according to projectile velocity into missile and nonmissile injuries.Aim of Study: Our study discussesclinical-radiological profile and outcome of patients of penetrating brain injuries.Material and Methods: This is a prospective hospital based study includes 30 patients with penetrating head injuries admitted and managed at Department of Neurosurgery and Trauma Units of Assiut University Hospital through one year from March 2015 to March 2016.Results: The mean age was 25 years. 27 patients were males (90%). Brainmatter herniation and Cerebrospinal Fluid (CSF) leak was the most common clinical presentation in 28 (93.3%) patients followed by decreasedlevel of consciousness in 26 (86.6%) patients. Multiple lobe injury was noted in 14 (46.6%) patients followed by parietal lobe in 10 (30%) patients. 12 patients died during the hospital stay. Three patients were discharged in GOS-3, 5 in GOS-4, and 10 in GOS-5. Wound infection occurred in3 (10%) patients, and seizure developed in 7 (23.3%) patients.Conclusion: Penetrating brain injuries are rising issue in our community. It occurs commonly in young adults (20 to 40 year-old agegroup) and occurs more commonly in males. Firearm is the usual mode of injury and carries worse prognosis than other modes of injury. Higher mortality wasobserved among missile injuries compared to non missile injuries. Mostcases presented with brainmatter herniation or CSF leak. Multi lobar injury is themost common finding followed by parietal lobe injury. Aggressive resuscitation is required in cases of PBI. Prognosis of penetrating brain injuries is highly related to post resuscitation GCS.

Managing military penetrating brain injuries in the war zone: lessons learned.

OBJECTIVEManaging penetrating military brain injuries in a war zone setting is different than managing common civilian penetrating brain injuries. Triage, i.e., deciding on which patients to treat or not treat, and which to be flown back home, is essential to avoid wasting valuable limited resources. In this study the authors aim to identify reliable predictors of mortality and poor outcome to help develop a protocol for treating their patients in the battlefield. They also demonstrate all the lessons learned from their collective experience regarding some of the controversial management issues.METHODSThis study was a retrospective review of 102 patients with penetrating military missile head injuries treated by the authors in various facilities in northern Sinai between 2011 and 2018. Patient demographics, clinical characteristics, imaging characteristics, postoperative complications, and Glasgow Outcome Scale (GOS) scores were recorded for each patient. Several variables associated with mortality and poor outcome that were derived from the literature were analyzed, in addition to variables obtained by direct observation by the authors over time.RESULTSThere were 50 patients (49%) with GOS score of 1 (death), 12 patients (11.8%) with GOS score of 2 (survivors in persistent vegetative state), and 40 survivors (39.2%) with varying degrees of disability on the last follow-up evaluation. The authors identified an anatomical danger zone that was found to predict mortality when traversed. Bilateral dilated fixed pupils and low Glasgow Coma Scale score on admission were also found to be independent predictors of mortality and poor outcome. Based on these findings, a protocol was developed for managing these patients in the war zone.CONCLUSIONSManaging military penetrating head injuries in the war zone is different than civilian gunshot head injuries encountered by most neurosurgeons in urban cities. The authors developed a simple protocol for managing military penetrating injuries in the war zone. They also describe important lessons learned from this experience.