Shrapnel Wounds Research Articles

Медицинская помощь детям, пострадавшим в вооруженных конфликтах: систематический обзор литературы

Summary. The aim of the study is to analyze the data on mortality, structure of injuries, terms of hospitalization, routing of patients and organization of medical care for children injured in armed conflicts and terrorist acts. Materials and research methods. A systematic review was performed in accordance with the recommendations of the PRISMA protocol. A comprehensive search was conducted in PubMed, ScienceDirect, E-library, and GoogleScholar databases for the period from 1995 to 2022. The search revealed 2995 publications, of which 25 papers were included in the quantitative analysis according to the inclusion criteria. Results of the study and their analysis. We analyzed 54205 cases of medical care for children injured in 15 armed conflicts and 48 terrorist attacks between 1988 and 2020. The average age of the injured children was 9.7 years; the proportion of children in the total mass of the injured was 12.7%. The average percentage of bed days in children was 10.9%; the average duration of hospitalization was 7.4 days; 82% of patients required surgery; the pediatric mortality rate was 7.6%. The most common mechanisms of injury in children were shrapnel and explosive wounds; the most frequent cause of death was craniocerebral trauma.

The endoscopic removal of urethral foreign body (a fragment of an artillery shell): a clinical case

Gunshot wounds of the external genitalia are present in two-thirds of all penetrating genitourinary trauma in the military setting with prevailing shrapnel wounds.The reported clinical case is aimed at providing rational and demonstrating benefits of endoscopic removal of a splinter from the urethral lumen.The clinical case presents the successful removal of a splinter from the urethral lumen. A 22-year-old man suffered gunshot shrapnel wound to the scrotum and urethra 7 months ago, а splinter was located in the urethral lumen and was successfully removed using endoscopic approach. In some cases X-ray diagnosis does not allow detecting the exact location of the splinter. Therefore, it is rational to use endourological diagnostic procedures.

Intracardiac foreign bodies: Diagnosis and management

<b>Introduction:<i> </i></b>As a result of gunshot wounds due to a bullet or shrapnel entering the system of arteries or veins, direct wounds of the heart or vascular structures, as well as embolisms may occur. After entering one of the systemic veins, the bullet or shrapnel can enter the right heart or the pulmonary artery. Shrapnel embolism is a rare condition, usually asymptomatic and is detected accidentally during routine examinations. Due to the fact that the intensity of occurrence of this type of cases is quite rare, it was decided to present such clinical cases.<br /> <b>Material and methods:<i> </i></b>This article reports about 3 patients with intracardiac foreign body. All 3 patients took part in the battles during the Second Karabakh War and were hospitalized as a result of shrapnel wounds received in different parts of the body. In each of the patients, the lesion area was different, but as a result of venous migration, the movement of a foreign body (metal fragment) in the heart cavity was noted. In two patients, the foreign body was removed by open surgery (connection to a heart-lung machine) due to the presence of symptoms, but one patient was under observation due to the absence of symptoms.<br /> <b>Results:<i> </i></b>Bullet or shrapnel embolism is a very rare complication of gunshot wounds, occurring in about 0.3% of cases. These emboli often cause antegrade migration into the arterial system. However, in about 20% of cases, migration into the venous system can also occur. Venous embolism often results in foreign body migration into the right heart or the pulmonary artery. The diagnosis in these cases is often established by chance, but in some cases, arrhythmias and valve defects can occur due to exposure to a foreign body. The identification of such cases depends on the symptoms. A foreign body can be removed by an open method, as well as by invasive methods. In some cases, it is possible to keep the foreign body under control when it does not cause any symptoms.<br /> In the clinical cases we mentioned, we also mentioned the management of cases of foreign bodies entering the venous system from peripheral zones of penetration.

Advances in the treatment of combat trauma to the extremities: photodynamic therapy and methods of plastic wound closure

Objective. To evaluate our own ten–year experience in the use of photodynamic therapy and plastic wound closure methods in the treatment of combat trauma victims using various photosensitizers and light sources, as well as tissue therapy.
 Materials and methods. In the Department of Acute Diseases of the Major Vessels of the Zaitsev Institute of General and Emergency Surgery, 36 patients with mine–blast and shrapnel wounds with damage to the major vessels underwent staged treatment of infectious wound complications using negative pressure wound therapy, photo– and photodynamic therapy, followed by wound closure with a fibroblast matrix. Bacterial contamination with the identification of strains, the timing of pathogen eradication in the wound, and the duration of wound healing were assessed.
 Results. As a local treatment, negative pressure wound therapy was initially used in a constant vacuum mode of –75 to –115 mm Hg for 4 to 5 days. In case of reduction/disappearance of soft tissue edema, the wounds after fasciotomy were sutured, and dermotension was used in 5 patients. After photosensitisation, the wound was irradiated with Korobov photonic matrices "Barva–Flex" with a wavelength of 660 nm (red light). During the staged treatment of wounds, complete eradication of pathogens in the wound was recorded on the 5th day, and complete wound healing was recorded within 17 days.
 Conclusions. Comprehensive treatment of infectious wound complications in victims with combat trauma using negative pressure wound therapy and photo– and photodynamic therapy, especially in the context of the formation of infectious pathogens resistance, led to better wound healing in a short time.

Организация оказания первой помощи раненым военнослужащим в зоне вооруженного конфликта

Summary. The objectives of the study are to analyze the role of knowledge and skills acquired by servicemen when they render first aid to the wounded in combat conditions; to study the structure of sanitary losses in a military unit in the zone of Special Military Operation. Materials and research methods. Materials of the study are the experience of first aid in combat conditions. On the battlefield, various medical means of defense were used to provide first aid to the wounded. Soldiers, who were wounded, used first aid kits individual medical AI-3-1BC as a means of self-help. Sanitary straps, cloak tents and improvised means were used for medical evacuation of the wounded to a safe zone. Belts, ropes and other available materials were used as improvised means. In the field, the servicemen were trained to: search for the wounded; in case of various external bleeding — to apply hemostatic tourniquets, tourniquets, compression bandages, aseptic bandages on wounds; in case of injuries — to immobilize limbs. In case of wounds and traumas, intramuscular injection of anesthetic agents contained in a syringe-tube was performed. Medical evacuation of the wounded to a safe zone was carried out with observance of safety measures — both for the wounded and for the first aid provider. Research methods were analytical, statistical and field observation methods. Results of the study and their analysis. In the zone of the Special Military Operation the enemy actively uses remote and combined methods of defeat, which creates difficulties in the medical evacuation of wounded servicemen from the battlefield. During the first two hours after being wounded, about 11.0% of the wounded were received at triage points; between two and 6 hours, no more than 11.0% of the wounded were received. Most of the wounded arrived at triage points at later dates. In the structure of sanitary losses, the share of shrapnel wounds was 79.0%; bullet wounds — 10.0%; non-combat-related injuries and somatic diseases — 11.0%. The wounds were mixed and combined by nature. The share of severe wounds amounted to 23.0%; the share of moderate wounds — 50.0; the share of light wounds — 27.0%. It is concluded that timely and competent rendering of first aid to the wounded on the line of contact with the enemy is of paramount importance for saving lives of servicemen.

Surgical treatment of isolated soft tissue gunshot shrapnel injuries by combining primary delayed sutures with platelet-rich autoplasma injections into mine-explosive wounds

Aim: to assess the treatment effectiveness in patients with soft tissue gunshot shrapnel injuries by applying primary delayed sutures in combination with platelet-rich autoplasma injections into wounds. Materials and methods. The study included 60 (100.0 %) patients with soft tissue gunshot shrapnel wounds. All wounded were divided into two groups. The comparison group consisted of 30 (50.0 %) patients admitted to a hospital with primary delayed sutures (6–7 days). The main group included 30 (50.0 %) patients whose local treatment modification consisted in a combination of primary delayed suturing with platelet-rich autoplasma injection into a wound. A wound channel was observed on the 8th, 11th –14th days from the moment of injury using visual inspection, linear measurements and diagnostic ultrasound system (Mindray M6, 220A). Results. 60 (100.0 %) patients were urgently hospitalized to the third stage of medical evacuation and treated according to standard treatment protocols for this pathology at the third stage of evacuation. According to a wound defect localization, the wounded of the comparison groups, 30 (50.00 %), were distributed as follows: a lower limb wound – 22 (73.33 %) patients, an upper limb wound – 6 (20.00 %), and a trunk wound – 2 (6.67 %). The main group also included 30 (50.00 %) wounded, whose treatment at the third stage of medical evacuation was modified by using a combination of primary delayed sutures and platelet-rich autoplasma injection. On the 8th day after an injury, a visual inspection of the wounds detected no hyperemia or suppuration in both groups. The visual inspection of wounds in the comparison group at 11.0 ± 3.9 days post-injury revealed 24 (80.00 %) patients with complications such as seromas in 17 (56.67 %) cases, hematomas with wound suppuration – in 7 (23.33 %). In the main group, 2 (6.67 %) cases of wound suppuration were detected (U = 120.00, p = 0.000001). The basic parameters of wound linear measurements according to the diagnostic ultrasound system data at the 11th–14th day post-injury after primary and delayed suturing in the studied groups: in the comparison group, upper limb wounds – S (mm2) 43.3 ± 12.6, V (mm3) 53.3 ± 13.9; lower limb wounds – S (mm2) 194.7 ± 50.7, V (mm3) 706.3 ± 190.4; trunk wounds – S (mm2) 20.5 ± 7.2, V (mm3) 22.5 ± 5.4. In the main group, upper limb wounds – S (mm2) 28.2 ± 8.5, V (mm3) 23.2 ± 7.1; lower limb wounds – S (mm2) 56.4 ± 19.6, V (mm3) 102.4 ± 21.1; trunk wounds – S (mm2) 12.3 ± 3.2, V (mm3) 10.4 ± 2.9. The total duration of inpatient treatment at the 3rd stage of medical evacuation in the comparison group wounded was 30.0 ± 2.3 days, and in the main group it was 12.0 ± 3.1 days (U = 290.00, p = 0.0354). Conclusions. In the structure of gunshot shrapnel wounds in both groups, there were 43 (71.67 %) lower limb traumatic injuries, 11 (18.33 %) upper limb, and 6 (10.00 %) trunk injuries. The use of platelet-rich autoplasma in combination with primary delayed suturing stimulated wound healing and accelerated wound-healing process as evidenced by a significant decrease in the wound defect area and volume on the 11th–14th day post-injury in the main group compared to the comparison group. The method for treatment of gunshot shrapnel wounds developed by us reduced the frequency of postoperative complications since 24 (80.00 %) patients were diagnosed with complications in the comparison group, while only 2 (6.67 %) patients in the main group (U = 120.00, p = 0.00001). The use of platelet-rich autoplasma made it possible to reduce the length of hospital stay for patients at the third stage of medical evacuation: in the comparison group, this period was 30.0 ± 2.3 days, and in the main group, 12.0 ± 3.1 days (U = 290.00, p = 0.0354).

Clinical application of neodymium magnetic instruments for the removal of foreign bodies in blind wounds

A feature of modern military conflicts is the high frequency of shrapnel wounds. The search for foreign bodies, even under X-ray navigation, can be technically difficult, lengthy and not always successful. Most injuring objects have ferromagnetic properties.
 AIM: The Military Medical Academy, Saint Petersburg purpose of the study: to evaluate the effectiveness of removing ferromagnetic foreign bodies from blind wounds using neodymium magnetic instruments.
 MATERIALS AND METHODS: Instruments based on a neodymium magnet for removing foreign bodies and a technique for their use have been developed. An analysis was made of 45 operations where traditional instruments were used and 75 operations using original magnetic instruments. Of these, in 40 cases of blind wounds, foreign bodies were removed from the soft tissues of various areas, and in 35 cases, foreign bodies were removed during videothoracoscopy operations for blind penetrating chest wounds. The criteria for evaluating the effectiveness of the method were the duration of the operation, the duration of work with the X-ray unit and the number of detected and removed foreign bodies in a fixed period of time.
 CONCLUSION: High efficiency, simplicity, accessibility, minimally invasiveness of the developed instruments have been proven. Neodymium magnets made it possible to reduce the time of radiation exposure and the duration of the operation, to increase the efficiency of removing ferromagnetic foreign bodies. The use of original instruments makes it possible to detect 80% of foreign bodies in 10 minutes, and within 30 minutes to remove 90% of foreign bodies from the soft tissues of the wounded. With videothoracoscopy, the time of fluoroscopy was halved, and the total duration of the surgical intervention was reduced by 40%.

Analysis of the history of creation and improvement of personal protective equipment: from bronze armor to modern bulletproof vests

In this article, using real historical examples, the authors tried to trace the evolution of personal protective equipment. This has made it possible to perform a comparative historical analysis of the development of scientific research and industrial technologies, which made it possible to manufacture specific personal protective equipment in a certain historical period. Also in this review article, the authors have analyzed the stages of modern technologies that are currently used in the manufacture of various types of bulletproof vest. And given that the overwhelming majority of authors of publications devoted to the history of the creation of bulletproof vests write that: the bulletproof vest does not have a specific inventor, in this review article the authors also talk about specific, undeservedly forgotten now, the creators of the world's first officially patented prototypes of bulletproof vests for the police and VIP-persons, at the beginning of the 20th century, who stood at the origins of the bulletproof vest industry. With the development of the industrial revolution and technological progress, new materials and production technologies have appeared, allowing the creation of more effective bulletproof vest. Bulletproof vest has become lighter and more effective over time, thanks to the use of new materials such as Kevlar, aramid fibers and ceramics. Thus, the history of the development of bulletproof vest includes the contribution of many scientists, engineers and inventors who have contributed to the improvement of protective armor over the years. In the article, the authors show that modern realities put forward new requirements for quality, weight and functional characteristics for design engineers and manufacturers of bulletproof vest. The authors of the article analyze the main directions in which research work is currently underway to improve bulletproof vests. The authors of the article show that in different countries of the world there are different standards and classifications for bulletproof vest. Each standard usually has its own classification, which determines the level of protection of bulletproof vest against specific types of threats, such as bullets, shrapnel or stab wounds. Therefore, the task of developing a single standard for modern bulletproof vest is important.

Актуальные вопросы подготовки медицинских сил и средств Службы медицины катастроф Алтайского края в рамках проведения командно-штабных и тактико-специальных учений

Summary. Investigation purposes – to make reasonable a usage of equipment report card of specialized medical-nurses teams (MNT) of Service of disaster medicine (SDM) of Altay region (Service), made for elimination of medical-sanitary consequences of emergency situations (ES), including cases of conducting antiterrorists operations; to teach specialists, according to crated situation exercises, from Service a skills of medical sorting conduction of victims and injured with gunshot and shrapnel wounds in the conditions of field medical sorting point (FMSP). Materials and methods of investigation. Investigation materials – normative legal acts in the spere of organization and conducting of antiterrorists exercises with attracting of forces and means of SDM, including material of inter-department work group which leads by deputy Governor of Altay region. Legislative and regulatory framework were analyzed. Experience of conducting a command-staff exercises (CSE) and elimination of medical-sanitary losses, including losses in case of antiterrorists operations, was researched. It allowed to assess a system of medical treatment provision and to develop a complex of measures for Service improvement. During summarizing of exercises results of the intermediaries reference was analyzed. Investigation results and their analysis. During the exercise to eliminate a medical-sanitary consequences of ES a work of Service forces and measures in pre-hospital periods was organized; FMSP was deployed; Ensuring of temporary medical points for providing round-the-clock urgent medical help in the points of temporary placement (PTP) of population by the forces of SDM was provided for; Provision of psychological help was ensured by specialists from Altay region clinical psychiatrist hospital named after Y.K. Ardman. In addition, members of unregular former of Altay region bureau of forensic medical examination were on alert. This way, all forces and measures of SDM were ready for the elimination of medical-sanitary consequences of ES according to the plan for municipal formers.

Первичная отсроченная хирургическая помощь пациенту с боевым ранением глаза

Currently, injuries to the visual organ are one of the most important causes of blindness and disability due to the complicated course of the post-traumatic process and an unfavorable functional outcome, in the vast majority of cases of the able-bodied population. The timeliness of providing highly specialized ophthalmic surgical care is a fundamental factor that allows for the medical and social rehabilitation of patients with various visual organ injuries in the shortest possible time. In turn, the prolongation of the terms of primary surgical treatment dictates slightly different approaches to the conservative and surgical treatment of such patients. Objective. To evaluate the effectiveness of primary delayed simultaneous surgical care for a patient with a penetrating comminuted battle wound of the eye. Material and metods. Patient K., 35 years old, was admitted to the ophthalmological department of the State Medical Institution «OOKB» of Orenburg with complaints of decreased visual acuity of the left eye with the diagnosis: OS – Multiple military trauma. Consequences of penetrating eye injury. Corneal scar. Traumatic cataract. Partial hemophthalmos. Local retinal detachment. Intraocular foreign bodies. From anamnesis: a month ago, during military operations, he received a shrapnel wound to the head. An open penetrating comminuted fracture of the left temporal bone was performed in a military hospital. I did not receive surgical ophthalmological care. Ophthalmological status: Vis OD = 1,0: OS = movement of the shadow at the face. The IOP of both eyes is normal. OS – conjunctiva is injected, a metallic foreign body is embedded in the sclera at the meridian of 7 hours, 5 mm from the limb, the cornea is transparent, the corneal scar, the anterior chamber is shallow, the moisture is transparent, the iris is edematous, the pupil in the center is deformed, tightened for 7 hours, the pupil reaction is slowed down, inhomogeneous opacities in the lens. The reflex is dim, the details of the fundus and vitreous are not ophthalmoscoped. Preparatory measures were carried out before the surgical intervention: antibacterial and anti-inflammatory therapy. At the first stage, phacoemulsification of traumatic cataract with posterior continuous capsulorexis was performed in the conditions of medical mydriasis. The second stage was a standard three-port vitrectomy of 25 G with the removal of organized vitreous blood clots and the removal of the posterior hyaloid membrane. During the revision, a parietal foreign body with local retinal detachment is visualized in the middle outer part. A 23 G tweezers were used to remove the foreign body, which required the replacement of one of the ports. Delimitative endolasercoagulation was performed. The foreign body was removed through the posterior capsulorexis: brought to the iris in the anterior chamber of the eye, then evacuated through a tunnel incision of 2.75 mm. Then a perfluoroorganic compound (PFOS) was introduced, the retina was attached, additional retinal endolasercoagulation was performed. At the third stage, a simultaneous replacement of PFOS with silicone oil was carried out. The Miol-soft intraocular lens was implanted. At the last stage, the embedded foreign body of the sclera was removed, the conjunctival wound was sutured. On the fifth day after surgical treatment, the patient was discharged for outpatient follow-up with the functions of vis OS = 0.2 sph (+) 4.0 = 0.4 with recommendations. Conclusions. As a result of simultaneous high-tech vitreoretinal surgical treatment against the background of anti-inflammatory and antibacterial therapy, high functional results were achieved. Keywords: injury, penetrating wound of the eye, foreign body of the eye, local retinal detachment

Лечение слепого осколочного ранения с повреждением печени, левого легкого, диафрагмы, сердца, осложнившегося внутрисердечным тромбозом и материальной эмболией левой общей бедренной артерии

The experience of staged treatment of a wounded man with a thoracoabdominal shrapnel wound, accompanied by the development of complications not typical for combat trauma: intracardiac thrombosis in the location of the interventricular septum shrapnel wound and material embolism of the left common femoral artery with a foreign body (shrapnel) from the left ventricular cavity is presented.

ТРАВМАТИЧНИЙ ПНЕВМОНІТ ВНАСЛІДОК ВІЙСЬКОВОЇ ТРАВМИ ГРУДНОЇ КЛІТКИ ЯК ФАКТОР РИЗИКУ ПНЕВМОНІЇ

The relevance of the problem of gunshot wounds and injuries as a result of the war with Russia continues to grow. Gunshot wounds and chest injury can cause several life-threatening conditions: bleeding, airway obstruction, tension pneumothorax with pericardial tamponade, open pneumothorax, massive hemothorax, chest dissection, tracheobronchial injury, diaphragm damage, myocardial injury, rupture thoracic aorta, esophageal damage and lung contusion. Lung contusion or traumatic pneumonitis is characterized by hemorrhage and swelling in the alveoli. This causes respiratory distress which develops 24 hours after lung injury, causing perfusion/ventilation mismatch by increasing pulmonary vascular resistance and decreasing lung compliance. From February 24, 2022 to February 18, 2023, in the Pulmonology Department of Volyn Regional Clinical Hospital, the rate of hospitalized military patients with chest injury due to mine-explosive wounds, shrapnel wounds, gunshot bullet wounds, and stub-cut wounds of the chest amounted to 19.3% of all pulmonary cases among military, admitted this year (n=88). Penetrating chest injury occurred in 41.1% of cases, nonpenetrating blunt chest injury (including behind armor blunt trauma) in 23.5 % of cases, chest trauma with soft tissue injury in 35.2 % of cases. Chest injury with fractured chest bones was detected in 47% of cases. In 52.9 % of cases, chest injuries and one stab-cut wound were on the side surface and chest, which was not protected by a bulletproof vest. Lung contusion or traumatic pneumonitis was observed in 70.5% of cases, including destruction in 29.4 %. Post-traumatic pneumonia was observed in 58.8 % of cases, that was caused by a non-hospital and hospital infection, pleurisy was observed in 17.6 % of cases. After chest injury, infiltrative-destructive pulmonary tuberculosis was detected in 5.8 % of cases and invasive pulmonary aspergillosis in 5.8 % of cases. Thus, the occurrence of a specific infection that can lead to destruction and aggravate destructive changes in the lung parenchyma should also be taken into account. Also, in 64.7 % of cases, metal, fragmentary, foreign bodies of the chest organs were found, and required further surgical removal. The article presents clinical cases of patients with chest injuries received as a result of military operations in Ukraine. Key words: traumatic pneumonitis, lung contusion, gunshot wound, chest injury, behind armor blunt trauma, pneumonia.

Indicators of questionnaires of the International index of erectile function-5 (MIEF-5) of men injured as a result of hostilities

The modern scientific understanding of erectile dysfunction indicates the predominant secondary nature of sexual disorders in relation to the diseases that cause them. This largely applies to male victims of hostilities. The basis of the work was the results of a survey of 298 men injured as a result of combat operations (shrapnel and bullet wounds) using the International Index of Erectile Function-5 (MIEF-5) questionnaires. The research group was divided into two: men aged 20–39 years (group 1) and men aged 40–53 years (group 2). The control group consisted of 48 practically healthy men without complaints of sexual dysfunction or cardiac, neurological or endocrinological pathology. Among the men of the control group were 30 men aged 20–39 years (group 3) and 18 men aged 40–60 years (group 4). It is shown that 196 men of the 1st group aged 20–39 years have a mild form of erectile dysfunction (ED) where a total score was 19.57 ± 0.44. 102 men of the 2nd group aged 40–53 years also had a mild form of ED, but the total score was much lower as well as 17.94 ± 0.41. The indicators of individual 5 components of male sexual function and the erection hardness scale were also lower in patients of the 2nd group. The ED-MIEF-5 domain decreases most significantly with the severity of ED. All domains of the MIEF are significantly reduced in ED compared to a healthy group of respondents, but there is no differentiation according to the severity of ED. That is, with ED of any severity, all other sexual functions simultaneously suffer as well as sexual desire, confidence in erection, firmness and maintenance of erection, pleasure from sexual intercourse and sexual life.

Особенности оказания специализированной хирургической помощи при огнестрельных ранениях шеи с повреждением полых органов (гортани, трахеи, глотки, пищевода)

The objective of this work is to share our experience in providing specialized surgical care to patients coming from stages of medical evacuation with wounds of hollow neck organs. A special military operation (SMO) takes place in an environment different from previous local wars. The nature of military operations and the saturation of the enemy's armed forces with new types of weapons gave a significantly higher number of wounded than previous local conflicts. The predominance of mine-explosive shrapnel wounds, different time intervals from injury to getting to the stage of specialized medical care for wounded with already existing purulent complications of gunshot wounds are the features of the SMO. Wounded with injuries of the hollow organs of the neck, entering the MMCH named after N.N. Burdenko from 3 to 6 days after injury, with already developed purulent complications, require comprehensive intensive therapy and participation in the treatment of specialists of various surgical specialties. An integrated approach with the compliance with the regulations of military-field surgery using new methods of diagnostics and treatment of wounds can improve the effectiveness of therapy and reduce the number of lethal outcomes. This article discusses diagnostic and treatment algorithms for different variants of neck wounds. The experience of the described cases of successful treatment of wounded with injuries of the hollow organs of the neck shows the possibilities of MMCH named after N.N. Burdenko in treatment using various methods, and can be useful to doctors of both the Ministry of Defense and the Ministry of Health of the Russian Federation.

GUNSHOT SHRAPNEL WOUND OF THE THIGH WITH DAMAGE TO THE SUPERFICIAL FEMORAL ARTERY (FEATURES OF CLINICAL MANIFESTATIONS, DEVELOPMENT OF COMPLICATIONS WITH LATE MEDICAL CARE AND PRESERVATION OF THE LIMB).

The aim: To demonstrate the features of clinical manifestations and complications that occur with delayed medical treatment in cases of gunshot shrapnel through a wound of the thigh with damage to the superficial femoral artery. Materials and methods: The wounded individual, S., was 52 years old and had sustained a gunshot wound through a shrapnel wound of the left thigh with damage to the superficial femoral artery and soft tissue defect. Medical assistance was provided during the stages of medical evacuation. Results: The soldier sustained a gunshot wound through the upper third of the left thigh, resulting in damage to the vascular-nerve bundle and a soft tissue defect. First aid was provided at the scene, and surgical procedures were performed during the stages of medical evacuation, including primary surgical treatment of wounds in the upper third of the left thigh. On the second day following the injury, the wounded man was transferred to the Vinnytsia Military Medical Clinical Center and admitted to the vascular surgery department. After an ultrasound examination and repeated surgical treatment of the wound on the left thigh, damage to the superficial femoral artery was identified. Conclusions: The presence of features of blood circulation in gunshot wounds of the main vessels of the lower limbs can favorably affect the possibility of saving the limb, as evidenced by the case presented.

Peculiarities of rehabilitation of patients after combat craniocerebral trauma

Introduction: The urgency of the situation on the territory of Ukraine has taken on an exceptionally crucial character. After a large-scale invasion and deployment of military operations, there has been a noticeable increase in the number of cases of mine-explosive injuries, shrapnel wounds, and gunshot injuries. Specifically, combat traumatic brain injury (combat TBI) has emerged as one of the most pressing issues. According to statistical data, combat TBI constitutes half of all reported injuries and holds paramount significance for public health. It arises due to mechanical damage to the skull or its internal components (vessels, nerves, brain membranes, and the brain itself). Importantly, the severity of combat TBI consequences depends on the degree and nature of the injury, potentially causing disruptions in the functioning of vital body systems. Accompanying traumatic brain injuries can lead to serious complications, such as disruptions in cerebral blood circulation, cerebrospinal fluid circulation, brain swelling, and more. The choice of treatment methods depends on the severity of the injury. For milder cases, like concussions, conservative treatment is applied. Severe injuries, including open head injuries, might require surgical intervention. After the surgical procedure, patients necessitate rehabilitation measures to restore bodily functions. During the postoperative period, rehabilitation interventions take on special significance, aiming to restore physical and psychological functions of the affected individual. This may encompass physiotherapy, speech therapy sessions, psychotherapy, and other methods of gentle therapy. Thus, combat traumatic brain injury poses a serious threat to the health and lives of individuals who have been affected during military operations. Achieving effective treatment and rehabilitation within this context stands as a crucial task for the medical community.

Treatment of gunshot wounds of the spine using full-endoscopic surgery: analysis of a small clinical series

Objective. To assess the effectiveness of the treatment of gunshot wounds of the spine using percutaneous full-endoscopic technique.Material and Methods. Three patients with gunshot shrapnel wounds of the spine were treated using percutaneous full endoscopy.Results. The patients underwent a removal of foreign bodies (metal fragments) at the cervical, thoracic and lumbosacral levels of the spine using percutaneous full endoscopic surgery. The operations were carried out without complications, with minimal additional trauma to soft tissues and the spinal motion segment. In all three cases, there was a positive dynamics in the form of regression of the pain syndrome. There were no infectious complications.Conclusion. The successful use of percutaneous full endoscopy in the surgical treatment of blind shrapnel wounds of the spine is shown. The results indicate the expediency of further research and development of this area to address the issue of introducing the technique into the routine practice of treating gunshot wounds both in peacetime in neurosurgical hospitals and centers of spinal neurosurgery, and in wartime at the stages of specialized care.

The Occurrence of Thrombotic Complications Due to Combat Trauma Against the Background of the COVID-19 Pandemic

An important point in the provision of highly specialized cardiac surgical care for combat trauma is determination of the optimal time, method and volume of surgical intervention, taking into account the persisting threat of infection with the SARS-COV-2 virus and associated thrombotic complications.
 The aim. To investigate the mechanism of development and methods of prevention of thrombotic complications resulting from combat trauma against the background of the COVID-19 pandemic.
 Materials and methods. We analyzed clinical case of patient R., a 37-year-old soldier with a postinfarction thrombosed aneurysm of the left ventricle. The patient underwent standard clinical and laboratory tests, electrocardiography, echocardiography, coronary angiography, computed tomography of the chest, duplex scanning of carotid arteries, arteries and veins of the upper and lower extremities. It was established that 4 months ago, during a combat mission, the service-man received a mine-explosive injury, shrapnel wounds of lower extremities, multifragmentary fracture of the right ϐibula and a gunshot wound to the right chest. The causes of post-traumatic myocardial infarction are mine-explosive injury, intramural course of the left anterior descending artery, youngage, poorly developed collaterals of coronary arteries, long-term transportation during the stages of medical evacuation and post-traumatic stress disorder. A month ago, the patient was diagnosed with COVID-19, thromboembolism of the right main branch of the pulmonary artery, for which thrombolytic therapy was performed. Follow-up computed tomography showed the signs of thromboembolism of the pulmonary arteries. Ultrasound examination revealed thromboses of upper and lower limbs. Thrombotic complications against the background of combat polytrauma are the result of hypercoagulation, acute inϐlammation with the release of proinϐlammatory cytokines and damage of the endothelium. SARS-COV-2 infection triggers a state of hypercoagulation and creates additional conditions for the occurrence of arterial and venous thrombosis. Considering the nature of the thrombotic lesions, was made a decision to postpone the cardiosurgical intervention for 3 months.
 Conclusions. Thrombotic complications are an urgent problem after combat trauma. COVID-19 is an additional risk factor for hypercoagulation and a reason for delaying elective cardiac surgery. Conducting an electrocardiography to the wounded, regardless of age, is crucial for timely diagnosis andtreatment of acute coronary events. It is important to initiate anticoagulant therapy after eliminating all possible sources of bleeding due to the high risk of thrombotic complications against the background of chest trauma and limb fractures.

Neurosurgery at Pearl Harbor: Ralph Cloward’s legacy

Ralph B. Cloward (1908-2000) was the sole neurosurgeon present during the Japanese attack on Pearl Harbor on December 7, 1941. Cloward operated on 42 patients in a span of 4 days during the attacks and was awarded a commendation signed by President Franklin D. Roosevelt in 1945 for his wartime efforts. During the attacks, he primarily treated depressed skull fractures and penetrating shrapnel wounds, but he also treated peripheral nerve and spine injuries in the aftermath. His techniques included innovative advancements such as tantalum cranioplasty plates, electromagnets for intracranial metallic fragment removal, and the application of sulfonamide antibiotic powder within cranial wounds, which had been introduced by military medics for gangrene prevention in 1939 and described for penetrating cranial wounds in 1940. Despite the severity of injuries encountered, only 2 soldiers died in the course of Cloward's interventions. As the sole neurosurgeon in the Pacific Theater until 1944, he remained in Honolulu through World War II's duration and gained immense operative experience through his wartime service. Here, the authors review the history of Cloward's remarkable efforts, techniques, injury patterns treated, and legacy.

Penetrating abdominal trauma: Evaluation in Baghdad during the pandemic Covid-19

Background: Trauma is one of the leading causes of deaths worldwide for all age groups, especially in the younger age group. The purpose of the current study is to assess/analyze the factors for mortality in penetrating abdominal traumas with respect to the total number of intra-abdominal organs injured, related extra-abdominal injuries, gender, type of injury, time of arrival, and amount of blood transfusion needed during the pandemic. Methods: A retrospective study including 523 patients underwent laparotomy in Al-Emamien Al-Kadhimin Medical City from March 2020 to September 2021 for a penetrating abdominal injury due to blast injury, bullet, shrapnel injury, and stab wounds. The study population with penetrating abdominal traumas and indicative abdominal signs was subjected to exploratory laparotomy. Results: In this study, 465 (88.9%) males and 58 (11.1%) females participated; the highest rate was found in small bowel injuries (40.73%) followed by large bowel injuries (21.99%), whereas the lowest rate was found in gallbladder injury (1.34%). Chest injuries represent the highest rate among extra-abdominal injuries (18.36%), whereas head and neck represent the lowest rate (1.34%). Regarding the risk factors affecting the mortality rate, the highest rate of mortality was found in the case of gunshot (13.11%), followed by shrapnel (6.38%) and stab wound injuries (5.26%), which was the lowest. Conclusion: Penetrating abdominal injuries were the most common among males, small bowel injuries are the commonest organs affected by the penetrating abdominal injuries, shrapnel injuries were the commonest causes in our country, and the highest mortality rate was related to gunshot and number of organs affected and delay of arrival to the hospital and number of pints of blood received.