Upper Limb Function in People With Upper and Lower Limb Loss 8 Years Postinjury: The Armed Services Trauma Outcome Study (ADVANCE) Cohort Study.

OBJECTIVE: Upper limb (UL) disability in people with UL amputation/s is well reported in the literature, less so for people with lower limb amputation/s. This study aimed to compare UL disability in injured (major trauma) and uninjured UK military personnel, with particular focus on people with upper and lower limb amputation/s. METHODS: A volunteer sample of injured (n = 579) and uninjured (n = 566) UK military personnel who served in a combat role in the Afghanistan war were frequency matched on age, sex, service, rank, regiment, role, and deployment period and recruited to the Armed Services Trauma Rehabilitation Outcome (ADVANCE) longitudinal cohort study. Participants completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, scored from 0 (no disability) to 100 (maximum disability) 8 years postinjury. Mann-Whitney U and Kruskal Wallis tests were used to compared DASH scores between groups. An ordinal model was used to assess the effect of injury and amputation on DASH scores. RESULTS: DASH scores were higher in the group with injuries compared to the group without injuries (3.33 vs 0.00) and higher in people with lower limb loss compared to the group without injuries (0.83 vs 0.00), although this was not statistically significant. In the adjusted ordinal model, the odds of having a higher DASH score was 1.70 (95% CI = 1.18-2.47) times higher for people with lower limb loss compared to the group without injuries. DASH score was not significantly different between people with major and partial UL loss (15.42 vs 12.92). The odds of having a higher DASH score was 8.30 (95% CI = 5.07-13.60) times higher for people with UL loss compared to the uninjured group. CONCLUSION: People with lower limb loss have increased odds of having more UL disability than the uninjured population 8 years postinjury. People with major and partial UL loss have similar UL disability. The ADVANCE study will continue to follow this population for the next 20 years. IMPACT: For the first time, potential for greater upper limb disability has been shown in people with lower limb loss long-term, likely resulting from daily biomechanical compensations such as weight-bearing, balance, and power generation. This population may benefit from prophylactic upper limb rehabilitation, strength, and technique.

Post-blast histological changes to three animal bones exposed to close-range chemical detonation.

A range of investigative practices to aid explosive-related death investigations currently exist, although the use of histopathological bone samples to diagnose blast exposure and the distance of individuals from the blast source has not been previously reported. Forensic histopathology has been used effectively on soft tissue samples to define blast-related injuries effectively, analysing human organs such as the lungs, brain, liver, and skeletal muscles, providing important and useful forensic pathology interpretations. However, no studies currently exist examining the post-blast histological changes in human or animal bones subjected to blasts for forensic pathology practice, despite the opportunity that hard tissue bone samples present, given their significantly lower rate of decomposition over soft tissue. This study presents the first evidence-based findings on the post-blast histological changes in three animal bones when exposed to close-range chemical detonation (C4). The study's qualitative findings highlight critical changes in the tissue architecture of three different animal bone sources due to blast effects with range from the blast source. This emphasises the potential use of histopathological bone sample analysis in future blast-related death investigations, while providing ideas to further explore this work using larger-scale experiments and post-blast case studies in aid of applying this work to human samples and forensic pathology practice.

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

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

Blast injuries with contrasting outcomes treated by military surgery strategies: A case report.

The treatment strategy for blast injuries is closely linked to the clinical outcome of blast injury casualties. However, the application of military surgery experience to blast injuries caused by production safety accidents is relatively uncommon. In this study, the authors present 2 cases of blast injuries caused by one gas explosion, both cases involved individuals of the same age and gender and experienced similar degree of injury. The authors highlight the importance of using a military surgery treatment strategy, specifically emphasizing the need to understand the concept of damage control and disposal. It is recommended that relevant training in this area should be strengthened to improve the clinical treatment of such injuries. This study provides a valuable reference for healthcare professionals dealing with blast injuries.

Alteraciones de la salud humana por artefactos explosivos improvisados. Revisión sistemática exploratoria / Alterations of human health due to improvised explosive devices. Exploratory systematic review / Mudanças na saúde humana devido a dispositivos explosivos improvisados. Revisão sistemática exploratória

Objetivo: revisar la literatura existente indagando por los tipos de lesión o enfermedad que se han identificado en supervivientes de artefactos explosivos improvisados (AEI), así como aspectos individuales y colectivos relacionados con la protección o destrucción de la salud humana enfrentada a los AEI. Metodología: revisión sistemática exploratoria de literatura publicada en bases de datos, como PubMed, SciELO, LILACS, JSTOR, OpenGrey y Google Scholar, entre 2001 a 2021 en cualquier localización geográfica. Se incluyeron artículos de investigación, de revisión o reflexión, libros o capítulos de libro de investigación e informes técnicos, en inglés, español, francés y portugués. Resultados: cumplieron con los criterios de inclusión y fueron revisados 76 documentos. Se han reportado múltiples lesiones asociadas al uso de los AEI, sin que exista un patrón característico de lesión o enfermedad; no obstante, la lesión más común es la amputación bilateral de miembros inferiores. En supervivientes se ha encontrado que el personal militar afectado suele mostrar una mayor capacidad de resiliencia, calidad de vida, tratamiento oportuno y capacidad física funcional más alta, comparado con civiles. El apoyo social genera efectos positivos en la salud y bienestar de los afectados. Conclusiones: los AEI generan múltiples afectaciones a la salud humana, físicas y psicosociales, los cuales requieren una atención integral y multidisciplinaria para el tratamiento, rehabilitación y reintegración de los supervivientes. Los aspectos protectores y destructivos identificados se encuentran asociados a mejores o peores resultados en la salud, existe una representación desigual entre civiles y militares.

Objective: to review the existing literature where we inquired for injury types or illness identified in victims of improvised explosive devices (IED), and also to look for individual and collective processes described in literature in relation with the protection or destruction of human's health and IEDs. Methodology: exploratory systematic review of the literature published on PubMed, SciELO, LILACS, JSTOR, OpenGrey and Google Scholar databases between 2001 and 2022, in any geographic location. We included research, review and opinion articles, books and book chapters reporting research results, and final technical reports in English, Spanish, French and Portuguese. Results: 76 documents met the inclusion criteria and were reviewed. Multiple types of injuries have been reported in relation with the use of IEDs, without a characteristic pattern of injury or disease reported; however, the most common injury is bilateral lower limb amputation. In survivors it has been found that affected military personnel tend to show greater resilience capacity, better quality of life, timely treatment, and higher functional physical capacity, compared to civilians. Social support generates positive health effects and wellness of people affected by IED. Conclusion: IEDs generate multiple effects on human health, both physical and psychosocial, which is why comprehensive and multidisciplinary care is required for the treatment, rehabilitation, and reintegration of their victims. The protective and destructive processes identified are associated with better or worse health outcomes, with unequal representation between civilians and military personnel.

Objetivo: Revisar a literatura existente investigando os tipos de lesão ou doença que foram identificados em sobreviventes de artefatos explosivos improvisados ​​(IED), bem como aspectos individuais e coletivos relacionados à proteção ou destruição da saúde humana diante de IEDs. Metodologia: Revisão sistemática exploratória da literatura publicada nas bases de dados Pubmed, Scielo, Lilacs, JSTORE, Open Gray e Google Acadêmico, entre 2001 e 2021 em qualquer localidade geográfica. Foram incluídos artigos de pesquisa, revisão ou reflexão, livros ou capítulos de livros de pesquisa, relatórios técnicos, em inglês, espanhol, francês e português. Resultados: Atenderam aos critérios de inclusão e foram revisados ​​76 documentos. Múltiplas lesões associadas ao uso de IEDs foram relatadas, sem um padrão característico de lesão ou doença; entretanto, a lesão mais comum é a amputação bilateral de membros inferiores. Nos sobreviventes, verificou-se que os militares acometidos tendem a apresentar maior resiliência, qualidade de vida, tratamento oportuno e maior capacidade física funcional, em comparação aos civis. O apoio social gera efeitos positivos na saúde e bem-estar das pessoas afetadas. Conclusões: Os IEDs geram múltiplos efeitos na saúde humana, física e psicossocial, que requerem atenção integral e multidisciplinar para o tratamento, reabilitação e reintegração dos sobreviventes. Os aspectos protetores e destrutivos identificados estão associados a melhores ou piores resultados de saúde, com representação desigual entre civis e militares.

The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage.

PURPOSE: Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population. METHODS: We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations. RESULTS: A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury. CONCLUSIONS: Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Firework-related ocular trauma in Pernambuco, Brazil / Trauma ocular por fogos de artifício em Pernambuco, Brasil

ABSTRACT Purpose: This study aimed to describe the demographic and clinical characteristics of victims of fireworkrelated ocular trauma treated at the ophthalmologic emergency de partments of two reference centers in Pernambuco, Brazil, and to identify risk factors related to poor visual prognosis. Methods: We retrospectively evaluated the medical records of patients admitted in emergency departments with a report of firework-related trauma between January 2012 and December 2018. Data collected included patient's age, sex, place of origin, month and year of the accident, ocular structures affected, characteristics of the injuries, and type of treatment that patients received. For patients who were followed for >30 days, the final visual acuity and patient's origin were analyzed. Results: Three hundred and seventy eyes from 314 patients were included, of which 248 (79.0%) were male and 160 (51.0%) were from the metropolitan region of Recife. The mean patient age was 25.6 ± 18.8 years. In 56 (17.8%) patients, the ocular trauma was bilateral. A total of 152 (48.4%) cases occurred in June. The most affected sites were the eyelids in 91 (24.6%) eyes and ocular surface in 252 (68.1%). Surgical treatment was required in 87 (23.5%) eyes. After clinical and surgical management, 37 (10.0%) eyes presented final visual acuity of <20/400. Of these, 34 (91.9%) eyes were from patients from the countryside or from another state. Patients from the countryside presented higher risk of developing blindness after a firework trauma than those from the metropolitan area (odds ratio of 5.46). Conclusions: Victims of firework-related ocular trauma were mostly male, from the metropolitan region of Pernambuco state and mainly pediatric patients or economically active. Those coming from the countryside and other states had higher risk of developing blindness

RESUMO Objetivos: Descrever as características demográficas e clínicas das vítimas de trauma ocular por fogos de artifício atendidas nas emergências oftalmológicas de dois centros de referência em Pernambuco e identificar fatores relacionados a mau prognóstico visual. Métodos: Avaliação retrospectiva dos prontuários de pacientes admitidos na emergência oftalmológica com história de trauma por fogos de artifício entre janeiro de 2012 e dezembro de 2018. A coleta de dados incluiu idade, gênero, procedência, mês e ano do acidente, estruturas oculares acometidas e características das lesões, além do tipo de tratamento a que os pacientes foram submetidos. Naqueles pacientes acompanhados por mais de 30 dias, analisou-se a acuidade visual final e a associação com sua procedência. Resultados: Foram incluídos 370 olhos de 314 pacientes. Destes, 248 (79,0%) vítimas eram do sexo masculino e 160 (51,0%) da região metropolitana do Recife, com uma média de idade de 25.6 ± 18.8 anos. Em 56 (17,8%) dos casos o trauma foi bilateral. No mês de junho ocorreu um total de 152 (48,4%) casos. Os sítios mais acometidos foram pálpebras em 91 (24,6%) olhos e superfície ocular em 252 (68,1%). O tratamento cirúrgico foi necessário em 87 (23,5%) olhos. Após manejo clínico-cirúrgico, 37 (10.0%) olhos desenvolveram visão pior do que 20/400. Destes, 34 (91,9%) olhos eram de pacientes do interior do estado de Pernambuco ou de outro estado. Os pacientes provenientes do interior do estado apresentaram maior chance de desenvolver cegueira quando comparados aos que eram provenientes da região metropolitana (Odds Ratio de 5,46). Conclusões: As vítimas de trauma ocular por fogos de artificio foram em sua maioria do sexo masculino, procedentes da região metropolitana do estado e das faixas etárias pediátrica e economicamente ativa. Aqueles provenientes do interior ou de outros estados apresentaram maior chance de desenvolver cegueira.

Long-term burden of war injuries among civilians in LMICs: case of the July 2006 war in Lebanon.

Introduction: Lebanon, a country located on the eastern shore of the Mediterranean Sea, is one of the world's smaller sovereign states. In the past few decades, Lebanon endured a perpetual political turmoil and several armed conflicts. July 12, 2006, marked the start of a one-month war in Lebanon, which resulted in thousands of casualties. Little is known about the long-term consequences of war injuries inflicted on civilians during the July 2006 war. Methods: The objectives of this paper were to identify and evaluate: 1- civilians' access to healthcare and medicine under conditions of war; 2- the long-term socioeconomic burden on injured civilians; and 3- their quality of life more than a decade post-war. We adopted a mixed-method research design with an emphasis on the qualitative component. We conducted interviews with patients, collected clinical and financial data from hospital medical records, and administered a self-rated health questionnaire, the EQ-5D-5L. Simple descriptive statistics were calculated using Excel. NVivo 12® was used for data management and thematic analysis. Results: We conducted 25 interviews. Injured civilians were mostly males, average age of 27. The most common mechanism of injury was blast injury. Most patients underwent multiple surgeries as well as revision surgeries. The thematic analysis revealed three themes: 1- recall of the time of the incident, the thousand miles journey, and patients' access to services; 2- post-trauma sequelae and services; and 3- long-term impact. Patients described the long-term burden including chronic pain, poor mobility, anxiety or depression, and limited activities of daily living. Discussion: Civilians injured during the July 2006 war described the traumatising events they endured during the war and the limited access to medical care during and post-war. Up until this study was conducted, affected civilians were still experiencing physical, psychological, and financial sequelae. Acknowledging the limitations of this study, which include a small sample size and recall bias, the findings underscore the necessity for the expansion of services catering to civilians injured during wartime.

Headache among combat-exposed veterans and service members and its relation to mild traumatic brain injury history and other factors: a LIMBIC-CENC study.

Background: Headache (HA) is a common persistent complaint following mild traumatic brain injury (mTBI), but the association with remote mTBI is not well established, and risk factors are understudied. Objective: Determine the relationship of mTBI history and other factors with HA prevalence and impact among combat-exposed current and former service members (SMs). Design: Secondary cross-sectional data analysis from the Long-Term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium prospective longitudinal study. Methods: We examined the association of lifetime mTBI history, demographic, military, medical and psychosocial factors with (1) HA prevalence ("lately, have you experienced headaches?") using logistic regression and (2) HA burden via the Headache Impact Test-6 (HIT-6) using linear regression. Each lifetime mTBI was categorized by mechanism (blast-related or not) and setting (combat deployed or not). Participants with non-credible symptom reporting were excluded, leaving N = 1,685 of whom 81% had positive mTBI histories. Results: At a median 10 years since last mTBI, mTBI positive participants had higher HA prevalence (69% overall, 78% if 3 or more mTBIs) and greater HA burden (67% substantial/severe impact) than non-TBI controls (46% prevalence, 54% substantial/severe impact). In covariate-adjusted analysis, HA prevalence was higher with greater number of blast-related mTBIs (OR 1.81; 95% CI 1.48, 2.23), non-blast mTBIs while deployed (OR 1.42; 95% CI 1.14, 1.79), or non-blast mTBIs when not deployed (OR 1.23; 95% CI 1.02, 1.49). HA impact was only higher with blast-related mTBIs. Female identity, younger age, PTSD symptoms, and subjective sleep quality showed effects in both prevalence and impact models, with the largest mean HIT-6 elevation for PTSD symptoms. Additionally, combat deployment duration and depression symptoms were factors for HA prevalence, and Black race and Hispanic/Latino ethnicity were factors for HA impact. In sensitivity analyses, time since last mTBI and early HA onset were both non-significant. Conclusion: The prevalence of HA symptoms among formerly combat-deployed veterans and SMs is higher with more lifetime mTBIs regardless of how remote. Blast-related mTBI raises the risk the most and is uniquely associated with elevated HA burden. Other demographic and potentially modifiable risk factors were identified that may inform clinical care.

Delayed cardiac tamponade secondary to blast injury from gunshot wound.

Penetrating injuries are recognized for the direct tissue damage, which is typically evident on physical examination. Secondary injuries resulting from kinetic energy transfer in the case of gunshot wounds (GSWs), often referred to as "blast injuries", may affect tissues distant to the ballistic trajectory and are often occult. We present a case of delayed cardiac tamponade resulting from secondary blast injury. The patient sustained a thoraco-abdominal GSW with entry adjacent to the cardiac box. An Advanced Trauma Life Support (ATLS)-guided assessment revealed intra-abdominal injuries necessitating operative intervention without evidence of cardiac injury. On post-operative day four, the patient developed chest pain, tachycardia, and shortness of breath. Imaging revealed a large pericardial effusion with cardiac tamponade. Emergent exploration revealed hemopericardium secondary to a bleeding epicardial hematoma without evidence of pericardial violation. Clinicians must maintain a high clinical suspicion for occult, indirect blast injuries which may be life-threatening.

Assessing Firefighters' Tourniquet Skill Attainment and Retention: A Controlled Simulation-Based Experiment.

BACKGROUND: The aim of this study was to train and assess firefighters' skill attainment in the use of tourniquets, and to assess their skill retention after 3 mo. The purpose is to show if firefighters can successfully apply a tourniquet after a short course based on the Norwegian national recommendation for civil prehospital tourniquet use. METHODS: This is a prospective experimental study. The study population were firefighters, and the inclusion criterion was any on-duty firefighter. The first phase consisted of baseline precourse testing (T1), a 45-min course, followed by immediate retesting (T2). The second phase consisted of retesting of skill retention after 3 mo (T3). RESULTS: A total of 109 participants at T1, 105 at T2, and 62 participants at T3. The firefighters achieved a higher proportion of successful tourniquet applications at T2 (91.4%; 96 of 105) as well as T3 (87.1%; 54 of 62) compared with 50.5% at T1 (55 of 109) (P = 0.009). Mean application time was 59.6 s (55.1-64.2) in T1, 34.9 s (33.3-36.6) in T2 and 37.7 s (33.9-41.4) in T3. CONCLUSION: A sample of firefighters can successfully apply a tourniquet after a 45-min course based on the 2019 Norwegian recommendation for civil prehospital tourniquet use. Skill retention after 3 mo was satisfactory for both successful application and application time.

FLUCTUATING HEARING LOSS AS A SYMPTOM OF ACQUIRED PERILYMPHATIC FISTULA (PLF) UNDER EXTERNAL INJURIES FACTOR.

OBJECTIVE: The aim: To evaluate the effectiveness of treatment patients with spontaneous PLF and labyrinthine window ruptures by studying the clinical and audiological results. PATIENTS AND METHODS: Materials and methods: 52 patients after exposure to traumatic factors in the anamnesis were evaluated. The perilymphatic fistula was diagnosed in 18 patients after the complex examination. All patients with PLF underwent surgical treatment. RESULTS: Results: Vestibular disorders and hearing loss were the predominant symptoms. The fistula test was positive in 11 (61%) patients. Fluctuating hearing loss was determined in 9 (50%) patients. Labyrinthine window ruptures were detected in 16 (88%) patients: oval window membrane rupture was identified in 6 patients, and in another 10 patients round window membrane rupture was found and was detected on CT scan. The surgical treatment included minimally invasive tympanotomy with combined microscopic and endoscopic visualization and sealing techniques. Results were evaluated in 6 months after surgical treatment, patients had a decrease in bone and air conduction thresholds at all evaluated frequencies and a significant decrease in the level of the air-bone interval. CONCLUSION: Conclusions: Fluctuating hearing loss is considered one of the key symptoms, which suggests the presence of PLF. Determination of PLF and its surgical treatment, by using minimally invasive tympanotomy with sealing technique using optimal combined visualization, allows obtaining a stable functional result, with hearing improvement and vestibular symptoms reducing.

Crosstalk between Inflammation and Hemorrhage/Coagulation Disorders in Primary Blast Lung Injury.

Primary blast lung injury (PBLI), caused by exposure to high-intensity pressure waves from explosions in war, terrorist attacks, industrial production, and life explosions, is associated with pulmonary parenchymal tissue injury and severe ventilation insufficiency. PBLI patients, characterized by diffused intra-alveolar destruction, including hemorrhage and inflammation, might deteriorate into acute respiratory distress syndrome (ARDS) with high mortality. However, due to the absence of guidelines about PBLI, emergency doctors and rescue teams treating PBLI patients rely on experience. The goal of this review is to summarize the mechanisms of PBLI and their cross-linkages, exploring potential diagnostic and therapeutic targets of PBLI. We summarize the pathophysiological performance and pharmacotherapy principles of PBLI. In particular, we emphasize the crosstalk between hemorrhage and inflammation, as well as coagulation, and we propose early control of hemorrhage as the main treatment of PBLI. We also summarize several available therapy methods, including some novel internal hemostatic nanoparticles to prevent the vicious circle of inflammation and coagulation disorders. We hope that this review can provide information about the mechanisms, diagnosis, and treatment of PBLI for all interested investigators.

Effects of orientation and distance of goats on blast lung injury characteristics on a plateau above 4500-meter.

PURPOSE: High explosives are used to produce blast waves to study their biological effects. The lungs are considered as the critical target organ in blast-effect studies. The degree of lung hemorrhaging is related to both the explosive power and the increased lung weight. We studied the characteristics of the biological effects from an air explosion of a thermobaric bomb in a high-altitude environment and the lethality and lung injury severity of goats in different orientations and distances. METHODS: Goats were placed at 2.5, 3, 4, and 5 m from the explosion center and exposed them to an air blast at an altitude of 4700-meter. A group of them standing oriented to the right side and the other group seated facing the explosion center vertically. The lung injuries were quantified according to the percentage of surface area contused, and using the pathologic severity scale of lung blast injury (PSSLBI) to score the 4 injury categories (slight, moderate, serious and severe) as 1, 2, 3, and 4, respectively. The lung coefficient (lung weight [g]/body weight [kg]) was the indicator of pulmonary edema and was related to lung injury severity. Blast overpressure data were collected using blast test devices placed at matching locations to represent loadings to goats. All statistical analyses were performed using SPSS, version 26.0, statistical software (SPSS, Inc., Chicago, IL, USA). RESULTS: In total, 127 goats were involved in this study. Right-side-standing goats had a significantly higher mortality rate than those seated vertical-facing (p < 0.05). At the 2.5 m distance, the goat mortality was nearly 100%, whereas at 5 m, all the goats survived. Lung injuries of the right-side-standing goats were 1 - 2 grades more serious than those of seated goats at the same distances, the scores of PSSLBI were significantly higher than the seated vertical-facing goats (p < 0.05). The lung coefficient of the right-side-standing goats were significantly higher than those of seated vertical-facing (p < 0.05). Mortality, PSSLBI, and the lung coefficient results indicated that the right-side-standing goats experienced severer injuries than the seated vertical-facing goats, and the injuries were lessened as the distance increased. The blast overpressure was consistent with these results. CONCLUSION: The main killing factors of the thermobaric bomb in the high-altitude environment were blast overpressure, blast wind propulsions and burn. The orientation and distances of the goats significantly affected the blast injury severity. These results may provide a research basis for diagnosing, treating and protecting against injuries from thermobaric explosions.

Fluid management strategies for patients with severe blast injury / 中国实用护理杂志

Objective:To summarize the precision fluid management of patients with severe blast injury in the emergency intensive care unit, so as to help patients smoothly pass through the dangerous period and recover smoothly.Methods:Based on the experience of fluid management in 6 patients admitted to the Second Affiliated Hospital Zhejiang University School of Medicine in the tanker truck explosion on 14 June, 2020. The main measures included: fluid volume management and dynamic adjustment; assessment of intake, output and urine volume, and dynamic adjustment of infusion volume and speed; monitoring of pulmonary oxygenation and timely adjustment of fluid resuscitation strategies; monitoring indexes and providing nursing care strategies for fluid management.Results:Finally, among 6 patients with severe blast injury, 5 patients were discharged from the hospital with follow-up treatment after they suffered from the shock and infection phases and refined fluid management, 1 patient died due to severe injury and ineffective rescue.Conclusions:Adopting individualized, phased, and refined liquid management strategy has clinical significance for patients with severe blast injury to smoothly pass the risk period.

Effects of orientation and distance of goats on blast lung injury characteristics on a plateau above 4500-meter / 中华创伤杂志(英文版)

PURPOSE@#High explosives are used to produce blast waves to study their biological effects. The lungs are considered as the critical target organ in blast-effect studies. The degree of lung hemorrhaging is related to both the explosive power and the increased lung weight. We studied the characteristics of the biological effects from an air explosion of a thermobaric bomb in a high-altitude environment and the lethality and lung injury severity of goats in different orientations and distances.@*METHODS@#Goats were placed at 2.5, 3, 4, and 5 m from the explosion center and exposed them to an air blast at an altitude of 4700-meter. A group of them standing oriented to the right side and the other group seated facing the explosion center vertically. The lung injuries were quantified according to the percentage of surface area contused, and using the pathologic severity scale of lung blast injury (PSSLBI) to score the 4 injury categories (slight, moderate, serious and severe) as 1, 2, 3, and 4, respectively. The lung coefficient (lung weight [g]/body weight [kg]) was the indicator of pulmonary edema and was related to lung injury severity. Blast overpressure data were collected using blast test devices placed at matching locations to represent loadings to goats. All statistical analyses were performed using SPSS, version 26.0, statistical software (SPSS, Inc., Chicago, IL, USA).@*RESULTS@#In total, 127 goats were involved in this study. Right-side-standing goats had a significantly higher mortality rate than those seated vertical-facing (p < 0.05). At the 2.5 m distance, the goat mortality was nearly 100%, whereas at 5 m, all the goats survived. Lung injuries of the right-side-standing goats were 1 - 2 grades more serious than those of seated goats at the same distances, the scores of PSSLBI were significantly higher than the seated vertical-facing goats (p < 0.05). The lung coefficient of the right-side-standing goats were significantly higher than those of seated vertical-facing (p < 0.05). Mortality, PSSLBI, and the lung coefficient results indicated that the right-side-standing goats experienced severer injuries than the seated vertical-facing goats, and the injuries were lessened as the distance increased. The blast overpressure was consistent with these results.@*CONCLUSION@#The main killing factors of the thermobaric bomb in the high-altitude environment were blast overpressure, blast wind propulsions and burn. The orientation and distances of the goats significantly affected the blast injury severity. These results may provide a research basis for diagnosing, treating and protecting against injuries from thermobaric explosions.

Intoxicación cronica por metales tóxicos en supervivientes de artefactos explosivos improvisados con fragmentos incorporados y su potencial neoplásico. Revisión sistemática exploratoria / Chronic heavy metal intoxication in survivors of improvised explosive devices with embedded fragments and its neoplastic potential. Exploratory systematic review

Resumen Introducción: Los artefactos explosivos improvisados son armas no convencionales que pueden provocar múltiples lesiones y dejar esquirlas a modo de cuerpos extraños que pueden contener metales tóxicos, con potencial afectación a la salud de las víctimas según reportes datados desde 1977, los cuales mencionan alta mortalidad por cáncer y otros síntomas compatibles con toxicidad crónica Objetivo: Describir los resultados de investigación que informen sobre la toxicidad crónica producida por metales en personas víctimas de artefactos explosivos improvisados con esquirlas internalizadas, y sus posibles relaciones con cáncer. Metodología: Revisión sistemática exploratoria de literatura publicada y gris que se realizó entre los meses de marzo a mayo de 2021 en diferentes repositorios de tesis y bases de datos (Scielo, Pubmed, Academic Search Complete, JSTOR, Biblioteca Virtual en Salud, Freepdf, Google Académico, Open Grey); sin límite temporal o geográfico. Se incluyeron artículos originales de revistas indexadas o informes finales no publicados, correspondientes a investigaciones científicas con texto completo, en inglés, español y portugués. Resultados: De 56 documentos evaluados, solamente tres cumplieron criterios de inclusión. Todos estaban escritos en idioma inglés. Solo un estudio iraquí abordó población civil y los otros trabajos aludían a veteranos norteamericanos. Los niveles elevados de metales tóxicos, asociados con alteraciones tisulares circunscritas, fueron hallazgos recurrentes. No hubo reportes de patologías instauradas o manejos clínicos. Conclusión: Fue escasa la evidencia científica recabada; sin embargo, sí se han reportado cambios tisulares circundantes a esas esquirlas. Se considera necesario realizar más estudios relacionados con el tema, incluyendo seguimientos a largo plazo de las afectaciones tisulares detectadas.

Abstract Introduction: Improvised explosive devices are unconventionalweapons that can cause multiple injuries and splinters internalized containing heavy metals, potentially affecting the victim's health, according to reports dating from 1977, which mention high mortality from cancer and other symptoms suggestive of chronic metal toxicity. Objective: To describe the research results that report on the chronic toxicity produced by heavy metals in people who are victims of improvised explosive devices with internalized splinters, and its possible links with cancer. Methodology: Systematic exploratory review of published and grey literature which was carried out between march and may of 2021, in thesis repositories and different databases (Scielo, Pubmed, Academic Search Complete, JSTOR, Biblioteca Virtual en Salud, Freepdf, Google Académico, Open Grey); without time or geographical limit. Original articles from indexed scientific research journals or unpublished final reports were included, corresponding to scientific research with full text, in english, spanish and portuguese. Results: 56 documents were evaluated, three were selected fulfilling the inclusion criteria. They were all written in the english language. Only one Iraqi study addressed the civilian population and the other studies referred to North American veterans. Elevated heavy metal levels, associated with circumscribed tissue abnormalities, were recurrent findings. There were no reports of established pathologies or clinical management. Conclusion: The scientific evidence was scarce; as well as its relationship with established cancer, however, tissue changing surrounding these splinters have been reported. It is considered necessary to carry out more studies related to the subject, including long-term follow-up of detected tissue damage.

A Fatal Tyre Blast Injury: An Autopsy Case.

A 49-year-old man sustained an accidental injury when he was changing and inflating the tyre of a truck, and there was a sudden explosion of the truck tyre at the service station, which was by the roadside of the highway. With the pressure of air generated due to the exploding tyre, the victim was blown to around 6 feet away. He was declared dead on admission. The medico-legal examination was conducted, and death was determined to be multiple organ injuries [mainly head, chest, and abdominal injuries] caused by the shock wave produced due to tyre explosion. Tyre blast injuries are not so common. A meticulous post-mortem examination is fundamental in formulating and recording the pattern of traumatic injuries. Preventive occupational measures should be put in place.

Pediatric Blast Trauma: A Systematic Review and Meta-Analysis of Factors Associated with Mortality and Description of Injury Profiles.

INTRODUCTION: Blast polytrauma is among the most serious mechanisms of injury confronted by medical providers. There are currently no specific studies or guidelines that define risk factors for mortality in the context of pediatric blast injuries or describe pediatric blast injury profiles. OBJECTIVE: The objectives of this study were to evaluate risk factors for pediatric mortality and to describe differences in injury profiles between explosions related to terrorism versus unrelated to terrorism within the pediatric population. METHODS: A PRISMA systematic review and meta-analysis was performed where articles published from the years 2000-2021 were extracted from PubMed. Mortality and injury profile data were extracted from articles that met inclusion criteria. A bivariant unadjusted odds ratio (OR) analysis was performed to establish protective and harmful factors associated with mortality and to describe the injury profiles of blasts related to terrorism. Statistical significance was established at P < .05. RESULTS: Thirty-eight articles were included and described a total of 222,638 unique injuries. Factors associated with increased mortality included if the explosion was related to terrorism (OR = 32.73; 95% CI, 28.80-37.21; P < .05) and if the explosion involved high-grade explosives utilized in the Global War on Terror ([GWOT] OR = 1.28; 95% CI, 1.04-1.44; P < .05). Factors associated with decreased mortality included if the patient was resuscitated in a North Atlantic Treaty Organization (NATO)-affiliated combat trauma hospital (OR = 0.48; 95% CI, 0.37-0.62; P < .05); if the explosive was fireworks (OR = 3.20×10-5; 95% CI, 2.00×10-6-5.16×10-4; P < .05); and if the explosion occurred in the United States (OR = 2.40×10-5; 95% CI, 1.51×10-6-3.87×10-4; P < .05). On average, victims of explosions related to terrorism were 10.30 years old (SD = 2.73) with 68.96% (SD = 17.58%) of victims reported as male. Comparison of victims of explosions related to terrorism revealed a higher incidence of thoracoabdominal trauma (30.2% versus 8.6%), similar incidence of craniocerebral trauma (39.5% versus 43.1%), and lower incidence of extremity trauma (31.8% versus 48.3%) compared to victims of explosions unrelated to terrorism. CONCLUSION: Explosions related to terrorism are associated with increased mortality and unique injury profiles compared to explosions unrelated to terrorism in the pediatric population. Such findings are important for optimizing disaster medical education of pediatric providers in preparation for and management of acute sequelae of blast injuries-terror-related and otherwise.

[Explosion trauma part 1 : Physical principles and pathophysiology]. / Explosionstrauma Teil 1 : Physikalische Grundlagen und Pathophysiologie.

After explosions, various injury mechanisms lead to multiple injuries that can affect the entire body. While high pressure peaks and exposure to heat, especially in the vicinity of a detonation, can cause severe injuries and organ damage, fragments also pose a considerable threat to explosion victims even over long distances. The recognition and treatment of life-threatening disorders and the assessment of the severity of the injury are just as challenging for the entire treatment team as long-term operative management, reconstruction strategies and rehabilitation of the complex injuries. Knowledge of the injury mechanics and the pathophysiology of blast injuries should help the interdisciplinary team to master this challenge.