PaperPost Gulf war explosive injuries in liberated Kuwait
Abstract
We collected the statistics of the victims affected by explosive injuries in liberated Kuwait during the period March to December 1991. Included were 1679 patients treated at nine different hospitals in Kuwait.
As members of a trauma team, we, the plastic surgeons, were involved in the care of 152 victims of explosive injuries admitted at Al-Razi Orthopaedic Hospital. The records of these patients were reviewed in detail and the results were analysed. Of the patients, 58 had penetrating wounds and 94 explosive blast wounds. In all, 69 patients (45.3 per cent) were found to have associated fractures, 8 (5.3 per cent) had vascular injuries and in 10 (6.5 per cent) a nerve was also involved. There were 41 patients (26.9 per cent) who required amputations.
The mainstay of surgical treatment was adequate wound excision, skeletal fixation and soft tissue coverage. Split-skin grafts were used in 34 patients, local flaps in seven and free flaps in four.
Most patients healed within 2–3 weeks. There were 10 patients with explosive blast wounds who developed infection and needed staged wound excision before providing final coverage.
References (3)
- A.H. Abdulla
Cited by (26)
An Analysis of Intracranial Hemorrhage in Wartime Pediatric Casualties
2021, World NeurosurgeryCitation Excerpt :Unfortunately, the mortality of those specifically with ICH in that civilian cohort is not described, and there are no comparable civilian studies on traumatic pediatric ICH to accurately compare the rate of mortality seen in this cohort. A review from Hargrave et al. on blast injuries in children found that cerebral hemorrhage and direct cranial damage following the blast was the leading cause of death in 46%–71% of fatalities.23-28 These patients are associated with increased operative demands for neurosurgical procedures that put stress on medical services in austere environments.
Children make up a significant cohort of patients treated at combat support hospitals. Where traumatic head injury, including intracranial hemorrhage (ICH), is well studied in military adults, such research is lacking regarding pediatric patients. We seek to describe the incidence and outcomes of ICH within this population.
This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry for all pediatric casualties in Iraq and Afghanistan from January 2007 to January 2016. Within our dataset, we searched for casualties with an ICH.
Of the 3439 pediatric encounters in our dataset, we identified 495 (14%) casualties that had at least 1 type of ICH. Most were between 5 and 12 years of age, male (74%), and injured by an explosive (42%). Of the casualties with ICHs, 82 had epidural (16.6%), 237 had subdural (47.9%), 153 had subarachnoid (30.9%), 157 had parenchymal bleeds (31.7%), and 239 had ICHs not otherwise specified (48.3%). In the hospital setting, the epidural group was more frequently treated with skull decompression (41%) and craniotomy with skull elevation (28%). The subdural group was more frequently treated with a craniectomy (17%) and the parenchymal group had more frequent intracranial pressure monitoring (18%). In our dataset, 22 received ketamine prehospital (4.4%) and most were discharged alive from the hospital (79%).
Within our dataset, we identified 495 cases of ICH in pediatric patients. Most survived to hospital discharge despite less than half undergoing a decompression procedure.
Assessment of war and accidental nerve injuries in children
1999, Pediatric NeurologyEleven children with war-related peripheral nerve injury and 16 children with accident-related nerve injury between the ages of 3 and 15 years were assessed clinically and electromyoneurographically for 1-15 months. Lesions of 32 peripheral nerves were registered in children with war injuries. Children with accidentally acquired injuries had lesions of 27 peripheral nerves. A complete loss of voluntary motor unit potentials and signs of total axonal damage were recorded in the upper arms of seven of 11 children with war injuries and in five of 16 children with accidental injuries. There was a diminished number of motor unit potentials and a reduction in compound muscle action potential amplitudes, indicating partial nerve lesions, in 11 of 16 children with accidental injuries (mostly after humeral fracture) and in three of 11 children with brachial plexus war injuries. Reinnervation signs first occurred after 5-9 months (mean = 6.2 months) in war-injured children receiving conservative treatment and after 2-7 months (mean = 3.4 months) in children with accidentally acquired injuries. War-related peripheral nerve injuries in children are more frequently associated with complete denervation followed by slower or delayed nerve regeneration. In children with accidentally acquired nerve injuries the course is significantly better.
Immediate and delayed nerve repair using freeze-thawed muscle autografts in complex nerve injuries: Associated arterial injury
1998, Journal of Hand Surgery: European VolumeFive sheep underwent repair of the median nerve along with the establishment and repair of a brachial artery defect adjacent to the site of nerve injury. The defect in the brachial artery was of similar length to the nerve defect and lay in parallel with it. It was repaired using a reversed vein autograft harvested from one of the superficial veins of the arm. A further five sheep underwent similar treatment with the repair of the nerve delayed for 30 days after the establishment of the complicating vascular injury. Six months after the nerve repair, each group of sheep was assessed using electrophysiological and morphometric methods in order to establish objective indices of nerve recovery and regeneration. These results were compared with those from other sheep which had undergone nerve repair both immediate and delayed with no complicating injury and groups in which the complicating injury consisted of a cavity, fibrosis and haematoma. It was found that delay in the nerve repair and the presence of a complicating arterial injury, both separately and additively, contributed to a poorer outcome in recovery of nerve function and maturation. The effect of an arterial injury, in both of these respects, was to produce a worse outcome than the presence of a cavity with fibrosis and haematoma.
Toxicology of blast overpressure
1997, ToxicologyBlast overpressure (BOP) or high energy impulse noise, is the sharp instantaneous rise in ambient atmospheric pressure resulting from explosive detonation or firing of weapons. Blasts that were once confined to military and to a lesser extent, occupational settings, are becoming more universal as the civilian population is now increasingly at risk of exposure to BOP from terrorist bombings that are occurring worldwide with greater frequency. Exposure to incident BOP waves can cause auditory and non-auditory damage. The primary targets for BOP damage are the hollow organs, ear, lung and gastrointestinal tract. In addition, solid organs such as heart, spleen and brain can also be injured upon exposure. However, the lung is more sensitive to damage and its injury can lead to death. The pathophysiological responses, and mortality have been extensively studied, but little attention, was given to the biochemical manifestations, and molecular mechanism(s) of injury. The injury from BOP has been, generally, attributed to its external physical impact on the body causing internal mechanical damage. However, a new hypothesis has been proposed based on experiments conducted in the Department of Respiratory Research, Walter Reed Army Institute of Research, and later in the Department of Occupational Health, University of Pittsburgh. This hypothesis suggests that subtle biochemical changes namely, free radical-mediated oxidative stress occur and contribute to BOP-induced injury. Understanding the etiology of these changes may shed new light on the molecular mechanism(s) of injury, and can potentially offer new strategies for treatment. In this symposium, BOP research involving auditory, non-auditory, physiological, pathological, behavioral, and biochemical manifestations as well as predictive modeling and current treatment modalities of BOP-induced injury are discussed.
Maximal exercise performance-impairing effects of simulated blast over-pressure in sheep
1997, ToxicologyLung contusion has been identified as a primary blast injury. These experiments addressed a fundamental and overt endpoint of primary blast injury, incapacitation (performance decrement). Respiration, hemodynamics, and blood gases were measured in sheep undergoing incremental exercise challenge before and l h after simulated blast exposure of the thorax. Pathologic examination of lung tissue was performed after exposure and exercise testing. Blast overpressure was simulated in the laboratory using a compressed air-driven shock tube. Three levels of lung injury (Levels 1–3, ‘Trivial’, ‘Slight’, and ‘Moderate’ injury, respectively) were examined for effects on maximal oxygen consumption (V̇O2max), an index of cardiorespiratory fitness. Resting hemodynamics and blood gases were relatively normal an hour after exposure, immediately before exercise. However, Levels 1–3 lung injury were associated with average 4.8, 29.9 and 49.3%V̇O2max decreases, respectively. These performance decrements for Levels 2 and 3 were significantly different from respective controls (non-exposed). Exercise caused significant hemoconcentration in sheep under control conditions, before exposure (resting 9.5 ± 0.9, end-exercise 11.8 ± 0.9g/100ml). Blast exposure resulted in average decreases of 4.9 ± 3.4, 12.8 ± 4.0, and 12.6 ± 3.3% in exercise-induced hemoconcentration for Levels 1–3 injury, respectively. Normal exercise-induced hemodynamic increases were also attenuated after exposure. Levels 2 and 3 injury resulted in average 22.6 ± 2.9 and 18.5 ± 11.2% stroke volume decreases, and also 22.3 ± 8.4 and 29.0 ± 14.2% cardiac output decreases, respectively, during exercise. While blast lung pathology and pulmonary function changes could account for post-blast performance decrements, these experiments suggest that in sheep, early after exposure, diminished hemoconcentration and cardiac disfunction may also contribute to decreased exercise performance.
Immediate and delayed nerve repair using freeze-thawed muscle autografts in complex nerve injuries: Cavitation, fibrosis and haematoma
1997, Journal of Hand Surgery: European VolumeSix sheep underwent repair of the median nerve along with the establishment of a cavity, fibrosis and haematoma at the site of injury. A further six sheep underwent similar repair delayed for 30 days after the establishment of the complicating injury.
Six months after the nerve repair each group of sheep was assessed using electrophysiological and morphometric methods to establish objective indices of nerve recovery and regeneration. These results were compared with sheep which had undergone both immediate and delayed nerve repair with no complicating injury.
It was found that delay of the nerve repair and the presence of a complicating injury, both alone and together, contributed to a poorer outcome in recovery of nerve function and maturation.