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23/09/2019

+ il y a de couches + c'est important

The effect of military clothing on gunshot wound patterns in a cadaveric animal limb model.

Stevenson T et Al Int J Legal Med. 2019 Aug 14. doi: 10.1007/s00414-019-02135-9.

The majority of injuries in survivors of gunshot wounds (GSW) are typically to the extremities. Novel wound ballistic research is encouraged to try and capture corporate knowledge on the management of these injuries gained during recent conflicts and understand the wounding patterns seen. With recent work examining the effect of UK military clothing on extremity GSW patterns in a synthetic model, a model with greater biofidelity is needed for ballistic testing. The aim of this study was to assess the effect of UK military clothing on GSW patterns within a cadaveric animal limb model using two types of ammunition commonly used in recent conflicts-7.62 × 39 mm and 5.45 × 39 mm. In total, 24 fallow deer hind limbs were shot, 12 by 7.62 mm projectiles and the remaining 12 shot by 5.45 mm projectiles, further divided into four with no clothing layers (Cnil), four with a single clothing layer (Cmin) and four with maximum clothing layers (Cmax) as worn on active duty by UK military personnel. Limbs were analysed after ballistic impact using contrast CT scanning to obtain measurements of permanent cavity damage, and results were compared using analysis of variance (ANOVA).

Couches.jpeg

Results showed significantly different damage measurements within limbs with Cmax for both ammunition types compared with the other clothing states. This may result in GSWs that require more extensive surgical management, and invites further study.

17/09/2019

Violences urbaines et tueries massives: Des profils proches ?

Comparison of the Causes of Death and Wounding Patterns in Urban Firearm-Related Violence and Civilian Public Mass Shooting Events.

Maghami S et Al  J Trauma Acute Care Surg. 2019 Aug 5. doi: 10.1097/TA.0000000000002470.
 
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Tueries massives et actes isolés de vilence urbaines par armes à feu, les profils lésionnels et causes de décès sont très proches. La première cause de décès évitable apparaît être les lésions thoraciques.
 

BACKGROUND:

There are no reports comparing wounding pattern in urban and public mass shooting events (CPMS). Because CPMS receive greater media coverage, there is a connation that the nature of wounding is more grave than daily urban gun violence. We hypothesize that the mechanism of death following urban GSWs is the same as has been reported following CPMS.

METHODS:

Autopsy reports of all firearm related deaths in Washington, DC were reviewed from January 1, 2016 to December 31, 2017. Demographic data, firearm type, number and anatomic location of GSWs, and organ(s) injured were abstracted. The organ injury resulting in death was noted. The results were compared to a previously published study of 19 CPMS events involving 213 victims.

RESULTS:

186 urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight gunshots (59%) were to the chest/upper back, 85 (46%) to the head, 77 (42%) to an extremity, and 71 (38%) to the abdomen/lower back. The leading mechanisms of death in both urban firearm violence and CPMS were injury to the brain, lung parenchyma, and heart. Fatal brain injury was more common in CPMS events as compared to urban events involving a handgun.

CONCLUSION:

There is little difference in wounding pattern between urban and CPMS firearm events. Based on the organs injured, rapid point of wounding care and transport to a trauma center remain the best options for mitigating death following all GSW events.

15/09/2019

Tueries par armes à feu: Causes évitables de décès

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event.

Smith ER et Al. Prehosp Emerg Care. 2018 Nov-Dec;22(6):662-668.

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Cet article confirme que la nécessité d'une organisation spécifique de la prise en charge des victimles de terrorisme. La répartition des causes évitables de décès après tirs d'armes à feu diffère quelque peu des problématiques militaires. La probabilité de survie est moindre. Si la stratégie de pose précoce du garrot est importante, elle n'est pas suffisante.  Ainsi il est rapporté qu'un tiers des décès pourrait être évités, que si des exsanguinations liées à des atteintes des membres sont observées, les causes thoraciques apparaissent être une cible de prise en charge précoce notamment par exsufflation de pneumothorax compressif dont l'occurence apparaît plus fréquente qu'en milieu militaire.

Lire aussi

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BACKGROUND:

Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma.

METHODS:

A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury.

RESULTS:

There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital.

 

Potential Civil shooting.jpeg

 

One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head.

CONCLUSIONS:

A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

24/07/2019

Examiner un bassin: Peu faible en préhospitalier

Clinical Examination of the Pelvic Ring in the Prehospital Phase.

 
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Bien que ce travail soit réalisé sur des trauma fermés,  il milite pour un emploi systématiques des ceintures pelviennes dès lors qu'il existe la notion de trauma à haute énergie
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INTRODUCTION:

Instable pelvic fractures are associated with significant hemorrhage and shock. Instability of the pelvic ring should be tested with the manual compression test (MCT) and instable pelvic ring fractures should prompt mechanical stabilization. However, the accuracy of the prehospital MCT in patients, that sustained a high energetic trauma, is still unknown.

SETTING:

Radboudumc Nijmegen, level 1 trauma center, the Netherlands.

METHODS:

This prospective blind observational study included all patients after a high impact blunt trauma treated by an experienced Helicopter Emergency Medical Service (HEMS) physician. Nominal arranged questionnaires were filled in by the HEMS physician prior to the radiological examination of the patient.

RESULTS:

We included 56 patients of which 11 sustained a pelvic ring fracture. 13 patients were treated with pelvic compression devices, of which only five patients had a pelvic ring fracture. Prehospital performed clinical examination by the HEMS physicians had an overall sensitivity of 0.45 (95% CI 0.16-0.75) and a specificity of 0.93 (95% CI 0.29-0.96).

CONCLUSION:

Pelvic ring instability cannot accurately be diagnosed in the prehospital setting, based on the MCT. The use of the pelvic binder should standard in high impact blunt trauma patients, independently of the MCT or trauma mechanism.

| Tags : pelvis

12/12/2018

Tueries massives: Une distribution différente des blessures de guerre

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event.

 
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Si les actions de terrorisme mettent en jeu souvent des armes de guerre, les lésions observées sont notoirement différentes les cibles. Si les hémorragies des membres se rencontrent, en terme de décès évitables elles passent bien après les lésions thoraciques et de l'extrémité céphalique. Une évacuation rapide coordonnée vers une structure chirurgicale apparaît être un facteur de survie.

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BACKGROUND:

Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma.

METHODS:

A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury.

RESULTS:

There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head.

CONCLUSIONS:

A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

Tueries massives: Une distribution différente des blessures de guerre

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event.

 
--------------------------------
Si les actions de terrorisme mettent en jeu souvent des armes de guerre, les lésions observées sont notoirement différentes les cibles. Si les hémorragies des membres se rencontrent, en terme de décès évitables elles passent bien après les lésions thoraciques et de l'extrémité céphalique. Une évacuation rapide coordonnée vers une structure chirurgicale apparaît être un facteur de survie.

--------------------------------

BACKGROUND:

Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma.

METHODS:

A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury.

RESULTS:

There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head.

CONCLUSIONS:

A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

21/07/2018

AP-IED: +grave que mine

Injury profile suffered by targets of antipersonnel improvised explosive devices: prospective cohort study


Victims of AP-IED were more likely, compared with APM victims, to have multiple amputations (70.0% vs 10.4%; p<0.001) or genital injury (26% vs 13%; p=0.007). Multiple amputations occurred in 70 patients: 5 quadruple amputations, 27 triple amputations and 38 double amputations. Pelvic fracture occurred in 21 victims, all but one of whom had multiple amputations. Severe perineal, gluteal or genital injuries were present in 46 patients. Severe soft tissue injury was universal, with injection of contaminated soil along tissue planes well above entry sites. There were 13 facial injuries, 9 skull fractures and 3 traumatic brain injuries. Eleven eye injuries were seen; none of the victims with eye injuries were wearing eye protection. The casualty fatality rate was at least 19%. The presence of more than one amputation was associated with a higher rate of pelvic fracture (28.6% vs 3.3%; p=0.005) and perineal–gluteal injury (32.6% vs 11.1%; p=0.009).

Conclusion

The injury pattern suffered by the target of the AP-IED is markedly worse than that of conventional APM. Pelvic binders and tourniquets should be applied at the point of injury to patients with multiple amputations or perineal injuries.

| Tags : blast

06/02/2018

Gilet de protection: A porter près du corps

Do air-gaps behind soft body armour affect protection?

 
 

INTRODUCTION:

Body armour typically comprises a fabric garment covering the torso combined with hard armour (ceramic/composite). Some users wear only soft armour which provides protection from sharp weapons and pistol ammunition. It is usually recommended that body armour is worn against the body with no air-gaps being present between the wearer and the armour. However, air-gaps can occur in certain situations such as females around the breasts, in badly fitting armour and where manufacturers have incorporated an air-gap claiming improvements in thermophysiological burden. The effect of an air-gap on the ballistic protection and the back face signature (BFS) as a result of a non-perforating ballistic impact was determined.

METHODS:

Armour panels representative of typical police armour (400x400 mm) were mounted on calibrated Roma Plastilina No 1 and impacted with 9 mm Luger FMJ (9×19 mm; full metal jacket; Dynamit Nobel DM11A1B2) ammunition at 365±10 m/s with a range of air-gaps(0-15 mm). Whether or not the ammunition perforated the armour was noted, the BFS was measured and the incidence of pencilling (a severe, deep and narrow BFS) was identified.

RESULTS:

For 0° impacts, a critical air-gap size of 10 mm is detrimental to armour performance for the armour/ammunition combination assessed in this work. Specifically, the incidences of pencilling were more common with a 10 mm air-gap and resulted in BFS depth:volume ratios ≥1.0. For impacts at 30° the armour was susceptible to perforation irrespective of air-gap.

 

Airbag.jpeg

CONCLUSIONS:

This work suggested that an air-gap behind police body armour might result in an increased likelihood of injury. It is recommended that body armour is worn with no air-gap underneath.

14/11/2017

Balles en caoutchouc: Pas si anodines !

Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir.
 
 

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Cet article ne fait que confirmer le fait que certaines munitions en caoutchouc sont dangereuses (1) voire mortelles (2). Les lésions rapportées sont ici périphériques mais tout peut se voir: Atteintes faciales (3);oculaires (4), thoraciques (5), crâniennes (6), vasculaires (7). Evidemment cela dépend du type de munitions employées qui sont d'une grande variété.

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Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature.

METHODS:

From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered.

RESULTS:

All patients weremales with an age range of 11-32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot.

CONCLUSION:

Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.

30/06/2017

Trauma sonore: Protection et corticoïdes

Acute Acoustic Trauma among Soldiers during an Intense Combat.

 
 
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On a toujours tendance à l'oublier un peu. Mais mieux vaut prévenir que guérir par le port de protections adaptées en particulier chez les porteurs d'armes lourdes et les opérateurs radios qui doivent faire l'objet d'un ciblage "éducationnel". Le port de bouchons de protection de type EAR semblerait plus complexe à utiliser. Une amélioration notable peut être obtenue par une corticothérapie avec un équivalent de 1 mg/kg de prednisone démarré dans la première semaine 

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BACKGROUND:

During military actions, soldiers are constantly exposed to various forms of potentially harmful noises. Acute acoustic trauma (AAT) results from an impact, unexpected intense noise ≥140 dB, which generates a high-energy sound wave that can damage the auditory system.

PURPOSE:

We sought to characterize AAT injuries among military personnel during operation "Protective Edge," to analyze the effectiveness of hearing protection devices (HPDs), and to evaluate the benefit of steroid treatment in early-diagnosed AAT injury.

RESEARCH DESIGN:

We retrospectively identified affected individuals who presented to military medical facilities with solitary or combined AAT injuries within 4 mo following an intense military operation, which was characterized with an abrupt, intensive noise exposure (July-December 2014).

STUDY SAMPLE:

A total of 186 participants who were referred during and shortly after a military operation with suspected AAT injury.

INTERVENTIONS:

HPDs, oral steroids.

DATA COLLECTION AND ANALYSIS:

Data extracted from charts and audiograms included demographics, AAT severity, worn HPDs, first and last audiograms and treatment (if given). The Student's independent samples t test was used to compare continuous variables. All tests were considered significant if p values were ≤0.05.

RESULTS:

A total of 186 participants presented with hearing complaints attributed to AAT: 122, 39, and 25 were in duty service, career personnel, and reservists, with a mean age of 21.1, 29.2, and 30.4 yr, respectively. Of them, 92 (49%) participants had confirmed hearing loss in at least one ear. Hearing impairment was significantly more common in unprotected participants, when compared with protected participants: 62% (74/119) versus 45% (30/67), p < 0.05. Tinnitus was more common in unprotected participants when compared with protected participants (75% versus 49%, p = 0.04), whereas vertigo was an uncommon symptom (5% versus 2.5%, respectively, p > 0.05). In the 21 participants who received steroid treatment for early-diagnosed AAT, bone-conduction hearing thresholds significantly improved in the posttreatment audiograms, when compared with untreated participants (p < 0.01, for 1-4 kHz).

CONCLUSIONS:

AAT is a common military injury, and should be diagnosed early to minimize associated morbidity. HPDs were proven to be effective in preventing and minimizing AAT hearing sequelae. Steroid treatment was effective in AAT injury, if initiated within 7 days after noise exposure.

| Tags : blast

10/03/2017

Sauvetage au combat à la mer: Quid ?

Multi-Injury Casualty Stream Simulation in a Shipboard Combat Environment

 

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L'attention portée à la prise en charge des blessés de guerre se porte essentiellement aux blessés lors de combat se déroulant au sol. Il ne faut pas oublier aussi ce qui se passe sur (voire sous) la surface de la mer. Ce qui est vrai à terre ne l'est probablement pas à la mer. Le trauma des membres est certainement moins prééminent. Les mécanismes ballistiques, l'environnement de prise en charge sont totalement différents aussi les réponses, c'est à dire la manière de conduire le sauvetage au combat,  le sont également. Cependant la rareté des engagements sur mer rend difficile la mise sur pied d'une conduite basée sur les faits, d'où l'intérêt des outils de simulation statistique. C'est ce que propose cet  article.

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Accurate forecasts of casualty streams are essential for estimating personnel and materiel requirements for future naval combat engagements. The scarcity of recent naval combat data makes accurate forecasting difficult.  Furthermore, current forecasts are based on single injuries only, even though empirical evidence indicates most battle casualties suffer multiple injuries. These anticipated single-injury casualty streams underestimate the needed medical resources.  This article describes a method of simulating realistic multi-injury casualty streams in a maritime environment by combining available shipboard data with ground combat blast data.  The simulations, based on the Military Combat Injury Scale, are expected to provide a better tool for medical logistics planning.

 

Trauma Category AIREX(%) UNDEX(%)
     
Amputations (a) 3.00 3.00
Asphyxiations 1.34 3.50
Burns 25.30 15.09
Concussions/Internal Organs 2.85 9.29
Contusions/Abrasions 7.06 16.28
Fractures 6.70 11.52
Miscellaneous 4.96 12.08
Nonfatal Immersions 2.00 2.00
Penetrating Wounds 44.88 20.49
Sprains/Strains/Dislocations 1.91 6.75
Total 100.00 100.00
AIREX, attacks above the waterline; UNDEX, attacks at or below the waterline.
(a) Amputations and nonfatal immersions are subject matter expertadjusted values

| Tags : naval

10/12/2016

Tueries massives par armes à feu: Penser différemment !

The profile of wounding in civilian public mass shooting fatalities.

 
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Manifestement, lors de tueries massives par armes à feu, le garrot c'est bien mais cela ne fait pas tout. L'extraction rapide des blessés, une prise en charge préhospitalière revue par rapport à nos habitudes pour un transport sans délais vers un bloc opératoire apparaissent être des mesures cruciales.
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BACKGROUND:

The incidence and severity of civilian public mass shootings (CPMS) continue to r.ise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy.

METHODS:

A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author.

RESULTS:

A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases.

Active Mass shooting.jpg

Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity.

CONCLUSION:

The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries.

10/11/2016

Evasan: Surtout des blessés non en rapport avec la guerre

Surveillance of Disease and Nonbattle Injuries During US Army Operations in Afghanistan and Iraq.
Hauret KG et Al. US Army Med Dep J. 2016 Apr-Sep;(2-16):15-23.

 

Disease and nonbattle injury (DNBI) are the leading causes of morbidity during wars and military operations. However, adequate medical data were never before available to service public health centers to conduct DNBI surveillance during deployments. This article describes the process, results and lessons learned from centralized DNBI surveillance by the US Army Center for Health Promotion and Preventive Medicine, predecessor of the US Army Public Health Command, during operations in Afghanistan and Iraq (2001-2013).The surveillance relied primarily on medical evacuation records and in-theater hospitalization records. Medical evacuation rates (per 1,000 person-years) for DNBI were higher (Afghanistan: 56.7; Iraq: 40.2) than battle injury rates (Afghanistan: 12.0; Iraq: 7.7). In Afghanistan and Iraq, respectively, the leading diagnostic categories for medical evacuations were nonbattle injury (31% and 34%), battle injury (20% and 16%), and behavioral health (12% and 10%). Leading causes of medically evacuated nonbattle injuries were sports/physical training (22% and 24%), falls (23% and 26%) and military vehicle accidents (8% and 11%).

Bilan US.jpg

This surveillance demonstrated the feasibility, utility, and benefits of centralized DNBI surveillance during military operations.

09/10/2016

Blessés des combats modernes:Spécifiques

A modern combat trauma

 

INTRODUCTION:

The world remains plagued by wars and terrorist attacks, and improvised explosive devices (IED) are the main weapons of our current enemies, causing almost two-thirds of all combat injuries. We wished to analyse the pattern of blast trauma on the modern battlefield and to compare it with combat gunshot injuries.

MATERIALS AND METHODS:

Analysis of a consecutive series of combat trauma patients presenting to two Bulgarian combat surgical teams in Afghanistan over 11 months. Demographics, injury patterns and Injury Severity Scores (ISS) were compared between blast and gunshot-injured casualties using Fisher's Exact Test.

RESULTS:

The blast victims had significantly higher median ISS (20.54 vs 9.23) and higher proportion of ISS>16 (60% vs 33.92%, p=0.008) than gunshot cases. They also had more frequent involvement of three or more body regions (47.22% vs 3.58%, p<0.0001). A significantly higher frequency of head (27.27% vs 3.57%), facial (20% vs 0%) and extremities injuries (85.45% vs 42.86%) and burns (12.72% vs 0%) was noted among the victims of explosion (p<0.0001). Based on clinical examination and diagnostic imaging, primary blast injury was identified in 24/55 (43.6%), secondary blast injury in 37 blast cases (67.3%), tertiary in 15 (27.3%) and quaternary blast injury (all burns) in seven (12.72%).

CONCLUSIONS:

Our results corroborate the 'multidimensional' injury pattern of blast trauma. The complexity of the blast trauma demands a good knowledge and a special training of the military surgeons and hospital personnel before deployment.

| Tags : blast

17/06/2016

Protection: Hauteur du tronc plutôt que taille

Determining the dimensions of essential medical coverage required by military body armour plates utilising Computed Tomography

Breeze J et Al. http://dx.doi.org/10.1016/j.injury.2016.06.010

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Plus que la taille du combattant, c'est la hauteur du thorax qui doit guider le choix des protections ballistiques du tronc 

 -------------------------------------------

Introduction

Military body armour is designed to prevent the penetration of ballistic projectiles into the most vulnerable structures within the thorax and abdomen. Currently the OSPREY and VIRTUS body armour systems issued to United Kingdom (UK) Armed Forces personnel are provided with a single size front and rear ceramic plate regardless of the individual’s body dimensions. Currently limited information exists to determine whether these plates overprotect some members of the military population, and no method exists to accurately size plates to an individual.

Method

Computed Tomography (CT) scans of 120 male Caucasian UK Armed Forces personnel were analysed to measure the dimensions of internal thoraco-abdominal anatomical structures that had been defined as requiring essential medical coverage. The boundaries of these structures were related to three potential anthropometric landmarks on the skin surface and statistical analysis was undertaken to validate the results.

Results The range of heights of each individual used in this study was comparable to previous anthropometric surveys, confirming that a representative sample had been used. The vertical dimension of essential medical coverage demonstrated good correlation to torso height (suprasternal notch to iliac crest) but not to stature (r2=0.53 versus 0.04). Horizontal coverage did not correlate to either measure of height. Surface landmarks utilised in this study were proven to be reliable surrogate markers for the boundaries of the underlying anatomical structures potentially requiring essential protection by a plate.

Front and rear Osprey shape 

BodyArmorProtection1.png

Potential new Shape

BodyArmorProtection2.png

 

Conclusions

Providing a range of plate sizes, particularly multiple heights, should optimise the medical coverage and thus effectiveness of body armour for UK Armed Forces personnel. The results of this work provides evidence that a single width of plate if chosen correctly will provide the essential medical coverage for the entire military population, whilst recognising that it still could overprotect the smallest individuals. With regards to anthropometric measurements; it is recommended, based on this work, that torso height is used instead of stature for sizing body armour. Coverage assessments should now be undertaken for side protection as well as for other non-Caucasian populations and females, with anthropometric surveys utilising the three landmarks recommended in this study.

 

 

 

05/06/2016

40 years of terrorist bombings

40 years of terrorist bombings – A meta-analysis of the casualty and injury profile

Ewards DS et Al. Injury, Int. J. Care Injured 47 (2016) 646–652

 

Introduction: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide.

Methods: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords ‘‘terrorist’’, and/or ‘‘suicide’’, and/or ‘‘bombing’’) from 1970 to 2014 was performed.

Results: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P < 0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p < 0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p < 0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semiconfined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD 17.828) and 15.63 (SD 10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD 141.147), compared to CS, 79.20 (SD 59.8). Extremity related wounds were the commonest injuries seen (32%).

Discussion/Conclusion: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

20/03/2016

Blessés par balle: Civil et guerre, différent !

The profile of wounding in civilian public mass shooting fatalities.
 
Smith ER et Al. J Trauma Acute Care Surg. 2016 Mar 8. [Epub ahead of print]
 
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Des armes différentes, des distances de tir différentes, l'absence de protection balistique expliquent des lésions différentes. Dans cette publication, ce ne sont pas les lésions des membres qui sont les plus fréquentes mais les lésions du torse. A méditer pour la prise en charge des blessés, prise en charge qui semble devoir être différente en contexte civil de ce qui peut être fait dans un contexte de conflits armées, même asymétrique. D'autres expériences ont été rapportées exprimant la grande complexité du problème (1, 2, 3)
 
Ceci est d'autant plus vrai que la chaîne de relève est complètement différente avec notamment un accès aux structures chirurgicales beaucoup plus rapide qu'en contexte militaire. 
 
 
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Background: The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different than in military combat fatalities and thus may require a new management strategy.
 
Methods: A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. CPMS was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if pre-hospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author.
 
Results: A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity
 
Conclusion: The overall and fatal wounding patterns following CPMS are different than those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries.

17/07/2015

Protection ballistique et exposition céphalique ?

Combat Body Armor and Injuries to the Head, Face, and Neck Region: A Systematic Review

Tong D et Al. Mil Med. 2013 Apr;178(4):421-6

There has been a reported increase in combat-related head, face, and neck (HFN) injuries among service personnel wearing combat body armor (CBA) that have deployed to Iraq and Afghanistan. Modern ceramic plate CBA has decreased the incidence of fatal-penetrating injuries to the torso but offers no protection to the limbs and face which remain exposed to gunshot wounds and fragments from explosive devices. The aim of this review was to systematically summarize the literature reporting on HFN injuries sustained by combat personnel wearing CBA and to highlight recommendations for increased protection to the facial region. Three major contributing factors were identified with this proportional increase in HFN injuries, namely the increased survivability of soldiers because of CBA, fragments injuries from explosive devices, and the lack of protection to the face and limbs. There appears to be no evidence to suggest that by virtue of wearing CBA the likelihood of sustaining an HFN injury increases as such, but a higher incidence of fragment injuries to the HFN region may be due to the more common use of improvised explosive devicess and other explosive devices. Further development of lightweight protection for the face is needed.

28/03/2015

Blast et squelette osseux: Lésions spécifiques ?

Blast Injury and the Human Skeleton: An Important Emerging Aspect of Conflict-Related Trauma.

Dussault C. et Al. J Forensic Sci. 2014 May;59(3):606-12 [Thèse]

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La rupture de la membrane du tympan en cas serait un marqueur peu fiable du blast et de sa gravité  (1,2, 3). Il semblerait que certaines lésions osseuses soient assez spécifiques de blast osseux. Ceci a son intérêt en médecine médico-légale quand les circonstances de décès ne sont pas connues.

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Recent decades have seen an accelerating trend in warfare whereby a growing proportion of conflict-related deaths have been caused by explosions. Analysis of blast injury features little in anthropological literature. We present a review of clinical literature that includes prevalence of injury to anatomical regions and potential indicators of blast injury which can be used by forensic anthropologists. This includes high prevalence of extremity (22.8–91.2%) and facial (19.6–40%) injury in combat contexts, lower limb fractures (19–74.3%) in suicide bombing, traumatic amputation (3–43%) and diffuse fracture patterns in terrorist bombings. Potential indicators of blast trauma include blowout fractures in sinus cavities from blast overpressure, transverse mandibular fractures, and visceral surface rib fractures. Ability to recognize blast trauma and distinguish it in the skeleton is of importance in investigations and judicial proceedings relating to war crimes, terrorism, and human rights violations and likely to become increasingly crucial to forensic anthropology knowledge.

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1. Les factures mandibulaires transverses

[Mandibular fractures in British military personnel secondary to blast trauma sustained in Iraq and Afghanistan. Breeze et al. Br J Oral Maxillofac Surg. 2011 Dec;49(8):607-11]

Elles portent essentiellement sur la symphyse et le corps alors qu'en traumatologie civile il s'agit essentiellement d'atteintes du condyle et de l'angle

2. Les fractures de plancher de type "Blow out"

Le cadre orbitaire reste intact. Le plancher de l'orbite est atteint. Il y a irruption du contenu orbitaire dans le sinus. Le risque est que ces fractures passent inaperçues. Cliniquement elle se traduise par une anomalie de l'occulomotricité.

3. Les fractures de cotes en aile de papillon

 [Rib Butterfly Fractures as a Possible Indicator of Blast Trauma. Christensen et Al. J Forensic Sci. 2013 Jan;58 Suppl 1:S15-9.]

blast

blast

 

| Tags : blast

11/01/2015

Histoire de casque de protection

Ballistic helmets – Their design, materials, and performance against traumatic brain injury

Kulkarni SG et Al.  Composite Structures 101 (2013) 313–331

Protecting a soldier’s head from injury is critical to function and survivability. Traditionally, combat helmets have been utilized to provide protection against shrapnel and ballistic threats, which have reduced head injuries and fatalities. However, home-made bombs or improvised explosive devices (IEDs) have been increasingly used in theatre of operations since the Iraq and Afghanistan conflicts. Traumatic brain injury (TBI), particularly blast-induced TBI, which is typically not accompanied by external body injuries, is becoming prevalent among injured soldiers. The responses of personal protective equipment, especially combat helmets, to blast events are relatively unknown. There is an urgent need to develop head protection systems with blast protection/mitigation capabilities in addition to ballistic protection.

Modern military operations, ammunitions, and technology driven war tactics require a lightweight headgear that integrates protection mechanisms (against ballistics, blasts, heat, and noise), sensors, night vision devices, and laser range finders into a single system.

The current article provides a comparative study on the design, materials, and ballistic and blast performance of the combat helmets used by the US Army based on a comprehensive and critical review of existing studies. Mechanisms of ballistic energy absorption, effects of helmet curvatures on ballistic performance, and performance measures of helmets are discussed. Properties of current helmet materials (including Kevlar K29, K129 fibers and thermoset resins) and future candidate materials for helmets (such as nano-composites and thermoplastic polymers) are elaborated. Also, available experimental and computational studies on blast-induced TBI are examined, and constitutive models developed for brain tissues are reviewed. Finally, the effectiveness of current combat helmets against TBI is analyzed along with possible avenues for future research.

| Tags : balistique, blast, tbi