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Surgery for blast injuries: experience of an Australian surgical team in Afghanistan

2011; Wiley; Volume: 81; Issue: 3 Linguagem: Inglês

10.1111/j.1445-2197.2010.05652.x

1445-2197

Anthony J. Chambers, Patrick Liston, Michael C. Reade, Brett G. Courtenay, Andrew Higgs, Jeffrey V. Rosenfeld,

Trauma, Hemostasis, Coagulopathy, Resuscitation

From 2001 to the present day, the military forces of the USA, the United Kingdom, Australia and other allied nations have been involved in operations in Afghanistan. Following a short initial period of conventional operations, coalition forces are now engaged in an ongoing conflict against insurgent groups. In this asymmetric warfare, the weapons of choice for insurgents are improvised explosive devices and attacks with rockets and mortars. For this reason, blast injury is the most common cause of wounding of coalition troops, accounting for more than 78% of battle casualties in US forces.1 The purpose of this manuscript is to describe the experiences of an Australian military surgical team managing civilian and military casualties with blast injuries while deployed to the Oruzgan region of Afghanistan in 2009. During this deployment to Afghanistan, 74 patients with blast injuries were managed and 60 surgical procedures were performed for casualties with these injuries. Blast injuries were the most common cause of wounding in both civilian and military casualties presenting during this deployment. The injuries caused by blast weapons in these patients are detailed in Table 1. Improvised explosive devices were the most common cause of blast injury. Other causes of injury included conventional weapons such as rockets, rocket-propelled grenades, grenades and mortars. Unexploded military ordinance found throughout war-torn nations such as Afghanistan may also cause blast injuries, particularly to civilian populations, and several paediatric patients were managed by our surgical team with injuries caused by these devices. More recently in Iraq, Afghanistan and elsewhere, there has been a disturbing trend towards the use of explosive devices employed in suicide attacks.2 During the deployment of our Australian surgical team, several civilians wounded in such attacks did present to our facility during mass-casualty events. The blast injuries encountered during the deployment of this surgical team were classified according to the four mechanisms involved in wounding from these weapons. All four types of blast injury were encountered during the deployment of this Australian surgical team, with secondary (penetrating) injuries from fragmentation being the most common (Table 1). Primary blast injuries are caused by propagation of a high-pressure shock wave created by the rapidly expanding gases from the explosive detonation.3,4 This typically produces injury at sites of interface with gas- or air-containing structures, such as rupture of the tympanic membranes, pulmonary injury ('blast lung') and abdominal hollow viscus perforation.5 Although modern combat body armour systems provide protection to soldiers against penetrating injuries caused by blast, these do not protect the wearer from the effects of primary blast injury. Primary blast injuries have been an uncommon cause of wounding in recent conflicts in comparison to penetrating injuries, occurring in only 7% of US personnel wounded by blast.5 Our experience was similar, where only three patients with primary blast injuries were encountered; one patient had bilateral tympanic membrane perforations and two patients had blast-related pulmonary injury that was apparent on chest radiographs at presentation. Secondary blast injuries are those due to penetrating trauma. This may be caused by fragmentation of the explosive device itself or its casing, which may be specially designed to maximize fragmentation injury. Improvised explosive devices, including those used in suicide bombing attacks, may incorporate metallic objects such as nails, bolts, screws and ball bearings to achieve these same wounding effects (Fig. 1). Penetrating wounds are the most common injuries occurring from blast in battle casualties reaching treatment facilities alive.3 Of the patients with blast injuries who underwent surgical management by our military surgical team, 73% had multiple penetrating wounds and 47% had multiple body regions injured. The upper and lower extremities were the regions most frequently injured by penetrating wounds from blast (Fig. 2). In US forces in Iraq and Afghanistan, penetrating injury to the abdomen and chest has become less common (accounting for 8–14% of casualties with penetrating wounds) due to the protection provided by body armour, and this is in keeping with our own experiences.6 Photograph taken at laparotomy for a civilian patient wounded in a suicide bombing attack with a penetrating wound to the abdomen. Multiple perforations are shown in the caecum. A ball bearing used in the explosive device is displayed. Picture of the lower limb of an 8-year-old female civilian with multiple secondary (fragmentation) blast injuries from a rocket-propelled grenade. Tertiary blast injuries are those caused by blunt trauma, due to the collapse of surrounding structures such as buildings damaged by the blast, or due to the casualty being displaced or thrown by the blast wind, for example, against another structure. As for other forms of blunt trauma, this may produce injuries including fractures, head injuries, chest injuries, crush injuries to the extremities and abdominal injuries such as splenic or hepatic rupture. Tertiary injuries were relatively common in blast-injured patients managed by our surgical team, occurring in 18% of cases. Traumatic brain injury can also occur as a result of blast exposure, due to the effects of primary blast injury and/or tertiary mechanisms, and can be defined as any head injury leading to loss of consciousness or altered mental status. Two patients with traumatic brain injury due to primary and tertiary blast mechanisms were managed by our deployed military surgical team. Quaternary injuries are those caused by burns (thermal and chemical) involving the skin or airway, as well as inhalational injury to the lungs and airways due to noxious gases. Burns were rarely seen in casualties injured by blast managed by our team, occurring in only one patient. This may be due to the high proportion of injuries occurring in open spaces, the distance of the victims from the epicentre of the blast or the types of explosive weapons used by insurgent forces in this region. In conclusion, blast was the most commonly encountered mechanism of injury for military and civilian patients managed by this Australian surgical team deployed to Afghanistan in 2009. Secondary injuries from penetrating wounds were the most common form of blast trauma in these patients, with the extremities being the most common site of injury. The management of blast-injured casualties was complex due to their presentation in mass-casualty events, the presence of multiple penetrating wounds and the possibility of coexisting primary, secondary, tertiary and/or quaternary blast injuries. The authors have no financial interests or conflicts of interest to declare. The views expressed in this article are the personal opinions of the authors alone and are not representative of those of the Australian Defence Force, Department of Defence or the Australian Government. None of the figures in the manuscript depict the military personnel of any nation. The authors would like to acknowledge the service of all the surgeons, anaesthetists, medical officers, nursing officers and medical assistants who have been deployed as part of this and other Australian Defence Force surgical teams to Afghanistan.