Thoracic injuries in U.S. combat casualties: A review of Operation Enduring Freedom and Operation Iraqi Freedom

Ivey, Katherine M.; White, Christopher E.; Wallum, Timothy E.; Cannon, Jeremy W.; Chung, Kevin K.; McNeil, Jeffrey D.; Cohn, Stephen M.; Blackbourne, Lorne H.

doi:10.1016/j.jamcollsurg.2012.06.134

Cited by 22 publications

(39 citation statements)

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“…Examples of penetrating lung injuries include direct damage to the lung parenchyma (pulmonary laceration or pulmonary contusion), tracheobronchial injury, and pulmonary vascular injury. In a 2013 study of data from the Joint Theatre Trauma Registry, penetrating injury was the most common mechanism of thoracic injury among patients injured in Iraq and Afghanistan from 2002-2012, with an incidence of 67.2 % and mortality rate of 10.89 %, and more than half of the thoracic injuries involved an explosion [5,37].…”

Section: Penetrating Lung Injuriesmentioning

confidence: 99%

“…Tube thoracostomy was the most common surgical procedure performed for management of thoracic injuries in US soldiers during OEF/OIF from 2003-2011, accounting for 47.1 % of all procedures; thoracotomy only accounted for 8.6 % of all procedures [5]. A study of 1168 civilian patients with penetrating lung injuries found that 74 % of gunshot wounds and 77 % of stab wounds were able to be treated with a chest tube alone [39], and another study of 1123 patients admitted with penetrating thoracic trauma reported that thoracotomy was only needed in 14 % of patients [40].…”

Section: Penetrating Lung Injuriesmentioning

confidence: 99%

“…Pain management is crucial to the care of patients with blastrelated thoracic trauma, as adequate pain control allows for better lung expansion during recovery, improving oxygenation and ventilation, and decreasing the risk of developing pneumonia, which has been variably associated with increased mortality in thoracic trauma patients [5,54]. Systemic analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs, and opioids can be used for patients with only one to two rib fractures and minimal comorbidities, but regional anesthesia is preferred in patients with three or more rib fractures [55,56].…”

Section: General Management Principles For Blast-related Lung Injuriesmentioning

confidence: 99%

“…A review of US military combat casualties from January 2003 through May 2011 reported an overall mortality rate of 8.3 % among soldiers with thoracic injuries. When considering only those patients with blast injury, the mortality rate increased to 17.9 %, revealing the serious nature of blast-related thoracic injuries [5]. This article will review blast-related lung injuries by discussing (1) basic pathophysiology; (2) presentation and management of PBLI; (3) penetrating and blunt trauma to the lungs and neighboring structures; and (4) general management principles.…”

Section: Introductionmentioning

confidence: 99%

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Blast-related lung injuries

Ferraro

Hiles

2016

Curr Pulmonol Rep

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Blast-related lung injuries are occurring with increased frequency in a variety of circumstances, necessitating that both civilian and military providers across the healthcare spectrum understand how to promptly diagnose and manage these injury patterns. Primary, secondary, and tertiary blast injury mechanisms are most commonly encountered and can result in primary blast lung injury, air embolism, pulmonary contusion, rib fractures, and penetrating lung injuries. Primary blast lung injury occurs when a blast wave injures the lung parenchyma and vasculature and presents as acute dyspnea, cough, and hypoxemia with airspace disease on chest imaging. The treatment of primary blast lung injury, as well as other blast-related lung injuries, involves maintaining oxygenation and using a lung-protective strategy with low tidal volumes and minimal PEEP for patients requiring mechanical ventilation. Pain management, preferably in the form of regional anesthesia, is also crucial in improving outcomes in patients with blast-related lung injury.Keywords Primary blast lung injury . Explosion . Blunt thoracic trauma . Penetrating lung injury A 25-year-old male with no past medical history is transported to a hospital by ambulance after suffering multiple traumatic thoracic injuries when a bomb was detonated within 30 m of him at a sporting event. He has several soft tissue injuries over the torso and extremities. Pressure dressings were applied by first responders with hemostasis achieved. His vital signs include a temperature of 37.8°C, heart rate of 114/min, blood pressure of 92/50 mmHg, respiratory rate of 28/min, and oxygen saturation of 91 % on 15 LPM of oxygen via nonrebreather mask. His thoracic injuries include several leftsided non-displaced rib fractures with associated pulmonary contusion, a left-sided pneumothorax, and primary blast lung injury (PBLI). A chest CT (Fig. 1) in the Emergency Department demonstrates some of these findings. How should his case be managed?

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Section: Penetrating Lung Injuriesmentioning

confidence: 99%

Section: Penetrating Lung Injuriesmentioning

confidence: 99%

Section: General Management Principles For Blast-related Lung Injuriesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Blast-related lung injuries

Ferraro

Hiles

2016

Curr Pulmonol Rep

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“…Larger and more complex injuries (grade III to V) are extremely uncommon with civilian firearms, although they may be seen with high-velocity weapons, blast injuries, or shotgun wounds [51][52][53]. Grade III-IV defects may be mobile enough to repair primarily but often require debridement and a more complex reconstruction.…”

Section: Managementmentioning

confidence: 99%

Penetrating Traumatic Diaphragm Injuries

DeBarros

Martin

2015

Curr Trauma Rep

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Traumatic diaphragm injuries (TDI) are uncommon but can result in major morbidity or mortality if missed. Penetrating thoracoabdominal injuries carry a high risk of TDI, but can also pose a diagnostic dilemma due to their small size and the frequent lack of an associated hernia. Despite advances in imaging, diagnosis without presence of a hernia remains difficult and a high index of suspicion must be maintained. Chest x-ray remains an important tool in early diagnosis, but primarily relies on the presence of a hernia or a discontinuity of the diaphragm, which is not typically seen with penetrating injuries. Computed tomography has a higher sensitivity and specificity and improves preoperative diagnosis, but most TDI are still diagnosed intra-operatively. Minimally invasive modalities allow for both diagnosis and repair of suspected injuries in hemodynamically stable patients while avoiding the morbidity of an open approach. All penetrating diaphragmatic injuries require repair in order to avoid the major morbidity and mortality of a chronic diaphragmatic hernia. The principles of diaphragmatic injury repair are complete reduction of all abdominal contents, lavage and evacuation of any associated hemothorax or gastrointestinal spillage, and watertight, tension-free closure. Most injuries can be closed primarily, but some may require use of prosthetic material or other advanced reconstructive techniques for larger defects. Mortality remains primarily dependent on the mechanism of injury and the presence and severity of associated injuries, with overall Injury Severity Score serving as an independent predictor of early mortality.

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