War injuries.pdf

War injuries (Ballistic injuries) Weapons are divided into: 1-Small arms: like pistols, rifles and machine guns. 2-Explosive munitions: like artillery, grenades, hand grenades, mortar, bomb, mine & anti-armor weapons. Small arm injuries: is common in civil practice(peace time). Pathophysiology: the...

War injuries (Ballistic injuries) Weapons are divided into: 1-Small arms: like pistols, rifles and machine guns. 2-Explosive munitions: like artillery, grenades, hand grenades, mortar, bomb, mine & anti-armor weapons. Small arm injuries: is common in civil practice(peace time). Pathophysiology: the injury is caused by transfer of energy of the moving projectile to the body, it depend on: 1-Projectile factors: mass, speed, nature(bullet, shrapnel or shell), composition (fragmentatiom) &stability(tilt, rotation). 2-Anatomical factors: density &elasticity of the injured tissue. Small arms (both high velocity missile >600m/s and low velocity missile < 600m/s): cause two areas of tissue injury: 1-permanent cavity: is a localized area of cell necrosis caused by direct injury of the missile along it's path. 2-temporary cavity: is a transient lateral displacement of tissue surrounding the permanent cavity. Elastic tissues(skin, muscles &vessels) are pushed aside, then rebound, usually need no excision if their blood supply is intact. While, inelastic tissue, like bone, may fracture in this area. Treatment: І-Emergency Ŗ: 1-stop bleeding &general resuscitation; 2-cover with sterile dressing; 3-start AB &anti tetanus. П- Definitive treatment: soft tissue injury: Low velocity missile injury(pistol): there is little tissue destruction and cavitations. So, superficial debridement is enough provided the entry and exit wounds are clean. High velocity missile injury(rifle): there is marked tissue destruction &cavitation, which should be cleaned by thorough debridement &excision of all dead tissue leaving the wound open for daily dressing till become clean before closure. Bone injury: any associated # should be stabilized using either traction, splintage or external fixation (definitive fixation or temporary external fixation for few weeks then internal fixation). Anti-personal mine injury Explosive munitions injuries: common in war time &terrorist attacks. They cause blast injuries which are divided into 4 types: 1-Primary blast (wave)injury: caused by the direct effect of blast over pressure on the tissue leading to : a-complete or incomplete amputation (usually irreparable). b- injury to any gas containing organs like lungs, tympanic membrane and bowel. 2-Secondary blast injury: is the penetrating injuries caused by the weapon shell & shrapnel (primary fragment injuries) &the fragments resulting from explosion(secondary fragment injuries). 3-Tertiary blast injuries: caused by displacement of the body by shock wave striking other objects that may cause #. 4-Quaternary blast injuries: are injuries resulting from building collapse &fire like burn &toxic chemicals poisoning. The most common pattern of injury seen in is multiple small fragment wounds of the extremities. Treatment: ( Treat the wound, not the weapon.) Start with: history, physical exam., radiological evaluation &classification of wounds & # (Gustillo's system), then either: non-operative(rare) or usually operative Ŗ which includes: 1-AT prophylaxis, 2-AB., 3-Wound irrigation &meticulous debridement (usually 2nd, 3rd look debridement). 4-Fracture stabilization which is critical for wound healing &to ↓ the risk of infection. 5-definitive wound cover. Fracture stabilization: 1-Traction: has limited use nowadays. 2-Splitage: used for closed # and for low energy open # of the leg, ankle & upper limb(G І & П). 3-External fixation: is the method of choice for high energy open # (G П & Ш). It ↓ the systemic effect of injury in multiply injured patients by ↓ hemorrhage &↓ the release of inflammatory mediators. External fixator can be used as a temporary fracture stabilizer for 2 weeks then change (when the wound become clean and the risk of infection negligible) to internal fixation; or as a definitive fixation till # healing. Indications of external fixation: 1- open fractures of the lower limb. 2- impending open fracture. 3- # associated with vascular injury. 4- fracture with significant bone loss. 5- to restore length and alignment. 6- pelvis fracture. 7- closed # that are difficult to splint during long transport. Complications of external fixation: 1-joint stiffness, 2-pin tract infection, 3-pin placed into # site. 4-pin placed into the joint, 5-pin placed too shallow. 6-pin placed too deep causing neurovascular injury. 7-pin fracture in side the bone. Prevention of war wound infection: 1-aggressive wound care. 2-early & enough AB. 3-fracture stabilization. Retained missile: not all missiles, remaining in the body, could or should be removed. Many of them are small, innocent &inaccessible and attempting removal is risky because damage to nearby structures may happen during operation more than the missile caused. Indications of missile removal: 1-persistent pain, 2-discharging sinus, 3-arterio-venous complication. 4-delayed nerve palsy, 5-limitation of joint movement, 6-local &systemic effects according to chemical nature of the missile. 7-patient fear of malignancy.