DOCSLIB.ORG

Military-Relevant Traumatic Brain Injuries: a Pressing Research Challenge

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Military-Relevant Traumatic Brain Injuries: a Pressing Research Challenge Military-Relevant Traumatic Brain Injuries: A Pressing Research Challenge Ibolja Cernak last-induced neurotrauma, i.e., traumatic brain injuries caused by a complex environment generated by an explosion and diverse effects of the resulting blast, currently represents one of the highest research priorities in military medicine. Both clinical experience and experimental results suggest specific blast–body–brain interactions causing complex, interconnected physiological and molecular alterations that can lead to long-term neu- rological deficits. The Biomedicine Business Area at APL has developed a capability to reproduce all major types of military-relevant traumatic brain injuries (primary blast- induced, penetrating, and blunt head injures) comparable to those caused by explosions in theater by using well-defined experimental mouse models. The overarching research approach aims at obtaining a full understanding of blast-induced neurotrauma; devel- oping reliable, fieldable, and user-friendly diagnostic methods; and designing novel treat- ments and preventive measures. INTRODUCTION The DoD Personnel & Procurement Statistics data1 long-term consequences, including those related to show that more than 73% of all U.S. military casual- blast-induced traumatic brain injuries (TBIs), shows ties in Operation Enduring Freedom and Operation an increasing trend. The Defense and Veterans Brain Iraqi Freedom were caused by explosive weaponry Injury Center (DVBIC) estimated, on the basis of medi- (e.g., rocket- propelled grenades, improvised explosive cal records and actual medical diagnoses, that more devices, and land mines). The incidence of primary than 202,000 service members were diagnosed with blast injury increased from 2003 to 2006, and return- TBI between 2001 and 2010, with the overwhelming to-duty rates in patients injured in explosions decreased distribution of mild TBI caused by blast. Nevertheless, by half.2 Although the mortality caused by explosion it has been hypothesized that this number could be has remained low and unchanged, the incidence of even higher given the fact that many war fighters with 296 JOHNS HOPKINS APL TECHNICAL DIGEST, VOLUME 31, NUMBER 4 (2013) potential TBI are un diagnosed or have delayed diagno- ments of debris are propelled by the explosion; tertiary sis. Among the symptoms the war fighters experience blast, which is the acceleration/deceleration of the whole are irritability; memory and speech problems such as body or part of the body by a blast wind (Fig. 1); and qua- reduced verbal fluency, working memory, and executive ternary blast, where flash burns are a consequence of the functioning;3 headache; dizziness and balance problems; transient but intense heat of the explosion.8, 9 and psychological impairments including depression, There are numerous controversial opinions about the posttraumatic stress disorder, substance abuse, and sui- cause of neurological deficits that develop after expo- cide.4, 5 It is important to note that nearly half of the sure to blast. These opinions range from the belief that time these problems developed or were noted after the blast-induced mild TBI is a mere concussion, and as acute phase.4 Nevertheless, blast-induced neurotrauma such the nature of its symptoms is similar to those of a (BINT) is not only a military problem: a high proportion temporary postconcussive syndrome,10 to the belief that of diffuse brain injury due to blasts and relative to all blast-induced neurological deficits are caused by unique other types of injuries has been observed among civil- interactions of systemic, local, biomechanical, and ians both during wartime6 and during peacetime.7 cerebral responses to blast.11–13 Despite concentrated Accumulating experimental data and clinical evi- efforts to clarify the molecular mechanisms underlying dence show that blast waves can cause brain injury with BINT, definitive diagnosis and specific evidence-based or without blunt impact or penetrating head wounds. therapy have yet to be developed for preventing and/ This is caused by a series of effects such as primary blast, or reducing the detrimental effects of blast exposure on or the shock wave itself; secondary blast, where frag- the brain. Figure 1. The complex injurious environment generated by explosion: primary blast effects of the blast wave itself causing primary blast injury; secondary blast effects due to fragments generated and propelled by blast-force causing secondary blast injury (blunt or penetrating); and tertiary blast effects caused by acceleration and deceleration of the body thrown by the kinetic energy of the blast and colliding with other objects (similar to “coup-countercoup” injuries). CNS, central nervous system. (Reproduced with permission from Ref. 13.) JOHNS HOPKINS APL TECHNICAL DIGEST, VOLUME 31, NUMBER 4 (2013) 297 I. CERNAK RESEARCH APPROACH ity and more severe organ damage than when the ani- mals were positioned so that their backs were turned Experimental models of blast injuries used to study toward the shock wave front. This has been previously BINT differ widely from one another, making the com- confirmed in both animals and people16–19 and can be parison of the experimental results extremely difficult. explained, at least in part, by the interaction between Often, instead of mimicking real-life conditions by the shock wave’s kinetic energy and the elastic abdomi- generating blast signatures with multiple shocks and nal wall.13, 20, 21 expansion fronts as seen in theater, blast injury models It is important to note that we confirmed the vital replicate the ideal blast wave from an open-field explo- importance of the systemic response to blast exposure sion. This significantly reduces their clinical and mili- in the pathobiology of blast-induced TBI. In an attempt tary relevance. The APL team designed and developed to link systemic and cerebral inflammation as one of the a modular, multichamber shock tube capable of tailor- potential mechanisms underlying long-term neurologi- ing pressure wave signatures and reproducing complex cal deficits caused by blast, we performed real-time, in shock wave signatures seen in the military operational vivo imaging of myeloperoxidase (MPO) activity of acti- environment. Moreover, we developed and standardized vated polymorphonuclear leukocytes in mice exposed to a mouse model able to replicate the main pathophysi- mild-intensity blast during a 1-month postinjury period. ological consequences of graded blast injuries and pri- Namely, migration and accumulation of polymorphonu- mary BINT, including the long-term neurological effects clear leukocytes are among the major hallmarks of the seen in war fighters. Additionally, aiming to compare the host response to injuries.22–24 Briefly, mice were anesthe- mechanisms of a blunt head injury caused by a direct tized, mounted in supine position to the animal holder impact to the skull with the primary blast-induced secured inside the driven section of the helium-driven TBI, we also developed a weight-drop blunt head injury shock tube, and exposed to mild-intensity shock wave mouse model. Finally, in collaboration with the Karolin- [measured rupture pressure: 183 ± 14 kPa (26.5 ± 2.1 psig); ska Institutet, we built a penetrating head injury device measured total pressure: 103 kPa (14.9 psig), causing 5% to study mechanisms and consequences of penetrating mortality].20 Subsets of animals (n = 5) were exposed to brain injury in mice. whole-body blast; blast with torso (chest and abdomen) protection using a custom-made rigid plexiglass “body armor” with the head exposed; or blast with head protec- RESULTS tion using a custom-made plexiglass “helmet” covering Physiological parameters, functional (motor, cog- the skull, face, and the neck of the animal with the torso nitive, and behavioral) outcomes, and underlying exposed. Ten minutes before imaging, mice were injected molecular mechanisms involved in brain inflammation with a XenoLight RediJect Inflammation Probe (Caliper measured in the brain over the 30-day postblast period Life Sciences, Hopkinton, Massachusetts) at 200 mg/ showed that this model is capable of reproducing major kg (150 ml per mouse) intraperitoneally. The XenoLight neurological changes caused by clinical BINT. We have RediJect Inflammation Probe is a chemiluminescent established a causal relationship between the intensity of reagent in a ready-to-use format that allows for longitu- the mechanical force (i.e., overpressure of the blast) and dinal tracking of MPO level and inflammation status, long-term functional (i.e., motor performance, cognitive in vivo, in a variety of disease models. Bioluminescence performance, and behavior) outcomes; demonstrated a imaging was performed using the IVIS Imaging System graded decline in functional performance; and showed 3-D Series (Caliper Life Sciences). During the imag- an intensity-dependent difference between mild and ing, the animals were anesthetized with a gas mixture moderate injury groups. Similar to the main systemic (isoflurane:nitrous oxide:oxygen at 1:66:33 proportions, and neural impairments seen in patients,4, 5, 14, 15 our respectively) using the integrated system for gas anesthe- model reproduced weight loss, unstable heart and respi- sia. The duration of imaging was 5 min. Sham control ratory rates, motor deficits, memory decline, depression, animals did show only low-intensity localized biolumi- and loss of interest toward environment after blast expo- nescence at the injection site (results not shown).
Load more

Recommended publications
  • Blast Injuries – Essential Facts
    BLAST INJURIES Essential Facts Key Concepts • Bombs and explosions can cause unique patterns of injury seldom seen outside combat • Expect half of all initial casualties to seek medical care over a one-hour period • Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals • Predominant injuries involve multiple penetrating injuries and blunt trauma • Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality • Primary blast injuries in survivors are predominantly seen in confined space explosions • Repeatedly examine and assess patients exposed to a blast • All bomb events have the potential for chemical and/or radiological contamination • Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk of exposure to caregivers is small • Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers • For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current) Blast Injuries Essential Facts • Primary: Injury from over-pressurization force (blast wave) impacting the body surface — TM rupture, pulmonary damage and air embolization, hollow viscus injury • Secondary: Injury from projectiles (bomb fragments, flying debris) — Penetrating trauma,
    [Show full text]
  • Blast Injury REGION 11 Section: Trauma CHICAGO EMS SYSTEM Approved: EMS Medical Directors Consortium PROTOCOL Effective: July 1, 2021
    Title: Blast Injury REGION 11 Section: Trauma CHICAGO EMS SYSTEM Approved: EMS Medical Directors Consortium PROTOCOL Effective: July 1, 2021 BLAST INJURY I. PATIENT CARE GOALS 1. Maintain patient and provider safety by identifying ongoing threats at the scene of an explosion. 2. Identify multi-system injuries, which may result from a blast, including possible toxic contamination. 3. Prioritize treatment of multi-system injuries to minimize patient morbidity. II. PATIENT MANAGEMENT A. Assessment 1. Hemorrhage Control: a. Assess for and stop severe hemorrhage [per Extremity Trauma/External Hemorrhage Management protocol]. 2. Airway: a. Assess airway patency. b. Consider possible thermal or chemical burns to airway. 3. Breathing: a. Evaluate adequacy of respiratory effort, oxygenation, quality of lung sounds, and chest wall integrity. b. Consider possible pneumothorax or tension pneumothorax (as a result of penetrating/blunt trauma or barotrauma). 4. Circulation: a. Look for evidence of external hemorrhage. b. Assess blood pressure, pulse, skin color/character, and distal capillary refill for signs of shock. 5. Disability: a. Assess patient responsiveness (AVPU) and level of consciousness (GCS). b. Assess pupils. c. Assess gross motor movement and sensation of extremities. 1 Title: Blast Injury REGION 11 Section: Trauma CHICAGO EMS SYSTEM Approved: EMS Medical Directors Consortium PROTOCOL Effective: July 1, 2021 6. Exposure: a. Rapid evaluation of entire skin surface, including back (log roll), to identify blunt or penetrating injuries. B. Treatment and Interventions 1. Hemorrhage Control: a. Control any severe external hemorrhage (per Extremity Trauma/External Hemorrhage Management protocol). 2. Airway: a. Secure airway, utilizing airway maneuvers, airway adjuncts, supraglottic device, or endotracheal tube (per Advanced Airway Management protocol).
    [Show full text]
  • Evaluation and Treatment of Blast Injuries
    9/4/2014 Blast Injuries Objectives • An Overview of the Effects of Blast Injuries at the • Describe the basic physics, mechanisms of injury, and Medical Level pathophysiology of blast injury • List the four types or categories of blast injuries • List the factors associated with increased risk of Presented by: Jay Wuerker, EMT-P primary blast injury EMS Instructor II Objectives…cont. Why? • Recognize the key diagnostic indicators of serious • Combat primary blast injury • Terrorism • State the most common cause of death following an • Accidents explosion Combat: Iraq & Afghanistan Terrorism: USS Cole 1 9/4/2014 Terrorism: ??? Terrorism • Bombings are clearly the most common cause of casualties in terrorist incidents. • Recent terrorism has shown increasing numbers of suicidal bombers wearing or driving the explosive device • A poor man’s guided missile! Boston Marathon April 15, 2013 Pressure cooker device • Pressure cooker device (2), form of an IED • “Inspire” magazine Summer 2010, “Make a Bomb in • Same type of device used in Mumbai train bombings the Kitchen of your Mom”, by “The AQ chef”. in 2006 and Time Square car bomb attempt in 2010 • Al-Qaeda publication article on the step by step • Often packed with nails, ball bearings and other small process for making a Pressure cooker bomb. metal objects Boston Marathon Results • Three killed, 264 wounded – many with amputations, scene described as a war zone • One Police officer killed in shoot out with bomber suspect Dzhokhar Tsarnaev 2 9/4/2014 Not in Wisconsin? • Steve Preisler - aka “Uncle Fester” , from Green Bay , graduated from Marquette University in 1981 with a degree in Chemistry and Biology.
    [Show full text]
  • Blast Injuries
    4/6/2020 Guidelines for Burn Care Under Austere Conditions Special Etiologies: Blast, Radiation, and Chemical Injuries 1 BLAST INJURIES 2 1 4/6/2020 Introduction • Recent events, such as terrorist attacks in Boston, Madrid, and London, highlight the growing threat of explosions as a cause of mass casualty disasters. • Several major burn disasters around the world have been caused by accidental explosions. • During the recent conflicts in Iraq and Afghanistan, explosions were the primary mechanism of injury (74% in one review). • Furthermore, explosions were the leading cause of injury in burned combat casualties admitted to the U.S. Army Burn Center during these wars, who frequently manifested other consequences of blast injury. • Thus, providers responding to burn care needs in austere environments should be familiar with the array of blast injuries which may accompany burns following an explosion. 3 Classification of Blast Injuries • Blast injuries are classified as follows: • Primary: Direct effects of blast wave on the body (e.g., tympanic membrane rupture, blast lung injury, intestinal injury) • Secondary: Penetrating trauma from fragments • Tertiary: Blunt trauma from translation of the casualty against an object • Quaternary: Burns and inhalation injury • Quinary: Bacterial, chemical, radiological contamination (e.g., “dirty bomb”) • In any given explosion, these types of injuries overlap. • Primary blast injury is more common in explosion survivors inside structures or vehicles because of blast-wave physics. • By far, secondary blast injury is more common. 4 2 4/6/2020 Classification of Blast Injuries (cont.) • A study of 4623 explosion episodes in a Navy database identified the following injuries among U.S.
    [Show full text]
  • Abdominal Blast Injuries
    BLAST INJURIES Abdominal Blast Injuries Background Abdominal blast injuries are a significant cause of injury and death. The actual incidence of abdominal blast injury is unknown. Incidence and clinical presentation of abdominal blast injury will vary significantly depending upon the patient and the nature of the blast. Underwater blasts carry a significantly greater risk of abdominal injury. Children are more prone to abdominal injuries in blast situations due to their unique anatomy. (For further information please refer to CDC’s “Blast Injuries: Pediatrics” fact sheet.) Clinical Presentation Gas-containing sections of the GI tract are most vulnerable to primary blast effect. This can cause immediate bowel perforation, hemorrhage (ranging from small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture. Blast abdominal injury should be suspected in anyone exposed to an explosion with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia, or any findings suggestive of an acute abdomen. Clinical findings may be absent until the onset of complications: • Clinical presentation of abdominal blast injury may be overt, or subtle and variable, and may include: abdominal pain, rebound tenderness, guarding, absent bowel sounds, nausea and vomiting, fever, and signs and symptoms of hypovolemia or hemorrhage. Victims of closed space bombings are at risk for more primary blast injuries, including abdominal injury. • Predominant post-explosion abdominal injuries among survivors involve standard penetrating and blunt trauma (secondary and tertiary blast injury), but include primary blast injuries, including ischemia secondary to arterial gas embolism. • Abdominal injuries are particularly severe in underwater blasts; the lethal radius of an underwater explosion is about three times that of a similar explosion in air because waves propagate faster and are slower to lose energy with distance due to the relative incompressibility of water.
    [Show full text]
  • Challenges in Management of Blast Injuries in Intensive Care Unit: Case Series and Review
    Brief Communication Challenges in management of blast injuries in Intensive Care Unit: Case series and review Tanvir Samra, Mridula Pawar1, Jasvinder Kaur2 Blast injuries are rare, but life-threatening medical emergencies. We report the clinical Access this article online presentation and management of four bomb blast victims admitted in Intensive Care Unit of Website: www.ijccm.org DOI: 10.4103/0972-5229.146317 Trauma center of our hospital in 2011. Three of them had lung injury; hemothorax (2) and Quick Response Code: pneumothorax (1). Traumatic brain injury was present in only one. Long bone fractures were Abstract present in all the victims. Presence of multiple shrapnels was a universal fi nding. Two blast victims died (day 7 and day 9); cause of death was multi-organ failure and septic shock. Issues relating to complexity of injuries, complications, management, and outcome are discussed. Keywords: Blast lung, bomb blast injuries, clinical presentation, outcome Introduction Minimal peritoneal fl uid collection was reported on Focused Assessment Sonography in Trauma (FAST); A high intensity bomb blast exploded in Delhi on computed tomography (CT) abdomen confi rmed right 7 September 2011. Four of the most severely injured ileal injury. A large (7.2 cm × 3.7 cm) parietal hematoma were shifted to Intensive Care Unit (ICU) of our Trauma and fracture right temporal bone was reported on CT center after primary resuscitation by a team of advanced head [Figure 1]. trauma life support providers in the emergency department (ED). He underwent craniotomy and evacuation of hematoma, exploratory laparotomy, wound debridement and Case Reports application of external fi xator of lower limb on day 1 of Case 1 admission.
    [Show full text]
  • Blast Injuries: Fact Sheets for Professionals
    BLAST INJURIES Fact Sheets for Professionals National Center for Injury Prevention and Control Division or Injury ResponseU.S. Department of Health and Human Services Centers for Disease Control and Prevention CS218119-A Blast Injuries In an instant, an explosion or blast can wreck havoc; producing numerous casualties with complex, technically challenging injuries not commonly seen after natural disasters such as floods or hurricanes. To address this issue, Centers for Disease Control and Prevention (CDC), in collaboration with partners from the Terrorism Injuries Information, Dissemination and Exchange (TIIDE) Project, as well as other experts in the field, have developed fact sheets for health care providers that provide detailed information on the treatment of blast injuries. These fact sheets address background, clinical presentation, diagnostic evaluation, management and disposition of blast injury topics and are available in many languages including Arabic, Bengali, Spanish, French, Chinese, Hindi, Marathi, Russian, and Urdu. Additional terrorist bombing and mass casualty event preparedness and response information for professionals including fact sheets, multimedia tools, and communication messages are available for download and order from CDC’s website at http://emergency.cdc.gov/BlastInjuries. Post these fact sheets in emergency departments where visible and accessible to staff only and include the fact sheets in your hospital emergency plan binders. Note: Please use caution with posting these fact sheets in public areas, such
    [Show full text]
  • Blast Injuries
    COORDINATEDCOORDINATED EFFORTSEFFORTS OFOF VHA,VHA, DODDOD ANDAND USUHSUSUHS TOTO DEVELOPDEVELOP EDUCATIONALEDUCATIONAL MATERIALS:MATERIALS: PLPL 107-287107-287 OfficesOffices ofof PCSPCS andand OPHEHOPHEH Thanks:Thanks: AbidAbid RahmanRahman Ph.D.,Ph.D., SusanSusan MatherMather MDMD MPHMPH andand othersothers includingincluding ColCol DavidDavid Burris,Burris, CreightonCreighton BB Wright,Wright, HowardHoward Champion,Champion, MichaelMichael JJ Hodgson,Hodgson, VirginiaVirginia Hayes,Hayes, ArtieArtie Shelton,Shelton, BrianBrian JJ McKinnonMcKinnon CmdrCmdr USNUSN forfor TMTM guidanceguidance BlastsBlasts andand explosions:explosions: physical,physical, medical,medical, andand triagetriage considerationsconsiderations RelationshipsRelationships toto emergencyemergency cachescaches TBITBI ProgramProgram relationshipsrelationships FutureFuture ProgramsPrograms GOALSGOALS ofof PROGRAMPROGRAM •• UnderstandUnderstand thethe mechanismsmechanisms ofof blastsblasts andand blastblast injuriesinjuries –– TypesTypes ofof explosionsexplosions •• UnderstandUnderstand thethe medicalmedical consequencesconsequences andand syndromessyndromes fromfrom blastblast injuryinjury –– TypesTypes andand classificationclassification ofof injuriesinjuries •• BeBe ableable toto applyapply aa triagetriage algorithmalgorithm toto blastblast injuryinjury –– TriageTriage algorithmalgorithm •• OtherOther treatmenttreatment considerationsconsiderations ExplosiveExplosive EffectsEffects •• BlastBlast PressurePressure WaveWave –– Over-pressureOver-pressure –– Under-pressureUnder-pressure
    [Show full text]
  • Modeling Primary Blast Injury in Isolated Spinal Cord White Matter
    Modeling Primary Blast Injury in Isolated Spinal Cord White Matter Sean Connell, B.S., 2 Hui Ouyang, B.S. 1, 2 and Riyi Shi, M.D., Ph.D. 1, 2 1Department of Basic Medical Sciences, 2Weldon School of Biomedical Engineering Purdue University, West Lafayette, Indiana, USA [email protected] understanding of the mechanisms involved in blast injury is Abstract - Primary blast injury (PBI) is a common injury paramount for increasing soldier survivability and treating associated with present military conflicts and leads to significant afflicted individuals. neurological deficits. In order to prevent and treat this injury, an The current study introduces several novel ex vitro appropriate understanding of the biological response is required. techniques to model the effects of PBI in an attempt to A blast wave generator was created as an experimental model to elucidate this response by creating a repeatable blast injury on elucidate the mechanisms of blast injuries on the CNS, ex-vivo guinea pig spinal cord white matter. Subsequently, this particularly in relation to spinal cord tissue. For this study, a study defines approximate limits for blast force and provides a blast wave generator was created to model an improvised relationship between axonal damage, nerve conduction explosion in order to create a reproducible and controllable parameters and functional recovery. Action potential generation degree of injury for analysis. Functional and anatomical and physical deficits of spinal cords exposed to blast injury were deficits resulting from blast exposure will be continuously measured using a double sucrose gap-recording chamber and a monitored using an electrophysiological recording apparatus dye-exclusion assay.
    [Show full text]
  • Central Cord Syndrome from Blast Injury After Gunshot Wound to the Spine: a Case Report and a Review of the Literature
    Citation: Spinal Cord Series and Cases (2017) 3, 17003; doi:10.1038/scsandc.2017.3 © 2017 International Spinal Cord Society All rights reserved 2058-6124/17 www.nature.com/scsandc CASE SERIES Central cord syndrome from blast injury after gunshot wound to the spine: a case report and a review of the literature Juan Galloza1, Juan Valentin2 and Edwardo Ramos2 INTRODUCTION: Central Cord Syndrome (CCS) is the most common of the spinal cord injury syndromes. Few cases have been presented with gunshot wound (GSW) as a cause of a central cord syndrome, and none, to our knowledge, has been presented without any evidence of central canal bullet/bone fragments. CASE PRESENTATION: A 27-year-old male suffered two close-range gunshot wounds, one to the left neck and one to the left shoulder. CT scan showed C5 spinous process fracture and paraspinal muscle hemorrhage without evidence of central canal stenosis or bullet/bone fragments. Physical examination showed severe weakness and dysesthesias in bilateral upper extremities and mild weakness in bilateral lower extremities. Diagnosis of central cord syndrome was made. He was treated conservatively and started inpatient rehabilitation. Four months post injury, the patient had almost full recovery with only left proximal arm and bilateral distal hand weakness. DISCUSSION: Only four cases of CCS caused by GSW have been reported in the literature. Some suggested algorithms exist regarding the management of these patients, but still cases should be individualized depending on the specific nature of their presentation. The prognosis for patients with CCS tends to be favorable in regaining sensory, bladder, bowel, gross motor function and ambulation, but fine motor skills may remain impaired.
    [Show full text]
  • The Blast Exposure and Brain Injury Prevention Act of 2018
    The Blast Exposure and Brain Injury Prevention Act of 2018 Since 2000, more than 370,000 servicemembers have received a first-time diagnosis of traumatic brain injury (TBI).1 The use of improvised explosive devices in the wars in Iraq and Afghanistan has contributed to an increase in head injuries treated by the military; indeed, TBI has been called the “signature wound of today’s wars.”2 However, while TBI is often associated with blunt physical injuries to the head, recent research has shown that the blast wave produced by even minor explosions can result in TBI – and even if the individual does not exhibit outward physical signs of head injury. Blast overpressure – the pressure caused from a shock wave that exceeds normal atmospheric values – causes harm to the brain not just by moving the brain around inside the skull, but also by damaging the brain at the sub-cellular level. The Department of Defense (DOD) could substantially improve its ability to protect servicemembers from blast exposure and TBI and treat the hundreds of thousands of servicemembers already diagnosed with TBI. Exposure to blast pressure may result not only from battlefield IEDs, but also from smaller concussive events such as firing artillery and other heavy-caliber weapons, which military personnel may do tens or hundreds of times a day, over multiple days at a time, while training to use these weapons. And although research has demonstrated that exposure to blast pressure can damage the brain, scientists’ ability to longitudinally track these effects and understand variation in health outcomes is constrained by the limited data collected on soldiers’ exposure to blast pressure events during their military service.
    [Show full text]
  • Compartment Syndromes
    Orthopaedic Blast Injuries OTA Disaster Preparedness Committee Christopher Born, MD (Chair) Mark McAndrew, MD Christiaan Mamczak, DO Eric Pagenkopf, MD Mark Richardson, MD David Teague, MD Philip Wolinsky, MD Created: March 2015 Objectives • Recognize the increasing threat of blast injuries • Understand basic blast wave mechanics • Understand blast wave wounding mechanisms • Describe initial management of blast wave injuries The Threat Blast wave injury • Blast forms when solid or liquid fuel is rapidly converted into its gaseous state • Resulting detonations can produce injuries rarely seen outside of combat • Severe, multi-system injuries are common • Mass casualties are common Sources of blast injury • Accidental – Industrial accidents • Non-accidental – Military combat operations – Acts of terrorism Industrial accidents • Coal mines • Fertilizer and chemical plants • Fireworks factories West, Texas 2013 ©AP Photo/Tony Gutierrez (used by permission) Military combat operations • High velocity conventional weapons • Landmines • Improvised Explosive Devices (IED) Combat related blast injury • Over 16,000 attempted IED attacks annually in Afghanistan • U.S. casualties since 2001 – > 6,800 deaths – > 50,000 wounded – > 1,500 amputations www.defense.gov/news/casualty.pdf Accessed : 09Mar15 Afghanistan injury mechanisms US Army Surgeon General’s Report on Dismounted Complex Blast Injuries, Jun11 Improvised Explosive Devices • Not confined to combat zones • The weapon of choice for insurgents, terrorists, and home-grown violent extremists
    [Show full text]