Extracorporeal shock-wave lithotripsy in horseshoe kidneys

Using the Dornier HM-3 lithotriptor, 10 patients (11 renal units) with calculi in horseshoe kidneys were treated with extracorporeal shock-wave lithotripsy (ESWL) and ancillary procedures. Six renal units (55%) underwent pre-ESWL manipulation consisting of a Double J stent, ureteral catheter, or percutaneous nephrostomy. The "blast path" was employed to treat five renal units which could not be positioned at F2. Good initial stone fragmentation was obtained in eight renal units (73%). There were two episodes of post-ESWL obstruction requiring intervention; both occurred in the same patient. A total of seven post-ESWL procedures were performed on two renal units. After all procedures, eight renal units (73%) were rendered stone-free, six (55%) with ESWL alone. The average follow-up interval was twelve months (range 1-28 months). ESWL can be used effectively to treat some patients with calculi in horseshoe kidneys. The ectopic location of these renal units may make it difficult to position calculi at F2, thus necessitating treatment on the blast path or placement of the patient in prone position. Multiple ancillary procedures may be necessary.     

Rodent model of direct cranial blast injury

Traumatic brain injury resulting from an explosive blast is one of the most serious wounds suffered by warfighters, yet the effects of explosive blast overpressure directly impacting the head are poorly understood. We developed a rodent model of direct cranial blast injury (dcBI), in which a blast overpressure could be delivered exclusively to the head, precluding indirect brain injury via thoracic transmission of the blast wave. We constructed and validated a Cranium Only Blast Injury Apparatus (COBIA) to deliver blast overpressures generated by detonating .22 caliber cartridges of smokeless powder. Blast waveforms generated by COBIA replicated those recorded within armored vehicles penetrated by munitions. Lethal dcBI (LD(50) ～ 515?kPa) was associated with: (1) apparent brainstem failure, characterized by immediate opisthotonus and apnea leading to cardiac arrest that could not be overcome by cardiopulmonary resuscitation; (2) widespread subarachnoid hemorrhages without cortical contusions or intracerebral or intraventricular hemorrhages; and (3) no pulmonary abnormalities. Sub-lethal dcBI was associated with: (1) apnea lasting up to 15?sec, with transient abnormalities in oxygen saturation; (2) very few delayed deaths; (3) subarachnoid hemorrhages, especially in the path of the blast wave; (4) abnormal immunolabeling for IgG, cleaved caspase-3, and β-amyloid precursor protein (β-APP), and staining for Fluoro-Jade C, all in deep brain regions away from the subarachnoid hemorrhages, but in the path of the blast wave; and (5) abnormalities on the accelerating Rotarod that persisted for the 1 week period of observation. We conclude that exposure of the head alone to severe explosive blast predisposes to significant neurological dysfunction.     

Extracorporeal shock-wave lithotripsy (ESWL). I. In vitro results of blast path treatment of human gallstones

To evaluate the efficacy of extracorporeal shock-wave lithotripsy (ESWL) for human gallstone fragmentation, biliary calculi of different size and composition were evaluated to determine clinical applicability of this technique. Human biliary calculi composed primarily of cholesterol (Group I, N = 6) and calcium bilirubinate (Group II, N = 6) were shocked in vitro at varying positions along the ESWL blast path. All calculi subjected to lithotripsy were fragmented. Cumulative fragment size was less than or equal to 2, 3, 5, and 8 mm in 73, 86, 94, and 100% of all stones treated, respectively. No statistically significant differences were observed following stone fragmentation when the two groups were compared. Further, no statistically significant differences were evident when comparing the energy expended during fracture of stones in the two groups, or in comparison of fracture with old or new electrodes. However, when fragmentation for stone remnants less than or equal to 2 mm in size was compared at 6- and 10-cm positions on the blast path, a statistically significant difference was noted (P less than 0.001). Stone fragmentation was greatest at positions closest to F2. These data indicate that biliary calculi can be fragmented when subjected to lithotripsy and positioned on the ESWL blast path.     

Influence of vagal injury on acute traumatic reaction after blast injury

Introduction

A prospectively randomised, controlled animal study was conducted to analyse the influence of vagal injury on acute cardio-respiratory responses to blast injury.

Materials and methods

We used a previously described model of blast-fragment combined injuries to divide dogs randomly into three groups: normal control, blast injury with fragment shot at the masseter and blast injury with fragment shot at the neck. The vagal histomorphologic changes were investigated by haematoxylin–eosin staining and immunocytochemical analysis of neuron-specific enolase and glial fibrillary acidic protein. The indices of respiration, heart rate, blood pressure and body temperature were recorded continuously before and after blast exposure.

Results

The vagal injury was more severe in the neck-injured than in the face-injured group. However, bradycardia, hypotension and absence of compensatory peripheral vasoconstriction, which are typically seen in animals subjected to blast injury without vagal nerve injuries, were partly inhibited when the vagal nerve was injured.

Conclusion

A vagally mediated reflex, such as a cardio-respiratory system defensive reflex that caused shock, was observed immediately after blast pressure wave injury. These observations may have important implications for the emergency management of blast injury cases.     

Blast injuries--and the pivotal role of trauma surgeons

An explosion is the sudden release of energy and its radial propagation through air, solid structures and living tissue. Treatment of blast injuries is complex and combines the principles of penetrating and blunt trauma, chemical or thermal burns and disaster and mass casualty management. Primary blast injuries are a direct result of the explosion itself. The sudden release of energy is translated into a shock wave that travels at supersonic speed (5000 metres/second). There is a sudden and short-lived rise in pressure, followed by a prolonged negative pressure, or vacuum, responsible for additional injury. The organs most at risk for primary blast injuries are the lungs, the ears and the gastrointestinal tract. The explosion also sets solid objects in motion; these act as projectiles, and can travel over far greater distances (secondary blast injuries), and their management is no different from penetrating or blunt trauma from other causes. The explosion may cause not only "projectiles," but the body itself to be displaced: These tertiary blast injuries include traumatic amputations and crush injuries following land mine explosions. Finally, quaternary blast injuries comprise other forms of associated trauma, such as burns, asphyxia or poisoning from release of noxious substances by the blast. These injuries can be particularly taxing for rescue teams because of their tendency to affect large amounts of patients and the risk they pose to the rescuers themselves. Individual management of the blast injury victim requires a multidisciplinary team; terrorist or wartime bombings also require expertise in disaster management and triage.     

Blast Injury in the Spine: Dynamic Response Index Is Not an Appropriate Model for Predicting Injury

Background

Improvised explosive devices are a common feature of recent asymmetric conflicts and there is a persistent landmine threat to military and humanitarian personnel. Assessment of injury risk to the spine in vehicles subjected to explosions was conducted using a standardized model, the Dynamic Response Index (DRI). However, the DRI was intended for evaluating aircraft ejection seats and has not been validated in blast conditions.

Questions/purposes

We asked whether the injury patterns seen in blast are similar to those in aircraft ejection and therefore whether a single injury prediction model can be used for both situations.

Methods

UK military victims of mounted blast (seated in a vehicle) were identified from the Joint Theatre Trauma Registry. Each had their initial CT scans reviewed to identify spinal fractures. A literature search identified a comparison population of ejected aircrew with spinal fractures. Seventy-eight blast victims were identified with 294 fractures. One hundred eighty-nine patients who had sustained aircraft ejection were identified with 258 fractures. The Kruskal-Wallis test was used to compare the population injury distributions and Fisher’s exact test was used to assess differences at each spinal level.

Results

The distribution of injuries between blast and ejection was not similar. In the cervical spine, the relative risk of injury was 11.5 times higher in blast; in the lumbar spine the relative risk was 2.9 times higher in blast. In the thoracic spine, the relative risk was identical in blast and ejection. At most individual vertebral levels including the upper thoracic spine, there was a higher risk of injury in the blast population, but the opposite was true between T7 and T12, where the risk was higher in aircraft ejection.

Conclusions

The patterns of injury in blast and aircraft are different, suggesting that the two are mechanistically dissimilar. At most vertebral levels there is a higher relative risk of fracture in the blast population, but at the apex of the thoracic spine and in the lower thoracic spine, there is a higher risk in ejection victims. The differences in relative risk at different levels, and the resulting overall different injury patterns, suggest that a single model cannot be used to predict the risk of injury in ejection and blast.

Clinical Relevance

A new model needs to be developed to aid in the design of mine-protected vehicles for future conflicts.     

Chronic myeloid leukemia in pregnancy: an absolute contraindication to neuraxial anesthesia?

Chronic myeloid leukemia is rare in pregnancy with an estimated incidence of 1:75 000. It is a genetic myeloproliferative disorder marked by increased and unregulated growth of myeloid cells in the bone marrow. The terminal phase of chronic myeloid leukemia may develop into a blast crisis, defined as >30% myeloblasts in the circulation. A blast crisis resembles an acute leukemia and is associated with rapid clinical deterioration and short survival. Targeted gene therapy with tyrosine kinase inhibitors is effective in treatment but when these agents are discontinued, as in pregnancy, the patient may relapse and blast cells may enter the circulation. Theoretically, a central nervous system blast crisis may be induced by inadvertent intrathecal seeding of circulating blast cells, and is associated with a high mortality rate and a median life expectancy of three months. We describe the anesthetic management of a patient with chronic myeloid leukemia and blast cells in the circulation who required cesarean delivery. After considering the potential anesthetic risks and benefits, general anesthesia was chosen. Although an iatrogenic central nervous system blast crisis is extremely rare, the high morbidity and mortality associated with such an event should be considered when formulating an anesthetic plan.     

Blast trauma: the fourth weapon of mass destruction.

Injury from blast is becoming more common in the non-military population. This is primarily a result of an increase in politically motivated bombings within the civilian sector. Explosions unrelated to terrorism may also occur in the industrial setting. Civilian physicians and surgeons need to have an understanding of the pathomechanics and physiology of blast injury and to recognize the hallmarks of severity in order to increase survivorship. Because victims may be transported rapidly to the hospital, occult injury to gas and fluid containing organs (particularly the ears, bowel and lungs) may go unrecognized. Information surrounding the physical environment of the explosion (whether inside or outside, underwater, associated building collapse, etc) will prove useful. Most of the immediate deaths are caused by primary blast injury from the primary blast wave, but secondary blast injury from flying debris can also be lethal and involve a much wider radius. Liberal use of X-ray examination in areas of skin punctures will help to identify a need for exploration and/or foreign body removal. Biologic serum markers may have a role in identifying victims of primary blast injury and assist in monitoring their clinical progress. Tertiary blast injury results from the airborne propulsion of the victim by the shockwave and is a source of additional blunt head and torso trauma as well as fractures. Miscellaneous (quaternary) blast injury include thermal or dust inhalation exposure as well as crush and compartment syndromes from building collapse. Any explosion has the potential to be associated with nuclear, biologic or chemical contaminants, and this should remain a consideration for healthcare givers until proven otherwise.     

Does Blast Medium Affect Heterotopic Ossification in a Blast-amputation Model?

Background

Heterotopic ossification (HO) develops after nearly 2/3 of traumatic blast amputations in the contemporary battlefield. This phenomenon has potentially devastating consequences for servicemen and women and its pathophysiology warrants further investigation using a previously developed animal blast model.

Questions/purposes

We asked, what is the (1) severity (quantity) and (2) type (location) of HO bone formation after a hindlimb blast amputation with two distinct blast media. We hypothesized that a more “war-relevant” blast medium could be a more accurate model and potentially intensify the development of HO.

Methods

Using a Sprague-Dawley rat model, the pathophysiology of ectopic bone formation in a traumatic hindlimb blast amputation was evaluated. Twenty-four animals underwent blast amputations and closure based on a previously established experimental model. Half the amputations were subjected to blasted sand and the other 1/2 to blasted water. Serial orthogonal radiography was performed on each animal until euthanasia at 24 weeks to track the development of HO. Heterotopic bone severity and type were assessed by three independent graders at each time using a novel grading scale to assess quantity and quality of HO.

Results

All animals had radiographic evidence of HO develop. No differences were observed in ectopic bone development between sand and water blasting regarding severity or type at any time. Animals that received water and sand blasting had moderate HO develop at 24 weeks (median, 2.0 and 2.5 weeks, respectively; range, 1–3 weeks; difference of medians, 0.5; p = 0.67). At the time of euthanasia, 10 animals that were water blasted had Type 3 HO compared with 11 in the sand-blasted group (p = 1.00).

Conclusions

Our study showed a clear development of HO after hindlimb blast amputation in a Sprague-Dawley rat model; however, no difference was observed in HO development based on the type of blast media. This suggests it is the blast mechanism that induces ectopic bone development, regardless of the blasted medium. The grading scale we developed for our animal-model study provided a reliable means of assessing HO severity and type.

Clinical Relevance

We anticipate that future investigations will elucidate similarities between service members’ wartime extremity injuries and the animal model used in our study, and with focused future research this model may have beneficial therapeutic implications as the pathophysiology of HO development is further understood.     

Blast-induced color change in photonic crystals corresponds with brain pathology

A high incidence of blast exposure is a 21st century reality in counter-insurgency warfare. However, thresholds for closed-head blast-induced traumatic brain injury (bTBI) remain unknown. Moreover, without objective information about relative blast exposure, warfighters with bTBI may not receive appropriate medical care and may remain in harm's way. Accordingly, we have engineered a blast injury dosimeter (BID) using a photonic crystalline material that changes color following blast exposure. The photonic crystals are fabricated using SU-8 via multi-beam interference laser lithography. The final BID is similar in appearance to an array of small colored stickers that may be affixed to uniforms or helmets in multiple locations. Although durable under normal conditions, the photonic crystalline micro- and nano-structure are precisely altered by blast to create a color change. These BIDs were evaluated using a rat model of bTBI, for which blast shockwave exposure was generated via a compressed air-driven shock tube. With prototype BID arrays affixed to the animals, we found that BID color changes corresponded with subtle brain pathologies, including neuronal degeneration and reactive astrocytosis. These subtle changes were most notable in the dentate gyrus of the hippocampus, cerebral cortex, and cerebellum. These data demonstrate the feasibility of using a materials-based, power-free colorimetric BID as the first self-contained blast sensor calibrated to correspond with brain pathology.     

Multiple blast extremity injuries: is definitive treatment achievable in a field hospital for local casualties?

Purpose

The objective of this report was to analyse injury patterns and definitive management of local casualties with multiple blast extremity injuries in the Kabul International Airport Combat Support Hospital.

Methods

A clinical prospective study was performed from July 2012 to January 2013. Afghan victims of a blast trauma with a minimum of two extremities injured and an Injury Severity Score (ISS) greater than 8 were included. Two groups were considered for analysis: group A including patients with amputations and group LS including patients with limb salvage procedures.

Results

During this period 19 patients were included with a total of 57 extremity injuries. There were six patients in group A and 13 patients in group LS, with a mean number of injuries of 3.5 and 2.8, respectively. The ISS, blood products utilization and overall time of surgery were significantly greater in group A.

Conclusion

Reconstruction of multiple blast extremity injuries may be achieved in a field hospital despite limited resources and operational constraints. However, this activity requires the utilization of significant supplies and major investment from the caregivers deployed.     

Extracorporeal shock-wave lithotripsy (ESWL). II. In vivo canine results of blast path treatment of human gallstones

To evaluate the role of ESWL in vivo for the treatment of human gallstones positioned on the blast path, a canine model was developed to determine the efficacy of stone fragmentation and the subsequent histopathological injury that occurs as a result of this therapeutic technique. Twenty-four 16- to 20-kg mongrel dogs were divided into five groups: I: ESWL without stone, autopsy at 48 hr (N = 6); II: ESWL with stone (mean diameter 16.8 mm, range = 14-19 mm), autopsy at 48 hr (N = 10); III: ESWL without stone, autopsy at 41-46 days (N = 6); IV: ESWL without stone, autopsy immediately after ESWL (N = 1); V: No ESWL or stone, autopsy 2 hr after anesthesia induction (N = 1). A human gallstone (96% cholesterol) was inserted by cholecystotomy (N = 10) in Group II only. All groups (N = 24) had operative placement of a 6.5 Fr accordion catheter into the gallbladder for radiographic visualization. For each blast path treatment, 2000 discharges were delivered at 18-24 kV. Histopathologically, the Group V gallbladder served as a control. Groups I, II, and IV revealed mild subacute injury; dog gallbladders in Group III showed regression of these changes. Total surface area (TSA) of Group II stones increased from a pre-ESWL mean of 6.60 +/- 0.0.84 cm2 to 53.84 +/- 26.8 cm2 post-ESWL (P less than 0.001). Cumulative post-ESWL fragment sizes for particles in less than or equal to 2-, less than or equal to 3-, less than or equal to 5-, less than 10- and greater than or equal to 10-mm categories represented 32.9, 41.6, 49.4, 74.3, and 100% of pretreatment stone weight, respectively. These data indicate that human gallstones can be fractured to a variable degree when treated on the ESWL blast path and that TSA increased significantly. Gallbladder histopathologic changes appear to be reversible by 41-46 days post-ESWL.     

Ureteral contusion and delayed necrosis from gunshot injury

The blast effect surrounding the path of a gunshot wound near the ureter can cause ureteral contusion with hematuria, no extravasation on the intravenous pyelogram, and an intact ureter found at laparotomy. Subsequent progression of the ureteral contusion to delayed necrosis and urine leakage can occur.     

Abdominal blast injuries: different patterns,severity, management,and prognosis according to the main mechanism of injury

Purpose

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

Methods

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

Results

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

Conclusions

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.     

A laboratory model for studying blast overpressure injury

Blast injury remains an important source of trauma in both civilian and military settings. We have studied a recently developed blast wave generator to evaluate its effectiveness for laboratory study of blast injury. In order to determine the reliability of the device and the pathology of the lesions caused by the short duration (0.5-1.0 msec), and high intensity (60-375 psi) pressure wave, laboratory rats were exposed to the pressure waves generated by the machine. The animals were divided into three groups: the first exposed to midthoracic blasts, the second to abdominal blasts, and a group of controls exposed to a gentle stream of gas. Group I showed gross and microscopic evidence of lung blast injury of "rib imprint" hemorrhages, intra-alveolar hemorrhage, marked increase in lung weight, prolonged apnea, and bradycardia. Group II showed typical blunt abdominal trauma at the closest ranges, but characteristic submucosal hemorrhages up to 4.0 cm from the blast nozzle. In both groups, a protective effect was seen in heavier animals. The blast wave generator permits reproducible blast injury in the laboratory that is safer and faster than current methods. The lung and bowel lesions induced are grossly and microscopically similar to injuries of blast exposure seen in clinical patients.     

The "in vitro skin test": a reliable and repeatable assay of immune competence in the surgical patient

In vitro blast transformation of human peripheral lymphocytes was tested using standard skin test antigens, the mitogens PHA and Con A, and the mixed lymphocytes reaction. The study group included 15 patients with multiple trauma, 40 with major burns, six following cholecystectomies, six following aortic reconstruction, and 30 normal volunteer controls. Repeated skin testing may sensitive patients to candida and streptokinase-streptodornase (SKSD), and desensitize them to mumps antigen. Blast transformation in response to PPD did not correlate with the clinical status of the patients; similarly, blast transformation in response to stimulation by the mitogens PHA and Con A could not reliably predict the occurrence of septic complications. Reactivity in response to stimulation by the soluble antigens SKSD and mumps and in the one-way mixed lymphocyte reaction accurately predicted the clinical course of patients. This method of "in vitro skin testing" is a reliable and repeatable method of monitoring the immunologic status of patients whose illness or injury requires longitudinal study.     

Chronic depression of lymphocyte traffic by long-term administration of prostaglandins to peripheral lymph nodes in sheep

The objective of this study was to determine the effect on lymphocyte traffic of the long-term administration of prostaglandins to peripheral lymph nodes of sheep in vivo. In 12 studies prostaglandin E2 (PGE2) was infused continuously by digital syringe pump into cannulated afferent lymphatics of nine popliteal lymph nodes in eight sheep. In 32 studies, arachidonic acid emulsified in sterile autologous serum or lymph was injected subcutaneously into the drainage area of peripheral lymph nodes in 11 sheep. Lymphocyte traffic was monitored by the output of small and blast lymphocytes into efferent lymph, which was collected by long-term cannulation. Long-term infusion of PGE2 produced a sustained decrease in the output of small lymphocytes in all of 12 studies and a decrease in blast cell output in all of the six infusions in which blast cell output was elevated prior to infusion. Cessation in PGE2 infusion was associated with increase in the output of small and blast lymphocytes into afferent lymph in all of eight studies. Single or repeated depot-type emulsion injections of arachidonic acid in amounts of 20 mg or more depressed small lymphocyte output in all of 30 studies, and injections of 0.2 mg or more depressed blast lymphocyte output in all of 22 studies in which blast cell outputs were elevated prior to the initial injection. It is observed that long-term bombardment of peripheral lymph nodes of sheep in vivo with prostaglandins, primarily of the E series, produces a chronic depression in lymphocyte traffic as mirrored in the output of small and blast cells into efferent lymph. We suggest that this response may be one of several mechanisms by which prostaglandins may affect the immune response in vivo.     

Long bone fractures caused by penetrating injuries in terrorists attacks

BACKGROUND: High-energy penetrating injuries are increasingly common in the civilian setting. During the years 2000 to 2003, more than 70 suicide bombing attacks occurred in Israel. These were characterized by high numbers of casualties, primarily caused by blast injuries. Injury caused by a blast can be either a primary blast effect of acceleration-deceleration of the blast wave or a secondary effect of metal fragments deliberately placed in explosives, causing severe penetrating injuries. The latter type of injury may result in severe open limb fractures. METHODS: We identified and reviewed 91 patients with 117 long bone fractures caused by penetrating terror-related injuries treated in our institution during 2000 to 2003. The patients were divided according to the mechanism of injury, i.e., either gunshot injury or blast injuries; several parameters were compared. RESULTS: Patients in the blast injury group included more children and elderly patients than the gunshot injury group did. This group also had a significantly higher Injury Severity Score and a higher number of associated injuries, including multiple fractures and mortality. The treatment modalities for the fractures were similar for both groups, as was the fracture final outcome. Local soft tissue injury was more severe in the gunshot injury group, as demonstrated by a higher number of type IIIC fractures, as well as more nerve injuries. CONCLUSION: Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures. These should be aggressively treated by physicians remaining cognizant of other systemic and general implications of such a severe trauma.     

Treatment of the mangled lower extremity after a terrorist blast injury

Terrorist bombings, with resultant blast injuries, have been increasing in frequency during the past 30 years. Injury to the musculoskeletal system is common in victims who survive such attacks. Substantial injury to the limbs may occur through several different mechanisms, each of which may affect prognosis and alter the treatment algorithm. An analysis of the available literature on terrorism and blast events revealed that resource use of the treating medical facility is high during the initial hours after a blast attack, but usually is manageable. A resource management protocol was developed to organize the treatment of limb salvage into four phases. This management protocol may improve the medical facility's ability to manage system resources while treating patients with severe blast injuries. The decision of whether to salvage or proceed with limb amputation is one of the most difficult in orthopaedic trauma. A basic education in the mechanisms of blast damage, a methodical approach to resuscitation, and mangled extremity treatment, likely can improve surgical success.     

Galveston brain injury conference 2010: clinical and experimental aspects of blast injury

Abstract Blast injury is the most prevalent source of mortality and morbidity among combatants in Operations Iraqi and Enduring Freedom. Blast-induced neurotrauma (BINT) is a common cause of mortality, and even mild BINT may be associated with chronic cognitive and emotional deficits. In addition to military personnel, the increasing use of explosives by terrorists has resulted in growing numbers of blast injuries in civilian populations. Since the medical and rehabilitative communities are likely to be faced with increasing numbers of patients suffering from blast injury, the 2010 Galveston Brain Injury Conference focused on topics related to the diagnosis, treatment, and mechanisms of BINT. Although past military actions have resulted in large numbers of blast casualties, BINT is considered the signature injury of the conflicts in Iraq and Afghanistan. The attention focused on BINT has led to increased financial support for research on blast effects, contributing to the development of better experimental models of blast injury and a clearer understanding of the mechanisms of BINT. This more thorough understanding of blast injury mechanisms will result in novel and more effective therapeutic and rehabilitative strategies designed to reduce injury and facilitate recovery, thereby improving long-term outcomes in patients suffering from the devastating and often lasting effects of BINT. The following is a summary of the 2010 Galveston Brain Injury Conference, that included presentations related to the diagnosis and treatment of acute BINT, the evaluation of the long-term neuropsychological effects of BINT, summaries of current experimental models of BINT, and a debate about the relative importance of primary blast effects on the acute and long-term consequences of blast exposure.