Features of medical care in patientswith elbow joint gunshot wounds

Gunshot wounds of the elbow joint are the third most common after knee and shoulder injuries. Features of the anatomical and functional structure of the elbow joint, the close location of the vascular and nervous formations, favorable conditions for the development of infection determine the severity of gunshot wounds and cause the complexity of its treatment. Objective. To evaluate the frequency and nature of the elbow joint gunshot wounds in the structure of the general combat injuries, as well as to determine the volume of medical care and direction of treatment of such injuries in the conditions of the regional hospital as a stage of care. Methods. A retrospective study included 1 809 patients (96.0 % of men, mean age (33.7 ± 0.2) years). Firearms limb injuries were detected in 1 013 (56.0 %) of all victims, of which the elbow joint — 25 (2.47 %). Mines and explosives injuries were in 22 (88 %) of the patients, bullet — in 3 (12 %). Results. Tactics of treatment of elbow joint gunshot wounds depended on the severity of the condition of the victims and the nature of concomitant traumatic injuries. In the structure of combat injury of the elbow joint the majority was combined (52 %) and multiple (40 %) injuries and was accompanied by gunshot fractures in 60 %. In patients who were in severe state, applied the tactics of Damage control in two stages. At the first stage the fractures were fixed with plaster splints or external fixation devices (EF), the wounds were not subjected to full surgical debridment (SD), but only washed with antiseptics and the visible foreign bodies were removed. In patients with soft tissue injuries wounds the primary SD was performed according to general principles, injured nerves were not restored. In the second stage, after patient is stabilized, the repeated SD of the wound was performed. After their uncomplicated healing the EF was removed and the method of fixation was changed to internal osteosyntesis. Conclusions. It is recommended to perform stabilization of intra-articular gunshot fractures of the elbow joint with EF and after uncomplicated wound healing go to the internal osteosynthesis. Key words. Elbow joint, gunshot wounds, treatment.

EXPERIENCE OF USING NPWT-THERAPY IN THE TREATMENT OF COMBAT INJURIES OF SOFT TISSUES OF THE LIMBS AND BODY

Summary. Aim. NPWT-therapy (Negative-pressure wound therapy) or VAC-therapy (Vacuum Assisted Clousur) - a modern method of wound healing, which significantly improves the course of all stages of the wound process and is relevant today due to the large number of wounded during hostilities in eastern Ukraine. Often these injuries are combined and lead to the formation of large soft tissue defects. The aim of the study. Improving the results of treatment of the wounded with extensive defects of the soft tissues of the torso and extremities through the use of NPWT therapy. Materials and methods. Under our supervision in the period from 2017 to 2020 there were 60 wounded who were hospitalized in the surgical departments of the Military Medical Clinical Center of the Southern Region, who received vacuum therapy in the treatment of wounds. 38 (63.3%) had gunshot wounds to the extremities, and 22 (36.7%) had soft tissue injuries to the torso. The age of the wounded ranged from 19 to 58 years, among them young people under 30 years of age. Before installing the device, it was necessary to perform surgical treatment with excision of necrotic tissue and removal of fibrin layers. Negative pressure was set at -125 mm Hg. Art. in the non-stop mode for soft tissue defects of the extremities and variable pressure in the -40 mm Hg mode. Art. -70 mm Hg Art. for wounds of the anterior abdominal wall. The duration of treatment with NPWT therapy was from 5 to 25 days. The systems were replaced at least once every 3-5 days. Criteria for discontinuation of NPWT therapy were: cleansing the wound of necrotized tissues and fibrin, improving clinical performance, filling the wound defect with granulation tissue. Results and discussion. The use of this method of treatment allowed to close wound defects by autodermoplasty in 21 patients (35%), primary-delayed sutures in 11 (18%), secondary sutures in 15 (25%) and local tissue plastics in 13 (22%). Complications after NPWT therapy in the form of re-suppuration of the wound, bleeding or perforation of hollow organs and large vessels were not observed. Conclusions. The use of NPWT therapy can significantly increase the effectiveness of comprehensive treatment of the wounded with damage to the soft tissues of the torso and extremities. It allows you to quickly clean the wound surface, fill the wound defect with granulation tissue and prepare the wound for plastic closure.

The Impact of Health Threats on the Security of Peacekeeping and Stabilization Missions

Soldiers are currently one of the largest professional groups treated as long-term travelers. They are stationed in difficult environmental conditions for many months. The purpose of this article is to present the scale of health threats faced by participants in peacekeeping and stabilization missions / operations. Today's security challenges encompass a huge mass of complexes and evolving threats such as pandemics, international terrorism, organized crime, cyber threats, environmental degradation and natural disasters. The thesis of the article is that in the era of modern threats, health problems of soldiers include transmission diseases, zoonoses, combat and non-combat injuries. The Central and South Asian region has the highest rate of infectious and invasive diseases in the world. Afghanistan and Pakistan are the reporting countries for poliomyelitis. Taking into account the following issues, it is extremely important to monitor the scale of health threats to participants in military operations, to conduct appropriate risk assessments so that control measures reflect the latest scientific knowledge in the field of protection against the risk of infection, disease or injury management. A comprehensive emergency preparedness plan enables military operations to be better prepared for a swift, coordinated and effective response, while tailoring resources to the specific situation.

FAST-PROTOCOL AND INTERVENTIONAL SONOGRAPHY IN THE DIAGNOSTIC AND TREATMENT OF COMBAT INJURIES OF THE ABDOMEN

Summary. The aim — improvement of diagnostic and surgical treatment of wounded abdominal injuries by introducing emergency ultrasound techniques and mini-invasive surgery under the control of ultrasound imaging. Materials and methods. A clinical and statistical analysis of the results of surgical treatment of 293 wounded with combat injuries of the abdomen who underwent treatment in military mobile hospitals was carried out. In the comparison of the wounded with combat injuries of the abdomen, additional diagnostic tests were carried out in the comparison groups — FAST protocol, puncture sanitation and draining surgical interventions under ultrasound navigation. Results and discussion. In the main group, unlike the control group, all wounded were followed by the FAST protocol. Widespread introduction into the diagnostic program of FAST-protocol and diagnostic punctures under ultrasound navigation allows to reduce the level of more traumatic diagnostic laparocentheses from 24.7 to 2.2 % and unreasonable surgical interventions from 3.2 to 0.7 %. Based on the results of the study, we have developed an algorithm for diagnostic and therapeutic actions for the wounded with combat trauma to the abdomen according to the results of the FAST-protocol. Conclusions. The data obtained indicate that the widespread adoption of the FAST protocol, transcutaneous puncture sanitation interventions under ultrasound guidance in the diagnosis and treatment of combat abdominal trauma and its complications contribute to a decrease in the number of invasive and more traumatic (often unreasonable) diagnostic and treatment methods, which leads to faster recovery and shortened treatment time.

Patriarch of military neurosurgery

January 19, 2021 marks the 75th anniversary of the birth of one of the leading Russian neurosurgeons, Academician of the Russian Academy of Sciences Boris Vsevolodovich Gaidar. Eight years at the head of the Department and Clinic of Neurosurgery at the Military Medical Academy and 7 years at the head of Military Medical Academy, when his talent as a teacher and leader was most clearly revealed. Academician B.V. Gaidar is one of the countrys leading scientists in the field of treatment of combat injuries of the central nervous system (craniocerebral trauma and mine-explosive wounds of the central nervous system), vascular neurosurgery, and neurooncology. He made a major contribution to solving the issues of organizing specialized neurosurgical care in the Armed Forces in peacetime and in wartime. He personally took part in providing medical assistance to the wounded during the armed conflict in the North Caucasus. B.V. Gaidar represented Russian science at international forums in Austria, Germany and the United States of America, in 2005 he led the organization of the World Congress on Military Medicine for the only time in our country. During the years of leadership of the S.M. Kirov Military Medical Academy B.V. Gaidar carried out a large-scale reconstruction and re-equipment of a number of leading surgical clinics, which contributed to the progressive development of the academys scientific schools. B.V. Gaidar created a scientific school of neurosurgeons, prepared a rich legacy of articles, textbooks and monographs, his merits were recognized by the scientific community and the state. Celebrating the anniversary, Boris Vsevolodovich continues to actively engage in scientific work, training, counseling critical patients, passionately defending the interests of the Military Medical Academy.

Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003–2017

IntroductionLaryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq and Afghanistan describes initial treatment outcomes.MethodsUS service members who sustained ‘laryngotracheal’ and ‘pharyngoesophageal’ injuries while deployed in military operations from 2003 to 2017 were identified from the Expeditionary Medical Encounter Database. Those with inhalation or ingestion injuries and an Injury Severity Score (ISS) <16 were excluded. Data on demographics, survival, mechanism and type of injury and diagnostic and therapeutic intervention were recorded.ResultsA total of 111 service members met inclusion criteria. Nearly one-third (32.4%) were killed in action (KIA) or died of wounds (DoW). Fatality was not significantly associated with age, theatre of operation, type of injury or mechanism of injury, but was associated with a higher ISS and those in the Marines. Although survival rates were not significantly different, the frequency of these injuries decreased after the introduction of cervical collar protection in 2007. Of those who DoW or survived, 41.1% required a surgical airway. Tracheobronchoscopy was performed in 25.6%, oesophagoscopy in 20.0% and oesophagram in 6.7%. Of the 85 with penetrating neck injuries, 43 (50.6%) underwent neck exploration, in which 31 (72.1%) required intervention.ConclusionsSevere laryngotracheal and pharyngo-oesophageal injuries have a high fatality rate and demand prompt treatment from skilled providers. Further work will elucidate preventive measures and clear management algorithms to optimise outcomes.

Ketamine Use in Operation Enduring Freedom

ABSTRACT Introduction Ketamine is a dissociative anesthetic increasingly used in the prehospital and battlefield environment. As an analgesic, it has been shown to have comparable effects to opioids. In 2012, the Defense Health Board advised the Joint Trauma System to update the Tactical Combat Casualty Care Guidelines to include ketamine as an acceptable first line agent for pain control on the battlefield. The goal of this study was to investigate trends in the use of ketamine during Operation Enduring Freedom (OEF) and Operation Freedom’s Sentinel (OFS) during the years 2011-2016. Materials and Methods A retrospective review of Department of Defense Trauma Registry (DoDTR) data was performed for all patients receiving ketamine during OEF/OFS in 2011-2016. Prevalence of ketamine use, absolute use, mechanism of injury, demographics, injury severity score, provider type, and co-administration rates of various medications and blood products were evaluated. Results Total number of administrations during the study period was 866. Ketamine administration during OEF/OFS increased during the years 2011-2013 (28 patient administrations in 2011, 264 administrations in 2012, and 389 administrations in 2013). A decline in absolute use was noted from 2014 to 2016 (98 administrations in 2014, 41 administrations in 2015, and 46 administrations in 2016). The frequency of battlefield ketamine use increased from 0.4% to 11.3% for combat injuries sustained in OEF/OFS from 2011 to 2016. Explosives (51%) and penetrating trauma (39%) were the most common pattern of injury in which ketamine was administered. Ketamine was co-administered with fentanyl (34.4%), morphine (26.2%), midazolam (23.1%), tranexamic acid (12.3%), plasma (10.3%), and packed red blood cells (18.5%). Conclusions This study demonstrates increasing use of ketamine by the U.S. Military on the battlefield and effectiveness of clinical practice guidelines in influencing practice patterns.