John Breeze

Combat-related craniofacial and cervical injuries: a 5-year review from the British military.

BACKGROUND Recent international publications have noted a sustained increase in the incidence of head, face, and neck (HFN) wounds in comparison with total battle injuries from the 20th to the 21st century. The aim of this review was therefore to perform an analysis of the epidemiology of all HFN injuries sustained by British forces in Iraq and Afghanistan from March 1, 2003, to December 31, 2008. METHODS Descriptive injury data for this research were obtained from the Joint Theater Trauma Registry and overall battle injury and evacuation figures from the Defense Analytical and Statistical Agency. RESULTS During this period, 448 servicemen sustained injuries to their HFN. A total of 71% of HFN injuries were sustained in battle. Of all service personnel sustaining HFN injuries, 32% died before the field hospital and a further 6% died subsequently. A total of 73% of injuries required evacuation back to the United Kingdom, whereas 27% of injuries were managed definitively in the theater of operations. HFN injuries altogether were found in 29% of battle injuries between 2006 and 2008. CONCLUSIONS The individual incidences of head (15%) and face (19%) injuries in relation to total battle injuries, although greater than seen in previous United Kingdom conflicts, were only slightly higher than that seen by US forces. The incidence of neck injury alone in relation to total battle injuries of 11% in United Kingdom forces in comparison with 3% to 5% found in US forces warrants further investigation. This article also provides further evidence to support the existing published opinion of multiple international authors in the requirement to develop innovative methods of protecting the vulnerable HFN regions.

Mortality and morbidity from combat neck injury

BACKGROUND: Neck injury represents 11% of battle injuries in UK forces in comparison with 2% to 5% in US forces. The aim of this study was to determine the causes of death and long-term morbidity from combat neck injury in an attempt to recommend new methods of protecting the neck. METHOD: Hospital and postmortem records for all UK servicemen sustaining battle injuries to the neck between January 1, 2006 and December 31, 2010 were analyzed. RESULTS: Neck wounds were found in 152 of 1,528 (10%) of battle injured service personnel. Seventy-nine percent of neck wounds were caused by explosions and were associated with a mortality rate of 41% compared with 78% from gunshot wounds (GSWs). Although current UK OSPREY neck collars can potentially protect zone I from explosive fragments, in the 58% in which the wearing of a neck collar was known, all service personnel chose not to wear the collar. The most common cause of death from explosive fragments was vascular injury (85%). Zone II was the most commonly affected area overall by explosive fragments and had the highest mortality but zone I was associated with the highest morbidity in survivors. CONCLUSIONS: Nape protectors, that cover zone III of the neck posteriorly, would only have potentially prevented 3% of injuries and therefore this study does not support their use. Current UK OSPREY neck collars potentially protect against the majority of explosive fragments to zones I and II and had these collars been worn potentially 16 deaths may have been prevented. Reasons for their lack of uptake by UK servicemen is therefore being evaluated. Surface wound mapping of penetrating explosive fragments in our series has been used to validate the area of coverage required for future designs of neck protection. LEVEL OF EVIDENCE: II.

Surface wound mapping of battlefield occulo-facial injury

INTRODUCTION Accurately determining the entry location of penetrating eye and face wounds and relating that to mortality and long-term morbidity is of vital importance in the design of future personal protective equipment. METHOD Hospital and post mortem records for all UK servicemen sustaining penetrating battle injuries to the face or eye during the period 01 January 2005 to 31 December 2009 were analysed. RESULTS Face and eye injuries were found in 391/1187 (33%) and 113/1187 (10%) of all battle-injured servicemen respectively. 27% of eye wounds from explosions resulted in blindness and a further 17% in significant permanently reduced visual acuity (<6/12). Those servicemen that chose not to wear Combat Eye Protection (CEP) were 36 times more likely to sustain an eye injury from explosive fragmentation than those that did. However only 36% of servicemen chose to wear CEP. 7 deaths could potentially have been prevented had the serviceman chosen to wear their CEP. The lower third of the face was most commonly injured (60%) followed by the upper third (24%). CEP reduced facial injuries as a whole (bone and soft tissue) by 15% (p<0.01). Potentially changing the existing material used for chinstrap and helmet covers to that with ballistic protection would further reduce this incidence by up to 9%. CONCLUSIONS Although the lower third of the face remains poorly protected, the incidence of lower facial wounds could be further reduced by the use of ballistic visors by servicemen in exposed positions in vehicles (which represented 16% of facial injuries). Such a visor could potentially have prevented 17 deaths. A rigid attachment to the front of a ballistic helmet would allow either a visor, a high visibility LED lamp or a night vision goggle to clip in and we believe this capability should be investigated through future human factor trials.

Current Concepts in the Epidemiology and Management of Battlefield Head, Face and Neck trauma

There has been a significant increase in the incidence of head, face and neck (HFN) injuries in the 21st century in comparison to that experienced in the previous century. In the majority of HFN injuries the primary cause of death is secondary to airway compromise and with the exception of severe neck wounds haemorrhage is an unusual cause of death. Emergency cricothyroidotomy and semi- elective tracheostomy are skills that should be taught to deploying surgeons. There are now significantly increased numbers of potentially salvageable HFN injuries resulting from new and effective armour that protects the torso and abdomen. Equivalent armour to protect the neck and face is not yet effective and requires development. We describe the current epidemiology and management of battlefield head, face and neck trauma.

Determining the wounding effects of ballistic projectiles to inform future injury models: a systematic review.

Introduction Penetrating wounds from explosively propelled fragments and bullets are the most common causes of combat injury experienced by UK service personnel on current operations. There is a requirement for injury models capable of simulating such a threat in order to optimise body armour design. Method A systematic review of the open literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Original papers describing the injurious effects of projectiles on skin, bone, muscle, large vessels and nerves were identified. Results Projectiles injure these tissues by producing a permanent wound tract (PWT), comprised of a central permanent wound cavity, in conjunction with a zone of irreversible macroscopic tissue damage laterally. The primary mechanism of injury was the crushing and cutting effect of the presented surface of the projectile, with an additional smaller component due to macroscopic damage produced by the radial tissue displacement from the temporary tissue cavity (TTC). No conclusive evidence could be found for permanent pathological effects produced by the pressure wave or that any microscopic tissue changes due to the TTC (in the absence of visible macroscopic damage) led to permanent injury. Discussion Injury models should use the PWT to delineate the area of damage to tissues from penetrating ballistic projectiles. The PWT, or its individual components, will require quantification in terms of the amount of damage produced by different projectiles penetrating these tissues. There is a lack of information qualifying the injurious effect of the temporary cavity, particularly in relation to that caused by explosive fragments, and future models should introduce modularity to potentially enable incorporation of these mechanisms at a later date were they found to be significant.

Defining combat helmet coverage for protection against explosively propelled fragments

Introduction Prevention against head wounds from explosively propelled fragments is currently the Mark 7 general service combat helmet, although only limited evidence exists to define the coverage required for the helmet to adequately protect against such a threat. The Royal Centre for Defence Medicine was tasked by Defence Equipment and Support to provide a framework for determining the optimum coverage of future combat helmets in order to inform the VIRTUS procurement programme. Method A systematic review of the literature was undertaken to identify potential solutions to three components felt necessary to define the ideal helmet coverage required for protection against explosively propelled fragments. Results The brain and brainstem were identified as the structures requiring coverage by a helmet. No papers were identified that directly defined the margins of these structures to anatomical landmarks, nor how these could be related to helmet coverage. Conclusions We recommend relating the margins of the brain to three identifiable anatomical landmarks (nasion, external auditory meatus and superior nuchal line), which can in turn be related to the coverage provided by the helmet. Early assessments using an anatomical mannequin indicate that the current helmet covers the majority of the brain and brainstem from projectiles with a horizontal trajectory but not from ones that originate from the ground. Protection from projectiles with ground-originating trajectories is reduced by helmets with increased stand-off from the skin. Future helmet coverage assessments should use a finite element numerical modelling approach with representative material properties assigned to intracranial anatomical structures to enable differences in projectile trajectory and helmet coverage to be objectively compared.

The Problems of Protecting the Neck from Combat Wounds

Email: johnobreeze@doctors.org.uk Introduction Combat neck injury continues to cause significant morbidity and mortality in the current operational environment due to its inherent anatomical vullnerability. The severity of these injuries have been reflected in changes made to the recently introduced military version of the Abbreviated Injury Score system (AIS 2005Military) [1]. Of all of the areas of the body, neck wounds were ascribed the second highest increase in severity when compared to their civilian equivalent. However with little written in the literature about either the morbidity or mortality associated with combat neck injury it is unclear as to how these increases in severity were determined.

Defining the essential anatomical coverage provided by military body armour against high energy projectiles

Introduction Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles. Methods A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy. Results and conclusions Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage.

Damage control surgery and combat-related maxillofacial and cervical injuries: a systematic review

Damage control surgery involves rapid assessment, life-saving resuscitation, and abbreviated surgery for a patient with severe injuries. Traditionally the concept of damage control surgery has been restricted to penetrating abdominal injuries, but more recently it has been expanded to areas outside of the abdomen including the maxillofacial and neck regions. However, we know of little evidence that, when applied to injuries to the face and neck, it changes outcomes. We systematically reviewed published papers to identify those that discussed damage control in the context of combat-related trauma of the face and neck. We identified three papers that discussed the principles of managing combat-related maxillofacial injuries, all three of which were review articles that advocated the use of damage control principles in facial injuries either in isolation or as part of a multisystem approach. Anecdotal experience and opinion indicates that the concept of damage control is applicable when managing combat-related injuries of the face and neck, but no outcomes were confirmed. Further studies are required to validate the concept.

Using computerised surface wound mapping to compare the potential medical effectiveness of Enhanced Protection Under Body Armour Combat Shirt collar designs

Introduction Protecting the neck from explosively propelled fragments has traditionally been achieved through a collar attached to the ballistic vest. An Enhanced Protection Under Body Armour Combat Shirt (EP-UBACS) collar has been identified as an additional method of providing neck protection but limited evidence as to its potential medical effectiveness exists to justify its procurement. Method Entry wound locations and resultant medical outcomes were determined using Abbreviated Injury Scale (AIS) for all fragmentation neck wounds sustained by UK soldiers between 01 January 2010 and 31 December 2011. Data were prospectively entered into a novel computerised tool base and comparisons made between three EP-UBACS neck collar designs in terms of predicted reduction in AIS scores. Results All collars reduced AIS scores, with the greatest reduction provided by designs incorporating increased standoff from the neck and an additional semi-circle of ballistic material underneath the collar at the front and back. Discussion This technique confirms that reinforcing the neck collar of an EP-UBACS would be expected to reduce injury severity from neck wounds. However, without knowledge of entry wound locations for injuries to other body areas as well as the use of AIS scores without clinical or pathological verification its further use in the future may be limited. The ability to overlay any armour design onto a standardised human was potentially the most useful part of this tool and we would recommend developing this technique using underlying anatomical structures and not just the skin surface.