Michael R. Galarneau

Injuries from combat explosions in Iraq: Injury type, location, and severity

INTRODUCTIONnExplosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This studys objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel.nnnMATERIALS AND METHODSnA descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion.nnnRESULTSnA total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%).nnnCONCLUSIONnThe results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries.

Prevalence and Psychological Correlates of Traumatic Brain Injury in Operation Iraqi Freedom

ObjectiveTo describe the prevalence and psychological correlates of traumatic brain injury (TBI) among injured male combatants in the Iraq conflict. ParticipantsA total of 781 men injured during military combat between September 2004 and February 2005. Main Outcome MeasuresMental health diagnosis (ICD-9 290–319), particularly posttraumatic stress disorder and mood/anxiety disorders, assigned through November 2006. Results15.8% met criteria for TBI (13.4% mild, 2.4% moderate-severe TBI), 35.0% other head injury, and 49.2% non-head injury. Multivariate logistic regression suggested lower rates of posttraumatic stress disorder and mood/anxiety disorders among those with mild and moderate-severe TBI. ConclusionsThese findings could reflect a problem with differential diagnosis or, conversely, a low rate of self-presentation for symptoms. Further research is needed to elucidate the psychological consequences, clinical implications, and overall impact of TBI among military combat veterans.

Psychological Correlates of Battle and Nonbattle Injury Among Operation Iraqi Freedom Veterans

Limited research exists on the relationship between physical injury and PTSD within military populations. The present study assessed postinjury rates of PTSD and other psychological correlates among battle and non-battle injuries. A total of 1,968 men (831 battle injuries and 1,137 nonbattle injuries) injured between September 2004 and February 2005 during Operation Iraqi Freedom (OIF) composed the study sample. Patients were followed through November 2006 for mental health diagnosis (ICD-9 290-319). Compared with nonbattle injuries, those with battle injuries had a greater risk of PTSD and other mental health diagnosis, and there was a positive association with injury severity. Self-reported mental health symptoms were significantly higher for both minor and moderate-severe battle injury in comparison to nonbattle injury and previous population estimates from an earlier OIF period. More research is needed to further define this relationship by examining potential mechanisms and addressing the possible contributing effect of combat exposure.

Injury-specific predictors of posttraumatic stress disorder

OBJECTIVEnPosttraumatic stress disorder (PTSD) is an important source of morbidity in military personnel, but its relationship with characteristics of battle injury has not been well defined. The aim of this study was to characterise the relationship between injury-related factors and PTSD among a population of battle injuries.nnnPATIENTS AND METHODSnA total of 831 American military personnel injured during combat between September 2004 and February 2005 composed the study population. Patients were followed through November 2006 for diagnosis of PTSD (ICD-9 309.81) or any mental health outcome (ICD-9 290-319).nnnRESULTSnDuring the follow-up period, 31.3% of patients received any type of mental health diagnosis and 17.0% received a PTSD diagnosis. Compared with minor injuries those with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.61-3.48), serious (OR, 4.07; 95% CI, 2.55-6.50), and severe (OR, 5.22; 95% CI, 2.74-9.96) injuries were at greater risk of being diagnosed with any mental health outcome. Similar results were found for serious (OR, 3.03; 95% CI, 1.81-5.08) and severe (OR, 3.21; 95% CI, 1.62-6.33) injuries with PTSD diagnosis. Those with gunshot wounds were at greater risk of any mental health diagnosis, but not PTSD, in comparison with other mechanisms of injury (OR 2.07; 95% CI, 1.35, 3.19). Diastolic blood pressure measured postinjury was associated with any mental health outcome, and the effect was modified by injury severity.nnnCONCLUSIONSnInjury severity was a significant predictor of any mental health diagnosis and PTSD diagnosis. Gunshot wounds and diastolic blood pressure were significant predictors of any mental health diagnosis, but not PTSD. Further studies are needed to replicate these results and elucidate potential mechanisms for these associations.

Cigarette Smoking, Body Mass Index, and Physical Fitness Changes Among Male Navy Personnel

INTRODUCTIONnCigarette smoking has been reported to be higher among deployed military men than among similarly aged civilian or nondeployed men, but the short-term effect of smoking on physical fitness among these young healthy men is unclear. This study examined self-reported smoking status and change in objectively measured fitness over 1-4 years while controlling for body mass index (BMI).nnnMETHODSnThis study included a large sample of male U.S. navy personnel who deployed to Iraq or Kuwait between 2005 and 2008. A mixed modeling procedure was used to determine factors contributing to longitudinal changes in both BMI and fitness (measured by run/walk times, curl-ups, and push-ups).nnnRESULTSnOf the total sample (n = 18,537), the 20% current smokers were more likely than nonsmokers to be enlisted, younger, and have lower BMI measurements at baseline. In addition, smokers had slower 1.5-mile run/walk times and could do fewer curl-ups and push-ups compared with nonsmokers. The run/walk time model indicated that over 4 years, smokers (compared with nonsmokers) experienced a significantly greater rate of decrease in cardiorespiratory fitness, even after controlling for changes in BMI.nnnCONCLUSIONSnThese results call for continued attention to the problem of nicotine use among young healthy men.

Postdeployment symptom changes and traumatic brain injury and/or posttraumatic stress disorder in men

In Operation Iraqi Freedom and Operation Enduring Freedom, blast-related injuries associated with combat are frequent and can result in traumatic brain injury (TBI) symptoms that may be difficult to distinguish from psychological problems. Using data from the Post-Deployment Health Assessment and Reassessment, we identified 12,046 male U.S. Navy sailors and Marines with reported combat exposure from 2008 to 2009. Symptoms potentially associated with blast-related TBI and posttraumatic stress disorder (PTSD) that were reported immediately after deployment were compared with symptoms present several months later. Our study supports others that have found that subjects with blast-related injuries may experience the development or worsening of symptoms during the months following deployment. Additionally, our study found that those who screened positive for PTSD and TBI formed a unique group, with the presence of TBI exacerbating development of PTSD symptoms at reassessment. Providers should recognize the late development of symptoms, consider the possibility of comorbidity, and be prepared to treat multiple symptoms rather than a specific diagnostic category.

Co-occurring mental health and alcohol misuse: Dual disorder symptoms in combat injured veterans

OBJECTIVEnService members face difficulties during military deployment potentially resulting in morbidities such as posttraumatic stress disorder (PTSD), depression, and alcohol misuse. The co-occurrence of alcohol misuse and mental health disorders is termed dual disorder and has been associated with adverse outcomes.nnnMETHODSnThe study included 812 high-risk (i.e., endorsing combat exposure with documented combat injury) male U.S. veterans of Operation Iraqi Freedom, injured between October 2004 and November 2007, identified from the Expeditionary Medical Encounter Database.nnnRESULTSnPTSD and depression symptoms were significant correlates of alcohol misuse. Veterans with dual disorder symptoms reported a significantly higher mean number of health complaints on the Post-Deployment Health Reassessment compared with those endorsing only mental health symptoms.nnnCONCLUSIONSnThese results highlight how mental health disorders among injured service members increases the odds of problem drinking and those with dual disorder have elevated health complaints.

Airway Management in Severe Combat Maxillofacial Trauma

Objectives Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma. Study Design Retrospective database analysis. Setting Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers. Subjects In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Methods Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy. Results A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001). Conclusions There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Glasgow Coma Scale scores, early opioids, and 4-year psychological outcomes among combat amputees

Morphine and fentanyl are frequently used for analgesia after trauma, but there is debate over the advantages and disadvantages of these opioids. Among combat amputees, intravenous (IV) morphine (vs IV fentanyl) after injury was associated with reduced likelihood of posttraumatic stress disorder (PTSD). The previous results were based on military health diagnoses over 2 yr postinjury. The present study followed psychological diagnoses of patients with amputation for 4 yr using military and Department of Veterans Affairs health data. In-theater combat casualty records (n = 145) documented Glasgow Coma Scale (GCS) scores and/or morphine, fentanyl, or no opioid treatment within hours of injury. We found that (1) GCS scores were not significantly associated with PTSD; (2) longitudinal modeling using four (yearly) time points showed significantly reduced odds of PTSD for patients treated with morphine (vs fentanyl) across years (adjusted odds ratio = 0.40; 95% confidence interval = 0.17–0.94); (3) reduced PTSD prevalence for morphine (vs IV fentanyl; morphine = 25%, fentanyl = 59%, p < 0.05) was significant, specifically among patients with traumatic brain injury during the first 2 yr postinjury; and (4) PTSD prevalence, but not other disorders (e.g., mood), increased between year 1 (PTSD = 18%) and years 2 through 4 postinjury (PTSD range = 30%–32%).

A Comparison of Four Year Health Outcomes following Combat Amputation and Limb Salvage

Little research has described the long-term health outcomes of patients who had combat-related amputations or leg-threatening injuries. We conducted retrospective analysis of Department of Defense and Department of Veterans Affairs health data for lower extremity combat-injured patients with (1) unilateral amputation within 90 days postinjury (early amputation, n = 440), (2) unilateral amputation more than 90 days postinjury (late amputation, n = 78), or (3) leg-threatening injuries without amputation (limb salvage, n = 107). Patient medical records were analyzed for four years postinjury. After adjusting for group differences, early amputation was generally associated with a lower or similar prevalence for adverse physical and psychological diagnoses (e.g., pain, osteoarthritis, posttraumatic stress disorder) versus late amputation and/or limb salvage. By contrast, early amputation was associated with an increased likelihood of osteoporosis during the first year postinjury. The prevalence of posttraumatic stress disorder increased for all patient groups over four years postinjury, particularly in the second year. The different clinical outcomes among combat extremity injured patients treated with early amputation, late amputation, or limb salvage highlight their different healthcare requirements. These findings can inform and optimize the specific treatment pathways that address the physical and psychological healthcare needs of such patients over time.