Elsevier

Injury

Volume 43, Issue 10, October 2012, Pages 1678-1682
Injury

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

https://doi.org/10.1016/j.injury.2012.05.027Get rights and content

Abstract

Introduction

Explosions 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 study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel.

Materials and methods

A 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.

Results

A 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%).

Conclusion

The 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.

Introduction

The effects of explosions have caused a greater percentage of injuries in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) than in any other large-scale conflict.1 As of 28 May 2010, over 37,000 US service members have been wounded in action and over 4000 have been killed in action as a part of OIF and OEF.2 The majority of these combat injuries and deaths are due to explosions,3, 4 which can cause a wide spectrum of injuries.5 While there have been reports of specific injuries such as tympanic membrane injuries,6 eye injuries,7 burns,8 and traumatic brain injuries,9 as well as the constellation of injuries described as primary blast injuries,10 there has been no comprehensive investigation into the type, location, and severity of injuries due to combat explosions.

Five different explosion injury mechanisms have been described.5, 11, 12, 13 These injury mechanisms do not occur in isolation and have the potential to impact multiple body systems.5 Primary blast injuries are caused by an overpressurization shock wave followed by an underpressurization wave that travels through the body. Traumatic brain injury (TBI), lung injury, and tympanic membrane ruptures are caused by these shock waves.5 Secondary injuries are created by bomb fragments and other fragments from the environment that are propelled by the explosion and are considered the most common cause of explosion-related injury.11 The severity of these injuries can range from lacerations to traumatic amputations. Tertiary injuries are caused by a blast wind that can throw a victim to the ground as well as cause the collapse of buildings and other structures. Blunt and crushing injuries are common tertiary injuries. Quaternary blast injuries are all other injuries including burns and the inhalation of toxic substances released from the explosion. Quinary injuries are specific to additional elements found in a bomb, such as metals, fuels, radiation, and bacteria.

Champion et al. described the need for research in the epidemiology of wounds from explosions as well as the consequences of these injuries.5 Advances in body armour have reduced the frequency of penetrating injuries, and improvements in field medical care have increased the survival rate in those experiencing explosions in combat. These advancements create a different combination of injuries in service personnel injured in explosions than seen in past conflicts,13, 14 thus, a comprehensive investigation of all explosion injuries is warranted to inform providers involved in trauma care and rehabilitation. The primary objective of this study is to describe the nature, body region, and severity of injuries caused by an explosion during combat in surviving male service personnel participating in OIF between March 2004 and December 2007. Individual demographics, injury circumstances (type of explosive device and use of personal protective equipment [PPE]), and the disposition of the service personnel after examination will also be explored.

Section snippets

Materials and methods

The Expeditionary Medical Encounter Database (EMED), formerly known as the Navy-Marine Corps Combat Trauma Registry, is a collection of data sets from multiple levels of care. The data for this study were primarily from frontline naval medical treatment facilities (MTFs) in Iraq as well as military hospitals outside of the continental United States and military hospitals within the continental United States.15 The EMED includes data from both casualty medical records and clinical information

Results

The study population was composed of 4623 episodes of explosions that resulted in a survivable injury. Demographics of the injured personnel and explosion episode characteristics for each combat explosion episode are documented in Table 1. The average age of the personnel injured was 24 years, with a range of 18.3–58.7 years. The pay grade category with the highest episode proportion was junior enlisted (E1–E3) (41.7%), closely followed by midlevel enlisted (E4–E6) (39.8%). Marines had the

Discussion

With the large proportion of injuries caused by explosions in the current military conflicts and the changing injury profiles from improved body armour and frontline medical care, understanding the scope of injuries due to explosions will improve the mitigation, treatment, and rehabilitation of combat explosion consequences in survivors. This comprehensive report of all injuries resulting from 4623 combat explosion episodes is unique because data are used from Level 1 and 2 MTFs in Iraq and all

Conclusion

The most common single injury in the cohort of 4632 injuries from combat explosions was a TBI Type 2 internal injury, which is consistent with a concussion. When the body region and nature of injury were collapsed into broader categories, surface wounds of the extremities were the most common injuries. Understanding the nature and body region of injuries due to combat explosions will assist in providing adequate PPE and inform clinicians who are providing care for wounded service personnel. In

Conflict of interest statement

Authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

Acknowledgments

This work was supported by the US Navy Bureau of Medicine and Surgery under the Wounded, Ill, and Injured/Psychological Health/Traumatic Brain Injury Programme, Work Unit No. 60808. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Approved for public release; distribution is unlimited. This research has been conducted in compliance with all

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