. A. Nechaev, A. I. Gritsanov, I. P. Minnullin, N. V. Ruhliada, N. F. Fomin, V. M.

Shapovalov

EXPLOSION INJURIES
Manual for physicians and students Under edition of the corresponding member of Russian Academy of Medical Sciences Professor E. A. Nechaev St.-Petersburg 2002

Nechaev E. A., Gritsanov A. I., Minnullin I. P., Ruhliada N. V., Fomin N. F., Shapovalov V. M. Explosion injuries.: A manual for the doctors and students / Under edition of the corresponding member RAMS prof. E. A. Nechaev. SPb., 2002. 656 p., pictures. The present edition represents a manual for the doctors and students, in which all aspects of a major modern problem the explosion injuries of people are displayed and considered. Local wars and armed conflicts, terrorism, technogenic accidents and natural disasters the situations, when the person becomes an object of influence of the injury factors of explosion. In this manual the historical, legal, humanitarian aspects of a problem are covered, technical characteristics of modern engineering mines, means of preventive maintenance of explosion injuries are submitted, results of multiplane scientific experimental researches on pathogenesis of explosion injuries in air and water environments are stated, their clinical picture is described and recommendations for diagnostics and treatment with reference to stages of the medical care are given. The individual sections of a manual are written by the experts of the appropriate field. All members of author's collective are the professors, teachers and employees of Russian medical-military academy; they have a rich personal experience on treatment of explosion injuries in warfare and extreme conditions. The manual is intended for the experts in the different fields, engaged in questions of liquidation of consequences of disasters, technogenic and natural accidents, terrorist acts, for the organizers of public health care service and practical doctors participating in this work, and also for learning purposes of medical schools.

Nechaev Edward Alexandrovich (born in 1934). The corresponding member of RAMS, MD, PhD, professor, general-colonel of medical service (ret.), Chief surgeon of Soviet Army (19871988), Chief of Medical Service of USSR and Russian Federation Armed Forces (1988-1994), Minister of Health and Medical Industry of Russian Federation (1992-1995). Gritsanov Alexander Ivanovich (born in 1936). MD, PhD, professor, colonel of medical service (ret.), Chair assistant of department of military traumatology and arthopaedics (1977-198. 19871988), Chair of department of operative surgery and topographical anatomy (1988-1993) medical-military academy (St.-Petersburg), main scientific employee of Russian Research Institute of Traumatology and Orthopaedics by R.R.Vredeb (1993-1996). Minnullin Ildar Pulatovich (born in 1950). MD, PhD, professor, Honoured doctor of Russian Federation, colonel of medical service, Chair assistant of the department of naval and general surgery of medical-military academy (St.-Petersburg). Ruhliada Nickolai Vasilievich (born in 1947). MD, PhD, professor, Honoured doctor of Russian Federation, colonel of medical service, Chair of department of naval and general surgery of medical-military academy (St.-Petersburg). Fomin Nickolai Fedorovich (born in 1949). MD, PhD, professor, colonel of medical service (ret.), Chair of department of operative surgery and topographical anatomy of medical-military academy (St.-Petersburg). Shapovalov Vladimir Mikhailovich (born in 1946). MD, PhD, professor, major-general of medical service, Chief traumatologist of Ministry of Defence of Russian Federation, Chair of department of military traumatology and orthopaedics of medical-military academy (St.Petersburg). Participating specialists: MD, PhD, prof. Bagnenko S. F.; MD, PhD Badikov V. D.; MD, PhD, prof. Balin V. N.; MD Besugluy A. V.; MD, PhD, prof. Vorobiev V. V.; MD, PhD, prof. Glasnikov L. A.; MD, PhD, prof. Gofman V. R.; MD, PhD, prof. Grechko . .; MD, PhD, prof. Gumanenko E. K.; MD, PhD, prof. Zuev V. K.; MD, PhD, prof. Kitchemasov S. H.; MD, PhD, prof. Komarov V. I.; MD Kusmin V. P.; MD Lashenov G. V.; MD Lipin A. N.; MD, PhD, prof. Litvintsev S. V.; MD, ass.prof. Minchenko A. N.; MD, ass. prof. Monahov B. V.; MD Naidenov A. A.; MD, PhD, prof. Petrov S. .; MD Pimenov P. V.; MD, PhD, prof. Polushin U. S.; MD, PhD, prof. Prohvatilov G. I.; MD, PhD, ass. prof. Rustanovich A. V.; MD Ruhliada N. N.; MD, PhD, prof. Skvortsov U. R.; MD, PhD, prof. Troyanovsky R. L.; MD, PhD, prof. Utichkin A. P.; MD Homchuk I. A.; MD Chernysh A. V.; MD, PhD, prof. Shamrei V. K.; MD, ass. prof. Sheluhin V. A.; MD, PhD, prof. Spilenya E. S.; MD, PhD, prof. Shulev U. A

CONTENTS PART I Chapter I. Historical essay ........................................................................................... 1 Chapter II. The characteristics of engineering mine weapon10 Chapter III. Explosion injuries in wars and armed conflicts of XX century24 3.1. Definition and classification of explosion injuries ...24 3.2. Statistics of the combat explosive trauma ..44 3.3. Explosive trauma a major problem of surgery .50 3.3.1. Injury factors of explosion and their action on a man at non-shielded mechanism ..50 3.3.2. Peculiarity of the underwater explosion effects on a submerged human.73 3.3.3. Peculiarity of injury action of the factors of explosion on the personnel inside vehicles (shielded explosion variety)..83 3.4. Mine pollution problem in the regions of armed conflicts and local wars. ..89 3.5. International humanirian law and mine problem.101 Chapter IV. The injuries of a man at technogenic accidents, caused by explosions115 4.1. Injury factors of explosions and mechanism of damages of the body and tissues.118 4.2. Distinction of technogenic explosions...121 4.3. Basic variants of explosion injuries and their clinical displays.126 Chapter V. Explosion injuries at terroristic acts..132 Chapter VI. Mechanism peculiarities and structural functional damage of the body and tissues at various kinds of explosion injuries .136 6.1. Morphofunctional peculiarities of mine explosion wounds ...136 6.2. Clinical and morphological peculiarities of mine explosion damages. .147 6.3. Morphofunctional and clinical peculiarities of injuries by mine weapon in NAVY and in explosions in water 152 6.4. Clinical and microbiological aspects of wound process at explosion injuries ...194 6.4.1. Microbiology of explosion injuries .194 6.4.2. Antibiotic prophylaxis and therapy of wound infection at explosion injuries .192 Chapter VII. Peculiarity of pathogenesis of traumatic disease at explosion injuries ...206 7.1. Microcirculation disturbances ..212 7.2. Arterial air embolism.216

7.3. Changes of the acid-alkaline balance and blood gases in blood .223 7.4. Metabolic disorders...227 7.5. Changes in central hemodynamics ..230 PART II Chapter VIII. Peculiarity of medical care organization for injured by explosions.233 8.1. Experience of medical care of armed forces being at war conflict in Afghanistan ..233 8.2. Peculiarity of organization of surgical care in Northern Caucases in 1994-1996 and 1999-2000 .244 8.3. Organization and management principles of light injured at explosions .246 Chapter IX. Diagnostics and treatment of explosion injuries ..256 9.1. Basic principles of prehospital care of explosion injuries....256 9.2. Peculiarities of intensive care and anaesthesia in injured with explosions ..261 9.3. General principles of diagnostics and treatment of skeleton damages in explosion injuries...281 9.3.1. External osteosynthesis at gunshot extremities injuries. 293 9.3.2. Transosseous osteosynthesis treatment of injuries in penetrating gunshot wounds of major joints of extremities ..303 9.3.3. Correction of neurotrophic disturbances at explosion injuries .. ..309 9.3.4. General principles of hyperbaric oxygenation application in m anagement of explosion injuries ..318 9.3.5. Morphofunctional and topographic anatomical rationale of saving methods of lower extremities amputations in mine-blast trauma .330 9.4. Damage of skull and spinal column at explosion injuries .338 9.4.1. Damaging mechanisms of explosion on a brain ..338 9.4.2. Clinical and morphological characteristics of brain disturbances at explosion injuries341 9.4.3. General principles of diagnostics and treatment of explosion injuries of brain345 9.4.4. Peculiarities of injuries of a vertebral column and spinal cord at explosions ..353 9.5. Explosion injuries of the sight organs..360 9.5.1 Medical care at different stages of medical evacuation..361

9.5.2. Specialized treatment of explosion injuries of an eye .365 9.6. Explosion injuries of the maxillofacial area 378 9.7. Explosion injuries of acoustical and vestibular system ....393 9.7.1. Basic mechanisms of pathogenesis of neurological, acoustical and vestibular disturbances at explosive trauma ..395 9.7.2. General principles of medical care at stages of evacuation.406 9.8. Peculiarities of surgical tactics and treatment of chest and abdomen explosion injuries..432 9.8.1. Explosion chest trauma433 9.8.2. Explosion abdomen trauma .440 9.9. Explosion injuries of genital tract450 9.10. Explosion injuries of female genitalia ..466 9.11. Thermal injuries at explosions ..471 9.11.1. Peculiarities of pathogenesis and clinical picture ..471 9.11.2. Principles of medical care and treatment476 Chapter X. Mental disturbances at explosion injuries .483 10.1. General thesis 483 10.2. Mental frustration at head trauma .483 10.3. Mental frustration at extracerebral explosion injuries..496 10.4. Mental frustration at accompanying burn trauma .500 10.5. Surdomutism .502 10.6. Psychogenic mental frustration ..507 Chapter XI Disorders of internal organs at explosion injuries .519 11.1. Primary damages of internal organs ...519 11.2. Secondary pathology of internal organs .564 11.3. Clinical precursors and mechanisms of development of secondary pneumonia at explosion injuries ...574 Chapter XII. Development of individual means of military men protection from injury action of land mines ..585 Conclusion ....594 We dedicate this book to 300th Anniversary of Sankt-Petersburg Cradle of a Military Surgery

Acronyms AAE arterial air embolism ABB acid-base balance ABW air blast wave AF - armed forces Afghanistan APC armored personnel carrier APM anti-personnel mines; ARF acute renal failure; ASD acute stress disorders; ATM anti-armor missiles AVM anti-vehicle mines; CBI closed brain injury CBV circulating blood volume; CDA compression distraction apparatus CT -craniocerebral trauma DMU detached medical unit; EA explosive ammunition ED explosive device EI explosion injury EIC explosion injury conditions; EMA engineer mine ammunition EW explosion wound FNSH field neurosurgical hospital GIT gastrointestinal tract GPWI gas-producing wound infection HE - high explosives HO hyperbaric oxygenation IFV infantry fighting vehicle IV intravenous IM intramuscular

ITR - integral tonicity rate MBV minute blood volume; MFA - maxillofacial aria; MI mine injury MO mine obstacle MT mine trauma MW mine wound NCC -North-Caucasus territorial command; PCS prolonged crushing syndrome; PSD posttraumatic stress disorders PSR psychological stress reaction; RC - reserve coefficient; RMLS remote mine laying system; SC subcutaneous SFA - Soviet Forces in Afghanistan; TSE top-secret equipment; VI viscosimetric index WWII World War II

PART I
Chapter I HISTORICAL ESSAY
From ancient times and till now the history of wars has many examples of using barrages, pursuing the objective to hold back advance of enemy troops. One can consider as a prototype of modern mines metal balls with long sharp thorns, scattered by the Roman commanders to hold back enemy cavalry. The data are available, that sharp metal thorns (so-called "garlic"), scattered on roads to stop cavalry, were applied by war parties during many centuries. Mines and other ammunition of explosive action (mine ammunition) can be mentioned with the advent of gunpowder and high-explosives. This invention has led to creation of special combat means first sea and anti-personnel mines, followed by the anti-vehicle antitank mines. Originally mines were designed as the demolition munitions controlled on through wires and intended to destroy group targets. Use of such mines and minefields demanded greater explosive charges and equipment for their installation. This initial stage of development of the mine weaponry took place approximately from second half XVII century through second half of XIX century. The second period of mine weaponry evolution (second half XIX century the beginning of XX century) is characterized by occurrence of automatic anti-personnel mines and demolition mines. They allowed seizing long-term control of a certain space, without spending additional forces and means, except for what have originally been spent at the equipment. The prototype for many domestic mines is a jumping anti-personnel mine, invented by the Russian Army captain Karasev (a shrapnel demolition mine). He invented this mine and has successfully applied in the Russian-Japanese war in 1904. Advantage of automatic anti-personnel mines have led them to be the cheapest defensive weapon and thereof led to their mass production. However, along with advantages, their large disadvantage became clear lack of selectivity. After arming, mines become equally dangerous for enemy, friendly forces and peaceful population. Simplicity and cheap price of anti-personnel mines do not for allow friend-foe devices application. For this reason in some cases losses of the armies from anti-personnel mines can appear commensurable

with losses of the enemy. The third period (the beginning of 20th XX century) was characterized by invention of the demolition anti-personnel mines, designed against the single targets, and the fragmentation mines intended for a destruction of group targets. For the first time, these mines began to be used widely during the Russian-Finnish war 1939-194. and in the subsequent WWII and in numerous post-war conflicts. HE charges in them had mass close to 200g. In the fourth period (from the end of 60th till now) it is noted the tendency to HE charge reduction. It is connected the fact that it is possible to use only a small quantity of modern HE to inflict a wound and or decommission a soldier. Use of such modern mines has allowed enlarging considerably quantity of mines loaded in remote mine-planting devices or aircraft pods. Mineplanting opportunities of the armies essentially increased. Modern designs of fragmentation and demolition anti-personnel mines provide for safety and self-destruction mechanisms. As experts believe, the adoption of such mines will allow guaranteeing with a high degree of reliability a self-destruction of the installed minefields after the certain time Of essential interest are the data, concerning uses of an engineering mine ammunition during the WWII, contained in the information-analytical report of the Russian committee Doctors for prevention of nuclear war , dedicated to a theme Mines: a view from Russia (Moscow, 1999). In itself, in particular, it is spoken, that in the first months after an attack of Germany on the USSR the Red Army has been compelled to apply widely minefields to hold back or slow down advance of the opponent, to constrain its maneuver, to inflict losses in personnel armor. In an initial stage of WWII, owing to the limited quantity of engineering units and mines in armies, barrages were developed by blasting bridges and other constructions, first on the largest rivers, and mining detours around them. E.g, on Lepel direction the operatively-engineering group during July, 1941 blasted 34 road bridges, and on Vitebsk direction they blasted 51 bridge on highways from July, 2 till July, 10th, 1941 bridges. In addition to destructions of roads in some cases the barrier zones were created (for example, midriver Berezina and Dnepr). Their depth was up to 5km. As the frontline in Kiev, Moscow and Leningrad directions stabilized, the mine barrages began to be applied all in more mass volumes. Before preparing defense boundaries the pre-defense line was created. The first line of defensive boundaries was covered with minefields and other engineering barrages. Anti-personnel and mixed minefields were used frequently. So, before the Lug defensive position on distant approaches to Leningrad, Soviet army installed 24 thousand
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anti-vehicle (AVM) and 6 thousand anti-personnel (APM) mines Defending Moscow outskirts, only on Rzhevsko-Viazemskiy line, Soviet army installed 81 thousand different mines. On approaches to Kiev all roads were all mined, and the forests were mined too. Close to 100000 AVM and APM mines were installed on Kiev direction. Since autumn 1941 minefields were installed at any direction of enemy troops movement. E.g., in Kharkov region. 35 road sections were mined along with installation of 20 units of barrages. Railway junctions, airports, major objects and constructions sites in cities have been mined. As the enemy advanced 106 trains were derailed, destroying essential amount of enemy armor and personnel.1 Experience, gained through mining, showed high efficiency of the remote-controlled mines. E.g. in October 1941 German army was forced to refuse operation of the mined highway Kharkov-Chuguev. They were forced into construction of a gravel road instead, spending more than twice time and fuel. Soviet army also employed radio-controlled munitions (termed at TSE(top secret equipment). For example, the German 56th Mechanized Corps Command was entirely wiped out in the city of Krasnie Strugi on July, 12th, 1941. The city was 150 km beyond the front line and three demolition munitions with charges 250 kg each were blown up. It was the first combat use of F-10 remote control devices (mass of the device about 16 kg). F-10 kept the working capacity from 40 to 600 days and could be installed to prevent unauthorized removal. On November, 13th, 1941 the mine, controlled by F-1. destroyed a building where the garrison commander of Kharkov major-general Von Brown with the army headquarters was located. The mine with a charge of 350 kg was installed in a cellar at depth of 5 m. The mine was disguised by installation of another 150 kg mine above with time fuse, which has been later discovered by the German engineers. The detonation command was broadcast by Voronezh radio station. The action was supervised by the legendary colonel I.Starinov who celebrated 100st anniversary on August, 2nd, 2000. RF-controlled mines with F-10 devices not only caused considerable losses to German army, but also resulted in nervousness, complicated restoration of bridges, railway junctions and the important industrial objects. Thus, in November, 1941 high-river bridge over the river Istra was mined. Mines with F-10 remote control were established in bridge supports. After withdrawal of Soviet army the support structures of the bridge were blown up. When German army forced the
1

Historical essay section is modified by the translator for the purpose of preserving original content and unbiased point of view on WWII. Original copy of historical essay section is also available. 3

river and have seized the city of Istra, they have restored the bridge necessary for decisive strike on Moscow, using the intact supports. These supports were blown up by a RF command, sent from Moscow. Experience of war in Afghanistan and operations on Northern Caucasus in 90th years have shown that tactics of mine application is substantially defined by the specific conditions developing in the region. Using features of the mountain terrain, underdeveloped infrastructure in Afghanistan the enemy paid a special attention to the destructions of roads, blockages and mine planting. The mines were installed in places where there were no detours and the road cover can be easily dismantled (crossing of roads with a dried riverbed, mudslides). The main roads, were, as a rule, mined 2-4 hours before a convoy approached. The convoy approach event was communicated to the groups of miners through the fire smoke or couriers, driving motorcycles or cars. To maximize the inflicted damage the mines were set off after the convoy vanguard passed the point of mining. Most frequently mujaheedens mined roads where the troops returned from the mission, which frequently led to much higher sanitary losses than during the mission. As a rule, mine explosion effects was reinforced by small-arms, mortar and RPG fire. During the Afghan mujaheedens used antitank and antipersonnel mines, made in USA, UK, Italy, Israel, China, Sweden and Czech republic, along with elaborate IEDs of outstandingly high explosive properties. The difficulty of mine detection and removal tasks was underscored by the high iron content in the afghan soil.

Fig. 1.1. Mine obstacle groups RF mine detectors were ineffective, due to giving too many false alarms, leading to the mine removal squads fatigue and attention distraction. Most frequently mines were found out using standard mine probe and normal environment disruption sights (road cover integrity), as well as using specially trained dogs and minesweepers. Blast of an antitank or anti-vehicle mine was accompanied, as a rule, by destructions of the treads, armored vehicle bottom, ignition of fuel and explosion of an ammunition load. It in turn led to additional destruction of armored vehicles and transport. Crewmembers and personnel received multiple and combined injuries in this case. Rapid rise of mines efficiency and their wide circulation recently are bound first to a deployment of new mine weapons and improvements of the application tactics. Basic changes in theory and practice of mine obstacles application were brought by the remote mine planting systems. The basic features of remote mine planting are an opportunity of deep rapid mining using aircrafts and artillery, application not only in defense that was traditional, but also on offensive, and also
5

during withdrawal for a hindering pursuing enemy forces. As the experience of recent military campaigns shows, scales of mines application is on the sharp rise. Speaking about the remote prospects for the mine weapons development, it is necessary to tell, that now there are experimental samples of mines intended for a destruction of low-flying aircrafts (helicopters, cruise missiles, planes, UAVs). These systems can expand a scope of mine weapons application to airspace and, potentially space. Peculiarities of the explosive injury interested doctors and scientists for a long time. In 1773 the French military surgeon Petite has suggested to name a state of shaking(vibration) of all organism, resulting from explosions of an ammunition "commotio", and a damage of an organ "contusion". Renowned Russian military surgeon N.I.Pirogov was first (1865) to explain contusion damages of personnel, inflicted by the close explosions of shells, by the, unknown at the time, phenomenon of an air blast wave. Analysis of published results has allowed finding the following law. The amount wounded, injured by the blast factors, increased with rising of firepower and advent of new munitions. During the Russian-Turkish (1877-1878) and Russian-Japanese wars these wounds acquired systemic character, by WWI they became a majority. From this moment on the share of fragmentation-inflicted wounds and explosive traumas as a whole has exceeded a share of bullet wounds (5.9 %). Mono and multifactor damages during ammunition explosions began to be central in wars and regional conflicts of any scale [Pirogov S.S., 1951; Toropov J.G. and Fishkin V.I., 1988]. To that time, mechanogenesys of a damage, inflicted by the fragments, produced by an EA , became clear due to popular XIX-XX centuries theories of bullets wounds in a tissue. At the same time the injuring mechanism remained of a shock wave remained a mystery for the doctors. The discussion at V all- Russian therapist congress (1916), where questions of a clinical picture and a pathogenesis of an air explosive trauma were on the agenda, has not allowed to come to definite opinion. However in 1915 F. Rusca has published results of the studies of air and underwater explosion effects. Results of these studies, conducted on rabbits and fish, completely matched later studies of . Desaga (1950). WWII posed extraordinary complicated problems for physicians concerning development of pathogenetic bases for a medical care to the big contingents of explosion injury victims. Judging by the experience of Soviet -Finnish (1939-1940), M.N.Ahutin and P.A.Kuprijanov paid attention to a combat pathology, new and little known for doctors of that time injuries at the
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minefields [Fridkin V.J. and Kozyrev N.I., 1942]. At the initial stage of war, the German and English literature published detailed studies characterizing general action of a shock wave. Perennial mutual bombings, carried by Germany and the Great Britain, gave the big scientific base for an assessment of explosion factors mechanisms on a human [Falla, 1940; Hadfild, 1940; Zuckerman, 1941]. Many valuable developments of German scientists were secret and published later by USAF Medical Service [Rossle, 1950; Phillips et al., 1991]. Among studies, addressing WWII the outstanding place is held by the complex studies of the Soviet scientists, performed under supervision of I.S.Beritov and G.V.Gershuni in the Institute of Physiology Academy of Sciences in Georgia (194. 1946). Experimental and clinical studies, including those in field conditions during the combat operations, conducted by morphologists, physiologists, biochemists, allowed revealing largely nature of the pathological processes, caused by the air blast wave, estimate kill ranges for the basic munitions types. Starting 40th of XXth century and until the present time, the systematic scientific studies, addressing pathophysiological effects are carried out in Sweden.These works were initiated by [Clemenson et al. 1969]. The invaluable contribution to evaluation of destructive effects of an explosion on the human and animals was made by the basic studies of domestic and foreign scientists on study of nuclear weapons [White, Richmond, 1959; Glasstone, 1962]. The overwhelming majority of studies is classified, has, as a rule, outstanding methodical level, but, unfortunately, cannot be used by the broad audience of readers. The important contribution to the study of general-theoretical and applied aspects of an explosive trauma was made by scientists of Army Medical Academy, named by S.M.Kirov, published in 50-60th in a series of publications on pathomorfology and physiopathology of humans and animals injuries, inflicted by a blast ware: I.A.Chalisov (1957), V.I.Molchanov (196. 1965), L.N.Aleksandrov and E.A.Dyskin (1963), O.S.Nasonkin (1970). Due to many generations of contributors, the majority of whom we cannot quote due to the classified character of their works, at present the basic sets of symptoms and mechanisms of explosive damages are studied comprehensively. These data are comprehensively covered in the foreign and domestic literature. This is not the case of a mine -explosive trauma where the major scientific studies started in 80th and 90th and are far from generalization. Notwithstanding that the armies during WWII used both fragmentation mines of "jumping" type, and demolition antipersonnel mines, a main share of explosive damages was falling on demolition mines. V.J.Fridkin, N.I.Kozyrev (1942) demonstrate the following the statistics for infantrymen: in 4.6
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% of cases avulsions of the lower extremities segments (including 1.0 % at a shin level), in 2.4 % the open explosive fractures of foot bones, 32 % closed fractures of bones and damages of mild tissues of foot and shin. Presented data make no room for doubt in severe character of mineexplosive trauma. FEP-50 proceedings, published during WWII provide comprehensive analysis of open and closed mine-explosive traumas of extremities [by Guzhienko G.N., 1944; Gurvich S.V.,1944; Lurje J.I., 1944; Majorov A.I., Epstein G. Ya, 1944]. Detailed classification of the most vulnerable segment - extremity, is given, which is later published in Experience of the Soviet medicine in Great Domestic war of 1941-1945. This period gave birth to expressive, though also far from true explanation for a mine -explosive trauma, term mine foot, which became especially popular in the foreign literature [Epshtein G.Ya, 1952; Rubashov S.I., Saharin N.P., 1950; Popov I, 1950; Kazakov M. I., 1952]. Data on the peculiarities of personnel and armor damage during WWII became available only in 70th as retrospective analysis and search for an answer to the questions originated during Indochina and Vietnam operations. These and later sources, as it was correctly noticed by R. F. Bellamy (1988), enabled to draw only one reliable conclusion mild traumas during hit of armored vehicle practically do not happen. The overwhelming majority of wounds and damages of crewmembers, as it happened in the past and today, were of plural and combined character. Traumas inside the tank were inflicted on 60% of crewmembers, 40% outside [Dougherty, 1990]. Operations in Indochina were accompanied by large-scale mine usage, but the peak of mine application was achieved in Vietnam. Losses in armor and personnel made accordingly 70 % and 33 % of all battle losses, and number wounded due to mines achieved 12.6 % of over-all number of sanitary losses. Due to improvement of mine designs, the mine traumas became more diverse. The number of extremity avulsions reached 79-90 % of all trauma cases, caused by the anti personnel mine. Hip avulsions were not a rarity during a war in Laos 4-8 % [Dougherty, 1990; Hardaway, 1978; Traverso et al., 1981]. Plural fragmental wounds of an inverse extremity and other body parts have become the rule. Works of military physicians, including authors of the given monograph, received a high estimate on 1994 International workshop on questions of a battle surgical trauma and wound ballistics in Saint Petersburg. Already from the first classified reports, generalizing experience of treatment injured from mine
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weapons, it became apparent that practical doctors faced an extremely complex class of a combat surgical trauma. The attention was not only paid to essential share and plural character of segments of extremities destructions, but also combined damages of chest and abdomen internal organs, closed skull trauma, serious shock and a hemorrhage. All this distinguished mineexplosive traumas from other gunshot wounds, and from mine traumas, characteristic for WWII. The term mine-explosive wound which, in the first years Afghanistan war meant all classes of explosive traumas, became popular again. Expansion of scales and varieties of mine ammunition usage by the military opposition, low efficiency of personnel and armor protection from mine explosion at the war peak (1984-1987) were the causes of spontaneous mass evacuation of wounded The share of a serious plural and combined trauma [Gritsanov A.I., etc., 1987 Kosachev I.D., 198. etc.] has essentially increased among the Soviet and Afghan government troops. There was an acute necessity for explanation of pathogenesis for this aspect of a battle trauma and for development of classification of an explosive.

Chapter II MINE MUNITIONS CHARACTERISTICS

At present, in the published literature one can find detailed enough descriptions of various mine munitions, along with the description of their combat properties. The data are widely presented in domestic and foreign editions [Tanjurin, 1968; Edberg et al., 1978; Bellero, 1985; Dicker, 1986; Schofer, 1986]. The literature reviews, addressing aspects of an explosive trauma are periodically published. Tactical use of various standard and special mine munitions and explosive devices (ED) under the conditions of mountains and deserts in a hot climate are also well-known [Kosachev I., etc., 1986; Nizhalovsky, Bovda, 1988; Shapovalov V.M, 199. etc.]. Detailed characteristics of modern engineering mine munitions is presented in the analytical report of the All-Russia committee Doctors for prevention of nuclear war , specialized issue Mines: a view from Russia (Moscow, 1999). In this manual we will not only the present brief characteristics of typical mine ammunitions and explosives, but will also address properties of certain anti-personnel, anti-tank mines and other explosive munitions. We will present information in the sufficient amount to explain peculiarities of the explosive injuries to the physicians and from the appropriate point of view. Injuring action of the explosive ammunition (EA) is represented in two aspects, each of certain value for understanding of mechanogenesys of mine trauma (MT) and structure of the resulting injuries. Firstly, tactical characteristics of an ammunition and its application are considered: munitions type (fragmentation, demolition, fragmentation and demolition, incendiary, shape charge and fragmentation); type (monolithic or multiple submunitions); class of delivery precision (low-precision, medium-precision, high-precision); primary injuring action on the personnel (bullets, fragments, blast wave, thermal).

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Fig. 2.1. Anti-personnel mine classification The second aspect implies: Standard means of delivery; Ammunition type, according to operational and tactical application; Number of used ammunition; Location of personnel in the objects, being hit; Area (linear) characteristics of an object; The area of the elementary target and many other parameters. Majority of anti-personnel and anti-tank mines use high explosives (HE). Usually, TNT with energy of explosion 4.2 MJ/kg and detonation wave velocity of 6700 m/s is taken as a reference substance. Modern HE surpass TNT by 20-60% and even up to 200% due to a higher detonation velocity and specific energy of explosion [Opilat, 1980]. Currently the mostly widely spread are the solid and plastic HE hexagen, tetryl, octagen, pentrit, omposition-. omposition-. omposition-4 and the substances, with the properties similar to the latter hexoplast and plastit. Plastit, comprised of 80 % hexagen, 10 % vaseline and 10 % of other additives is being are widely used by terrorists.

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The quantum leap in the improvement of explosive properties is attributed to binary HE compositions astrolytes, developed based on missile fuel. Their detonation characteristics significantly surpass those of all the above compositions. Rapid destruction of the especially large objects or a mass extermination of enemy personnel and armor can be also achieved by using mines with a nuclear charge [Opilat, 1980]. Anti-personnel mines (APM) by a major injuring factor are classified as demolition, fragmentation, incendiary or bullet (Fig. 2.1). They can be established in anti-personnel minefields, groups of mines or as a single mine. Demolition APM are designed for destruction, as a rule, of the single targets and detonate at the immediate contact with a person. Design calculations for demolition mines are conducted so that the explosion, even with minimal HE charge, will injure at least a foot of an infantryman in army footwear or a car tire. Main core of these mines has HE charge from 8 up to 500g. The mines, used in systems of remote mine installation, have, s a rule, 10-30 g hexagen charge. It is quite enough for inflicting severe trauma on a soldier, causing decommissioning. Case of demolition mines is made of plastic or a special tissue, which combined with their small electronic or noncontact fusing system (from the pressure . 1. 7 kg/cm2) makes impossible their detection with inductor-type mine detectors. Italian engineers made the most progress in the demolition mine design. Anti-personnel mines were one of the basic defensive weapon kinds in the engineering forces of the Soviet Army during post-WWII time. Their variety and mass production can be explained by the necessity to protect extended borders of the USSR, a important industrial and transport objects, export to other countries and other reasons, related to the state policy, implemented during that time. Anti-personnel demolition press-on mines in the Soviet Army were mainly exhibited by four types: an anti-personnel mine in wooden case PMD-6M, anti-personnel press-on mines NML and PMN-2. The cassette mines were represented by PFM-1c mine ( a green parrot ).

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Fig.2.2. Mine PMD-6M (safety pin is intact) Mine PMD-6M has wooden case (Fig. 2.2) with inserted conventional 200g TNT charge. Antipersonnel demolition mine PMN has the cylindrical plastic case with HE charge, trigger and a fuse. Before the installation, the fuse is inserted into a special socket, i.e. this mine is initially safe for storage and transportation. Distinctive feature of the demolition mines PMN-2 is in the deployment consists that they are deployed being completely armed (Fig. 2.3). The mine has a pneumomechanical safety mechanism, which provides safety of the mine installation (time of a mine arming from 30 to 300s).

Fig. 2.3. Anti-personnel demolition mine PMN-2 APM improvement is concentrated mainly towards raising their combat efficiency.

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Consequently, the special attention is given to the development of fragmentation mines. Fragmentation mines inflict injury on the personnel by demolition and fragments. Sizes and the form of damage areas of personnel depend on the geometry of fragments scattering and their quantity. Spontaneous destruction of a munitions shell, not designed for the generation of fragments with certain mass and the sizes, leads to "irrational", from the standpoint of enemy personnel destruction, fragments. For this reason, programming of ammunition fragments is a major way to improve their damaging properties. In the majority of fragmentation mines designs, they apply off-the-shelf kinetic elements (metal balls with diameter from 3.5 up to 8 mm, cubes with a side of . 0 mm, wires with notches, etc.). Their quantity varies in various samples from hundreds to several thousand units (more often 500-1200 pcs). In addition to fragments, a case of certain munitions is made from half-fragments with a mass close to 3.5 g, scattered during the explosion of a mine with a velocity higher than 1500 m/s. That prevents "irrational" destruction of a mine case into large fragments. Fragmentation mines can be used in various tactical regimes detonation on the ground, in the air and in the certain direction. Latter two regimes assume remote fusing activators (press-on, clamping), installed at the distance up to 15 m from a mine installation site. Circular fragmentation mines can explode on the ground or in the air 1-2 m above the ground, which provides more effective scattering of fragments. Lethal radius of mines with circular fragment scattering can make from 6 to 15 m, while directed explosion mines up to 150 m [Edberg et al., 1978]. Personnel kill effectiveness by explosion of one anti-personnel mine is equivalent to small arms fire, delivered by two infantry platoons for 10-12 sec. Destructive properties of fragmentation mines surpass similar characteristics of demolition APM with comparable charges due to inflicting wounds of the vital organs by the shrapnel elements. In 16% of cases, gunshot traumas appear to be serious or the extremely serious, at the same time 20% of cases and more can be constituted by light fragment wounds, ending by returning to ranks within three day. [Edberg et al, 1978].

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Fig. 2. 4. Anti-personnel mine POMZ-2M

Fig. 2. 5. Anti-personnel fragmentation mine OZM 72

Fig. 2.6. Anti-personnel fragmentation mine with directive explosion MON-5. installed at the terrain.

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Fragmentation APMs were widely represented in the Soviet Army. Through many the mines POMZ-2M, OZM-. OZM-. OZM-72 etc were deployed. They consist of HE charge, a fuse and the case. Jumping mines OZM-4 and OZM-72 are equipped by launch charge providing mine explosion at the preset height above the ground. Contact fuses of fragmentation mines can be mechanical or electromechanical with clamping or rupture target sensors. Anti-personnel fragmentation mine with circular fragments scatter POMZ-2 (Fig. 2.4) has a lethal radius of 4m. The mine consists of the cast-iron case, conventional 75g TNT charge, a fuse and installation accessories. Fragmentation mine with circular fragments scatter OZM-72 (Fig. 2.5) has a lethal radius of 25m. This is jumping mine and is supplied by cylindrical shrapnel (2400 pieces). HE charge (TNT) mass is 660g, and mass of the launch charge is 7g. Height of a mine explosion is 0.6-0.9m above the surface. The mine design provides for different installation options and remote installation. The mine can be installed manually. Mines of a circular fragment scatter provides horizontal angle of fragments scattering, equal to 360 deg.

Fig. 2.7. Anti-personnel mine with directed explosion MON-9. installed in a tree

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Fig. 2. 8. Fragmentation mine with the directed explosion MOI-100

Fig. 2. 9. General view of PFM-1c mine

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Fig 2.10. General view of POM-2 mine No less effective anti-personnel fragmentation mines are mines of the directed fragments scatter (directed explosion). Explosion of mines of the directive fragments scatter may produce scatter angles from units to several tens of degrees. Most widespread directed explosion mines are MON-5. MON-9. MON-10. MON -200. They can be compared to US-made Claymore mine, M18A1. The mine MON-50 (Fig. 2.6) has horizontal angle of the fragments scatter of 54 deg and destroys targets at the distance up to 50 m, while MON-90 (Fig. 2.7) has scatter angle of 120 deg and destroys the targets up 90 m distances. Quantity of ball or cylinder-shaped shrapnel in the mine is 485-540 and 2000 pcs. HE charge mass is 0.7 and 6.2 kg. Cases of mines MON-50 and MON-90 are made of plastic, the convex-concave shaped. Mine sight is at the top along with the two sockets for installation of electrodetonators or fuses. The folding legs are located at the bottom, together with a grooved flange for an adjusting clamp. Mines MON -100 and MON -200 are now obsolete, however still being applied rather effectively (Fig. 2.8). They have an identical design and differ in the sizes, mass and effective range (MON100 - up to 100 m, MON-200 - up to 200 m). Mines are applied for destruction of non-armored vehicles and enemy personnel and are used with all types of fuses, including remotely controlled option. Novel type of anti-personnel mines are remotely planted cassette mines, which have series of advantages in comparison with the mines installed manually. Cassette anti-personnel mines are stored and transported in cartridges and aircraft pods, used for the remote planting of minefields by multiple launch systems or aircrafts. Mine cartridges for all types of mines are unified in overall dimensions and basic components and only by external markings. Anti-personnel cassette mines include: demolition mine PFM-1c
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and fragmentation mine POM-2. Mine PFM-1C (Fig. 2.9) with a mass of 80 g has the polyethylene case with a 40 g charge of liquid HE, the hydromechanical press-on fuse, setting the mine of at pressure from 5 to 25 kg, a hydromechanical delayed safety mechanism with arming time from 60 to 600 s with and a self-liquidation mechanism, ensuring mine demolition after 40 hrs. This mine is nicknamed as a green parrot . The anti-personnel cassette mine of circular fragments scatter POM-2 (Fig. 2.10) with a mass of 1.6 kg consists from: a core charge, shell, launch element and fins. The mine has 140 g TNT charge, a mechanical fuse with four clamping target sensors (length of a sensor string is 10 m) with set-off force 0.3 kgs. The lethal radius of the mine is 16 m. The self-destruction mechanism ensures mine explosion of a mine after 100 hours. Bullet mines are intended for injuring of a soldier by a single bullet. Similar to incendiary mines, basic injuring factor is the flame containing of incendiary phosphorus-containing composition. These mines are not widespread due to their low efficiency. Anti-tank mines (ATM) are the basic and most widely spread type of landmines (Fig. 2.11). They can be subdivided into three groups: anti-tread, anti-bottom and anti-side. Design of modern ATMs is firstly directed towards inflicting maximal damage to the enemy armor through use of the advanced fuses: mechanical, pneumomechanical, electronic (contact and remote), electric, electromechanical and electromagnetic, piezoelectric, wireless etc.

Fig. 2. 11. Anti-tank mines (left) TS61 Mine (Italy), plastic case; (right) M6A Mine (US), metal case Initiation of a mine explosion is usually caused by closing of a contact, cable breakage and prolonged action of a heavy load or due to a predefined sequence. A mine can be triggered by
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any projection of an armored object [Mishin, 1981]. Mass of a soldier is insufficient to set off a fuse of a regular ATM. Explosion of an anti-tread mine destroys the treads or wheels of an armored vehicle. These mines play virtually no part in sanitary losses, since the crew in such cases escapes virtually undamaged. The basis of antitank mine inventory is represented by the anti-bottom mines, constituting 40 50 % of all ATM inventory in NATO in armies. Explosion of such mines causes destruction of the armored vehicles by to demolition (if HE charge is more than . 0 kg) or shape-charge action (Fig. 2.12). The majority of modern anti-bottom mines are shape-charge ones with mass of HE charge from 0.7 to 3.5 kg. Higher efficiency of shape-charge anti-bottom mines, while preserving their sizes and HE weight small, is achieved due to application of charges, producing cumulative jets. Explosion of such a mine forms a cumulative jet of explosive gases with the initial velocity of 7000-10000 m/s and pressure 1-2106 kg/cm2. This jet can pierce an up to 100 mm of armor at the distance of 2-6 calibers (diameters) of a mine [Opilat, 1980]. Even more effective ATM is based on a principle of "shock shape-charge kernel". A shock kernel is a metal in the quasiliquid state and its velocity is much less than that of a cumulative jet (1.5-2.0km/s), but its mass it is much higher. So the "kernel", maintains impressive damaging properties at the distances of tens and even hundreds calibers of a mine. Penetrating beyond an armor, shape-charge "kernel" causes drastic increase in pressure inside up to (up to 35 kg/cm2 in a shock wave front), and also forms "sheaf" of 200-300 metal fragments, killing a crew and possibly causing explosion of an ammunition, fuel and burning of a tank or armored vehicle [Zhukov, 1983]. Anti-side mines are designed to destroy sides of an armored vehicle. Depending on type of an active element they are divided in two categories: with a shape-charge (or shock kernel) and shape-charge anti-tank grenade. These mines are planted at the road shoulders. They are capable to inflict damage on armor at the distance of 50-80 m, piercing armor up to 70 mm [Zhukov, 1986]. Combat characteristics of modern anti-side mines do not concede to similar characteristics of other shape-charge ammunition and even anti-tank missiles. If an armored object is hit by an anti-bottom or anti-side mine, the inflicted wounds are incredibly severe. About half of crewmembers (53 %) in tanks, self-propelled howitzers and armored personnel carriers is killed, 34 % receive wounds of a various degrees and only 13% of crewmembers escape unwounded [Owen-Smith, 1977].
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Severe mine traumas (70-80 %) prevail among the sanitary losses inflicted. Among Soviet antitank mines, developed and deployed through the different years in Soviet Union, the following can be pointed out. Mine -41 has metal stamped cylindrical case, HE charge mass is 4 kg, mass of a mine is 5.5 kg (Fig. 2.13). This mine was simple, reliable and used since battle for Moscow and to the end of the war. Anti-tank mine YAM-5 had a wooden case, could be loaded with TNT pellets, molded TNT, dynamite or ammonite charge. Mass of HE charge ranged from 3.6 up to 5 kg. The mine was equipped by a modernized fuse MUV and it was invisible for mine detectors. Mine TMB-2 (Fig. 2.14) had the pressed carton case and an entire mass of 5-7 kg, HE charge mass (powdered ammonite or dynamite) consisted 4-6 kg. Its manufacturing was phased out in 1944.

Fig. 2.12. Damages, inflicted by anti-vehicle mines on armor and trucks

Fig. 2. 13. Anti-tank mine TM-41

Fig. 2. 14. Anti-tank TMB-2

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We shall point out that the majority of antitank and antipersonnel mines are made with a plastic case and have no metal details, posing essential difficulties in their detection. They can not be found by inductive mine detectors. In addition to antitank and antipersonnel mines, new methods are constantly being developed against armor and personnel, in particular, hand-held anti-tank grenade launchers (RPG), anti-tank missiles (PTUR), guided mines, launched from regular mortars (equipped by homing heads and shape charges). Usage of strike-recon complexes, including UAV, ground-based control center and cassette munitions seem to be a prospective idea [Fomin, 1987]. Further development of antitank grenade follows a way of increasing a hit range and accuracy of fire, improving an armor penetration, decrease of a weapon dimension and mass, hiding launch attributes (sound, a flame and a smoke). The majority of grenade launchers munitions are equipped with the simple or "jumping " fragmentation grenades containing hundreds of metal shrapnel with a killing range of 5m. The scatter velocity is frequently reaching 1500 m/s [Gromov A.V., Surov O. Ya, Vladimirov S.V 1984]. The last generation mines are equipped by acoustic, seismic, and infrared target sensors, microcomputer-based homing systems and are capable to find and hit armored targets on the ground and in the air (up to 100-150), on shallow-water. The target can be hit from any side, including top [Fomin, 1987]. In addition to direct hit of armor and personnel, usage of mines, increase probability of enemy armor and troops being hit by another weapon. Mine and explosive obstacles limit a maneuverability of armor and infantry at the battlefield, raise kill effectiveness by another weapon, hold back troops advance. Modern hand grenades are equipped by more powerful explosive charge on the basis of TNT and hexogen mixture, containing large amount of shrapnel (steel wire with notches through . 2 mm, steel balls 2-3 mm in diameter). Shrapnel quantity may reach from 2100 to 6500. Kill radius of a hand grenade reaches up to 20 m. At the same time, it is pointed out that hand grenades, much more often than other ammunition, become the reason of accidents in storage, training, handling and combat. The multiplicity of fuses designs (including electronic) witnesses to the ongoing search for more effective decisions. Nowadays several countries design the systems of remote mine planting. These systems enable sharp reduction of minefield installation labor expenses. The following systems of remote ground mine planting are widely spread GEMSS, MIWS (Germany), "Istriche" (Italy). These systems use antitank and antipersonnel mines scattered for several tens of meters. US ARMY is using
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MLRS systems with maximal range of remote minefield planting 40 km along with Germanmade MLRS LARS. Another system, deployed by US ARMY is GATOR, equipped by 72 anti-tank and 22 anti-personnel mines, and providing installation of mines over the areas more than 60000 m2 [Alexandrov, 1985; Zhukov, 1987; Mishin, 1991; Tanjurin, 1968; Fuks, Hartung, 1969]. Intensive R&D in the area of mine detection and deactivation is taking place. By experience of the Britain-Argentine conflict in 198. the RF mine detectors were used along with the inductive ones, providing detection of antitank mines in the plastic case at the depths up to 15 cm. The research and design works in the area of radar-based mine detectors, thermal vision equipment and chemical gas analyzers are being actively pursued [Kozlov, 1985]. Analysis of the published data allows drawing a conclusion that planning and financing of R&D in mine systems is directly related to the high efficiency of mine munitions. Also, the appreciable psychological effect rendered on enemy personnel and population, small weight and dimensions of an ammunition, a capability to plant remotely antitank or mixed minefields on ranges from tens of meters up to several hundreds of kilometers. Mortars, artillery and rocket systems, tactical air forces can be used for this purpose [Zhukov, 1980; 1981; 1983; 1985; 1986]. The basic directions of mine munitions improvement are: Development new HE types with different physical properties; Increasing efficiency of an ammunition by providing qualitatively new design features by it; Creation of new and improvement of traditional shrapnel [Zhukov, 1980; Opilat, 1980]. By a physics state, HE is subdivided into solid (cast, pressed), plastic, powdery, liquid, sludge and FAE. TNT is still considered the reference HE with specific energy of explosion 4.2 MJ/kg. Modern rocket fuels gave birth to a novel form of binary explosives astrolyte. Astrolyte shaped charges have piercing action (e.g charge 227g pierces steel plates up to 625 mm). US Army is widely developing small nuclear demolition munitions (SADM), as intended for rapid destruction of military equipment, personnel and creating serious obstacles [Opilat, 1980]. Nowadays, the minefield destruction and demolition of large objects can be reliably performed using fuel-air explosives [Kolesnikov, 1980] is real.

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Chapter III EXPLOSION INJURIES IN WARS AND ARMED CONFLICTS OF XX CENTURY

3.1. DEFINITION AND CLASSIFICATION OF EXPLOSION INJURIES
Ongoing armed conflicts in many countries of the world sustain an interest of medical experts to the studies in war surgical pathology, where the leading part belongs to the injuries caused by explosive ammunition (EA). Variety of injuring factors, which have a harmful effect on a human being during the explosion and peculiarity of general and local pathological changes taking place in a human body gave birth to numerous terms and concepts in the literature to define the consequences of explosion exposure: contusion; general contusion; air contusion; contusion trauma; explosion injury; blast wave injury; explosive trauma; blast damage; air explosive trauma; detonation trauma; explosion damages; commotiocontusional syndrome. Last term, especially popular nowadays, appeared due to S.I. Spasokukotskiy, who, considering difficulty of differentiation syndromes of the general concussion (commotio) and local contusion damages, suggested to merge them into commotiocontusional syndrome [Nifontov B.V.,1957]. During the World War II, and in the foreign literature of the following years as well, the damages resulted from an EA explosion, were combined into a general term mine foot. In the modern view of the basic injuring factors of EA action, this concept not only does not reflect variety of
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possible damages, but also does not allow to distinguish qualitatively different explosion injuries, and, hence, to choose rational approach to the treatment of victims. Some foreign authors, using this term, combine the damages resulting from injuring factors of explosion and those from separate fragments beyond the operating area of these factors. Actually, they combine fragmentation wounds and the damages, occurring in the impact zone resulting from explosion factors. This prevents from studying the structure of war injuries and, what is more important, estimating the necessary amount of efforts and facilities to provide aid for the most serious victims contingents. The theoretical and practical significance of any generalizations and classifications, their integrating role in a science evolution is usually of conditional character, and eventually requires revision and reflection, especially based on new achievements. At the same time, it is difficult to overestimate stimulating and consolidating role of the discussions results, concerning trauma, shock and traumatic illness problems, which arise periodically. When considering the definition and classification of explosion injuries, it is necessary to take into account that frequently the source of various existing classifications are the differing opinions of a term usage. Studying the literature on this particular problem makes evident one more peculiarity the majority of classifications creators, when suggesting their own terminology, do not dissect mistakes and positive experiences of their predecessors and virtually do not quote them. Until the middle of sixties, the explosive trauma was traditionally considered as a special type of gunshot damages with intrinsic characteristics of its mechanogenesis and clinical course. Hence, the gunshot damages are etiologically caused either by a firearm shot or by a shell or explosive blast [Molchanov V.I., 1965]. The essence of this fundamental statement is preserved now in overwhelming majority of war surgical trauma classifications. At the same time, in the past 20 years the publications appeared virtually offering the revision of the general gunshot damages classification and separating the explosion traumas into an independent group. E.g., in the forensic medicine textbook by V.L.Popov (1985) the following definition is given: Gunshot damage means the damage resulting only (emphasized by us) from a firearm . In the monograph, dedicated to forensic medical examination of gunshot damages (1990), the same author terms gunshot, as a damage which is inflicted by one or several shot factors. His position is stated even more strongly later (1991): Gunshot damage is the damage resulting only (emphasized by us) from a shot. Additionally the author sees a shot as a process of shell
25

ejection from a bore by the energy of gunpowder gases . This wording of a Gunshot damage concept completely excludes a concept of an exploding ammunition ability to cause Gunshot damage. On the other hand, adopting such an approach, all damages, which result from explosion, following the logic of counter definition, should be treated as explosive. This position of authors is the result of studying and classifying injuring factors of a shot and explosion, conducted for the last 40-70 years. These studies established drastic differences in the damages, resulting from the shots and explosions. The studies also allowed to separate the whole set of traumas into two groups. The damages, resulting from various kinds of small arms shots are included in one group. These damages retain the name of firearm damages. The other group included the damages resulting from explosions of munitions and IEDs. They are termed as explosion damages, or an explosive trauma [Popov V.L., 1991]. For the first time the separate descriptions of firearms and explosive damages have been presented by V.I.Molchanov in 1964 in the textbook of forensic medicine under edition of I.F.Ogarkov. It is difficult to disagree with the principal viewpoint of authors, insisting on qualitatitave differences in firearm and explosion damages, however only on one condition if the issue in question is multifactor explosive damages, where the leading part is played by a blast wave. If the question is the multifactor fragmentation damages, resulting from ED explosion outside the injuring radius of an blast wave, then this is controversial position. Not only the statistics of explosive traumas, as it is observed in some publications, will be ultimately confusing, as it happens when fragmentation wounds are considered as explosive damages. Numerous studies of injuring effects of the standard and nonstandard ED fragments were carried out by both domestic, and the foreign researchers, and generalized comprehensively in a series of articles by Bellamy et R. Zujtchuk (1991). These studies testify to principal similarities of the terminal wounds ballistics for bullets and fragmentation wounds (certainly, for comparable masses and velocities of wounding shells/bullets). However, there are qualitative and quantitative differences in the sequences of time-pulsating cavity formation, force characteristics of the direct and side impact, morphology of a standard bullet and fragmentation wound. Purposefully, in the Experience of the Soviet medicine in World War II and the subsequent years it was mostly popular to divide firearm damages into two groups: bullet and fragmentation, i.e. by a shape of wounding shell, instead of its origin. However, even this, at first sight, simple classification of firearm damages frequently represented a difficult problem for the diagnosis.
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Considering a wound, depending on the type of injuring bullets or fragments is extremely difficult, wrote A.N.Maksimenkov (1952), as neither wounded person, nor the doctor, when treating a wound, cannot precisely determine in each separate case what fragment caused the wound. It is equally difficult, especially for the through wounds to determine the origin of a wounding shell in general. The injuries caused by bullets and fragments are very similar. Later in the classification of firearm damages, suggested by S.S.Girgolav (1956), he proposed to separate fragmentation wounds (from artillery and mortar shells) and mine wounds, as a special category of the damages inflicted by a blast wave of the deliberately planted mines. The opinion of S.S.Girgolav (1951) on the latter category of gunshot damages (explosion damages) is quite remarkable: 1. During the WWII we observed substantial number of damages when the wound was caused by only the blast wave impact. Even if these similar wounds contained small metal particles, clothes fragments, scraps of a moss, soil or peat, they were only casual foreign bodies brought in a wound by a force of explosion. 2. The Wounds caused by a blast wave, without introduction of foreign bodies, have no wound channel. In these cases an extremity avulsion is observed, or defect of integuments and liable tissues with more or less expressed wound cavity. These wounds have all features of the bullet wounds . Thus, all local tissue damages arising from ED explosion factors, during the WWII and Korean War were treated as the firearm damages. Devising general classification of the war-inflicted surgical traumas is nowadays also a difficult task in view of extreme multitude of firearms, munitions and their damage factors. Below, we shall consider some from them. P.N. Zubarev and M.I. Lytkin (1991) put forth classification considering four categories of gunshot damages, depending on the injuring agent: bullet, fragmentation, mine and programmed injuring ammunition elements (in our opinion, the latter should be understood as an injury by the ammunition elements). Each kind of an injuring shell, as authors fairly mention, has distinctive ballistic properties, which in the end determine morphofunctional characteristics of damages they inflict. Disregarding principal remarks on the authors viewing the mine trauma as a kind of gunshot trauma, it is necessary to point out the formal logic contradictions in this classification. If statistical groups of "bullet" and "fragmentation" damages are termed as the injuring agent
27

criterion, then the "mine" category responds to another definition a source of injuring agents. Mine ammunition can be a source of all mentioned and other injuring agents which, depending on detonation conditions, can inflict mono- or multifactor damages. G.M. Ivashchenko in his doctoral thesis, written in 1963 under A.N. Maksimenkovs supervision, suggested the classification consisting of 15 separate individual classifications. Particularly, based on the injuring agent kind, he separated the following wounds: bullet, fragmentation, bullet and fragmentation simultaneously, wounds by the secondary injuring shells, wounds by the blast wave in the air or water (baro-and hydrotrauma), and combined damages. All kinds of traumas here, as well as in his subsequent publications, were referred to as a gunshot, while the source of injuring agents was disregarded. Considering development of differentiated classification characteristics of gunshot and explosive traumas, of special interest are the approaches of military medical service providers, which they use to calculate irrevocable and sanitary losses, caused by EA explosion. Only those damages are considered as explosion, or demolition, traumas, which arise from explosions in the radius of the air blast wave action. There is a system in place to calculate the sanitary losses, caused by the explosive trauma. This system is verified in full-scale experiments (for open spaces, closed defensive fortifications, armored objects, etc.). Two kinds of demolition traumas can occur within the calculated radius multifactor (a blast wave combined with other injuring factors) and single-factor (an air blast wave solely), depending on what kind of EA is used and a person exposure conditions to the explosion factors. Outside of the air blast wave action radius the injuries are mainly fragmentation and not considered to be an explosive trauma. In particular, it is possible to indirectly define the damaging influence of a blast wave, by estimating the radius of contusion injuries inflicted on the personnel at the time of conventional ammunition explosions, as:

R y = ( Lq ) ,
0.4

where Ry is the radius of blast wave contusion injuries; is a coefficient, specific to each kind of ammunition; L is a coefficient, pertinent to used HE; q is a charge weight. As follows from these calculations, the explosion of an antipersonnel mine can produce injuries in 2-3 m area, while an antitank mine can cause injuries in 6-8 m area (in hard rocks these distances increase by 1/5 of the radius). Therefore, considering other injuring factors, the wound caused by an explosion is attributed to a cumulative multifactor damage occurring in the area of

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the basic injuring factors, and blast wave in the first place (Fig. 3.1). J.G. Toronov and E.P. Roslova (1991) maintain another position. In their opinion, damages are explosive when they result from cumulative (emphasized by us) impact of the basic injuring factors of explosion on the human: a blast wave, fragments, gas jets, high temperatures and flame, toxic products of explosion and intense psychoemotional impact. Suggested definition absolutely does not clarify how we address single-factor explosion injuries, inflicted, for example, by an air blast wave. Is it possible to estimate fragmentation damages by the same principle? With the advent of gunpowder, the mankind obtained not only new and particularly dangerous arms, but also became subject to a qualitatively different type of a mechanical injury gunshot. In any war, in addition to political and exclusively military tasks and objectives, there are always two more principal ingredients: warfare and fighting methods. While war objectives, as well as fighting methods, can coincide somehow, have something in common and even repeat themselves, warfare military is generally acknowledged to be the dominant, most dynamical and permanently varying "value" arms, military equipment, weapons, etc. (Fig. 3.2). Nowadays, there are more than six types of weapons known, distinguished from the medical point of view. They are distinguished mainly by a damaging character of the principal traumatizing factor (causing mechanical traumas, including gunshot, thermal, chemical, etc.) or by a combination of some physical effect agents [Davydovskij I.V., 1952; 1954]. Combined radiation injuries, resulted from nuclear weapons can be an example of the latter. Evidently, one can not complicate the questions of the battle surgical trauma classification to such an extent that using one class of weapons, like firearms, only resulting specific mechanical traumas are referred to as gunshot. It has to be remembered that the concept of "firearms" includes not only fire shooting arms (e.g. rifle), but other kinds of arms with explosive charges, i.e. equipped with non-nuclear explosives surface-air bombs, torpedoes and sea mines, artillery shells and mines, all types of missiles, grenades and engineer mine munitions. Each type of a trauma, including gunshot, has inherent specific set of integrity breaches for any anatomical structure at any level of the morphological organization: molecular, cellular, histic and organ, with appropriate pathomorphologic reactions and processes. However, interspecific differences of damages always existed and will exist. They are inevitable and depend, first, on ongoing warfare improvement. For this reason mine wounds dramatically differ from typical bullet wounds, and the wounds inflicted by a bullet of .62 mm caliber are so
29

different from those, caused by modern small arms. Though, both of them are gunshot traumas.

Fig. 3.1. Basic injuring factors effective areas In recent years, views, whereby the explosion as a source of injuring agents can inflict both an explosive and typical gunshot fragmentation wound tend to prevail. It all depends on a set of injuring factors and conditions of interaction with a target (distance from the target to the point of explosion, level of object protection, etc.). At present time, there are three views on a place of an explosive trauma in the general classification of the war surgical trauma. In the first case, the blast damages are regarded as a type of gunshot injuries. In the second case, all damages resulting from the explosion are regarded as an independent type of injuries. In the third case only those traumas, which result from isolated or combined action of the blast wave are considered as explosive. It is clear that different views on the explosive trauma influence gunshot damages concept in whole. Any of the considered views, claiming to describe interrelations between gunshot and explosive damages, is not capable to capture all optional versions and situations of traumas, caused by a shot or an explosion. For instance, can possibly a typical explosive damage of tissues result from a shot? Following definition of V.L. Popov, it is not possible. However, considering mechanism of tissues damage by the factors of a close-distance shot or a blank shot, the disorders, inflicted by powder gases (blast, blowout and destructive action), will hardly qualitatively differ from tissues destructions resulting from explosive gases. There is no need to mention here even those unique cases, when tissue damage can occur

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in a identical situation, like gas jets penetration through apertures in hard barriers. The gunshot damage concept definition has to be very tolerant so this kind of "gunshot" wound is equal to a typical bullet or fragmentation wound and with qualitatively different terminal ballistics. Moreover, how to interpret an injury by specific bullets, equipped by ancillary HE charge? In such cases, local tissues destructions, being, as a rule, extremely serious, are caused not only by the direct and side bullet impact, but also due to explosion of a specific HE/fragmentation "microartillery projectile". Considering current opportunities in creation of programmed injuring ammunition elements, a situation, when the bullet wound would result from an explosion, does not seem to be impossible. Development of fragmentation elements in the form of bullets, but with more rational ballistic properties, has been carried out for many years. On the other hand, injury by the primary fragmentation field can take place not only because of a shot, but, for example, while shooting through hard barriers when a bullet, approaching a target, is fragmented. Summarizing the given comparisons, which are far from being just formal, it is possible to conclude that the shot and the explosion specified by modern evolution of warfare means have potentially equal capabilities (meaning the quantitative list of agents generation, including those not mentioned here: temperature, chemical, etc.). In addition, it means that the concept of "shot" can come in quite equilibrium with the concept of the "explosion" regarding the criterion of an injuring agents source. However, by all means, the ratio of major injuring agents absolutely is not equal in typical cases of the shot and the explosion. The analysis of existing classifications and deductive methods of definitions extension to various situations of the bullet, fragmentation and explosive traumas, shows, that either formal or principle contradictions develop from new criterion introduction, an injuring agents source, and its application simultaneously with the former criterion an injuring agent type. We conclude that while creating unified general war injuries classification both criteria should be considered, although on but on the different levels of classification. It has to be emphasized, however, (the last criterion was always of the crucial importance for clinicians), that the type of injuring projectile, its absolute energy and conditions of interaction with body organs and tissues basically determine the character of local damages and clinical course of a traumatic injury Thus, currently there is no mutually acceptable general classification of explosive and gunshot damages yet, in which mutual relations and hierarchy of the basic categories would correspond
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with the laws of formal logic. There is a possibility, that the views according to which the explosive trauma is referred to as a type of gunshot trauma, will be reconsidered in the near future. As already stated, since the time of the World War I, terms and classifications have been developed to define damages, which occur during detonation of minefields or separate mines and explosive devices. Especially large number of classifications, terms and concepts, concerning a problem of an explosive trauma, appeared during the war in Afghanistan. A classification suggested by V.M. Shapovalov (1989) is among of the first ones, generalizing experience of treatment of personnel with explosion injuries in Afghanistan. It embraced all possible damages, which victims received from explosive wounds and traumas. The author emphasized that extensiveness and multiplicity of damages did not allow constructing a brief classification, however he has combined all most frequent damages in separate groups. It allowed formulating the correct and complete diagnosis with isolation of a major syndrome. Depending on mechanogenesis, two basic groups of damages have been singled out in classification: the unshielded explosive damages explosive wounds, and the shielded explosive damages explosive traumas. Extremity segments avulsion, some organs avulsion (mostly cavitary), nonperforating, perforating and gutter wounds have been specified regarding the character of injuries. Damages of soft tissues, major vessels, nerves and joints regarding concomitant injuries of tissues. Acoustic-barotrauma as a consequence of a blast wave impact in confined space as well as damages of a head, a chest, an abdomen, a pelvis and genitals have been distinguished with regards to combined damages. In the combined injuries structure the author singled out penetrating and nonpenetrating wounds as well as nonpenetrating trauma of organs. Fractures, depending on their character, are subdivided into gunshot, open, closed and combinations of fractures with plural injuries. This work classification appears to be competent and can be used in clinical practice. In the Soviet military-medicine another classification was used. It was developed based on generalization of a clinicopathological material (about 1500 injured and 497 dead) by the group of military surgeons under I.D. Kosachevs supervision (1986). Explosion injuries as a term designated all damages inflicted on victims in demolition of various explosive devises mines, shape charge shells, grenades, fuses, demolition munitions, artillery ammunition, bombs, etc. With regard to main attributes of an injury, explosive wounds and explosive traumas have been conditionally singled out in this classification. The explosive
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wound, according to definition of the authors, is a damage caused by direct impact of injuring shells (primary and secondary) and the blast wave. In the structure of all explosion injuries, they comprised 69%. Explosive traumas result from indirect impact of the blast wave through any obstacle (an armor plate, a body or the chassis of a vehicle), when the victims are inside a vehicle or on top of it, and also from the fall of an armor at the moment of a blast. The proportion of the explosive trauma in the structure of explosion injuries comprised 31%. Regarding to clinicopathology the explosive wound is characterized by plural fragmentation wounds (nonperforating, gutter, perforating) in combination with signs of distant and direct damages of internal organs. Explosive traumas appear as various degrees of concussions, bruises, hemorrhages, hematomas, breakages, disruptions, organs avulsion, open and closed bones fractures, extremity segments destruction or avulsion.

Figure 3.2. Classification of modern warfare means Classification attributes provided also segmentation of explosive wounds and explosive traumas according to localization a type (isolated, plural, associated, and combined). Severity of blood loss, a degree of a shock, evidences of mental disorders and their clinical variety have been considered as well. This classification, included in the Guideline of the 40-th Army principal surgeon [Kosachev I.D., 1985], according to the opinion of its founders, provided more complete and correct diagnosis with detection of a leading syndrome, enabled better organization and treatment-andevacuation tasks based on pathogenetic features of explosion injuries. In the research of I.D. Kosachev et al. (1991) there are similar groups of victims of injuries, caused by blast of anti-

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personnel and anti-tank mines, which are named identically explosive wounds and explosive traumas, and in addition, the term explosion injuries is applied as a collective name. All three terms have been employed in the research with the only a difference that explosive wounds and explosive traumas have collateral names the unshielded and shielded explosion injuries. Mentioned classifications, as authors admit themselves, have an essential shortcoming. It is the conditional character of victim groups naming and the explosive trauma in whole. Any of the suggested names does not cover all open and closed damages of extremities and, internal organs, which occur during the standard demolition of anti-personnel or anti-tank mines. Achievement of this task is even more problematic, when many other damages, caused by explosions of ammunition of other designs and tactical functions, are being differentiated. In our opinion, the main cause why it is difficult to establish acceptable terminology, is the attempt of research group of I.D.Kosachev to apply concepts "trauma", "damage", "injury", "wound", which are definite enough in clinicopathological respect and contradictory in medicosocial one, in order to define the entirety of all explosive pathology , caused by the demolition of anti-personnel and anti-tank mines. Since any explosion results in victims receiving significant variety of mono-and multifactor organs and tissues damages, any of the listed terms, in fact, is not sufficient to describe a medicotactical situation of personnel target destruction. The terminology established by A.V. Alekseyev et al. (1986) is sufficiently faultless in this respect, and it subsequently was applied in Guidelines on the organization of medical care in evacuation stages in the presence of explosive traumas, under I.A. Eriuhin supervision (1987). Authors define the explosive trauma as follows: the explosive trauma is a combat-related multifactor injury caused by the combined impact of a blast wave, effluxes, flame, toxic products, ammunition shell fragments and secondary injuring shells on a person, and producing severe damages in the area of direct impact and in the entire body. For practical work, in authors opinion, it is acceptable to separate the open damages the explosive wounds, open and closed traumas, resulting from beyond-armor effect and overturning of an armored vehicle. In the absolute majority of cases, as it is emphasized in the research, victims are noticed to have the combination of these injuries types that allows considering them as a unified victims category with the explosive trauma. It is hardly possible to consider successful an unequal names application by A.V. Alekseev et al.
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(1986) for the morphologically identical open explosion injuries explosive wounds (in open terrain) and the open explosive traumas (inside armored vehicles). Besides, it is again an attempt to apply definite morphological categories to explosive trauma types, which are complex in etiopathogenetic and clinical respects. Since in the presence of virtually any variety of an explosive trauma the open explosive damages are frequently combined with closed damages, including associated damages (of an abdomen, chest, skull), the terms explosive wound or open explosive trauma are as far from truth, from the standpoint of the integrated victim description, as the outdated term mine foot. Nevertheless, we cannot support opinion of A.P. Kuzminyh and O.N. Shtanakov (1988) about the hierarchy of traumatology concepts: "harm" "damage" mechanical trauma "fracture". It is constructed without taking into account modern requirements to the use of terms and does not consider historic tendencies of foreign terms russification. Many of these foreign terms, being seemingly similar to native Russian word by semantic meaning, are frequently used in the modern language to indicate permanently used broader concepts. Assuming the hierarchy of concepts suggested by A.P.Kuzminyh and O.N. Shtanakov as a basis, a number of widest concepts from traumatic surgery, which became very common in our vocabulary long ago, remain suspended: war a traumatic epidemy (Pirogov N.I.), "traumatology", trauma dystrophy, "traumatism", etc. The word "trauma" is a generic term for all these generalizing terms, but not "damage", though, at first sight, they both have an identical semantic meaning. Moreover, the authors contradict themselves, asserting the definitions they gave to such words as "damage", "wound", "fracture", and their hierarchy. In the same article they justly specify that there can be several damages and just one trauma. The terms "trauma" and "damage" cannot be considered as synonyms, as we see it, because they convey different semantic styling. Former "trauma" has broader semantic meaning. The Table 3.1 introduces its substantiation. The necessity to introduce terms "unshielded" and "shielded" explosive damages to designate direct and indirect (through protection) impact of injuring factors of explosion is indisputable for separation of different in the characterological respect explosive structural damages. Especially, when the terms are specified depending on either presence or absence of the shield in the path of primary injuring agents. However, application of these terms in order to distinguish the traumas received in open terrain (unshielded) and inside armor (shielded), makes them conditional and rather inaccurate.
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Table 3.1 Meaning content of the terms "trauma" and "damage" Trauma Damage 1. Social and clinical category 2. Result of interaction of a body and aggressive external factors 3. There is always just one trauma, but it can have various qualitative and quantitative characteristics 4. It has the entire complex of cause-and-effect relation the pathogenesis 5. Reflects both injuring impact on the body and reaction of the latter to this impact and possible consequences 1. Pathomorphologic category 2. Breach in any anatomic continuity at any level of the structural organization 3. One injured can have several damages 4. It has a specific cause and forming mechanogenesis 5. It characterized by stability and clear objective manifestations of organs and tissues continuity breach and their consistent transformations

Thus, for instance, standard models of infantryman footwear may or may not manifest their protective shield properties when anti-personnel mine detonates. It depends on the mine type, its charge and a distance from the explosion. Consequently, following the explosion of antipersonnel mines both unshielded and shielded mine injuries can occur; moreover, the probability of unshielded damages decreases if special protective footwear is used. Similar discrepancy appears in case of an armor crew mine-related demolition, i.e. in group of the so-called shielded traumas. For example, when armor protection is destroyed, multiple open damages occur along with closed traumas of limbs, chest and abdomen due to the direct impact of a leaking blast wave, i.e. the unshielded wound are observed. Similar discrepancy appears in case of an armor crew mine-related demolition, i.e. in group of the so-called shielded traumas. For example, when armor protection is destroyed, multiple open damages occur along with closed traumas of limbs, chest and abdomen due to the direct impact of a leaking blast wave, i.e. the unshielded wound are observed. As we see, three conditions have to be met in order to use this terminology appropriately. First, it is necessary to specify "the shield" concept similar to the barrier concept in case of typical bullet wounds. Second, to separate three categories of mine traumas regarding to the shield presence "unshielded", shielded without destruction of the shield and shielded with destruction of the shield. Third, to assume the principled possibility that any of the mentioned traumas types can occur
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resulting from the explosion both in open terrain and inside the armor. Only if these conditions are met, the terminology satisfying both clinicopathologic, and medicotactical classification criterions can be established. All authors, quoted above, consider grenades, mines, artillery shells, bombs, warheads of missiles, fuel-air ammunition to be explosive ammunition, i.e. basic groups of non-nuclear weapons. Nevertheless, they mainly describe quite narrow clinicopathologic variety of mine traumas and injuries that result from grenades and shape charge explosions. Consequently, the description of the explosive trauma is narrowed and depleted, meaning that this term actually designates consequences of the damage, inflicted by various ammunitions. In other words, seeing the explosive trauma essence in such way, authors have to either narrow the collective term and use explosive ammunition list or expand the range of possible clinicopathologic varieties of the explosive trauma, to correspond with broad range of ammunitions regarding their mechanism of action. Otherwise, the name and the terminology have the same conditional character, as well as definitions of their precursors. Regarding present-day documents, the classification term "mine" is applied for the first time in Guidelines on examination and treatment of injured patients, compiled by V.A. Popov et al. (1986). Authors have divided basic groups of injured patients according to explosion characteristics in open terrain (mine wounds) and inside armor (mine traumas). Evolution of this manual authors views on the explosive trauma problem can be divided into two stages. The first stage is directly linked to their participation in practical surgical work on injured patients treatment during the war in Afghanistan when practical skills and experience were accumulated and this problems significance and complexity were digested. In the years, following Afghanistan war, experimental verifications of the views and ideas developed during the war have been conducted and research materials have been generalized and published as numerous publications in periodicals and monographs. The second stage begins in the middle of nineties, at this particular time frequent terror acts in apartment buildings and infrastructure objects in many cities occurred. Mechanogenesis of traumas, their character, peculiarities of treatment-and-evacuation measures have let us to see the problem in a new fashion. Originally, military personnel injured in the war was the research object, but nowadays there is an insistent need to look at the problem on a broader scale. Scientific concepts are known to be established at rather high stage of science evolution, and
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definitions introduction is preceded by the long period of their formation and development. However, to overcome terminological dissent on the explosive and mine traumas problem, in our opinion, it is not enough to continue different studies, including the analysis of applications and tendencies of lexical norms development in terms usage. Today, series of existing contradictions should be eliminated based on a mutual consent and by adopting common decisions. It is especially important, regarding that even the most successful and general-purpose definitions have restricted possibilities according to objective learning laws. As V.P. Petlenko (1982) has fairly mentioned, the improper standpoint on a character of scientific definitions, according to which a definition should cover all characteristics and properties of the phenomenon, is frequently the basic epistemological source of discussions. Since it is impossible as a matter of principle, such views led to relativity, conventionalism, and, through them, to agnosticism in concepts as conditional categories of medicine. The necessity to choose a definite terminology to present the materials of our own studies has induced us to carry out an estimation of lexical norms in modern Russian to define most exact designations of the mine traumas entirety and their most widespread types occurring in different situations of mine explosion as well. For that purpose the authors have compared the definitions of key words and concepts concerning a problem of mine trauma, which are given by the general and specialized (military, physical, military-medical and medical) explanatory dictionaries and encyclopedias: explosion, explosives, HE detonation, blast wave, a shot, ammunition, mine, bomb, shell, grenade, demolition munitions, damage, injury, wound, trauma. The Common Dictionary of modern Russian lexicon (1991) was the guidebook in reference literature. Adequacy of foreign terms to analogous concepts in Russian was verified with the help of multilingual military dictionary by Brassi 1987) while translating foreign military-medical literature. We have also considered principled approaches in use of technicalities, which were paid attention to in debating articles of native surgical magazines, concerning the regulation of definitions in injury surgery. In 198. we have suggested a classification, which was subsequently supplemented and improved (Fig. 3.3). It has been established proceeding from the literature analysis and from understanding that the majority of known and presumptive classifications in surgery in the first place are meant to assist the therapist at the stage of diagnostics, namely in formulating of the most complete diagnosis, lacking which it is difficult and sometimes impossible to outline and implement the plan of remedial measures.
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We think that the explosion injury is a generalizing term, which, first of all, means multifactor character of a trauma in an explosion.
EXPLOSION INJURIES Combat explosive trauma Noncombat explosive trauma

Explosive trauma

Mine trauma

Explosive (mine) wound unshielded

Explosive (mine) damage shielded

With destruction of a "shield"

Without destruction of a "shield" beyond-armor effect

Fig. 3.3. Explosion injuries classification Explosion injury can be determined as a multifactor, as a rule, combined or multiply injury of a person, caused by instantaneous damaging action of explosion factors or by damages or destructions of buildings constructions or details, and described by local damages of tissues and general commotiocontusional syndrome. The most typical features of explosion injuries resulting from terrorist acts in cities or from manmade disasters are combinations of mechanical and thermal injuries, including extensive and penetrating flame burns following to fires or clothes combustion, burns of upper respiratory tracts, toxic and combustion gases poisonings, and the acute situationally conditioned psychoses as well. Terrorist acts and accident victims are exposed to traumatizing impact always unexpectedly, as a rule, amid complete physical and psychoemotional well-being. This also describes a concept of a non-combat explosive trauma. Yet, military personnel participating in combat are in state of a permanent psychoemotional tension and stress. Undoubtedly, it has an effect on the subsequent posttraumatic course both in an acute stage and in the distant future. Authors witnessed situations when soldiers, being in state of a combat stress and having received wound, continued to fight and retained ability to render first medical aid to themselves and fellow injured. In this connection, it is obviously possible to
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refer to a combat explosive trauma as a variant of explosion injury. Considering that any classification cannot claim to be exhaustively complete and that all of them are to some extent conditional, we, nevertheless, on the basis of clinicopathologic peculiarities, have reduced all varieties of the explosive trauma into two groups with common pathogenesis features, but different in character of dominating morphofunctional disorders: 1. Explosive (mine) wounds are the result of a person direct interaction with injuring impact, inflicted by all/or major factors of ammunition explosion in open terrain. For contact detonation, the combination of explosive extremity avulsion and destructions with mainly closed craniocerebral trauma and closed damages or wounds of internal organs, torso, and head is the most typical. If wound has resulted from detonation of a mine, it is possible to consider a mine wound. If a trauma has occurred because of a short distance explosion of the other ammunition, it is appropriate to mention an explosive wound. 2. Multiple or combined trauma, inflicted on the armor-shielded personnel, which is positioned on the top or inside of an armored vehicle or on the victims of terrorist acts, protected with structures or buildings, is termed as explosive damages. Exposure to the major injuring factor, which in this case is mainly an blast (seismic) wave, causes mainly closed and open damages of the locomotorium (multiple splintered fractures, bruises, dislocations) and internal organs, combined with general commotiocontusional syndrome. When the reason of the mediated explosion of personnel is a landmine or a mine (as a rule, antitank), it is possible to speak about mine damage. The question on classification principles concerning explosion injuries in specific naval conditions warrants a special discussion. The whole variety of human injuries in explosions in special conditions of naval combat can be divided into the following 3 groups (Fig. 3.4). I. Ship explosive trauma the most considerable and multifaceted damage character constituent of a naval explosive trauma. Firstly, it is related with the vast majority of losses in navy occurring when the ship crew is hit. When a ship is blasted with a mine or torpedoed, it leads to a single-stage and mass occurrence of victims requiring surgery. II. Explosion injuries from underwater explosions. When in combat during a naval battle, a significant quantity of seamen can be overboard and receive specific damages resulting from ammunition explosions in the water environment. III. Mine wounds resulting from antipersonnel mine demolitions in shallow-water is as much as specific explosive trauma too, which considerably differs from similar damages
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on land by its characteristics. It is typical for assault troops crossing an anti-landing defense zone in the shallow-water during landing on the coast.

Fig. 3.4. Explosion injuries types in the navy Mine wounds resulting from anti-personnel mine demolitions in the shallow-water Substantial evidence in the literature suggests that initial conceptions about "torpedo" or "deck" fractures as a basic and almost unique difference of an explosive trauma in the navy are rather simplified. Experience of first aid to seamen in two world wars, specially designed fundamental and experimental studies, engineering analyses and generalization of the rescue operations experience at sea suggest that the ship explosive trauma is the collective concept including various types of combat damages, as a rule, serious. They have common occurrence conditions, which in their turn, have determining influence with a trauma. Impact of an explosion under the ship bottom of a ship on a crew depends on many factors: depth of a sea, bottom topography, explosive device capacity, size of a vessel, etc. Beside this, localization of a person on a ship at the moment of an explosion and a work pose of each member of a crew also greatly influence the character of damages. Remoteness from a coastal base, unfavorable weather conditions, lack of life saving equipment, acute psychoemotional stress and a panic, ship premises isolation, fires, a realistic possibility of freezing and drowning, limitations of medical service this is nowhere complete list of specific conditions and the factors forming peculiarities of a ship explosive trauma.

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First attempts to study losses amount and structure in the navy relate to the Russian-Japanese War, 1905-1907. A vast amount of losses resulting from the "uncertain" reasons come under notice. These losses made 76% in Tsushima battle. A thorough analysis [Smolnikov A.V., 1941] has shown, that basically they were injured in explosions at ships and drowned soldiers. Even then principal causes of losses in explosions became clear: indirect impact of a blast wave, wounding by secondary injuring shells, burns, poisonings, drowning. Poisonings of seamen as a result of explosions and subsequent fires have been named by the French as the gunpowder illness. Immediately after an explosion a person is impacted with the upward shock acceleration impulse of a ship (a push). Experimental explosions of ships have allowed find a pattern: the less contact area of a person with a deck is, the more serious is the trauma. The impact received with straightened legs always proved to be more traumatizing rather than the one received with bent legs [Evenstein Z.M., 1961]. As noted before, it is very important where the person is located at the moment of an explosion, i.e. his remoteness from an explosion point. Influence of these additional conditions is extremely significant damages of crew members range from those incompatible with life to trivial bruises. Destruction force of the weapon always exceeded possibilities of combat injuries surgical treatment. The ship explosive trauma in this regard is extremely challenging problem in naval medicine and, first of all, in surgery, as overwhelming number of victims require surgical help. It is very difficult to predict amount and structure of surgical medical losses resulting from an explosion at each particular ship, which is caused by extreme variety of influencing factors. The explosive trauma of people in the water term is the concept which utterly specifies the subject. Turning back to the questions of the mine trauma classification, it is possible to draw the following analogy. According to E.A. Nechaeva's et al. (1994) suggestion, the whole variety of explosion injuries can be divided into two types: mine damages occurring at the indirect non-contact mechanism of injuring (1); mine wounds that occur at the direct contact of a person with an explosive device(2). Taking in the consideration specifics of naval combat damages, the first type of MT, mine damages, can be viewed as identical to a ship explosive trauma. In both cases, as a rule, crewmembers (of armor in the first case and of a ship in the second case) receive damages indirectly. Injuring factors of an explosion have an effect not directly but through the elements of an armored vehicle or a ship. Assuming this, it is necessary to consider, that regarding
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complexity and variety the ship explosive trauma should be viewed as a more complex type of damages, as mentioned earlier. The case is considerably more difficult when drawing analogies to contact mine explosions. Nevertheless, even in specific naval conditions there is a possibility to separate mine wounds (in the shallow-water) as well as explosive traumas received by people in the water, which result from underwater explosions. The main distinguishing characteristic of these specific damages is that the medium, transferring explosion energy is the water, which by density and other physical parameters is similar to human tissues. According to Professor B.V. Punin, who analyzed the experience of surgical treatment in Soviet Northern Fleet in World War II, injuries from a blast wave, received by people in the water, were frequently enough observed during sea combat. He pointed out that the victims conditions in subarctic were much more severe than in the other regions climate. B.V. Punin emphasizes that the severity of a condition going with these traumas is connected to the shock taking place, and it was sharply aggravated by stay in cold subarctic water. Unfortunately, he was not able to determine neither the incidence of these damages, nor lethality rate according to reporting records. Particular severity of such victims condition in the North requires prompt anti-shock treatment, correct diagnostics and adequate therapy. According to P.P. Rybkin (1956) 5.3% of seamen, located on a deck at the explosion moment, are being thrown overboard by a blast wave. Many of them are exposed then to blast waves from explosions of bombs, torpedoes and ships own ammunition [Hara .S., 1989]. The blast wave in the water results in lethal damages at a distance three times greater from an explosion point than on land. When the blast wave reaches a medium with the greater density or a surface, it is reflected. Depending on force and an angle of diffusion, interaction of a falling wave and a wave reflected from a body and water surface creates the zone of excess pressure, which considerably exceeds an initial impulse. Aside from direct shock front impact on a human body, damages can occur also because of the specific physical phenomena of a layering and an implosion [Owen-Smith M.S., 1979; Adler J., 1981]. When the excess pressure front transfers from one medium to another with lower density, for example from a liquid to the air, the reactive reflection at the interface occurs, creating a local stress in a former denser medium. This phenomenon is called layering. It causes a fragmentation, an edema and a hemorrhage in lungs and walls of hollow organs containing air. The effect of a layering at the moment of blast wave transfer through hollow organs can be supplemented with the phenomenon of an implosion when
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initially air bubbles are instantly compressed and then they expand releasing the absorbed-incompression energy and, hence, causing an explosive effect. The phenomena of implosion result in ruptures of mucous membranes, hollow organs walls hemorrhages, varying in intensity. Accomplishing set military tasks, Navy forces can face the problem of a special explosive trauma type occurring when the enemy shore defense zone is landed forced. The matter concerns contact mine explosions in the shallow-water. The task of shoreline defense is especially important for countries with extended sea borders. NATO experts consider that a war at its origin will be characterized by armed conflict from the sea against the continent. In this connection, it is supposed that amphibious landings, as well as a shoreline defense, are among basic interdependent tasks of the NATO forces. The urgency of this problem fully belongs to the medical service of Armed Forces, first when providing amphibious operations. When scrutinizing these questions closely, it becomes obvious that the urgency of an issue and the degree of its development contradict each other. First, this is reflected in extreme lack of literature on the medical provision, losses structure and character during amphibious landings, especially with a background of relative abundance of tactical studies [Zhurkovich K.YA., 1958]. At present, an injuring effect of modern antipersonnel mines, unintentionally or deliberately placed in shallow-water (mine installation on a shelf, outwash of mines into rivers and lakes, flooding of minefields etc.), is virtually unaddressed. Insofar, authors have considered that it will be timely and actual to look into the specified aspects of the problem.

3.2. STATISTICS OF THE COMBAT EXPLOSIVE TRAUMA

Published data convincingly indicate that in wars during XX century the portion of victims who were injured by small arms and machine-gun fire (bullet wounds) have steadily decreased and the amount of victims, injured by explosive ammunition, increased. During the World War II use of the latter was exceptionally frequent and various. For instance, German army used following kinds of weaponry: canons with the total weight of shells ranging from 115 g to 1020 kg; mortars, using artillery shells-mines weighting from 910 g to 149 kg; rockets weighting from 3 up to 127 kg, FAU-1 and FAU-2 missiles weighting up to 13 tons; hand, pistol and gun grenades; land mines for minefields and other purposes; sea mines, torpedoes and depth-charges; air dropped bombs weighting from 1 kg up to 11000 kg, and also guided air bombs [Ivashienko G. ., 1963].
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In general, during the World War II anti-personnel mines wounds made .7% out of all foot damages cases, however among foot wounded victims, situated in the specialized hospitals of Leningrad, their share mounted to 1.1% [Epstein G.YA., 1944]. Over the years of the war, the specific weight of serious foot traumas has increased more than twice. We have not found in the literature any data on proportion of other segments mine traumas in the structure of gunshot traumas of extremities. According to Yu.G. Toronov and V.I. Fishkin (1988), in the beginning of a century, during the Russian-Japanese War mine traumas hardly made more than 20% of all combat losses, but in seventies, during operations in the Middle East more than 80% (Fig. 3.5). Similar trends were established in studies, addressing the frequency of a mine trauma. According to the data of American sources, combat casualties resulting from mine explosions during the World War II and the war in Korea have made .0%, in Vietnam in 1968 1.46% [Hardaway R. ., 1978], and in 1970 3.91% [Sunshine I., 1970], while fragmentation wounds reached 5770% [Rich N. ., 1975]. Since many authors, when using mine injuries term imply not only the impact of injuring factors in the zone of a blast wave, but the impact of fragments as well, the amount of such damages during the Arab-Israeli War (1973) have made 85% [Spaccapeli D. et al., 1985] and 80% during the British-Argentine conflict [Shoulder P. J., 1983]. Some authors consider the frequency of mine injuries to essentially increase when defensive operations and guerilla war are waged, running up to 20-42% [Johnson D. E. et al., 1981; Traverso L.W. et al., 1981]. The data on the frequency of explosive injuries caused by various explosive devices in closed premises and streets, used by terrorists of Northern Ireland, are noteworthy. According to authors, they reached 25%, including killed and extremity avulsion injuries victims [Brismar ., Bergenwald L., 1980; Owen-Smith M. S., 1981]. Due to design evolution of demolition munitions and improvement of their injuring capabilities, the range of mine injuries severity has extended and they became more diverse. According to the statistics of some authors, the number of extremity avulsions reached 79-90% of traumas cases resulting from antipersonnel mine explosions. During wars in Laos, Thailand and Vietnam the hip avulsion in the general statistics of lower extremities explosive traumas occurred rather often 4-8% [Hardaway R.M., 1978; Traverso L.W., 1981; Dougherty, 1990]. Multiple fragmentation wounds of a contralateral limb and other body segments made the majority. In the Arab-Israeli conflict (1973) a small part of tanks (5-10%) was incapacitated by mine ammunition. At the same time 70% of injured tank crewmembers had a blast injury combined
45

with burns [Rignault, Dumige, 1981; Dougherty, 1990].

Fig. 3.5. The ratio of sanitary losses caused by explosive ammunition to sanitary losses caused by small arms in wars of XX century (quoting: Thoronov Yu.G., Fishkin V.I., 1988) According to the official statistical data, since 1984 a qualitative shift in the sanitary losses structure of the Soviet Forces in the Republic of Afghanistan has taken place. Since this period the overwhelming majority of wounds turned out to be fragmentation (6.4-7.5%). Most of traumas were multiple and combined (5.4-7.8%). At least a half of victims arrived in a serious and extremely serious condition. It is important to emphasize that during the undeclared war years the increase in the share of multiple and combined traumas (fourfold) and in the share of serious and extremely serious wounds (twofold) has taken place mainly due to a mine trauma, reaching 25-30% of all traumas (Medical services of 40-th Army. 1991). In the army of the Republic of Afghanistan during the the mine war peak (1984-1987) the number of mine weapons victims appeared even more significant up to 30-45% [Nechaev E.A., etc., 1991]. The unprecedented wide usage of mine weapons became one of the distinctive features of Afghanistan war. Relying on broad use of mine weapons, conflicting parties attempted to solve both tactical and strategic tasks through the entire war. In the mine war mujahadeens objective was not to inflict maximal irrevocable losses to the enemy, but utmostly inflict injuries on personnel. Even if the personnel death is not achieved, they never return to the ranks due to the wounds and complications even after lasting and complex treatment, extensively using efforts

46

and facilities of medical service. The mine trauma in the second period of Afghanistan war became dominant in the structure of combat sanitary losses of a surgical profile. For military medical service of the Republic of Afghanistan army it took on special significance not only because they faced an unheard-of in previous wars rise of its share in the gunshot wound volume, but also on account of more complex, extensive and combined destructions of human body tissue structures causing development of serious and frequently fatal homeostasis disorders. These injuries explain high proportion of lethality and invalidization of personnel, particular complexity and duration of victims treatment, and sharp increase in the treatment cost and material resources consumption. To substantiate this, we may present data concerning losses from mine weapons in the National Defense forces of Afghanistan. If within the first two years of war (1979-1980) the mine trauma in the structure of combat sanitary losses was practically absent, then in 1984-1987 it has already made 27-30%, and particular months and at particular operative theaters it became a prevailing kind of combat surgical pathology (Fig. 3.6). Typical gunshot wounds and fractures inflicted by bullets and fragmentations became less frequent. It proves better than anything else does the absence of continuous and indirect engagement contact of the opposing parties.

Figure 3.6. Dynamics of mine-explosive trauma in the Afghan Government Forces Usage of minefields at the supply routes of troops in Afghanistan sharply increased within 19841988. The arsenal of mines and demolition munitions expanded as well. Mutineers laid mines on the routes of troop movement beforehand or when combat and transport vehicles approached
47

places, convenient for mine installation and attacks with small arms. Taking into account, that at that time there was no the unified generally recognized classification of the mine trauma, it was accepted as appropriate to specify two subtypes of the mine trauma from the etiopathogenetic and treatment-and-tactic points of view: mine damages and mine wounds, with not only similar injury character, but also demanding treatments of the same kind (Fig. 3.7). As mine damages ( MD), in the Republic of Afghanistan army were regarded all human body traumatic damages with the body is protected from the direct impact of mine ammunition injuring factors by motor or armored vehicles. Mine damages, comprising one group of MT, represented mainly closed wartime polytrauma, which with massive use of explosives by confronting parties was claimed to become an independent type of combat surgical pathology. Due to mechanogenesis features, mine damages represented the plural or combined trauma distinguished by similar occurrence mechanism and significant severity of a victim general condition. In the MD development pathogenesis, the manifestations of the general commotiocontusional syndrome became tremendously important.

Figure 3.7. Mine-explosive trauma distribution in the Afghan Government Forces Under mine wounds (MW) we classify specific gunshot wounds, which occurred as a result of direct (contact and non-contact) impacts of mine ammunition explosion major factors on a human body. All mine wounds resulting from a contact interaction with the mine weapons, and the most of them resulting from a non-contact explosion, are characterized by multiple and combined open damages, extensive and deep destructions of the human body tissues structure, significantly grave

48

victims condition: Until recently, peacetime clinical practice had no analogues of mine wounds. In the general structure of the mine trauma they were a leading pathology, making 4/5 (8.7%) . Main mine wounds groups are: avulsion and gunshot crushes of extremities segments (47%), among which MW most frequently were localized at a lower leg level (6.2%) and a foot (2.4%), then a femur (.3%) and at various levels of upper extremities (.9%); multiple wounds of soft tissues with isolated gunshot extremity bones fractures (1.4%); multiple gunshot extremities bones fractures (.6%); isolated soft tissues wounds (2.7%). At the final stage of the war, in 1986-198. a share of mine damages has slightly increased from 1.3 up to 1.5%. Within last three years of the war, just before a withdrawal of the Limited contingent of the Soviet forces, the mine trauma became a dominating pathology in the structure of sanitary surgical losses. However, all military experts, and, first, medical aid providers and surgeons showed concerns. The matter of concern was not so much for the fact of mine trauma frequency increase, but rather severity and extensiveness of human body tissues destruction, complexity of diagnostics and medical care, drastic frequency and severity increase of wound infectious complications and the rise in consumption of ligature, transportation splints, medicines and other medical supplies. Moreover, by large-scale application of the mine weapons, the military opposition tried to achieve series of tactical tasks, directly relevant to medical care problems and additional recruitment for the army in general. The opposition relied on the fact that mine ammunition provided substantial percentage of irrevocable and sanitary losses. The majority of injured with the mine weapon was decommissioned after long-lasting and complex treatment. Thus, the presented data convincingly indicate that the war in Afghanistan was the last war in the contemporary history with large-scale and prolonged use of the mine weapon and explosive ammunition, especially when Soviet Forces were stationed on its territory. The data of the Table 3.2 demonstrate the scale of this war.

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Table 3.2 The scale of the mine war in Afghanistan in 1980-1988 Character of the mine war Removal of mines, installed by the Afghani military opposition during eight years of war 1. Mines and demolition munitions detected and disarmed 2. Mines and demolition munitions captured in warehouses 3. Removed: anti-personnel mines anti-tank mines demolition munitions Use of engineer mine ammunition by SFA to protect garrisons and guard posts (as of August, 1988) 1. Minefields installed 2. Minefields lifted in connection with withdrawal of troops 3. Minefields passed over to Afghanistan 4. Minefields temporarily kept Rise in mine war intensity 1. Mines and demolition munitions detected and cleared in 1980 in 1982 in 1983-1987 (annually) in the first half of 1988 2. Mines and demolition munitions swept on a 900-meter section of the Gardez-Host road in February, 1988

Quantity 24.000 18.000 1.000 3.000 about .000 .131 .518 100 about 500 .065 .118 .000-1.000 1.826 .100

3.3. EXPLOSIVE TRAUMA AS A MAJOR PROBLEM OF MODERN SURGERY 3.3.1. Injuring factors of explosion and their action on a human during unshielded demolition
Only having clear insight in the physics law of explosion, it is possible to understand the nature of structure functional derangements occurring in a human body during explosions Since these laws were unknown a long time, questions of a human explosion injuries pathogenesis were not covered with appropriate scientific studies for many years. Nowadays, explosion physics is explained in encyclopedic editions [Kuzin M. I. et al., 1976] and monographs [Pokrovskij G.I., 1960; 1980; Baum F.A. et al., 1975] in the form, comprehensible for a physician. The theory of explosion factors injury impact on a human and animals is also rather completely covered in domestic and foreign military-medical literature [Nifontov B.V.,
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1957; Chesnokov P.T., Kholodny A.Ja., 1970; Morozov V. et al., 1975; Mouden et al., 1986; Stumille. et al., 1991]. At the same time, in spite of numerous publications, many mechanogenesis and mine trauma clinical presentation character aspects remain disputable or obscure. However, the limits of this edition stipulate considering only well-established scientific data that allow better comprehension of those many-sided pathomorphologic and pathophysiological derangements, which occur in a human body at the moment of mine explosions. An explosion is an impulse exothermic chemical process of reconstruction (decomposition) of solid or fluid explosive molecules with their transformation into explosive gas molecules. The high-pressure center is formed and large amount of heat is released. Process of decomposition can transgress slowly by deflagration, when an explosive is heated layer-by-layer due to thermal conductivity, and fast by detonation, i.e. due to formation of a compression wave (blast wave). If the rate of the first process is measured by centimeters, sometimes by hundreds of meters per second (for gunpowder 400 m/s), then the rate of explosive decomposition due to detonation is measured by thousands of m/s (from 1000 to 9000). Rates of deflagration and detonation of different explosives are constant. Features of impulse explosive decomposition are assumed as a basis for their subdivision into propellants (powder), initiators and high explosives. Depending on the force and character of external influence, some explosives can both deflagrate and detonate. While an explosive is decomposing, the rate of explosive gases release greatly exceeds the rate of their dispersion. Originally, the total released gases volume approximates to the volume of a charge, which explains a huge jump in pressure and temperature. If, in the combustion process the gases pressure can reach several hundreds MPa (on condition of closed space), then in the detonation process it reaches 20-30 GPa and the temperature several tens of thousands of centigrade degrees. Pressure of explosive detonation products in a jet stream can reach 100-200 GPa (1-2 million atmospheres) at the travel speeds up to 1.7 km/s. No medium can withstand such pressure. Any solid object getting in contact with an explosive starts to splinter. Up to a certain distance, explosive gases preserve their destructive properties due to high speed and pressure. Then their movement is rapidly slowing down and they cease their destructive action. There are data that the piston action of gases occurs until their volume reaches the 20004000-fold volume of a charge [Pokrovskij G.I., 1980]. However environment disturbance continues and bears mainly blast-wave character.
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From the energy viewpoint, an explosion is characterized by release of a significant amount of energy during very short time and in confined space. The part of explosion energy is first spent to rapture the munitions shell (conversion in fragmentations kinetic energy). Approximately 30-40% of the released gases are spent to form a blast wave (areas of compression and underpressure of an environment with their distribution from a shot point), light and thermal radiations, to move environment elements [Spaccapeli D. et al., 1985]. In some publications heated gases effluxes and high flame temperature are ranked among injuring factors of explosion, which, most likely, are to be considered as merely indispensable components of a blast wave of the heated explosive detonation gaseous products. Explosion gaseous products during their expansion perform three basic forms of external work according to which three actions are distinguished: high-explosive (brisance), demolition, incendiary [Dorofeyev A.I. et al., 1968]. Brisance (high-explosive) is HE ability to a local destructive action expressed in a destructive impact of explosion products on subjects surrounding a charge. The brisant action of an exploding charge in fragmentation demolition ammunition is aimed mainly on steel case crushing; Demoliton is HE ability to a destructive action due to expansion and distribution of explosion products in all directions of a blast wave. The demolition action of ammunition depends on explosive charge HE weight, its efficiency and target remoteness from a point of explosion. At a short distance (up to 10-15 charge radii), a demolition action is caused by effect of expanding explosive gases, and their approximate damage radius can be calculated by the following formula [Pokrovsky G.V., 1980]:

R (0.5 0.75)3 ;
where R is a damage radius; is HE weight in kg. When increasing distance from an explosion point the demolition effect is caused by a mutual action of HE detonation gaseous products with a shock wave formed in an environment. After a degeneration of a blast wave into acoustic wave, pulsed noise is the only factor having damaging impact on a human. The wave of gaseous detonation products possesses explosive and contusing damaging effects on body tissues, causing bruises, ruptures, layering, hemorrhages and abrasions. The directional movement of explosive gases has the most dangerous effect, which can be observed even at

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distances approximately tenfold bigger than a charge radius. The skin is being destroyed by explosive gases at the distance of two HE charge radiuses. Explosive gases damaging action terminates at a distance of 20-30 charge radiuses [Pokrovsky G.V., 1960; 1980; Molchanov V.I, 1964]. Along with explosive gases, incomplete combustion products and unexploded HE particles scatter, which are present in large quantities especially in explosive devices that do not have a rigid case. The smallest HE firm particles penetrate into a body, causing fuliginosity and burns. They also have a toxic action. A chemical action is caused mainly by carbon oxide, which is abundant in explosive gases. Penetrating into destructed tissues, it produces carboxyhemoglobin. Explosion carbon soot impregnates superficial layers of epidermis and is precipitated on wound surfaces. In some cases of mine explosion, mainly in the confined space, especially serious damage can result from the secondary burns and toxic action of inhaled gases (. CO, HCN, NO, etc.), which caused some clinicians to treat the explosive trauma as the combined injury [Kosachev I.D. et al., 1989]. This conclusion can be illustrated with the well familiar explosion in Moscow in the underground passage on Pushkinskaya Square on August . 2000. Instant formation and propagation of explosive gases and HE detonation products causes a powerful percussion in an environment. Depending on a medium physical character, different types of a blast wave are distinguished air, water, in the ground and in other solid mediums (so-called "seismic blast wave"), in biological tissues as well. Blast wave destructive power mechanism studies have a rich history. Back in the World War I the significant amount of lethal outcomes was registered among soldiers, situated closely to exploding shells and mines but suffered no any considerable external damages [Owen-Smith M. S., 1979]. That and later time experimental studies [Hooker D., 1943] have shown that small animals, located at close distance to an explosion were killed, moreover, this distance was much longer in a water. All animals appeared to have lung damages, exhibiting as plural hemorrhages. Larger animals survived under the same conditions of experiment. In 1939 three assumptions describing lungs damage mechanism were made: alveolar pressure drop on account of change of pressure, leading to capillaries break in alveoluses; lung tissue stretch; blast wave impact on a chest wall.
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In 1940 Zukerman, and later P. L. Krohn (1942) and J. 1medson (1949), revealed the reason of lungs damage. Placing animals at different distances from a detonation site, they have defined specific sensitivity of animals to blast pressure change. Thus, under a pressure of 34 kPa there were no damages. Small animal (rabbits) were killed instantly under a pressure of 342 kPa and all animals were killed under 685 kPa. While there were no external signs of an explosive trauma, an autopsy has shown hemorrhages in lungs, ranging from microfocal to merged. Same damages were observed in other inner organs and in upper trachea submucous membrane. All animals appeared to have an eardrum broken. Carried out experiments allowed to conclude that intracavitary damages occurred under blast overpressure impact on a chest wall instead of rarefaction impact. Further experiments were aimed to define pressure levels, causing damages in the most blast sensitive organs. It has been found that 50.0 % of animals have had eadrum rupture caused by a pressure of 97.8-103 kPa [Owen-Smith M. S., 1979]. Humans also have been noted to have the same damage probability under a pressure of 100 kPa. Threshold pressure causing lung tissue damage amounted to 200-345 kPa [Owen-Smith M. S., 1979]. In addition, American experts noted that in the confined space under blast waves series impact the overpressure threshold level can be five times less. When carrying out experiments with animals, Desaga [Owen-Smith S., 1979] has proved that the unilateral pheumothorax protected an apneumatic lung but at the same time, the opposite lung was exposed to damage. While studying blast wave impact on animals Benzinger T. has carried out experiments with a plaster protection of a chest and a stomach. Although having a tracheostome, animals have been noticed to have no lung tissue damages. At the same time, the mechanism of lungs blast damage is not quite clear until now. It is presumed that intrathoracic pressure peak level, the rate of its rise and the rate of thorax deformation have certain importance. American personnel intrathoracic pressure research with a piezosensors inserted into an esophagus has shown that it was identical with protective clothes (a body armor made of kevlar, 2.9 kg, a vest made of ceramic fibers, 6.4 kg) and an ordinary field jacket. In the explosive lung pathogenesis the quickly occurring inward shift of a chest wall is confirmed by optical microscopy data [Graham I., Cooper Ph. P. et al., 1983]. Abdominal cavity organs injury resulting from a blast wave impact in the air is observed far less frequently than lungs injury. Experiments have shown that the majority of animals were killed after receiving such damages. Morphological changes, namely hemorrhages and perforations were localized at gastrointestinal tract sections with gas [Owen-Smith M.S., 1979; 1981].
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Further blast wave effect experimental studies have enabled to look into the neurologic disturbances mechanism. J. Graham et al. (1983) and U. Freund et al. (1980) works have ascertained that CNS changes result from the air embolism, caused by lungs damage. The air embolism has been proven to occur only in arteries, which is its main difference from the caisson disease syndrome; moreover, the air comes into the blood circulation system from damaged lung tissues through pulmonary veins. An autopsy has shown that the animals killed right after explosion had signs of the coronary arteries and a brain air embolism, and those who lived a little longer had focal cerebral signs. The possibility of animals life rescue was successfully proved by their positioning into increased pressure medium (3 atm.) followed by slow decompression. A conclusion has been made that the coronary arteries embolism is not the unique reason of lethal outcomes, however the elaborated air embolism theory substantially explains the mystery of victims sudden deaths. The blast effect mechanisms are studied most profoundly. Expanding explosive gases almost instantly displace equal air volumes. As a result, in the center of explosion the pressure, density and temperature increase very rapidly. The special sort of disturbance occurs in the air, expanding with supersonic velocity in all directions from its excitation point. The dense layer of compressed up to several thousand kPa air propagates from an explosion origin in the form of quickly expanding ball or a hemisphere (depending on an epicenter location relative to the ground surface). In the certain point of space, which the blast wave traverses, the increased pressure remains only for a short time (ten-thousandths or thousandths of a second). The next moment, the pressure in the given point drops below a normal level for a time interval measured by thousandths or hundredths of a second. In that way, a blast wave forms its positive (a compression zone) and negative (an underpressure zone) phases. The air blast wave positive phase expands eccentrically, while the negative phase expands concentrically. Any surface, exposed to a blast energy impact is subjected to positive and than negative pressure. The compression zone front is known as a blast wave front, and its overpressure ( inflicts a contusional trauma. Energetic potential of a negative pressure zone is the lowest ( does not exceed 20-30 kPa when falling smoothly) and consequently cannot pathologically influence a body.2 As a blast wave moves away from an explosion source, its intensity rapidly decreases due to wave energy absorption by gas heating in the area, beyond the wave front (straight behind an air

55

blast wave front the air temperature can rise by several hundred degrees). As the pressure in air blast wave decreases the compression phase duration lengthens, with this two parameters being commensurable [Edberg et al., 1978]. Air blast wave physical properties differ significantly from better studied acoustic waves. The latter represent consecutively repeating medium condensation and rarefication, propagating with rate of 340 m/s without air mass transfer. The pressure of even the strongest sounds does not exceed one-tenth of an atmosphere. Unlike the acoustic wave, the overpressure of a blast wave can reach several thousand kPa and speed of wave propagation reaches 3000 m/s. Air blast wave propagation is connected with air mass transfer, being the basis of its dynamic component. The force of originated wind will constitute the dynamic pressure. Anecdotic cases of peoples survival at close shells and air bombs explosions during the World War II were possible to explain only by air blast wave whirls and vortices existence, forming secure areas [Chalisov I.A., 1957]. Peak pressure levels can be achieved instantly (in the open space) or gradually (in the confined space) that can be a crucial point defining the injury severity of a human. For instance, when an air blast wave advances through tunnels and trenches the explosive injury outcome depends on a degree of blast wave reflection from one or the other wall or is defined by propagation rate difference in the center and on the edges of a trench (due to the funnel-shaped extension of an air blast wave front). This, by no means comprehensive, list of various external conditions influence on a humans injury, as inflicted by a blast wave, demonstrates the significant conditional character of calculations with incomplete data, for example, data on the force of explosive device and a distance from an explosion point. This also explains reasons of an exceptional variety in MT individual severity for different people injured with one explosion. In general, the air blast wave impact on a human is a complex process. When studying this process, it is common to consider the effect of following parameters: (a difference between normal pressure and the blast wave front pressure); the pressure difference value in the blast wave front and behind (i.e. the wave form); the dynamic pressure effect in an air blast wave front; blast wave effect duration (t, ms). However, the basic air blast wave injuring effect is considered to depend on the rate of maximum increase, i.e. on a blast wave impulse. This kind of statement is illustrated quite figuratively in literature: a blast wave impacts a target not as
2

Foreign military medicine. Info. bulletin, #1. L., 1989. P. 29-35. 56

huge press, but as a abrupt stroke of "cudgel" or a giant fist [Gershuni G.V., 1946], and, to be more precise, as a firm subject with a wide striking surface. This effect is clearly shown when an air blast wave acts in the apertures projection of rigid barriers placed on the way to a target: tissue damages remind squashing with a firm object. Depending on the maximum increase rate, the instant rise of an air blast wave impulse (in the open space) and gradual (in shelters and armored objects) is separated. In addition, overpressure injuring levels are utterly different [Morozov V.N. et al., 1975]. It is common to consider that in case of a instant increase, a blast wave with 100 kPa possesses unconditionally destructive effect. Its smaller values (according to different data from 20-30 up to50-60 kPa) can possibly still lead to the acoustic trauma. threshold causing lung tissue damages is the overpressure of 200-345 kPa [Owen-Smith M.S., 1979]. threshold levels for closed spaces are less by a factor of 5. As increases not only the risk of serious contusions rises but the gap between values causing damages of various severity is reduced. Insofar, the gap between value which is associated with 1% of lethality (approximately 3-4 thousand kPa) and the one leading to 100% lethality is very small [Buffat, 1988]. Such short range of entirely lethal levels and those, which are comparatively endurable, is one more explanation of the exceptional diversity in MT severity of the same crewmembers in a hit armored object. As experimental studies confirm, contusional damages received by animals, standing at the moment of explosion, as expected, turned out to be more severe in comparison with those which at the same moment were lying. As animals mass increases, their resistance to a blast wave impact grows [Buffat, 1988]. Blast effect tolerance of an organism increases when impulse duration prolongs according to some data up to 100 ms and other up to 400 ms. Further positive impulse effect time increase at constant values does not cause injuring effect increment. Significance of impulse duration can be demonstrated especially clear by the examples of injuring blast effect when conventional and nuclear ammunition explode. For instance, during shells and air bombs explosions when the duration of an air blast wave positive phase impulse varies from 1.6 up to 10.0 ms, the following events happen in the radius ranging from meters to several tens of meters: animals perceive the 20 kPa value as acoustical stimulation with no mechanical damages signs, 20-30 kPa pressure results in the eardrum damages, 100 kPa causes serious traumas and 200 kPa caused death of animals [Beritov I.S., 1944]. During nuclear
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explosions, when the time of an air blast wave positive phase is increased hundred fold, of 20-40 kPa can cause serious and lethal injuries in humans and animals within the radius of several kilometers. Unlike the investigated varieties of instant maximum increase, when it increases gradually the organism resistance is much higher. Thus, proceeding from materials of foreign experimental studies with dogs, rats and mice, the time of increase to a maximum ranging from 500-600 ms to 1.000-4.000 ms, there are no lethal outcomes even at =.300 kPa, and maximal lethality (90100 %) occurs at .600 kPa [Buffat, 1988]. Considering all evidence, one can suppose that the direct impact of a "leaking" blast wave in armor even with high pose no serious threat to a crew, if an air blast wave "leaks" through small apertures or there is a rigid barrier on the way of a compressed airflow. The primary (passive) reaction of a body to any external mechanical action including a blast effect is always tissues deformation by mechanical forces. Without knowledge of mechanical reactions, it is impossible to explain quantitatively how subsequent physiological reactions or either tissue structures damage occurs. In fact, the mechanisms of a human and animals injury by an air blast wave include several moments: 1) the direct or indirect impact; 2) missile effect; 3) acoustical stimulation effect [Spaccapeli D. et al., 1985]. In order to understand the pathology mechanism of a direct injuring blast effect it is important to consider that the time of its positive phase action (compression) at conventional ammunition explosions is significantly less than the period, corresponding to a target natural frequency, which is 50-150 ms (e.g. equals 4-8 ms for ammunition with 10 kg charge). Therefore, the process of a blast wave interaction with an unstable object should be regarded to as a hit of elementary target, which is subdivided into diffraction and quasistationary flow stages, or in other words stages of body immersion into a blast wave and blast wave flowing around a target [Nekliudov V.S., Stepanova N.P., 1966]. Stage I from the moment of the blast wave front contact with a human body up to the moment of the full body immersion in a shock wave is characterized by a value in the blast wave front. Initially the body surface directed to an explosion a compression shock occurs, which 2-8 times (!) higher than the blast wave front pressure. As a result, human being experiences total frontal or tangential impact and entire body concussion. An overload shock value can reach hundreds of G. Simultaneously, a blast wave due to its high frequencies spectrum prevalence
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easily penetrates into a body, generating the complex system of longitudinal, transverse and surface waves. The propagation speed of these waves is close to acoustic speed in medium with some density or other. The resonant frequencies of various body segments are different, but all of them are confined in the range of 4 to 6-10 Hz. Proceeding from tissues biophysical characteristics, longitudinal compression waves become more or less considerable at frequencies more than 1.000 Hz. At lower frequencies, the mechanical energy travels in the transverse shear waves form. At very low frequencies (less than 100 Hz) the wavelength becomes bigger than a body size. In this frequencies range, the blast wave propagation process is characterized by the transformation f elastic potential energy into the kinetic energy of localized mass [Gierke H., 1964]. The abovestated allows concluding that transverse shear waves in a human body due to body basic mechanical characteristics will occur because of blast waves with frequencies from 100 to 1.000 Hz. According to the published data the very same frequency characteristics are registered in a human body, as caused by explosions for example, in lungs the 400-500 Hz waves were excited [Gierke H.E., 1964]. Blast waves, propagating in a body through inhomogeneous media and histostructures cause three kinds of damage effects: splitting, inertial and cavitational [Edberg et al., 1978; Sharpnack et al., 1991]. Splitting effects are caused by the stretching forces caused by a blast wave reflection, diffraction and interference at the borders of tissues with unequal velocity. It is fair to say that in the domestic literature this effect for the first time was addressed in detail in the publication of L.N. Aleksandrov and E.A. Dyskin (1963). Inertial effects consist in velocity gradient formation in the neighboring tissues and organs areas, which have different mass and specific density. It results in body structure destruction due to a difference in g-stress overloads in tissues in the neighboring parts. Cavitational (implosion) damages mechanisms are caused by the abundant heat release and gas vesiculation in body fluids when air blast wave energy is instantly absorbed [Edberg et al., 1978]. Diffraction phase total duration, considering the air blast wave supersonic velocity, is negligibly small (the tenths of ms), however, as it was already mentioned, shock loads at this moment are extremely big. Stage II represents hundreds-thousands of times longer and more stable process, which takes the whole positive compression stage. During this period, a human body is exposed to the primary influence of a dynamic wave pressure.
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A body surface, facing an explosion point is subject to a pressure equal to the sum of the reflection pressure and the dynamic pressure, lateral surfaces are subjected to a pressure equal to in the blast wave front, a surface counter to explosion even lower pressure. The pressure difference originates the displacing force parallel to the ground surface and directed contrary of an epicenter. There is also a force difference in blast of a body from above and from below with a compressed air stream, hence leading to a lifting force forming. Because of a complex forces combination a resultant force, directed upwards and in all directions from an explosion point. Considering that the dynamic pressure nearby the explosion point approximates to , a human in this zone can be thrown several tens of meters distance by an ammunition explosion. For comparison: the hurricane force wind achieves of 17 kPa at the impulse duration of 54 ms [Edberg et al., 1978]. Injury severity is defined by a momentum, which is transmitted to a body by the air blast wave "wind" flow. The action of the latter, in its turn, depends on a so-called midsection of a target (body projection on a plane perpendicular to the blast wave propagation direction) [Morozov V.N et al., 1975]. The area of the standing human midsection makes 0.36 m. laying human being 0.125 m2. I.e. missile blast effect capacities depending on the body position can vary almost threefold. According to other data, these areas differ even more, making respectively 0.75 and 0.12 m2 [Kuzin M.I., et al., 1976]. The injury, inflicted by the air blast wave acoustic component in the overpressure damaging levels impact zone is not analyzed in the published data. On the contrary, the impulsive noises action after a blast wave has degenerated into an acoustic wave is traversed in detail. Impulsive noise is the propagation of wide-spectrum spherical elastic waves propagating with a sound, accompanied by a transfer of energy instead in the air. The acoustic attenuates in a direction away from a epicenter due to acoustic dispersion and absorption in the air. Impulsive noise key parameters are its intensity and duration. Depending on sound vibrations loudness and frequency levels, it may result in injury of an internal ear and an eardrum, impairment of consciousness. It is determined that an explosion is accompanied by an impulsive noise up to 150-160 dB, and the spectrum of deformation blast waves propagating in a body coincides with a maximum of ear sensitivity (1500-3000 Hz). This explains high ear vulnerability to explosions [Golovkin V.I., Glaznikov L.A., 1991]. Simultaneously with an injury of a person, an air blast wave destroying buildings, armor and other objects on its way accelerates their fragments up to the speed commensurable with an
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ammunition shell case fragments speed. Secondary injuring shells possibly including fragments of own damaged tissues are capable of causing the same damages as primary fragments [Molchanov V.I., 1961]. Thus, at the 120-ton TNT explosion in Arzamas the clinical course of registered glass fragments wounds (the design flying speed of glass fragments approximated 1500 km/s at the distance of 50 m from the scene of the accident) corresponded with the severity of typical fragmental gunshot damages [Anisimov V.N. et al., 1991; Botiakov A.G., 1992]. In the whole, all damages in a body resulting from the blast effect are commonly divided into primary, secondary and tertiary: primary damages result from the immediate blast wave impact on a body; secondary damages occur under the action of the objects actuated by a blast wave on a body; tertiary damages result from hits of a victims body, driven by an air blast wave, against neighboring objects, barriers, the ground, etc. [Spaccapeli D. et al., 1985; Buffat, 1988]. The proportion of these damages will depend on explosion kind and power, a distance from a epicenter point, a people protection rate and conditions of the air blast wave propagation (a relief, the presence of surrounding objects, a season, meteorological conditions, etc.). Thus, on the one hand, the injuring blast effect in a certain point of space is defined: by the character of overpressure changes, which, in its turn, is a derivative of ammunition capacity and design; by the distance from epicenter; by environment specific conditions and physical characteristics.

On the other hand the injuring blast effect is defined by a target resistance, i.e. by target mass, form, surface area, and by biomechanical and morphofunctional features of tissue structures and their correlation with surrounding objects. Along with damaging effect of HE detonation gaseous products and blast waves arising in an environment, at ammunition explosions explosive device fragments and parts units, detonators details and special injuring agents additionally included in ammunition take on special significance. Recently the theory of so-called fragmentation-bullet action was well developed. This theory includes ammunition fragmentation and conditions of injury by fragments. The fragmentation term covers the ammunition property of being splintered into the certain number of fragments. According to published data, the major part of fragments weigh from 3.5 up to 8.0 g, which enables them to store energy sufficient to injury a body at the distances exceeding the size of
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steel fragments .000 times and aluminum fragments .500 times [Pokrovsky G.I., 1980]. Fragmentation injury character and extent depend primarily on fragment kinetic energy defined by its speed and weight. Fragmentations forms and sizes, the striking surface area, fragmentation moving direction relative to the body surface and injured region anatomic structure peculiarities are also important for the surgical anatomy of injuries [Zhengguo et al., 1988]. Fragments in most cases cause wounds perforating, nonperforating and tangential. The fragments with a small speed (approximately 50 m/s), can inflict closed injuries bruises, fractures, raptures. Severity of injured men condition with fragmentation wounds is quite often inconsistent with the superficial tissues minimal morphological damages, which patients have. It gave grounds to some authors to assume that there are special reflexogenic zones in human and animal integument, and their impulsive stimulation result in "shock-producing" mental status changes. Depending on ammunition type, its tactics and injury conditions, effect of some above-listed explosion factors can become prevailing, and this, in the end, will define a mine trauma clinical variant. Within the air blast damage radius there can be two types of explosion injuries multifactor (blast injury in combination with other factors, primarily fragments) and monofactor (blast injury). This is related to the fact that modern ammunition (with fragmentation-demolition action) at explosions produces, as a rule, mapping fragmentation distribution. This situation is possible when a mine fuse is directly activated with a foot, when a mine explodes in arms at mine clearing or casual handling, and when a mine trip wire is touched with a leg in immediate proximity to a fuse (Fig. 3.8).

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Fig. 3.8. Mine wounds occurrence Wounds inflicted by shape charge grenades are worthy of special notice. Principles of shape charge jet cumulation and armor-piercing action can be demonstrated as follows (Fig. 3.9).

Fig. 3.9. The cumulation jet (shape-charge) illustration 1 detonator, 2 HE charge, 3 shell 5 shaped-charge jet, 6 pestle, 7 blast wave, 8 products of detonation The cumulation effect can be implemented by charges with a cavity (a hemisphere, a cone, a parabola, a hyperbolic, etc). Detonation products compression and acceleration of their movement along the axis leads to the formation of a so-called shape charge jet.

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Under the exposure to explosion products the metal coating implodes pressed out and turns into compact monolithic mass, which is known as a pestle and originates a shape charge jet. The jet is formed due to metal current adjoining to a coating internal surface, and the mass of metal turning into a shape charge jet on the average makes 6-20% of a shell weight. In the first phase, a pestle and a jet are integrated, however they move with different speeds. Pestle speed is 500-1000 m/s, while jet head speed can reach 1.000 m/s. In the second phase, the jet detaches from the pestle, and the jet temperature is 900-1000. When impacted with the jet, due to a high pressure the armor is pierced but not burnt through (fig. 3.10).

Fig. 3.10. The mechanism of explosive wounds by shape charge grenades

The injury of personnel occurs because of the shape charge jet direct impact, gas-detonation products high temperature, a bow blast wave and the fragments chipped off from an armor internal layer. Depending on the wounds mechanism by shape charge grenades, it is suggested to segregate

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wounded into three subgroups. Wounded soldiers, who received damages inside combat vehicles when the armor is pierced by the shape charge jet can be included in the first subgroup. Impact of the shape charge hot gas jet, vehicle damaged details and armor fragments in the closed space brings essential influence on the damage character and leads to irrevocable losses in the majority of cases. The second subgroup consists of wounded soldiers, who received damages near grenade explosions; the third subgroup includes wounded soldiers with damages, resulting from the direct grenade hit. We suggest isolating those, who received wounds at hand grenade explosions, into an independent (fourth) subgroup because of peculiarities of this category. Damages at the grenade explosion in a hand are more commonly presented due to an error at throw, and at grenade explosion under legs are less common. While the explosive wounds mechanism by fuses was studied (the fifth subgroup), it was noted that their distinctive feature in combat conditions is the prevalence of the damages inflicted to evade military service. They are characterized by absence of other hand, trunk and face damages, as these wounds occurred, as a rule, behind a shield. Out of a damaging blast effect, damages have, mainly, monofactor fragmentaion character. I.e. as a result of an explosion the wounds occur with such formation mechanism, which does not essentially differ from the typical gunshot (bullet) wounds mechanism (Fig. 3.11).

fragmentation and blast impact area blast area fragmentation impact area Fig. 3.11. Zones of mono-and multifactor personnel injuries formation at explosion of fragmentation-demolition ammunition In our opinion, in the mine extremities avulsions and destructions blast wave plays the main role. Flame and hot gas jets, mine ammunition fragments and secondary injuring shells while being

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obviously important yield to a blast wave in scale and depth of morphofunctional abnormalities and disorders in extremities tissue structures as well as in CNS and internal organs. The fact of biological summation of injuring factors of mine ammunition explosion, defining in their total ethiopathogenetic dissimilarity of a mine trauma from typical bullet and fragmentation wounds, is very important. The data are published concerning the mechanism of the blast effect on the locomotor system [Spaccapeli D. et al., 1983 are presented; 1985]. Authors have introduced the mine foot term, which means human foot damages entirety in the radius of the blast wave effect, as caused by the mine explosion. There are two types of damages opened and closed, related to direct foot contact with a mine as well as occurred at the blast wave impact through rigid barriers. In authors opinion, the open damages mechanism can be explained by the following sequence of events. The ultrahigh and reflected pressure, formed by an explosion, forms a very powerful united shock front on the encounter with an object. This being the case, most of energy either is spent to compress foot support structures or is converted into the kinetic energy, which defines the blast wave dynamic pressure. The aggregate of damages is considered to be defined by the explosive device type, HE weight and foot position when it touched the fuse. The character of damages, inherent to the antipersonnel demolition mines explosions is defined by the action of excessive and dynamic pressure, and for the fragmentation mines explosions by the additional impact of fragments. At the direct contact with EA a human can receive the avulsion of an extremity or its segment, extensive crateriform foot wounds and the plural open fractures. Penetrating into the wounds inflicted by the fragments, a blast wave additionally inflicts longrange tissue destruction. Specific dispersion of fragments, scattered as the shape of a cone defines typical topography of damages, which include avulsions or open fractures of the upper extremity bones directed to an explosion, fragmentation wounds of a trunk front, lower extremities, internal surfaces of upper extremities, and also face and neck which are slightly bowed at walking; damages of external genital organs, perineum and buttocks [Bronda F., 1949; Aulong J., 1955; Boucheron, 1955; Dudley H. A. F., 1968; Cutler B. S., Daggett W. M., 1973; Hillman J. S., 1975; Cornand L. et al., 1976; Owen-Smith M. S., 1981]. Severity of inflicted damages associated with hemorrhage and shock quite often entailed lethal outcomes even before medical assistance was rendered [Cutler S., Daggett W., 1973]. The theory of the unprotected person injury by the aggregate of near low-yield explosives detonation factors (within 10 radiuses of the charge geometrical sizes) in the systematized form have not yet been sufficiently explored.
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Individual statements do not allow forming a holistic view of mine trauma mechanogenesis at explosion on a mine in the open terrain. Well-known regularities of the human and animals injury by a blast wave in the air, water, or ground are not applicable here to the full extent. Comparatively low yield of anti-personnel mines (from 10 to 500 g of HE) results in the short radius of an injuring blast effect. The longitudinal axis of an injured persons body in the explosion typical situation is oriented perpendicularly to the overpressure front, therefore an impact is tangential. The area of the compressed air flow impact is also considerably smaller than at the explosions of air bombs and shells. Thus, the missile potential of dynamic pressure decreases. It is important too that the most sensitive to the blast effect organs (lungs, internal and a middle ear) at mine explosion are located in the opposite direction to an epicenter. Expressed views do not substantiate a common belief that the air blast wave plays a leading part in the pathogenesis of commotiocontusional syndrome which victims receive at anti-personnel mine explosions. In our opinion, at non-shielded injuries, inflicted by the contact or close explosion factors the tissue shock wave of deformation (compression and stretching) is formed. This wave is generated by direct gaseous HE detonation products impulse impact on an extremity and has the primary damaging effect in the body [Fomin N.F., 1994]. We have made such a conclusion according to the results generalization of the complex clinical-morphological studies, which have been performed with wounded and killed at mine explosions (75 cases), in full-scaled experiments on animals (40 dogs) and biologic objects (55 corpse limbs). As the experiments on animals have shown, a demolition 100 g charge of hexagen or plastit in mass (equal to powerful anti-personnel mine), established under a lope joint of the large dog suspended upright, throws a dog to the height of 3050 cm. However, the same explosion it is not capable to displace light objects (e.g., a boot), 50 cm being on distance from an explosive. It is obvious, that in the given demolition, the basic impact on a body is inflicted by the wave of gaseous detonation products. The major part of blast impulse energy, because of the big inertia of a body, is spent on the destruction of distal extremity segments, and smaller to excite shock wave oscillations of organs and tissues, development of shock accelerations and certain displacement of a body. Figuratively speaking, an anti-personnel mine demolition causes the victim not to be thrown upwards but, "being cut" from below, similarly to a tree, a bridge support or a building, and its body is exposed to powerful shock concussion.
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Performed multilevel complex studies using CAT, histological, ultramicroscopic techniques, and X-ray studied of the vessels and fiber clefts of the damaged extremity segments, allow to formulate some general laws of tissue and organs damage, caused by a close explosion. We understand as close explosion, as mentioned above, or demolition by an anti-personnel mine (mine-explosive wound), or the damage owing to explosion of other EA device (a shell, grenades, missiles, etc.) already was marked. In the latter case, it is possible to speak simply about explosive wound. From the standpoint of classification of biophysical mechanisms of organs and tissues explosive damages, in our opinion, one can allocate two zones of explosive effects qualitatively differing among themselves, each including two levels of structural damage severity. As classification concepts for a designation of damage zones of a human (Fig. 3.12) we will use the established "brisance" (HE explosive) and "demolition". By brisant (HE) explosive we will mean the explosive, capable of destroying objects by the supersonic blast wave, and by demolition the ability to produce a shock wave, being at the same time the major damaging factor of a munitions. Within the limits of the first zone explosive gases are responsible for the basic damaging action. I level can be characterized by a full decomposition of tissues (crushing, pulverization and scattering), irrespective of their biomechanical properties and topographic-anatomic mutual relations with absolute extremity defect formation. Proximal border of this level is the line of bones fracture. Only the tendons can hang down more distal than the extremities of bone fragments, rarely, skin flaps or separate elements of neurovascular fascicles. Incomplete destruction of these formations occurs, apparently, owing to their deflection at the moment of explosion beyond the center of ultrahigh pressure bounds. The boundary front of high-explosive defect of tissues tends to be spherical in shape. It especially noticeable, if the border of an extremity avulsion coincides with spongiform bones (middle or hind sections of a foot, metaepiphysises of shin bones). The surface of explosive bones fracture in such cases represents bulging pulverized that, to a certain extent, illustrates work of hightemperature gases in tissues.

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Fig. 3.12 Main damaging areas of demolition HE charge (100-g Hexagen); 1st zone of HE (fracturing) damages; level a entire HE damages of tissues; b partial HE damage of tissues; 2nd zone of blast wave damages; level a blast wave contusion of tissues; b contusion-commotion disorders. The size of an entire anatomic defect of an extremity is determined by used HE charge, its form (capability to form a shape charge jet), and the distance between an explosive and an extremity. Finally the area of "tissue minus is defined by how much damaging radius of a charge covers a planimetric structure of an extremity. The footwear, for the given level of damage, inflicted by the explosion factors, should be treated not as a shield, but as an object enlarging distance between an extremity and a mine. The importance of a charge linear sizes, target, being hit and the distance between them, gives an insight into answering the questions, like: why identical munitions (100-g HE charge), activated by same foot segment (thumb), can inflict damages of different severity for the different persons. For rather long foot (29 cm) there is its abruption at the level of a shopar joint, and for rather short (22 cm) an abruption of a shin in the bottom third. At explosion of identical mines under a heel, the bones high-explosive defect, inherent to an individually short shin is as high as 40 %, while for long shin, it is 25 %. These observations and studies prove that the most effective protection of a body against strong high-explosive action of factors of explosion is a protection by distance. Through the Ib level the size of high-explosive destructions of an extremity is entirely defined by the biomechanical properties of damaged anatomic structures and features bone-fascial architectonics of an extremity. The weaker a tissue is mechanically, the larger destructions it

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sustains. This explains, dissection of strong anatomic formations bones, tendons, skin, neurovascular fascicles, sometimes muscular groups or separate muscles, which is characteristic for an explosion. At the edge of an explosive wound, the destruction of quaggy tissues has continuous character. The proximal sections of the damaged segment are characterized by the deep longitudinal penetration of explosive gases along the weak places of extremities paravasal, paraossal, subfascial and intermuscular spaces. However this happens under an only condition if intervals are opened towards an explosive wound. Cellular tissue layers, facing away from an explosion, appear intact. The structure of gas-dust stream, alongside with the products of explosive decomposing, always includes soil particles and fragments of destroyed tissues, belonging to Ia level which, later serve as the secondary wounding shells. For the front, back and side locations of explosive munitions, in relation to the central shin axis, the bones can serve as the shield weaker tissues, protecting them from the side of extremity, opposite to an explosion. During the demolition of the shin axis (under a heel), fragment of a tibial bone acts as a splitter for a gas-dust jets, propagating from an explosion center. Certainly, rigid and strong materials, used as a shield within Ib level, should weaken damaging action of a gas-dust stream. Entire length of the first zone (high-explosive action) in our experiments was equal approximately to 15-20 radiuses of HE charge. Sites of an extremity with attributes of gas-dust tissues of tissues are adjacent to a zone of severe contusional damages, which can be traced through all of the extent of the open bone-fascial receptacles {On a level). Confluent and focal hemorrhages concentrate along the basic neurovascular fascicles; primary and secondary arterial and venous branches with primary hemoinfiltration of the muscles, attached to bones and adjoining damaged vascular fascial clefts. The proximal border {On a level} represents a complex picture. When estimating through the contusional disorders of microcirculation in bones, it is necessary to recognize the nearest articulate cleft as the borderline. According to studies of a muscular tissue, this border passes to an overlying segment, down to a level of an attachment of the damaged muscles. The character of morphofunctional damages changes starting from a level of the intact segment of an extremity (at shin avulsion from a level of a femur) and in more proximal body segments (Level 2b). On a femur one can notice persistent disorders of tonus in arteries and their branches, drainage
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function of capacitive vessels decreases. Mosaic disorders of microcirculation and dystrophic changes of muscles in the same extremity segments, supplement an entire picture of reversible regional circulatory disorders. When estimating conditions of the organs, belonging to a stomach, a breast and a brain in the conducted joint parallel studies [Rybachenko P.V et al, 1990; Odinak the M., et al, 2000], the authors confirmed the known facts of internal organs bruises development (first hearts and lungs) and CNS traumas in anti-personnel mines victims [Habibi, etc., 1989]. This fact is also proved also by the experiments with animals, directed on adequate modeling of a mine-explosive trauma. The model of experiment developed by us (the Authors certificate 1709381 of 01.10.1991) entirely excluded a possibility for animals to receive bruises due to tertiary mechanisms of a trauma (fall). There are grounds to regard the discovered changes as morphological expression of the general contusion-commotio syndrome, accompanying mineexplosive trauma. Through the 2b level of contusion-commotio disorders, the dependence of damages severity from the distance to the explosion center is not seen anymore, unlike in other levels. At the level of organism integrity, alongside with anatomical-biochemical features of organs and tissues damaged by a shock wave, of special value is their physical inequality. Here, one can mention remark of S.I.Spasokukotskiy, that in a pathogenesis of the general disorders at an explosive trauma it is impossible to discern mechanisms of a contusion and a commotio. Consequently, is more correct to speak about contusion-commotio syndrome [Nifontov B., 1957]. Contusion and commotion tissue damages, resulted from explosive shock wave propagation, are based on cavitational, inertial and splitting effects. Origin of the layering and splitting damages is closely related to the phenomena of phase shift, reflection and interferences of waves at the boundaries of tissues with different acoustic impedance. The data, presented in the Table 3.3 prove the great differences between human tissues physical parameters. Velocity and energy characteristics of shock waves till the moment of their degeneration into sonic waves, exceeds those of sonic waves, therefore the shock wave stretching forces, arising at the acoustic impedance boundaries exceeds by far the elasticity of tissues. Non-uniform biological structures in a zone of their contact are layered and destroyed. Therefore, for example, within the limits of the top third of a shin at distance of 5-10 cm from a soft tissues avulsion level, the investigators were finding almost circular layering of periosteums
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from tibial and fibular bones together with the attached muscles. Avulsions of a periosteum topologically were unrelated with paraossal high-explosive damages of tissues at 1b level. The similar phenomena were noted in the experiments with dogs and biologic objects. In the main arteries numerous radial cracks of internal and average walls were noticed, the cracks were running from a vessel lumen were revealed and repeatedly replicated through 812 cm from a place of an avulsion and end clotting of an artery. Abruption of a vascular wall integrity served as a source of mural or obturating trombs, aneurismatic artery expansions during the posttraumatic period. It is important that the described vascular disturbances were observed only in wounded men or during the experiments with the dogs. During the experimental demolitions of corpse extremities, vascular wall disruptions had the random character, were grasping less extended prolonged artery sections that to a certain extent proves important role of a blood column in the genesis of primary explosive damages in vessels. In the peripheral nerves of an extremity the earliest changes can be noticed in pulpous fibers. Already 30-40 mins after explosion the fragmentation and helicoid twisting of internal plates of a myelinic environment was noticed. Ultrastructural disorders of nervous conductors substantially fast turned into a retrograde periaxonal demyelination (1-3 days after), which obliterated almost half of pulpous nervous fibers of a sciatic nerve branches at a shin. Explanation of this phenomenon also can be found in splitting damages, as the density of a myelinic walse of live nervous fiber is three times higher than that of a fluid neuroplasm of the axial cylinder [Zhabotinskij J., 1965]. Consequently, contrast of mechanical impedance in periaxonal contact region appears even greater than that in a bone and a periosteum attachment zone. Thus, a shock wave will apply the maximal shear force in the regional of internal mezoaxon and axolemmas of pulpous nerve fibers. Summarizing the results, one can conclude that during demolition on anti-personnel mine mechanically homogeneous structures of an extremity and a blood column are the main conductors of shock waves in a proximal direction. Along these anatomic formations the deepest and most extended contusional damages of environment formations are formed. These damages can be traced at macro-, micro- and ultramicroscopic levels. Consequently, mechanogenesys of a mine-explosive trauma essentially differs from known mechanisms of gunshot wounds both by a set of damaging factors and effects on a human. Unequal biomechanical strength of extremity segments tissues, strongly expressed both in longitudinal and transverse directions, creates different opportunities to absorb an energy of
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explosion Macropreparation of contusional sites of extremity tissues at the edges of an explosive wound, aimed hystotopographic and ultramicroscopic studies revealed all tiers of structure disorders, which could be explained only by the consequences of splitting wave effects. Table 3.3 Physical properties of human tissues (by H.E.Gierke, 1964). Parameter Density, g/cm3 Shear elasticity, dyn/cm2 Break resistance, dyn /cm2 Stretch index Acoustic impedance, , dyn s/cm3 Sound velocity, cm/s Soft tissues .0-.2 .5104 5106-5107 .2-.7 .7105 .5105-.6105 Bones .93-.98 .11010 .75108 .05 6105 .36105

The Table 3.3 shows physical parameters difference, being expressed in the different damage character. According to the same reason, there are unequal conditions for the explosive gases and shock tissue waves action in the regions, adjacent to the wound. All these peculiarities determine complex shape of an explosive wound, polymorphism of structure disorders in the edges and internal organs.

3.3.2. Peculiarities of the underwater explosion effects on a submerged human

Crewmembers, which experiences underwater explosion in a submerged state experience damages of a special kind. For example, when an Israeli cruiser was hit and sunk by the Egyptian missiles in 196. 199 crewmembers were thrown overboard. Because of following underwater explosion, they have received damages. 5-6 hours later they have been evacuated to the hospital, however transportation 43 caused death of 43 sailors and 4 more sailors died in hospital. During debriefing of the survivors, 24 crewmembers claimed that being hit by a blast wave felt like a strong impact on the stomach, accompanied by nausea, vomiting and desire to defecate. 25 % of crewmembers experienced chest pains, 30% experienced shock by electric current from top to bottom through a spine and extremities with the subsequent temporary paraplegia (Foreign military review, 198. vol.. pp. 31-33). In the second similar study, concerning underwater munitions explosion, only 3 sailors of 1.
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thrown overboard, have survived. All crewmembers, who died within the first day exhibited symptoms of acute lung failure, loss of vision and gastrointestinal bleedings [Adler J., 1982]. Experimental studies of damage character during explosions demonstrated that 40 % of experimental animals exhibited combined damages of thorax and the abdominal cavity organs. The damages were manifested by subserosal and intersticial hemorrhages through a gastrointestinal tract, especially a colon, bleeding from a tissue of a lung, liver, spleen, vessels of an omentum and late complications (abscesses, peritonitis), caused by necrosis and perforation of bruised sites of a gastrointestinal tract [Harmon J. W., Halusska M., 1983]. Biophysical features of blast injuries in water are of special interest, since the majority of soft tissues of an organism (on the average up to 75 %) consist of liquid. Water is 2500 times denser than air and is 800 times less compressible. Thereof water masses transfer by an explosive shock wave is rather insignificant, and losses of a water shock wave propagation velocity are insignificant. At close distances, the velocity of a shock wave in water is equalized with sound wave velocity (14001500 m/s). For the same reasons, loss of pressure with the distance increase proceeds slower than for the air blast wave, and there is no area with lowered pressure. Therefore at the larger distances the pressure difference P for the water explosion is tens times higher than that in the air. The difference of the blast wave effects in water and air is clearly illustrated when studying humans, submerged in water. The lower body of the victims (extremity, abdominal cavity and a pelvis) received much more serious damages than the top body, despite the organs in the top body are more susceptible to an explosive shock wave effects [Edberg et al., 1978]. Difference of densities between water medium and soft tissues, when a body is immersed in water, is not as large as that in air; therefore the blast energy is absorbed by soft tissues ineffectively. The basic part of shear force is released at the boundary of water and air media of the organism [Pode, 1989]. That is why the water shock wave first of all inflicts damage on the gas-containing organs where differences of masses and densities (gas bubbles, air cavities, a pulmonary tissue and encircling anatomic formations) is especially high. Difference in the acoustic impedances of a body and water medium around it has evidently shown by the experiments, performed by J. J. Cooper and coworkers. (1990). Air layers between a body and water medium sharply reduced damaging effects of an explosive shock wave in water, but the same materials placed on a body at the moment of air blast wave hit, increased severity of lung damages twice. Consequences of an underwater explosion have been described for the first time in 1917
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[Mathew W., 1917], and more comprehensively in 1940-1941 [Timofeev. N.S., 1944]. Clinically they were characterized by an abdominal pain, a pneumorrhagia, vomiting blood and diarrhea. The conducted experimental studies at absence of external symptoms have revealed also hemorrhages in a trachea, bronchi and a pulmonary tissue, more extensive damages were inflicted on a lung tissue facing explosion, with development of hemo-and a pheumothorax [Bich N., 1973]. For the victims close to an explosion site, the researches discovered clinics of a peritonitis and presence of gas under a diaphragm that was proven by the results of morphological studies, in the form of ruptures of a stomach wall and a small bowel, and presence of hemorrhages in a mucosa of a small bowel. It has been noted that first of all the gas-containing organs were exposed to damages, while the liquid-filled ones were damaged extremely rare (cholic and urinary bubbles, renal cavities). Specificity of damages, caused by a close underwater explosion has originally isolated this trauma in a separate group of damages demanding special approach to diagnostics and surgical treatment [Adler J., 1981]. Detailed studying and treatment of victims [Goligher J. With, 1943; Jacobs R. G., 1943; Gage E. L., 1945] and experimental data of other authors have allowed to define precisely a clinical picture, pathogenesis and surgical tactics of such victims treatment. In a large share of experiments it has been noticed, that the volume of a discovered hemorrhage was insufficient for fast death of the animals [Chiffelle T. L., 1966]. The dedicated research of this phenomenon has led to the air emboli to be discovered in the dead experimental animals in cerebral and coronary arteries [Benzinger, 1950; Rossle R., 1950]. That proved a role of an arterial air embolism in a pathogenesis of damages, inflicted on a human, immersed in the water at the moment of explosion. P.P. Rybkin (1956), referring to the data of the English-American literature of the WW1 period, points out that damages of abdominal cavity organs are characteristic for the victims, immersed in the water during the explosions of the mines, torpedoes, depth charges. In addition, the strongest damages are observed at 2-45 m distance from an explosion site. The most damage is inflicted on the body parts, immersed in the water and facing towards explosion. According to the same author, after being subjected to an underwater explosion, the intestine of experimental animals had punctual hemorrhages and large bruises with extensive hemorrhages. It is possible to admit that the victims can really suffer extensive hemorrhages with the subsequent formation of necroses and secondary perforations of an intestine. Thus, organs of an abdominal cavity containing gas and a lungs parenchyma are damaged more than the other organs. Because
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of alveola rupture, air penetration in an arterial blood flow is possible, followed by the development of an arterial air embolism [Adler J., 1981]. Condition severity of the wounded men, who received an explosive trauma in water, varies depending on a distance to an explosion, degree of immersion in water and elapsed time. The clinical picture of victims is reduced mainly to pathological changes of organs of thoracal and abdominal cavities at full absence of external damages. Vestibular apparatus and urinary tract disorders have no definitive role in the trauma prognosis [Warely C, 1945]. Leading clinical symptoms of lung damages are the pain and feeling of constraint in the chest, weakened respiration, shortening of a percussion sound. X-ray inspection in victims found out darkening of the lung tissue different in intensity and size. Rales appear certain time later. Two weeks after the demolition the clinicoradiological symptomatology in chest organs disappears [Timofeev N.S., 1945]. Signs of damages of an abdominal cavity vary from light morbidity and an insignificant muscle tension to an acute abdominal distention and a strain of prelum abdominal muscles. In easy cases, the signs of an intestine paresis can be seen, while severe cases are accompanied by the diffuse peritonitis. According to J. W. Harmen (1983) opinion, differences of a clinical symptomatology are caused by two varieties of abdominal cavity organs damage. The first variety is exhibited by interstitial hemorrhages from petechias up to massive confluent. The second variety is accompanied by digestive tube walls rupture with a bleeding demanding urgent surgical intervention. Such complications develop in later terms after a trauma in the form of peritonitis and abscesses of an abdominal cavity. G. Gill, P. Hay (1943) based on their clinical experience, believe, that it is necessary to distinguish 4 degrees of underwater explosive trauma. 1st degree the extremely severe damages. The lethal outcome happens immediately or short time after explosion. This category of wounded is encountered rather infrequently as the basic share of victims perishes in water or immediately after salvage. 2nd degree severe damages. Are characterized by the perforations of hollow organs arising during the moment of explosion. Such victims require urgent surgery. 3rd degree damages of average severity. The basic pathomorphologic substrate of this wounded category consists in development of a hemorrhage in an intestinal wall without breaking of the wall integrity. Outcomes of average severity damages are, as a rule, recovery, less often a pyesis of hematomas and occurrence of secondary perforations with development of a peritonitis or formation of intraabdominal abscesses.
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4th degree light damages. These wounded as a rule have bruises of organs of thoracal and abdominal cavities. This classification of damages is now the main criterion of the basic categories, used for the victims of an underwater explosion. It is necessary to note, that even at presence of combined and explosive trauma the doctor should remember the possible latent damages, as well as that the components of the combined damage promote development of a "mutual complication syndrome. Medical tactics for underwater explosive trauma depends, first, on a victims condition severity. The basic difficulties are related to early diagnostics, treatment of systemic disorders and arterial air embolism. Analysis of the underwater trauma mechanism, accompanying structural damages, clinical symptoms and the character of a specialized surgical assistance, rendered to casualties allows treating a underwater explosive trauma as a specific kind of a battle trauma in NAVY. Pathogenesis of this trauma in the certain degree differs from other kinds of human damages, inflicted by an explosion. High damaging capabilities of the mines, planted close to shorelines, appreciable psychological effect of their use, opportunity of the remote installation of minefields, including technical feasibility of mines anchoring on a shelf, testify that use of mines in antiamphibious landing defense can be of appreciable scale. Many authors place a special accent on wide use of minefields as one component of antiamphibious defense. Studies of the foreign literature showed that for antiamphibious defense the close attention is being recently given to the engineering arming of the coast. Development of large-scale obstacles in water is one of the approaches. The water obstacles are comprised from bulges, poles, barbed wires and chains. The minefields are installed between poles. The intervals between obstacles range from .5 to 9 m. The obstacles are covered with small arms and mortar fire. I.D.Kosachev, S. S.Tkachenko (1991) point out that large share of anti-personnel mines is made in water-tight cases and allows their installation in river fords, lake and sea shorelines at the depths up to 5 m. For example, the most widely spread mines are the anti-personnel Italian water-tight mines " Misar " SB-33 (mass 140 g) , Valsella VS-MK2 (mass 135 g) , VS-50 (mass 185 g). Thus, solving the problems of modern war, Armed forces will encounter growth of the mineexplosive trauma share not only at sea, but also while conducting operations at coast. The shoreline defense mines will be the growing source of casualties, suffered by marines and assault troops, alongside with losses from a small arms fire. In opinion of W. J. Henniks (1990), the largest share of the probable serious wounds received by personnel during amphibious landing,
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will belong to the category of irrevocable losses. However, part of the casualties can be returned to ranks, but under condition of knowledge of a trauma character by surgeons, timely rendered medical care and the fastest possible evacuation. The most complex, from the physical processes standpoint, are the shoreline explosions (.5-1 m depth). Bottom and water surface proximity considerably influence classical propagation of a shock wave in water. There is a repeated reflection and a diffraction of a shock wave from a water surface and bottom with change of amplitude and duration of shock acceleration impulse. In this sense physical parameters of the explosion in water substantially differ from those on land. The quantitative estimation of an explosion effects at contact demolition on shorelines, in our opinion, cannot be made without answering to following questions: 1. Why destructive properties of an explosion shock wave on shorelines are highest at the boundary of different physical media as water and air? 2. What explains the appreciable expansion of severe extremity damage zones, inflicted by antipersonnel mines in water? 3. Why the opposite extremity is always damaged? This and a number of other questions arising when studying of an anatomic material can be answered, by estimating the major parameters of the physical phenomena occurring in tissues. For this purpose, such shoreline explosion parameters, as amplitude and shock acceleration action on separate body sites, change of a shock acceleration gradient through the body length, influence of environment (water or air) on these parameters, have been studied. Study of the listed factors [Chernysh A., 1995] was performed in eight experiments on anatomic objects, of which two were conducted on land and six in water. Of this six experiments, three were conducted with immersing object up to knee joints (.5 m) and three up to on hip joints (1 m). Explosive charges in verification experiments (demolition on a land) were planted on a surface of a loamy ground under a heel of a soldier's boot. The temperature of air during the experiments was equal to 10-15. Acceleration of separate body sites, as seen from the oscilloscope waveforms (Fig. 3.13), represented complicated set of shock impulses, with duration of each .5-3 ms. All burst of shock wave impulses took 10-20 ms on a land and 150-250 ms in water from onset to decay. It is clear that attenuation of longitudinal accelerations along a body from a shin level is very intensive at mine demolition on a land and is insignificant for shoreline explosions , especially for a body
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immersed up 1 m (Table. 3.4). Explosion on shoreline with immersion to 1 m caused four pulsations of explosion cavity with a period of 30-40 ms. Each pulsation caused from 4 to 10 half waves of acceleration impulses. At immersing a charge to .5 m only two groups of pulsation impacts were observed. There were no interferences of the reflected waves and waves of pulsations for the land explosion, but the action of gas jet and an air blast wave was added. Acceleration in this case included 3-4 half waves of strongly fading impulses.

Fig. 3.13. Typical shock acceleration waveforms in the body segments during the shoreline explosions. Plastic explosion charge of 50 g. Immersion up to a hip joint Explosion in water in comparison with explosion on a land for the equal charge led to growth of the first peak of shock acceleration amplitude approximately by a factor of 1.5 and number of impulses in a package by a factor of 3-4 (Fig. 3.14).

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Fig.3.14. Waveforms of the shock acceleration impulse in the experiments and verifications Calculation results prove that the explosion of a charge, planted at 0.5 m depth, cause the plume of water to form. This plume consumes up to 20% of explosion energy in the form of hydrojet and compressed gases. The mass of ejected water in the plume is equal approximately to 150-200 masses of HE charge. Damaging effect of water in the plume is distributed in a cone with forming angle near 50 degrees to a vertical. The base of the cylinder is facing the water surface. The human extremity in an explosion proximity is destroyed by the volumetric explosion blast wave and shearing effects of the hydrojets above the water surface. Intensity of hydrojet increases in a lateral direction from an explosion epicenter in cone-shaped sector, making approximately 60 degree angle with a horizon. Insofar, the foot, being destroyed by the contact explosion, creates wave shadow in the vertical direction and the extremity falls into this shadow. Calculated estimation of land and shallow-water explosion effects The shock wave parameters will be calculated according to the monograph of V.G.Stepanov and coworkers (1966).

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Table 3.4. Amplitude of shock accelerations at the different body sections during blasting of anatomic objects by different charges at land and shoreline Medium Air Water Depth, m 1 1 1 .5 .5 .5 HE charge mass, g 100 50 100 50 25 100 50 25 Acceleration peak amplitude, g Shin Sacrum Head 100 80 120 90 60 120 90 60 45 20 90 55 30 75 40 25 10 4 70 30 12 55 18 8

At contact explosion on a land the general impulse of explosion is defined by the formula:
J = 100C (kgs s);

where C is a charge mass in TNT equivalent, kg. For a 50g charge the general impulse of explosion acting on an obstacle of infinite radius, is equal to: J = 100.05 = 5 kgss. Shock impulse duration is equal to:

Ti = 830C 0.33 ; Then for a 50 g charge the shock impulse is equal to: Ti = 0.00044 s. The average force acting on

an obstacle (kgs), is defined under the formula:

F = 2 JTi 1 ;
Explosion of a 50 g charge creates a force of frames a power load in size: F = 22 493 kgs. For a body weight of the person about 80 kg the acceleration, created by the explosion, should be equal to: a = Fm 1 = 281g ; Actual measured value is equal to 80 g (see Table 3.4). Hence, only part of explosion energy is spent to accelerate a body, which is equal to 26 %. Decrease of an actual pulse in comparison with calculated one can be explained by the contact area of a sole being much less than the circular area of explosion load. For a 50 g charge the sole of 43rd size (size 10) footwear makes approximately 50 % of all effects zone. Therefore, it is

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possible to assume that the distribution of impulse during explosion looks as follows: 50% impulse, circumventing a leg; 26% impulse, accelerating a leg (body); 24% impulses losses for the dispersion in tissues. During an explosion in water effective impulse of contact explosion is 4 times higher .1 times longer. Accordingly, full impulse of a 50 g charge explosion g in water is equal to: J = 5100.05 = 25 kgss. Duration of shock impulse for a 50 g charge is equal to: Ti = .1.05.33/830 = .00093 s. Respectively the average force is equal to F = 225/.00093 = 51 613 kgs, which leads to calculated acceleration a =645g. Actual measured acceleration is equal to 90 g (see Table 3.4), which can be explained by this law. Correspondingly the share, of total impulse, transferred into motion is equal to 1.5%. Distribution of impulse at shallow water can be represented as: 50 % the impulse, circumventing legs (hydrojet); 1.5 % the impulse, spent on a body throwing; 3.5 % the impulse, spent on a dispersion in the foot tissues and destruction in other sites of a body. Thus, the presented numerical data (both actual and calculation results) confirms a 4-fold gain of impulse power during shallow water explosion. It is established that during a demolition of antipersonnel mine in water there is more efficient "work" of explosion products due to smaller losses of pressure in a shock wave front, if compared to that in an air. New damaging factor appears as well - a water column. It is proven experimentally that the explosion energy, circumventing an extremity in shallow water is similar to that on land. Differences consist mainly in increase of the energy, spent on dispersion in extremity tissues. In shallow water this number is 3.5 %, and actually, in view of a 4-fold gain of power, this number reaches 122 % versus 24 % on land. When comparing other parameters of an explosion impulse it is necessary to consider a 4-fold gain of an explosion yield as well. When estimating physical parameters of the explosions occurring in shallow water, the interrelation can be discovered between increase of shock accelerations impulse and increase of body segments damages severity. Damaging action of shock acceleration is supplemented by the water plume created during the explosion and volumetric detonation wave. Thus, as a result, charge acts more effective in shallow water, producing damages of both extremities, more severe
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than those resulted from the same charge explosion on land. These results confirm important explosion features, inherent only to the explosions in water.

3.3.3 Peculiarities of explosive damages inflicted on the personnel inside fighting or transport vehicles (shielded explosion variety)
When the personnel is hit by an explosive ammunition inside armor, the set of damaging factors changes, forming another conditions of damaging agents action. The analysis of modern data on a problem of mine ammunition interaction with armor testifies that character of crewmembers damages depends first on the fact of penetration or non-penetration of sides or bottom of a vehicle. In the first case, the damaging factors include: - air blast wave, EA fragments and secondary wounding projectiles, formed during penetration of personnel compartment for internal equipment in a vehicle, capable of inflicting different mechanical damages. high-velocity and high-temperature gas jets and particles of the melted metal causing mechanical and combined mechanic-thermal damages; flame (including flame from secondary fire), inflicting burns; toxic products of explosion and burning. The detonation of an ammunition load and ignition of fuel essentially increase severity of damages from armor explosion [Bellamy, 1988; Dougherty, 1990]. If armored bottom (or sides) is not penetrated, shock accelerations of the bottom, seat or walls of compartments are the leading damaging factor. Kinetic energy of explosion products and a primary fragments stream is spent not only for penetration of obstacles, but also, to a large degree on their deformation and moving. For crewmembers, the main damaging factor in such cases is the residual energy transferred by concussion and oscillation of barriers, through a "seismic" wave. Generated air blast wave is repeatedly reflected from the compartment walls is playing a major role, as well as impulse noises of high intensity inflicting shock barotraumas to an ear and internal organs. Damages, inflicted by secondary projectiles in the form of destroyed equipment and armor fragments (Fig. 3.15) can be observed as well. For example, consider the mechanism of the closed foot damages in the persons, who were in contact with dense immobile structures of armored vehicles or with a ship deck. Here, shock
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wave action is exhibiting indirectly, first, due to the expressed vibration of metal parts, which intensity depends on ammunition yield and masses of a support. The shock wave is known to pass easily through firm bodies, not causing their expressed deformation. Each particle in this body transfers energy to the following, one similarly to cars in the stopped train, which is mechanically hit [Spaccapeli D. et al., 1985]. Character of damage of basic human structures for this kind of a trauma is defined by the action of the overpressure, formed during demolition of anti-tank mines, thus less elastic structures are exposed to more severe damages (feet, pelvis and spine). Clinical and pathoanathomical studies of casualties extremities revealed flattening of longitudinal feet corpus due to multiple fractures of premetatarsus and calcaneus bones, dislocations in Shopar, ankle and Lisfrank joints, fractures of canon bones, extensive hemorrhages in a tissue of plantar area with the presence of expressed swelling at the back of a foot and in epidermal cavities, contusional damages and a spastic stricture of the main vessels, the segmentary clottages, leading to ischemic disorders and a gangrene of extremity [Nosny P., 1954; Aulong J., 1955; Boucheron, 1955; Whelan I., 1975; Spaccapeli D.et al., 1985]. Local damages of tissues are quite often combined with damages of organs that make general condition of victims much more severe [Bronda F., 1949]. When the bottom is penetrated, the crewmembers suffer plural and combined mechanical traumas, the combined thermo-mechanic and mechano-thermal damages. When the bottom is not penetrated they suffer combined mechano-acoustic damages, expressed as shock concussion of a body in the form of damages to lower extremities, a spine and a skull combined with a brain concussion, concussion of internal organs in thoracal and abdominal cavities and an ear barotrauma (acoutrauma) [Dougherty, 1990] Based on the analysis and generalization mainly foreign data, an attempt to systematize mechanisms of shock accelerations effects on a person has been made [Nekludov V.S., Stepanova N.P., 1966]. With an acceptable degree of approximation, the human body can be treated as the passive linear mechanical system reacting well to small accelerations. Under greater amplitudes and, that is especially important, short-term overstresses, it is quite acceptable to treat a body as rigid mechanical system, where the basic role is played by mechanical strength of tissues. Latter option of a body biodynamic behavior under the influence of shock acceleration has great value for understanding mechanogenesys of a mine-explosive trauma and deserves a detailed analysis.

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Skeletal bones perceive impulsive shock accelerations as a usual solid body, and soft tissues perceive it as elastic-viscous medium.

Fig. 3.15. Mechanogenesys of organs and tissues damages during the mine-explosive destruction of armor. Entire human body, when the acceleration develops, acts like complex multilink mechanical system with effective mass, strictly speaking, not equal to a bodyweight. There are viewpoints, according to which in the mechanical system equivalent of a human body, has four parts, reacting to acceleration independently: Dorsal a head, a neck, a spine; Thoracal heart, lungs, a thoracal wall; Abdominal a stomach, a liver, an intestine Extremities arms, legs [Nekludov V.S., Stepanova N.P., 1966; Kudrin I.D. et al., 1981]. From this standpoint, the systemic analysis of an explosive pathology by studying trauma mechanogenesys for demolition of armored vehicle crewmembers represents a complex multistage problem. Modeling of mine demolition for development of the integral characteristics of a mine-explosive trauma, at least, should include research of several parts, belonging to the human body mechanical system equivalent. Certainly, this equally concerns the segmentary analysis motor-functional disorders of an organism, occurring during the armor crews demolition. Biomechanical response of a human body to the shock acceleration is divided in two types: Intrasystem deformation of a body in the form of mechanical oscillations (interference) of organ parts, organs and organ complexes, propagating in heterogeneous medium, so-called intrasystem propellant effect;

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 Translation of a body and (or) its parts relatively to the support with possible secondary collision with an obstacle, or so-called intersystemic propellant effect. Impulse of shock acceleration, influencing the receptor apparatus of organs and tissues and leading to "eisodic impact on CNS, causes contraction of a sceletal and smooth muscles, deformation and shift of internal organs and vessels with a circulating blood. Shift of abdominal cavity organs becomes also dangerous if it exceeds limits of the ligamentous apparatus elasticity. Considering, that deformation waves propagation velocity in dense tissues and organs (an osteal tissue, a blood in vessels) is much higher than that in other tissues, biomechanical effects of shock acceleration firstly and most strongly implement in support structures, starting from a spot of body contact with a support, and in those organs, which are most closely attached to an axial skeleton of a trunk (head and a spinal cord), and also in the blood vessels, subjected to hydrodynamical impact of moving and incompressible liquid blood. The degree of biomechanical response is defined, first, by magnitude of shock acceleration and exhibiting in a wide range of evolutionally conditioned adaptive reactions, or in the form of damages to the extent of the fatal polytraumas. Nevertheless, the influence of shock acceleration on unstable human body depends not only on acceleration magnitude, but also on pulse duration and direction of its vector in relation to three orthogonal planes. Limits of a human organism tolerance to shock acceleration depend also on accelerations onset time and even more they depend on a magnitude of initial accelerations. Each of the parameters, mentioned above, influences the result to a different degree. Effects of different shock acceleration parameters on the different body segments are also different, since these segments are inadequate parts of multielement mechanical system. All this creates substantiated difficulties to isolate precise boundary of survivable shock loads. Analysis and systematics of the published experimental results is complicated also by a number of subjective matters. Many sources lack data not only on a pulse duration of shock acceleration, rate of increase and a vector of force, but even about a site, where the data were taken on a body or a mobile support. One also has to note the established facts testifying to great importance of a human pose, functional position in joints, presence or absence of linings (footwear, clothes and support cover), suits, helmets, which essentially change external conditions of the rigid screen-body interaction. All the above makes obvious a fact that a huge accumulated experimental database, generated in laboratory conditions, has low practical value as a starting point for experimental studies on clarifying a role of shock acceleration in a pathogenesis of mine -explosive trauma.
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As mentioned above, demolition of the battle ship or another vessel on a mine or torpedo hit exhibits regularities, characteristic, as a rule for the indirect (non-contact) demolition mechanism. During 60th USSR conducted extensive studies related to the f medical consequences of the mass destruction weapons application. The essential contribution to development of this problem was made by P.P.Rybkin, who experimentally investigated underwater nuclear explosion effects on biological objects (the experimental animals were at the ships deck). Interest to this model was related to the fact that the underwater nuclear explosion was considered at the time to be the most effective mean against ships. One of the main damaging factors is the concussion, generated by the underwater shockwave. It is considered that the most effective mean against Navy ships is an ammunition of .1.30 or 100 kilotons yield for the explosion depth ranging from 50 to 400 m. in Integral physical parameter, determining efficiency of damages is the maximal vertical velocity of ships decks and platforms, equal to 1-9 m/s. With the increase of explosion depth the role of shock concussions as damaging factor essentially increases. The damages, inflicted to an organism by the shock concussions, represent mechanical damages. By mechanism of occurrence and localization of damages, Rybkin (1956) recommended to categorize them as follows: Primary damages the mechanical traumas caused by direct action of shock concussions of decks and platforms, perceived by a person as impact or sharp jerk propagating through a support surface; Secondary damages the mechanical traumas caused by indirect action of shock concussions: impact with structures and elements of a battle post interior, when a crewmember is thrown in the air or falls; "combined" damages the mechanical traumas representing a combination of primary and secondary damages. Clinical displays of primary and secondary traumas have certain differences. Localization of primary damages depends on a pose of the person during the shock concussion, and secondary on features of interiors of ship battle posts of the ship. In 60th years because of the conducted studies the opinion was formed, that the basic requirement to ensure protection of ships crew against shock concussions, related to an underwater nuclear explosion is maintenance of inertial overstresses down to a value of 0.5-1 m/s, or 7-15 g. It has been noted that the propellant effect and any painful sensations do not arise for a deck or support velocities less than .5 m/s.

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Table 3.5. Characteristics and degree of severity for primary and secondary mechanical traumas, depending on the effects mechanism, person position at the battle post and maximal velocity of a shock concussion Clinical characteristics of shock traumas Maximal velocity of shock concussio ns, m/s Indirect effects of shock concussion (secondary damages)

Severity Direct effects of shock concussion (primary degree damages) Sitting position I light Brain concussion, bruises of soft tissues in hip, pelvis and back. Bruises of pelvis minor organs. Standing position Brain concussion. Bruises to joints of the bottom extremities. Insulated fractures of feet bones. Fractures of a fibular bone

Brain concussion. >3 Bruises of soft tissues. Uncomplicated dislocations of top extremities joints insulated fractures of a forearm, a clavicle, several ribs. Limited non-penetrating wounds without damage of large vessels and nerves II Light and moderate Light and moderate Light and moderate >5 average brain bruises. Fractures brain bruises. brain bruises. Extensive of bodies extensions of Fractures of bodies wounds of soft tissues. vertebra without damage extensions of vertebra Simultaneous multiply of a spinal cord. without damage of a rib fracturing. Closed Extensive bruises of soft spinal cord. pneumothorax The tissues of hip area, Dislocations of closed diaphyseal pelvis and spine. bottom extremities fractures of top Fractures of pelvic joints. Fractures of extremities bones. bones without damage feet bones stops, of internal organs cannon bone or both shin III Severe brain bruises. Severe brain bruises. Traumas of chest and >7 severe Pelvic bones fractures Hip bones fractures stomach with damage to with damage to internal with damage to internal organs. Plural organs. Fractures of internal organs. and open fractures of bodies extensions of Fractures of bodies extremity bones. Severe vertebra with damage of extensions of vertebra brain bruises. spinal cord. with damage of spinal cord. IV Plural and combined traumas incompatible with a life >9 extreme
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However when this speed exceeds .75 m/s they both appear. In addition to that, human body can be thrown up to of 7-8 cm, causing a short-term interaction in ability to perform duties, but without any traumas. For shock concussions and deck velocity around 1 m/s with duration of impulse 5 s the crewmembers observe unpleasant painful sensations and throwing in the air at the height of 1012 cm and higher. Such concussions are not yet hazardous to crewmembers health, but can lead to a trauma from impact with surrounding objects and prolonged break in operators activity. When the deck moves with the velocity of .5 m/s and the same impulse duration, short-term loss of consciousness is possible accompanied by the bruises of soft tissues with hemorrhages. In connection with the above-stated, 1 m/s velocity has been chosen as a safe shock influence margin for the underwater explosion shock wave hitting the ships hull at the safe distance. It has to be noted that the safe distance concept refers to a ships hull. For the shock wave velocity over 2 m/s the crew starts to suffer casualties due to mechanical traumas. The data presented in Table. 3.5 testify to their character. Thus, during the explosion of armor and vehicles the scope of damaging agents widens. Magnitude of all explosion parameters can change as well due to the tendency to use explosives with higher yields, distance to an explosion center, different poses of crewmembers, presence of objects and equipment parts etc.

3.4 MINE POLLUTION PROBLEM IN THE REGIONS OF ARMED CONFLICTS AND LOCAL WARS
The overwhelming majority of anti-personnel and anti-tank mines and other ammunition retain their capabilities for a long time after their manufacturing and the termination of military conflict. Long-term experience suggests that even total mine sweeping only reduces number of civilian casualties but falls short of preventing them completely. Exact quantity of mines installed in the world to is impossible to estimate, but even known approximate data allow to estimate scale of this problem. According to the United Nations and the International Red Cross, there are more than 110 million mines installed and armed. Another 100 million the mines ready for are in storage and ready for installation. Since the beginning of the WWII when the wide application of mine munitions has begun, around 400 million mines were installed through the world. This process became especially

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intensive in the last 20 years. Rates of mining considerably advance rates and technical capabilities of mine clearance: according to the United Nations, only in 1993 2 million new mines were planted, and only 100 thousand were cleared. It is counted that for each 48 inhabitants of a planet (or 16 children) there is one mine, and in countries as Angola and Cambodia quantity of mines exceeds number of inhabitants. Every week because of mine demolition around 800 persons are killed or become disabled. Statistical data of the Red Cross International Committee on the countries which have to the greatest degree suffered from mines, are presented in Table. 3.6. As follows from the published data, mines were used to some extent in all wars and confrontations in the newest history.
Combat operations in the North Africa, 1942 In Egypt and Libya, to compensate lack of troops

the opponents planted huge minefields, presenting danger till now.

Combat operations in the Europe,1944-1945 Retreating German and Italian armies widely left

behind mined territories. Mines were used with such intensity, as to this day in such countries as France, Holland and Slovakia, there are still unswept minefields. However, due to a special nature of combat they are mostly anti-tank. The data available hint that mine usage not only limited a maneuverability of German and Italian armies, but also led to appreciable losses in personnel and equipment in Allies armies.
War on the Korean peninsula, 1951-1953 Armies of the USA, Great Britain, Canada, Australia,

New Zealand, Turkey, and South Korea used mainly anti-personnel mines due to insignificant number of tanks in armies of Northern Korea and China. This situation has led to essential losses both in armies of allies, and in the North-Korean and Chinese armies. Since the minefields maps were lost, the mine clearance took very long and was very difficult.
War in Indochina, 1958-1968 Anti-personnel mines were used at all stages of operations. French

and American armies practiced encirclement Vietkong settlements by continuous "rings" of minefields with a lot of boobytraps, and at the closing stage of war US Army used air-based minefield installation. French, and then the American troop positions were also defended by minefields. To create minefields in the region of Diene Bien Fu, for example, the French army used 23 tons of anti-personnel mines. It is known, that losses of US Armed Forces, in particular Marines, from the mines were rather essential. After end of operations, it was found out, that no army kept track of the installed minefields. At the same time, any of the parties never put any doubt in chaotic use of huge quantity of anti-personnel minutes
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India - Pakistan armed conflict, 1947-194. 196. 1971. In these operations the insignificant

quantity of anti-personnel mines was used. This is due to their low efficiency due to the soft soils. Mines were used to guard troop locations. Minefields were accounted and mapped consistently, which allowed clearing them easily and in return lands to agriculture in shortest terms. Losses among the peace population from anti-personnel mines were minimal. Table 3.6. Statistical data on the countries, suffered most from mines (August 1996 data.) Country Population, Number of mines millions Total, millions 1.0 1.0 .0 1.0 .0 1.0 .0 .5 Per capita, pcs .450 .470 .360 .040 .250 .510 .040 .050 Number of minerelated disabled (lost extremity) 35 000 30 000 No data 25 000 No data 20 000 5000 60000

Afghanistan Angola BosniaHercegovina Cambodja Croatia Iraq Sudan Vietnam

2.10 1.00 .40 .60 .80 1.75 2.25 7.90

Indian- Chinese armed conflict, 1962 Efficiency of mine-fields was low as minefields were

planted in mountain district. Anti-personnel mines were difficult to maintain in snow, because they were rolling down on mountain slopes in case of snow avalanches and slides even if special anchors were applied. Maps of minefields were mostly inaccurate.
War for independence of Zimbabwe, 196. 1974-1980 .More than .5 million anti-personnel mines

were used in this war. Eight minefields were planted at the 766 km length along border of Zimbabwe and Mozambique. Since 1980 till present only 10 % of territory is cleared mines. Civilian populations suffered 66 killed 402 wounded.
Operations in the south of Africa (on border with Angola), 1960-1994 . Huge quantity of anti-

personnel mines was installed. Reduced troops mobility is noted in connection with the bad account and documenting of minefields. Witnessed described cases of mines displacement, sometimes involving great distances, by the strong rains. For this reason, mine sweeps suffered casualties. The idea to create a continuous mine belt along border with Angola has been rejected in connection with high cost, danger to the personnel and low efficiency.

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Internal conflict in Philippines, 1945 present time. With the purpose to winning hearts and

minds in rebellious provinces the government undertook unusual political step has forbidden army to use anti-personnel Claymore 181 mines. The mines were destroyed at the storage locations. The garrisons were guarded by engineering obstacles, the wolf pits and other traps.
The Arab-Israeli conflict, 196. 1973 minefields along borders of Israel, Egypt and Syria were

installed. Despite strict account of minefields, appreciable losses among friendly personnel were noted. By 1992 all minefields were encircled, marked, and many of them cleared.
Lybian-Chad confrontation, 1973-1994 a numerous minefields consisting from anti-personnel

and anti-tank minutes were planted. Minefields were planted with no mapping, installed chaotically, very frequently on the agricultural land. After the ceasefire the Libyan armies refused to transfer the data on the mined territories. Internal confrontation in Angola, 1975 present time. Angola now is the country with the greatest number of unswept mines. In this country, both the government army and their opponent planted huge number of various mines, without keeping any maps whatsoever. Number of disabled who lost extremities due to mine explosions is one of the greatest in the world.
War for independence of Mozambique, 1976-1993 All parties to the conflict planted minefields.

Their maps are absent. Large areas of agricultural soil are rendered useless.
Internal conflict in Cambodia, 1978 present time. Use of anti-personnel mines against the

peace population was a permanent tactics of Pol-Pot "khmer rouges. The account of antipersonnel mines was not kept, minefield maps do not exist. Despite relative armistice, mining proceeds till now. Now Cambodia is the most mined country. Here the world number of disabled is highest due to demolition on anti-personnel mines. War in Afghanistan, 1979 present time. It is a special page in history of mine weapons use. Because of continuous war which goes on for more than twenty years, Afghanistan became, alongside with Cambodia and Angola, one of three most mined countries in the world. Engineering forces of the Soviet armies and the Afghani governmental army used anti-personnel mines to protect country borders with Pakistan and Iran, to defend garrisons and block-posts, the important road installations and airfields. As a rule, all installed minefields were documented and mapped. According to official sources, before withdrawing from Republic of Afghanistan the Soviet army cleared all anti-personnel mines in the territories under their control. However, certain number of anti-personnel mines remained at the territory controlled by opposition. These minefields maps were transferred to the Defense Ministry of Afghanistan. With opposition
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coming to power, copies of these documents were transferred to a new military command of the Afghanistan Government, including through the Ministry of Foreign Affairs of the USSR and the United Nations twice. More than 30 various kinds of mines from six countries-manufacturers were used through the war. Table 3.7 addresses characteristics of some mines, used by opposition.
The British-Argentina conflict on Falkland (Malvin) islands, 1982 . Large number of anti-tank

mines was planted by the Argentina army. Attempts of clearing after the ceasefire were abandoned due to the mine sweeping teams casualties. Now the Government of Argentina established the program on mine clearing.
Internal confrontation in Liberia, 1989 present time. Mines were used in struggle against

Patriotic front of Rowanda. Part of minefields is mapped, their basic share is installed in the region of Ruhengeri and Nigali cities.
Internal armed conflict in Croatia, 1991-1995. Parties installed large number of anti-tank mines

in Croatia. Minefields, did not play a vital part in protection of the Serbian units in Krayna during Croatian army attack (1995), are deployed mainly along front lines. Serbian and Croatian minefields charts were handed over to the United Nations. Later, Croatia signed the Convention on the land mines control.
Desert Storm military operation, 1992. At the initial operations, stage Iraq has installed more

than 9 million both anti-personnel and anti-tank mines, which formed protective belts along the coast and in southern and western directions. Note that the possibility of installation in the desert directly on the ground surface, as they were soon covered with sand. Despite huge quantity of mines, the Coalition forces with new de-mining technologies and high mobility virtually escaped any damage while advancing on Kuwait. Minefields maps made by Coalition forces were later transferred to the Government of Kuwait.
Internal armed conflict in Bosnia-Herzegovina, 1992-1995. More than 6 million uncleared

mines, including some special versions, were left after the years of the conflict. For example, Yugoslavian-manufactured anti-personnel mine cases were made mainly of plastic. According to minefields maps a database, updated according to the Dayton Peace Agreement, was created. Parties gave up on de-mining attempts because of significant losses among mine sweeping teams.
Ecuadorean-Peruvian Rivalry, 1995. Despite short duration of operations (one month), more

than 10 thousand mines were planted along the borderline. Later, both parties took an active part in de-mining. Nevertheless, according to approximate calculations about 6 thousand mines
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remain in the ground, many of them present a threat to civilians. Table 3.7 Characteristics of mines used by the opposition in the Republic of Afghanistan Characteristics Set-off mine HE charge case force Mine type weight, Fuse Actuation weight, kg material operating kg force, kgs Anti-personnel mines Fragmentation Pressure2.3 0.155 Steel 8-25 Mechanical 2 (USA) operated Demolition No.4 0.35 0.2 Plastic (Israel) Fragmentation At the directional of 1.5 0.475 contact with Claymore type a trip wire M18 A1 (USA) Fragmentation 1.4 0.2 Steel bounding (USA) Demolition -50 0.05 Pressure0.2 Plastic Pneumomechanical (Italy) (hexagen) operated Anti-tank mines Combined anti-tank 3.6 2.5 Plastic -102 (Italy) Antitrack 1-102 8.0 7.5 Caseless 150-200 Mechanical (Sweden) Antitrack -5 (England) Antitrack -3 (Belgium) Antitrack (bottom action) -7 (England) Antitrack 5-55 (Italy) Antitrack -19 (USA) Antitrack PTM 1-k Antivehicle -6.1 (Italy) 5.4 6.8 13.6 7.3 12.7 7.5 9.5 3.6 6.0 (trialen) 9.1 5.5 9.5 6.0 6.1 Steel Plastic Steel Plastic Metal Plastic 150-220 150-250 150-220 Mechanical twostroke

150-310 Pneumomechanical 150-200 Mechanical

sustained Pneumomechanical load

The mine problem became just as aggravated in the former USSR territory, where many armed conflicts took place in the nineties, involving mines extensively. Confrontations in Chechnya,
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Tajikistan, Georgia and Transdniestria are notable for massive mine application and a degree of danger to noncombatants. All these conflicts are characterized by: mass and, as a rule, uncontrolled mines application by non-governmental forces, without proper documentation and without mine barriers removal when operations were over; extensive application IEDs along with standard engineer ammunition, air bombs and artillery shells adaptations; wide use of road mine war tactics mines and demolition munitions installed on communication lines;. mining of civilian and industrial targets, public and residential buildings, populated areas, frequent use of booby traps, "surprises", etc., banned by the Geneva Convention (1980).
Internal armed conflict in Moldova, 1992. Parties mainly used mines in Transdniestria, though

there were cases of mine installation on the right Dnestr bank. Both opposing parties used Sovietmade mines -57 and -62 (anti-tank), PMN, PMN-. OZM-7. MON-100 and MON-200 (anti-personnel) to protect land and infrastructure objects. A total area of 72 km2 was mined during the conflict. According to the Ministry of Foreign Affairs of Moldova, as of May, 199. approximately 15 km2 of the territory, posing a great threat to civilians, have not been cleared yet.
Internal armed conflict in Georgia, 1992-1993. Both Georgian and Abkhazian forces installed

mines. Minefields borders are not marked, charts are incomplete. According to the Abkhazian government, the number of mines installed in the territory of the republic during 1992-1993 war reaches 80 thousand. Parties installed mines in two regions: along the left bank of the Gumista River (close to Sukhumi) and along the right bank of the Inguri River in the Gali district. Basically, they used Soviet-made mines: anti-personnel PMN, PMN-2 and anti-tank -5. 62.
Internal armed conflict in Tajikistan, 1993 - present. Russian forces began extensive use of

mines after mujahedeens attacked Moskvoskiy border troop frontier posts in July, 1993. During July-August, 199. points of possible border cross and approaches to frontier posts were mined with OZM-7. PMN-. PFM-lc mines. In succeeding years, mine installation continued. Now, the wide areas affected by landmines are the Garm Valley, the central Tavildara region and the border with Afghanistan. According to rough estimates, there are approximately 10.000 landmines in Tajikistan. The Tajik government takes measures on territories clearance, where mine barriers fulfilled their mission. During the conflict, field engineers in Tajikistan detected
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and cleared more than 2.000 various explosive objects altogether.

Internal armed conflict in Chechnya, 1994-199. 1999- present. Parties massively used mines

and IEDs since the beginning of the confrontation. Insurgents used mines and demolition munitions for "harassing" mining to inflict casualties on federal forces and to exert psychological pressure on the population. Numerous terrorist acts with explosives in Russian cities have the same purpose. Moreover, if in 1994-1996 mines were installed by untrained people, since 1996 this process became a real mine war. Federal forces have been compelled to apply the whole complex of special measures to decrease personnel losses. Insurgents installed Soviet-produced mines PMN, PMN-. OZM-7. MON-10. and MON-20. and have been using hand-grenades with homemade tripwires. Minefields are not documented. Engineering troops cleared some mines on the main routes of federal forces, but remaining mines and demolition munitions result in civilian casualties until now. In the first Chechen campaign (1994-1996), federal forces used mines only to cover positions, base regions and checkpoints. Mainly anti-personnel fragmentation mines OZM-72 and MON-50 were used on regular basis, while demolition mines PMN-2 and PFM-1c were used to a lesser extent. Signal mines, installed mainly on approaches to guarded objects, were widely used. Their blasts warned of insurgents approach. When federal forces withdrew from Chechnya in September-October, 199. all the installed minefields were removed or cleared. The military commissions drew special reports about this. The following numbers reflect scales of explosive ammunition usage, during two years the federal engineer troops detected and disarmed 54.000 explosive objects. During antiterrorist operation performed by federal forces in Dagestan and Chechnia since autumn 1999 mining had been widely used by both: federal forces and insurgents. The federal forces installed minefields and mine groups using controlled mining. Using this approach helps protect troops positions, camps, check points and other objects. All installed minefields are documented; they are accurately associated with landmarks. When so-called sanitary zones are created, minefields are marked and wired. Using aircraft-based remote mine installation, federal forces closed passages and trails (mainly along the border with Georgia). Approaches to insurgents bases in mountain regions and the bases themselves are also mined. The basic type of mines applied is the anti-personnel demolition mine PFM-lc (a green parrot) that self-liquidates in 40 h after installing. Thus, practically during every armed conflict of the newest history confronting parties used
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explosive ammunition to achieve their purposes. What are the sources? As mentioned above, manufacture and application of IEDs is possible. Air bombs, artillery shells and other ammunition can be also adapted for these purposes. Nevertheless, a great challenge is presented by engineer mine ammunition, made and sold in large quantities by producing countries. In connection with a changing world political-military situation and in a specific region, because of priorities change, economic problem and under public organizations pressure the production of engineer mine ammunition in many countries was recently phased out. Particularly, the quantity of the anti-personnel mines producing countries in the world decreased from 54 to 16 by now. Among 38 countries, which stopped producing mines, there are also large manufacturers responsible for tens of millions of mines installed in the seventies, eighties and the beginning of the nineties. In particular, Belgium, Bosnia, Bulgaria, Czech Republic, France, Hungary, Italy, the Great Britain, Israel and Finland have discontinued the mine manufacture. Among 16 countries, continuing mine production, there are seven in Asia (Burma, China, India, Northern Korea, Pakistan, Singapore and Vietnam), three in Europe (Russia, Turkey, Yugoslavia), three in the Middle East (Egypt, Iran, Iraq) and two on the American continent (USA and Cuba). No former USSR country, except for Russia, produces anti-personnel mines, though such countries as Ukraine and Byelorussia possess necessary manufacturing capabilities. However, munitions factory conversion programs in these countries are still underway. One of the main destabilizing factors is the mine export. With rare exception, most affected countries were not mine manufacturers themselves. For example, all mines installed in Angola, Cambodia, Afghanistan, and some other countries were imports. USSR, one of the mine weapon development and manufacture leaders, naturally, could not stand aside of the world market. Anti-personnel mines of the Soviet origin were in great demand and exported to more than 40 countries. In the first place, USSR delivered mines to the countries of socialist camp and to countries that did not develop and did not produce this kind of weapon. Delivery quantity was defined by military strength, character and scope of problems they were facing, and by the quantity of the ammunition necessary to carry out certain operations. Soviet anti-personnel mines were exported to many countries of Africa, Asia, and Latin America. They have been used in Angola, Mozambique, Ethiopia, Nicaragua, Cuba, Kampuchea, Laos, Vietnam, and other countries. Until now, they are deployed in many countries along with their clones, being exact replicas or slightly modified to suit the producing countries technology. Anti-personnel mines foreign sales have been suspended in 1991 by decree of USSR Ministry of
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Defense and subsequently with the Decree No.2094 of the Russian Federation President of November, 21st, 199. that declared the moratorium anti-personnel mines export without neutralizing mechanisms and invisible to mine detectors. The moratorium has come into force since December, 1st, 1994 for the period of three years, and on December, 1st, 199. it was extended by Decree No.1271 of the Russian Federation President for five years. Although the Russian Federation has anti-personnel mines, meeting technical requirements of Protocol II Geneva Convention of 1980 and not falling under the moratorium of the Russian Federation President, they are not exported and there are no future plans to do that on the principles of peace and humanism. There were over 20 factories in the USSR in the structure of military-industrial complex, producing components or assembling anti-personnel mines. With the USSR collapse, this process was adversely affected. Since January, 199. manufacture of most dangerous to civilians antipersonnel demolition mines in Russia has been discontinued. The factories used to assembling these mines, now commercialize process of their utilization. The demand for mines is still high. Mines sale has been bringing the stable annual profit 200 million dollars to 96 mine-producing companies (by "Izvestia" newspaper. 12.25.1993). Experts consider that even if legal supply channels were blocked but without discontinuing mine production, then the black market would flourish. Minefields sweeping is a dangerous and very costly business. In the late forties France used German war prisoners when sweeping the Normandy coast. As the result of the, 1709 were killed and 2986 injured. It is necessary to note that the Normandy coast in France was one of the most mined places Rommel, preparing for a counter-landing assault, installed approximately 5 million mines [Lenning M.A., 2000]. Between 1945 and 1977 military engineers cleared around 15 million mines in Poland. In the same period of time, in this country about 4000 civilians were killed and 9000 were injured by mine explosions. It is cheaper to make and install a mine than to disarm it experts here are unanimous. On the average the production of one anti-personnel mine costs 2-4 dollars, while its clearance is 300 times more expensive. According to other estimates, it is required from 300 to 1000 dollars to clear a mine. Moreover, according to the latest statistics there are 20 newly installed mines per one cleared mine. As the United Nations predicted, the costs of the installed mines clearance will exceed 33 billion dollars. At existing sweeping rates, more than a thousand years will be required to complete it.
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The Washington Post reported that in USA the mine weapon has come into wide use since the civil war Confederates installed mines at roads and in flowerpots. As a retaliations, Federals forced Confederate POWs pick them out from the ground (The Saint Petersburg Vedomosti. 07.02.1996). It is known, that after the end of the war on Falkland (Malvinas) islands between the Great Britain and Argentina in 1982 mine clearing operations begun immediately. But, it turned out to be such a hard work that the operation was discontinued very soon. There is a question considering that it was necessary to stop mine-sweeping territory where minefields were marked and combat operations lasted only two months, what would happen if military actions took several years, and mining was large-scale and non-selective? As ICRC reported, the United Nations Office for the Coordination of Humanitarian (UNOCA) has started in Afghanistan the minesweeping program. The program provides creation of 27 minesweeping brigades, and the basic zones minesweeping is supposed to require at least 15 years. If 30 km2 were cleared annually, then 4300 years would be required to free from mines only 20% of the Afghanistan territory. Mine-sweeping is not only technically complex and expensive operation, but is also an extremely dangerous work. Less than in ten months 84 foreign and local mine-sweeping experts were killed in Kuwait, who worked there since military operations were terminated. In Afghanistan 16 UNOCA officers were killed and 20 officers were injured when only 68 km2 of territories were cleared from mines. In Bosnia during military operations 25 foreign peace makers were killed and about 250 have received wounds at mine-sweeping (The Saint Petersburg Vedomosti. 07.02.1996). Mine dangers can prevent refugees return home after the ceasefires. The Afghan refugees return problem can be an example. According to the Office of the United Nations High Commissioner for Refugees, more than one million refugees returned to Afghanistan in first 9 months of 1992. From April to June of this year quantity of mine explosions victims only in ICRC hospitals increased two-threefold, compared to the same period of the previous year. These numbers only partially reflect the actual state of affairs, as they do not include those killed and injured who died before delivery to surgical centers. Thus, millions of mines not only kill, mutilate and keep people in constant fear, but with the fact of their existence deprive refugees of their fundamental right the right of return to homeland. Large quantity of mines in any country inevitably damages its economy as for some population groups the impossibility to cultivate the land challenges the very fact of their survival.
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However, mines (both cheap and expensive) are only a part of complex systems for creation and application of mine obstacles. Considering that engineers are constantly improving other components of this system (investigation, delivery, management, etc.), it becomes obvious that it is practically impossible to limit mine war. The modern mine weapon has such a potential that the tank damage probability can reach 85-90%, and infantry 45%. In addition, it means that mine injuries in the foreseeable period will be an important component of combat medical losses, and most of them are extremely difficult to render the surgical help at all stages of medical evacuation. For Russia, the explosive objects clearance problem is of special importance. For the first time it has emerged after liberation of wide territories from German forces during WWII. A total area of the Russian Federation, affected by the war made 1000170 thousand km2. In the postwar years, Ministry of Defence engineering forces was responsible for explosive objects clearance. This work was conducted both routinely (continuous clearance of territory) and by individual requests (disarming of explosive objects detected by mobile sweeper teams). At every stage work, the minesweeping was conducted 30-40 cm beneath the surface, proceeding from capabilities of mine detectors. Explosive objects planted below frostline come up again due to physical effect of ejection. Experiments and calculations demonstrate that such rise of explosive objects in a ground can reach up to 2 cm/ year. Therefore, considerable areas in the Russian Federation, cleared once, become dangerous again, and in some cases, they were unusable long after the war ended. Entire area, requiring repeated explosive objects clearance, is estimated approximately 54.000 hectares. The system of land mine clearing, developed in Russia, can be described as follows. In each military district, mobile mine-sweeping teams are formed using regular engineer forces. Land sweeping applications from local government bodies, organizations, institutions and civilians are received by military commissariats. Military districts headquarters, receiving applications from military commissariats, give specific assignments to minesweeping teams. Nowadays, field engineers annually clear approximately 10.000 explosive objects remaining since WWII. However, there are still cases of explosions. In 1998 there were 13 explosions, killing 13 people, including eight children and injuring dozens. In the first half of 1999 three explosions killing five people, including one child, and injuring seven people. The analysis of minesweeping materials has shown that more than 55 years later after the WWII ended the majority of detected explosive objects consisted of the artillery, aviation, and mortar
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munitions with thick-walled metal cases. Most of mines have become unfit for use due to corrosion of thin-walled metal cases or decay of wooden cases. To resolve this problem, Government created the federal program Explosive objects destruction in the Russian Federation territories, constituting the area of operations in WWII. According to the experts, this program would allow to solve the land-clearing problem within 5-10 years.

3.5. INTERNATIONAL HUMANITARIAN LAW AND MINE PROBLEM

The overwhelming majority of engineer mine ammunition is capable of maintaining their combat characteristics for a long time after war termination. It creates actual danger to civilians in those regions where military operations took place and where warring parties used mines. According to long-term experience, even continuous land mine sweeping after war and armed conflict termination only reduces quantity of victims, but cannot eliminate them completely. It is this fact, together with extensive use of mines, in regions with a sensitive political-military situation, gave an impulse to a powerful international movement for prohibition of manufacture and use of automatic anti-personnel mines. International and legal public attention focused on questions of compliance with international humanitarian laws of the entire complex of problems, regarding mine weapon application. The international humanitarian law represents an aggregate of legal maxims and norms included in international agreements, regulating relations between countries during a military conflict and aiming to protect fundamental human rights and freedoms and on humanization of war. It is significant that the question on necessity to limit excessive suffering, caused by extremely destructive and non-selective weapon, is not new. The first international agreement concerning projectiles took place at the conference in St.-Petersburg in 1868. The decisions were supported by all European countries. The agreement banned the use of shells, weighting less than 400 g, supplied with explosive, inflammables or combustibles. This question has become very important again with the advent of explosive bullets Dum-dum in English army, which inflicted really horrifying wounds. In the October issue of Military-medical journal in 1898 professor Paul von Bruns article Inhumane weapon in war was published. He presented this publication on XXVII Congress of the German surgical society (April, 1898). The publication presented results of the experimental studies regarding injuring action of naked and semi-jacketed bullets. The author arrived at the conclusion that for all civilized countries, it should be a precept in the name
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of humaneness the bullet should make an injured person unable to combat, and not to mutilate and kill. It can be fully applied to other injuring agents in war as well. The further development of the international process concerning the humane attitude to war victims has been reflected in a number of legal documents. The Hague declaration of 189. the Hague conventions of 190. the Geneva conventions relating to the protection of war victims of 1949 and the Protocols Additional to them of 1977 are the most significant of those legal documents. Necessity of profound understanding of International Humanitarian Law norms and principles is emphasized by the Order of the USSR Defense Minister No.75 from 02.16.9. which declared for guidance the Geneva conventions relating to the protection of war victims and the Protocols Additional to them. The Supreme Court of the USSR also implemented reference guide on the International Humanitarian Law norms. In the clauses 3. 36 and 37 of the Protocol Additional I to the Geneva conventions the main principle of the International Humanitarian Law that the right of the parties to an armed conflict to choose methods or means of warfare is not unlimited is proclaimed, and three basic International Humanitarian Law criteria, determining specific weapon application illegality, are settled: causing of excessive sufferings (excessive injuries); indiscriminate character (without distinction between civilians and military personnel); insidious or perfidious weapon use. Anti-personnel mines application aspects are regulated now by two fundamental universally recognized acts. The first is Customary International Humanitarian Law (the Law of War) the International Human Rights Law. It states that: 1. The parties of a conflict always should distinguish the civilians and warring people. The civilians cannot be attacked directly, it is impossible to apply nondiscriminatory weapon against them (defeating undefined target). 2. It is forbidden to use weapon, causing unnecessary sufferings. It is forbidden to use the weapon with injuring action disproportionately higher than the military objectives achieved with its use: The second document is the Convention of 1980 on Prohibitions or Restrictions on the Use of Certain Conventional Weapons Which May be Deemed to be Excessively Injurious or to Have Indiscriminate Effects. The convention defines specific rules of mines use: it is forbidden to use mines against civilians under any conditions;; use of mines with indiscriminate effects is forbidden; it is necessary to apply all possible safety measures to protect civilians from consequences of
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mine explosions;; the remote mining is forbidden, if it is impossible to register precisely arrangement of mines or use a reliable neutralizing mechanism; if circumstances allow, at air-mining or in other cases of remote mining when the civilians can be harmed it is necessary to make the corresponding warning; the parties to a conflict should specify every zone where the scheduled mining was carried out; the parties should do their utmost to specify location of any other minefield; after termination of active military operations parties should try to reach the agreement between themselves and, if it is necessary, with other countries and international organizations to clear the mines installed during the conflict or to disarm them in any other way. These provisions were represented in the Protocol II, which provides prohibitions or restrictions on the use of mines, booby-traps and other devices. The Convention and the Protocol II have been signed on behalf of the USSR on April, 1. 198. and have come into force since December, . 1983. However, defects were noted in the first edition of the Protocol its provisions applied only to international conflicts, whereas the greatest number of mine victims is caused by socalled internal armed conflicts; the effective mechanism of anti-personnel mines uncontrollable export prevention was not suggested. In 1995 the group of UN experts Protocol II new edition. In May, 199. the Protocol II has been adopted as amended (it is also known as amended or revised Protocol II). In comparison with the original, the supplemented one considerably toughens restrictions on anti-personnel mines application. For example, application of undetectable mines and mines invisible to mine detectors is absolutely banned. New requirements for remotely delivered mines are being established. Restrictions on mines transfer and export are imposed these operations are not allowed for non-government entities formations and countries, not participating in the Protocol II. It is very important that the scope of the document was broadened to include internal conflicts in the territory of the states, participating in the Protocol II. The Protocol establishes a nine-year transition period for the countries ratified it to stop manufacture and application of anti-personnel mines banned with this document. The Protocol II incorporates mechanism of periodical (once in five years) revision of its regulations to gradually approach an ultimate goal absolute prohibition of anti-personnel mines. The first substantive steps to the international agreement on absolute prohibition of anti103

personnel mines were made in 1996 at the international conference in Ottawa (Canada). This conference has originated the so-called Ottawa Treaty, where Canada, Belgium, Norway, SAR, Mexico and a number of other states took the lead. Some nongovernmental organizations (the International Committee of the Red Cross, the International Campaign to Ban Landmines, International Physicians for the Prevention of Nuclear War, etc.) also have actively supported Ottawa Treaty. Such authoritative international organizations, as the UN, the OAU, the OAS, the UNICEF, etc., also voiced their support to the Treaty. The Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of AntiPersonnel Mines and on Their Destruction was adopted as final at diplomatic conference in Oslo (Norway) on September, 18th, 1997. Its signing took place in Ottawa in December of the same year. By the end of the 1999 the document has been signed by 135 states, however the key antipersonnel mines manufacturing countries Egypt, Israel, India, Iran, China, Pakistan, Russia, the USA, Turkey and some other countries have not done it yet. The Convention establishes strict period for the states-participants all stocks of mines should be destroyed within 4 years from the moment of the Convention ratification by the country. Within 10 years, all the territories affected in these countries should be cleared. The broad range of measures on the international cooperation in mine destruction and mine clearing is also provided for. It is especially important for those developing states (Angola, Afghanistan, Cambodia, Laos, Mozambique, etc.) that had mined extensive areas important for economic and social development, but do not have funds for mine clearing. In this connection their accession to the Convention can be explained in many respects by the interest in the financial and expert help for humanitarian mine clearing from quite wealthy states-initiators of the Convention. By October, 1998 the Convention has been ratified by the necessary 40 states, and on March, 1st, 1999 it came into force. Contribution to the development and signing of the Convention the International Campaign to Ban Landmines (ICBL) resulted in Nobel prize for coordinator Jody Williams in October, 1997. When signing the Convention in Ottawa, the representative of Russia has declared fundamentally positive attitude to the document, readiness for accession to it in reasonable time in the future. Delegations of the USA, China, Iran, Cuba, Israel and some other states have made corresponding statements about their motives of the nonaccession to the Convention. The International Committee of the Red Cross was one of the first in the post-war world to express concern over the mine injuries problem after the termination of military actions. The
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International Committee of the Red Cross, the independent nongovernmental humanitarian organization, acts as a neutral intermediary in case of armed conflicts or disturbances, directs its efforts to provide protection and help to victims of international and non-international armed conflicts, internal disorders and tension either on their own motion, or based on Geneva conventions regulations. The president of the International Committee of the Red Cross, Cornelio Sommaruga, in 199. urging all states, humanitarian organizations and nations of the world to unite the efforts in struggle against this danger, for the first time gave it a general characteristic. He mentioned that against the background of hardships and sufferings of people during a war the awful consequences of mines explosions are often forgotten, and millions of mines remain in the ground or on its surface and terrify people for many years and even decades after military actions ended. According to the president, the role of the International Committee of the Red Cross is, first, to force to respect the International Humanitarian Law, prohibiting indiscriminate use of mines and any intentional actions, both posing a threat to life or health of civilians and causing serious and long-term harm to the environment. Together with other organizations, the International Committee of the Red Cross tries to help victims of explosions and organizes surgical and orthopedic centers in those countries where armed conflicts take place. The task of these centers is to provide treatment to victims of explosions and to return them to a normal life. Moreover, the International Committee of the Red Cross regards it as its duty to remind the international community that huge efforts for mine clearing are required in affected areas. Why, despite the seeming expediency of the absolute prohibition on manufacture and application of anti-personnel mines, this process goes that slow and difficult? We analyze this question on the example of Russia. Russian Forces are now armed with anti-personnel mines developed and made in the former USSR. Russia has inherited entire supply of these mines. The Fundamental Provisions of the Russian Federation Military Doctrine enacted by the Decree No.1833 of the President of the Russian Federation from November, 2nd, 199. define solely defensive character of activity on maintenance of military safety of the Russian Federation and its allies; determine adherence of Russia to the purposes of wars and confrontations prevention, their elimination from the mankind life, comprehensive disarmament, elimination of military alliances; reaffirm the determination to achieve implementation of ideals of humanism, democracy, social progress, universal safety and peace.. Diring the years after adoption of fundamental provisions of the doctrine in the international
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climate there were essential changes, and it has caused the necessity to develop new military doctrine. This work is now underway. Moreover, the following factors are considered. Despite positive changes in the world, there are still threats to national security of the Russian Federation. Considering radical changes in relations of the Russian Federation with other leading powers, it is possible to make a conclusion that a threat of the large-scale aggression against Russia is improbable in the foreseeable future, but still remains. Attempts of power rivalries within Russia remains are a threat well. The most real threat to Russia in defense sphere is existing and potential local crisis areas and armed conflicts along its border. Economical crisis, social-political dissimilarity between republics, mutual territorial claims, national-ethnic and religious conflicts cause the nearest encirclement of the Russian Federation to become one of tension and potential conflicts sources, posing a threat to its safety. Regulations that Russia does not refer to any state as to military opponent, adopted by political authorities have brought drastic changes into the military doctrine. It has necessitated the refinement of approaches to all military command problems. The analysis of the military doctrine fundamental provisions demonstrates that they directly or indirectly predetermine role and the place of engineering obstacles in the general state defense system. In modern conditions, considering drastic reduction of border troops with simultaneous extension of defense zones, capabilities of troops to repel an assault are essentially reduced. In this connection, engineer obstacles are frequently among few effective protective measures for unprotected gaps in dangerous directions. Peculiarities of Russia geostrategy are such that while the borderlines are very extensive (land borders are more than 1.000 km), there are extensive unpopulated areas, which can be used for infiltration by terrorist groups, and during specific period for infiltration of armed units. The majority of the Russian Federation new borders are not equipped at all to repel a possible aggression. With reference to the military doctrine requirements of the Russian Federation, anti-personnel mines can be used to resolve the following tasks.
1. To cover the borders with the purpose of prevention of armed units and terrorist groups

infiltration, illegal gun-running and drug trafficking.

2. To protect important military and industrial facilities (Nuclear Power Plants, hydroelectric

power stations, dangerous chemical productions, etc.) from subversive and terrorist acts. 3. To cover defense positions, position areas, artillery and air defense facilities sites, deployment
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areas of control centers and warehouses, especially with ammunition, and other elements of defense posture in case of aggression against Russia.
3. To close defense gaps caused by massive attacks with modern weapons.. 4. To cover base areas (location areas, concentration areas) and checkpoints during internal and

external armed conflict.

5. To cover concentration areas (location areas, permanent bases) and positions of peacekeeping

forces of the Russian Federation when peacekeeping operations are performed by the decision of UN Security Council. According to the experts of the Ministry of Defense of the Russian Federation, mine ammunition is an integral part of the existing warfare Its withdrawal from this system is possible only by replacement with alternatives comparable with anti-personnel mines by efficiency, cost and mass production facilities. However, at present there are no weapons, capable to replace anti-personnel mines and perform all assigned tasks with required efficiency. Sudden prohibition of anti-personnel mines will have an extremely adverse effect on the defense capability of the country. Besides, with the prohibition of anti-personnel mines the expansion threat of application of self-made mines and explosives, which are much more dangerous and insidious, can increase. The proof is experience of armed conflicts during XX century last decades, including conflicts in the Chechen Republic and in Bosnia and Herzegovina. Last years events go to prove that in those regions, where volatile areas occur, criminal groups, occupied with illegal gun-running and drug trafficking, immediately become active. Such groups act impudently and with sophistication. Events in Tajikistan on the Moscow frontier troops section in July, 199. when the armed gang carried out the concerted attack on 12-th frontier post. The anti-personnel mine use to cover borders confirmed their application to increase the border troops capabilities by 20-30%. Mines are an effective and low-cost instrument to cover borders, especially in mountain regions. Moreover, considering that on the frontier the transfer of civilians should be strictly controlled or eliminated in general, explosions of civilians should be ruled out. Moreover, mines installed according to requirements of Protocol Additional II to the Geneva Convention of 1980 should be marked and carefully recorded. Another important problem solved with the anti-personnel mines use is protection of important military and industrial facilities, nuclear and hydroelectric power stations, and dangerous chemical productions to prevent the infiltration of the armed units and terrorist groups into these
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objects and to exclude sabotage. Unfortunately, lately terrorist acts, hostage taking, and sabotage at industrial facilities tend to increase. Existing guard practice considering object characteristics shows that existing security units are not able to provide required safety of these objects, first, because of insufficient manpower quantity, slow guard technology introduction and its inadequate efficiency, especially in northern and mountain regions and other special environments. An analysis shows that improvement of protection is possible using of guard troops, detecting devices, security alarm, communication, engineer obstacles, improvement of methods, options of their application and combination. Otherwise, there are two contradictions: on the one hand, imperfection of a human as an instrument of saboteurs detection and destruction (dependence of his capabilities on climatic and weather conditions, light level, easy fatigability, etc.), requires technology-based compensation and improvement of guard reliability; on the other hand, this technology is frequently unreliable, while reliability raise up to the required level causes multifold increase of expenses and cost. As for now, extra-high reliability of anti-personnel mines, automated operation, low prices and minimal expenses for obstacles establishment make them irreplaceable. Calculations show that in case of cancellation of mine application to guard important facilities it will be necessary to increase the number of security units by a factor of 1.3 or to replace them with alternative agents. At present, there is no ammunition, which could adequately replace anti-personnel mines and perform all assigned tasks with required efficiency. According to military experts, the prohibition of mines can affect not only defense capability of one country but also safety of many countries and nations, if a terrorist impact on an important object will cause a catastrophe similar to Chernobyl disaster. Thus, the decision on the prohibition of anti-personnel mines should not be hasty and irrelative to any side of this complicated question. Expert data proves that the complex of alternative agents should be developed for functional replacement of anti-personnel mines. The analysis of terms and definitions of the Ottawa Convention shows what to classify a munition as an anti-personnel mine is possible only in case it has three features [Ermakov A.A., et al., 1998]:
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the energy source to affect a human is an explosion; the reason of explosion is the contact or non-contact human influence (while a human is a target itself) on a fuse specially intended to react on the human; disabling or infliction of severe or mortal injuries to one person or several people.

Considering the above, further evolution of anti-personnel weapon assumes improvement of antipersonnel ammunition (agents) that do not have at least one of the listed characteristics. Even in the case of anti-personnel mines prohibition, one of the anti-personnel obstacles options is the creation of obstacles, which cannot be classified as an anti-personnel mine. These means could be controlled anti-personnel ammunition, which is activated by an operator. Therefore, controlled exploding parts of anti-personnel fragmentation mines can be an alternative to anti-personnel mines. From here, the further development of this direction goes in two directions: improvement of fragmentation ammunition;. creation of new control systems.

Development of these means cannot fully compensate prohibition of traditional anti-personnel mines, therefore, development and improvement of existing non-explosive agents is considered as an option. Among operationally available agents, it is possible to mention means to create electrified and barbed-wire/tape obstacles. In the long term, it is possible to create electroshock means and means of infantry neutralization by quick-setting foamy compositions, glues, fabric and metal nets [Shofield S., 1995]. Next direction leans toward use of non-traditional principles and methods. In the West this direction has begun to develop especially intensively in the 80s. The task of non-lethal weapon development was very urgent. They expected these weapons to achieve military and political objectives during local wars and armed conflicts, preventing heavy casualties, destruction of infrastructure elements and other undesirable consequences, resulting in exasperation of population and increased social tension. Non-traditional means include [Vybornov S., 1993]:
blinding effect from coherent and incoherent radiation of laser and pyrotechnic systems

causing temporary blindness disorientation;

acoustical effect from infrasound and sound generators, as well as pyrotechnic systems,

causing vomiting, internal organ disorders loss of sight;

electromagnetic effect by microwave generators, upsetting brain and CNS function;
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chemical effects, depending on the type of applied agents, can result in wide-ranging mental

disorders from immobilization up a schizophrenia (due to application of psychotropic aerosols and mental incapacitators), destruction of equipment and weapons (due to activators of an oxidation reaction) or can create hardly tolerable conditions of activity (for example, due to fetid and itchy substances);.
psychological effect, produced, for example, due to projection certain holographic images

causing subconscious apprehension and other emotions, impeding accomplishment of a mission. Therefore, in whole there is a wide spectrum of scientific and technical approaches, comprising basis of such protection weapon evolution. Leading world powers work on these directions and they are at various implementation phases. In this process the necessity to observe international agreements, restricting or prohibiting application of laser, chemical and other types of weapons, is a serious restraint to their practical use. Moreover, use of weapons with non-lethal outcome is associated with a great risk. For example, there are recorded death and mutilation because of police enforcement efforts with tear-gas and rubber bullets. It is also necessary to consider a wide range of critical effect parameters of these agents for different groups of population (state of health, national peculiarities), reduced efficiency because of weather conditions (strong wind, rain, snow). In this connection, considering two incompatible conditions (secured non-destruction of civilians, on the one hand, and on the other incapacitation of a soldier with appropriate physical fitness and equipment, goggles, a communication helmet, a respirator, etc.), creation of promising agents on the basis of observed effect principles is a complex scientific and technical problem.. Although, there is enough possible directions to create alternative to anti-personnel mines, their development will need a revolutionary weapon class and, accordingly, requires the system approach and a multipronged substantiation considering the general concept of the mine weapon application in present-day conditions. The disposal of anti-personnel mines that are decayed or subject to liquidation according to international agreements is another humanitarianly significant problem. Now, the problem of the anti-personnel mines disposal became very urgent because of the following: significant volumes and wide assortment of stocked anti-personnel mines which have to be disposed because of warranty period expiration and treaty obligations on their application restriction;
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dangerous explosive and environmentally hazardous character of works on storage and disposal of anti-personnel mines with expired shelf life; economic crisis in the country, a low level of state and capacities of available disposal industrial-technological facilities; hardening of environmental safety maintenance requirements in the process of industrial disposal and destruction of anti-personnel mines.

Adoption of legislative state and international acts on liquidation of anti-personnel mines stockpiles and on environmental protection forces to intensify search for environmentally safe and cost-effective ways of mine disposal. Regarding this, a question on the creation of tools and technologies for the anti-personnel mines disposal, meeting safety, environmentally friendliness and integrated utilization requirements, and allow recycling explosives and other materials from anti-personnel mines, has become very urgent. Anti-personnel mines stockpiles are disposed at industrial factories and at places of their storage. Nowadays factories use ineffective, low-productive technologies, involving a lot of manual labor to dispose of anti-personnel mines Anti-personnel mines stockpiles destruction at the places of their storage is done by a method of disassembly and destruction in the open terrain. For this purpose, the simplest mines are disassembled, while fully armed and cluster mines, including physically deteriorated antipersonnel mines, are destroyed. The development level of existing scientific and engineering basis of the anti-personnel mines disposal in the Russian Federation does not meet present-day performance and ecological requirements. Therefore, one of the solutions is the creation of perspective technologies and means of their disposal. It is obvious that under conditions of limited financing it is appropriate to count on those technologies and means that have analogs in the industry and prototype models, so that their finishing for the purposes of anti-personnel mines disposal would require minimal expenses. The anti-personnel mines assortment from the point of view of their stocks disposal can be divided conditionally into two groups. The first group would consist of anti-personnel mines, which are subject to liquidation, and the second one of mines, which are subject to disassembling with extraction of explosive. The disassembling method is labor-consuming, long-duration and requires the use of special manufacturing capabilities and qualified professionals. Its application allows disposing any anti111

personnel mines stocks types; moreover, the major part of explosives and materials is saved and can be used for secondary production. The method of destruction by detonation and incineration is least labor consuming and allows liquidating stockpiles of any anti-personnel mines in a short time. However, because there are no environmentally safe technologies, detonation and incineration of anti-personnel mines in the open air are environmentally dangerous as the destruction of mines pollutes an environment with various toxic substances, including heavy metals. Because of the low material capacity of the anti-personnel mines basic types, the disposal of their stocks in whole is unprofitable. In spite of this and following the humane principles, aiming to the complete anti-personnel mines prohibition and the destruction of their stocks, in 1998 approximately 500 thousands anti-personnel mines were utilized (destructed). This task was achieved by joint efforts of industrial factories and engineer ammunition depots (bases). At present, the industry develops mobile modular complexes for the anti-personnel mines disassembly. The complexes can be rapidly deployed at anti-personnel mines storage depots, providing decrease of capital expenditures on disposal of the whole anti-personnel mines stock. For example, Moscow State Technical University (MSTU) developed mobile anti-personnel mines disposal plant, but due to lack of financing they are not certified. Thus, the problem of the anti-personnel mines disposal and destruction in Russia gained status of national importance. What are the prospects of absolute anti-personnel mines abandonment by Russia? The position of Russia on this question is declared by the President of the Russian Federation on October, 10th, 1997 in Strasbourg. This declaration states, that the Russian Federation entirely supports efforts and aspiration of the world community regarding the prompt solution of the mine problem and is ready to do the utmost of its power to achieve this aim. At the same time, at the given stage we cannot immediately accede to the Convention due to political, military-technical and economic reasons. Politically, this Convention not only does not solve the mine problem, but, on the contrary, aggravates the issue. With its signing, alongside with the Protocol II to Geneva Convention of 198. one more alternative international mechanism on anti-personnel mines was created. The convention divided the world community into two camps: supporters of the immediate antipersonnel mines prohibition and those, who are not ready for this step due to objective causes, first, economic realities. In the political-military respect, anti-personnel mines belong to defense weapons. They have
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been created for many decades, and their existence reflects objective need for such kind of munitions. At present, there are no substitutes, which could adequately replace anti-personnel mines and achieve required efficiency. Sudden mines prohibition will have extremely negative impact on defensive capability of the country. In the economic respect, the accession of Russia to Ottawa Conventions is also unacceptable, as it will require destroying all available mine supplies within the four-year period. It is an impossible task not only for Russia, but for the majority of the "mine" countries as well. Nowadays Russia has no necessary technologies and sufficient capacities to dispose available anti-personnel mines supplies, meeting such tight schedule. It will require a series of research efforts and experimental development, preparation and organizational management at industrial factories. The problem is additionally aggravated with the fact that, considering the extensive territory of Russia, approximately 30% of total expenses for the disposal will consist of charges on the ammunition transportation to the places of their utilization. The destruction of larger lots of mines in their storage places is unacceptable in most cases for ecological reasons. As assumed in official circles of Russian Federation, the world community main efforts now are to be concentrated on the destruction and clearing of installed mines. Russia is ready to participate actively in implementation of international programs on mine-sweeping and makes certain practical steps, including following directions: training of national specialists on mine-sweeping based on high schools and educational centers of engineer forces or with the secondment of specialists-instructors to needy countries; direct participation in mine clearing activities with engagement of engineer forces reserve officers or specially trained engineer mine-sweeping subdivisions; supply of modern mine detection and clearing devices. In November, 1994 the President of the Russian Federation has ordered to implement Russia participation in international aid during emergency situations. Implementation of the Presidents Order was sequentially continued by the Government Regulation of the Russian Federation as of November 1. 1995 No.1010 About the Russian National Corps for the Emergency Humanitarian Response, in which tasks on organization and application of a UN standards compliant national infrastructure were assigned to the Russian Federation Ministry of Emergencies (RF MOE). By adopting this Regulation, Russia has opened a new direction of the Russian humanitarian potential practical use to rendering of aid in emergencies. Since November, 1998 the field
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engineers of the Ministry of the Russian Federation Ministry for Civil Defense, Emergencies and Disaster Response have started to sweep Bosnia and Herzegovina territories. For the first time, Russian specialists won the international competition under the aegis of the United Nations for the right to conduct this operation. According to the RF MOE, the most probable foreign regions where the Russian mine-sweeping forces and specialists can be required soon are Croatia, Egypt, the states of Northern Africa and the Middle East, and also Angola, Afghanistan, Ethiopia, Vietnam, Cambodia and Laos.

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Chapter IV INJURIES DURING THE EXPLOSION-RELATED TECHNOLOGICAL DISASTERS

XX century has demonstrated an astonishing combination of prominent discoveries, technical and technological breakthroughs, and common successes of the civilization, on the one hand, and severe droughts, destructive inundations, sanguinary world wars and decades of continuous interethnic, confessional and other armed conflicts, earthquakes and various technogenic disasters on the other hand. For instance, according to Dr. F. Bassani (1997), the director of the WHO Division of Emergency and Humanitarian Action, 213 natural and 89 man-made disasters occurred in 1995 alone, while 20 previous years brought 155 taken together. The world community is concerned by the fact that in the modern world the frequency and scales of catastrophes and major disasters constantly increase, causing tremendous difficulties in the operation of the basic life support services and innumerable sufferings to the population of certain countries as well as to the world community (S. William A. Gunn, M.D., 1997 the president of the World Association for Disaster and Emergency Medicine WADEM). This problem is especially urgent for our country, which politicians have named a problem of 2003, and specialists unanimously predict a stable increase tendency of technogenic disasters and major accidents caused by the extreme depreciation of basic infrastructure, power engineering, transport and communication, which was not maintained appropriately within last 10-15 years, and by 2003 depreciation will peak. According to statistics, explosions and resulting fires are leading causes of technogenic disasters. Thus, American authors, considering only disasters with at least 10 victims, have defined their frequency as 13.05% of all similar events, including natural as well as anthropogenic disasters. If to consider that the most aviation (23.3%), car (18.0%), ship (15.05%), railway (9.35%), mine shaft (6.05%) disasters, and also nuclear power plant accidents (0.59%) were the originated by explosions, then no doubts remain in the extreme urgency of these unpredictable and terrible events study. Only during recent years we witnessed large-scale explosions of railroad cars with explosives in the cities of Arzamas and Sverdlovsk (1988), the explosion of isothermal tank with liquid ammonia in Ivanov city (1988), the explosion on the products pipe line close to Ufa (1989), the
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wreck of Kursk nuclear submarine (2000), accompanied with mass people loss, serious injuries and burns in tens to hundreds casualties. Unlike explosions of standard ammunition, when their yield related to the kind and mass of the explosive charge, manufacturing and delivery methods, way of application, etc., the above-mentioned disasters were unplanned. Physical parameters of explosions were possible to determine only approximately, while inflicted injury types, mainly plural, associated and combined, have posed significant problems in providing medical aid. A certain analogy of many peacetime explosions with earlier defined mechanisms of standard ammunition injuring factors allows (certainly, with some restrictions) to use a military specialists experience to characterize a pathology also at explosions in peacetime. Naturally, not only generalizations should be applied, but also certain corrections in view of differences both in injuring factors and in actual target the noncombat population which, unlike soldiers, is not prepared morally for the explosion injuring factors impact and does not have means of necessary protection. Since casualties and personnel, providing medical aid, are not aware of character of explosive, physical and chemical properties of explosion, its parameters and the number of other technical details and are not able to apply them directly, it would be reasonable to digress into several general explosion characteristics, correlating them with the character of the most probable human injuries. As in publications any disaster, including an explosion, is commonly estimated by the number of casualties, then from this point of view (since explosion yield is impossible to define physically and has to be related to the number of casualties) it is conveniently to graduate explosive traumas instead of explosions. Hence, it is proper to distinguish explosions without injuries to people and explosions, leading to casualties. When evaluating disasters, explosions are commonly distinguished into the following types: with an injury to single person (a solitary explosive trauma); with an injury to several people up to 10 casualties (a group explosive trauma);
with an injury to 10 and more casualties (a mass explosive trauma).:

Many explosions in 20th century resulted in hundreds and even thousands of casualties (Table 4.1). Each had a specific character caused not only by an explosion type and yield, but also circumstances related to explosions in mine shafts mine traumas, on ships (ship trauma), in trains (railway trauma). The special blast effects and other explosion injuring factors can play an important role in origins of both basic and additional injuries. All these circumstances are impossible to consider in advance, but following characteristics are the most important when
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planning medical aid: explosions in the open air; explosions in the closed and open premises; explosions accompanied by toxicants formation or atmospheric emissions; explosions resulting in radioactive contamination.

Table 4.1 World greatest catastrophes related to explosions (1917-2000 Year Location Catastrophe type
killed

Number wounded

1917 Halifax (Canada) 1921 Oppau (Germany) 1933 Noshkirchen (Germany) 1942 Tessenderlo (Belgium) 1943 Ludwigshafen (Germany) 1944 Cleveland (USA) 1947 The Texas City 1948 1971 1978 1988 1989 2000

An explosion of a ship with a load of picric acid An explosion at a fertilizer factory A gas explosion at a metallurgical plant An explosion at a factory, manufacturing ammonium nitrate An explosion of 16 tons of butadionum at a chemical factory An explosion of 4300 m3 of liquefied natural gas

1963 561 63 200 57 136

More than 9000 About 1900 Several hundreds of thousands 1000 439 350 500 3800 About 200 200 More than 500 1368

An explosion of 1.7 tons of 532 nitramonium ship load Ludwigshafen An explosion at an aniline industrial 245 (Germany) complex Minsk (USSR) An explosion at a radio-TV cases More factory than 100 San-Carlos-de-la- Explosion of a truck with liquefied 216 Rapita (Spain) propylene Arzamas (USSR) An explosion of a freight train 91 loaded with explosives Ufa (USSR) An explosion of a oil byproducts 408 pipe line The Northern Fleet The wreck of the Kursk nuclear 118 (Russia) submarine

The logic dictates a necessity to classify mentioned explosion by the basic injuries classification; explosive traumas with mechanical injuries only; explosive traumas with combinations of mechanical and thermal injuries; explosive traumas with combinations of mechanical, thermal and radiation injuries; explosive traumas with combinations of mechanical and chemical injuries.
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Certainly, this classification describes dominating injuries to people at each explosion variety. They can be solitary, plural, and combined. Moreover, this classification allows considering injuries, occurring immediately during explosion, together with the fact that casualties can be exposed to after-effects of an explosion poisoning, irradiation, etc.

4.1. EXPLOSION INJURING FACTORS AND MECHANOGENESIS OF ORGANS AND TISSUES INJURIES
It is known from the theory and practice of military medicine that injuring factors of any ordinary (non-nuclear, non-fuel-air, non-chemical) ammunition include an air blast wave, explosive gases jets, ammunition fragments, flame heat, gas-detonation products, and secondary injuring projectiles. Basing on the data of domestic and foreign investigators experimental and clinical observations in the forties-eighties of 20th century, and first, on the experience of rendering medical aid to the wounded in realistic environment of notorious Afghanistan non-declared war, it is possible and pertinent to give the generalized description of the combat explosive trauma mechanism. This will naturally allow covering peculiarities of explosion injuries during man-made catastrophes. The blast effect makes oneself evident in the fact that when the explosive (HE) enclosed in an ammunition case detonates, a huge quantity of gases is emitted. Sharp rise of gaseous medium pressure fractures a case (mostly, metal), bringing fragments to initial high speed. Most of the remaining explosion energy is spent to form air and ground blast wave and flame heat. Air blast wave damaging action represents a complex process, involving injuring effects of excess pressure, pressure difference ahead of and behind a blast front and, at last, a dynamic pressure in a blast front. The sound constituent of a blast wave, leading to an acoustic trauma, is also an indispensable component of the air blast wave damaging action. Blast wave formation begins with an increased pressure impulse with duration of some milliseconds. Following a compression shock, the object on the way of a blast wave is exposed to total frontal and tangential impacts and compression. The dense air layer compressed up to several thousands of kPa propagates from an epicenter in the form of rapidly expanding sphere with a speed up to 3000 m/s; however, this speed quickly drops to the speed of sound. Similarly to acoustic waves, a blast wave easily penetrates obstacles and injures people behind them. From the practical point of view, they distinguish lateral pressure (perpendicular to a blast front) and
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the reflected pressure, being especially high at the explosions in the closed premises. The negative pressure, or blast wave rarefaction, is considerably lower than the positive pressure, but lasts approximately 10 times longer. Rapidly expanding gases, produced by an explosion, displace equal volume of air, which propagate with high speed and define the dynamic pressure in a blast front. This phase of a blast wave lasts hundreds and thousands times longer. The complex combination of various forces and pressures form a resultant, radiated upwards and in all directions from a ground epicenter, and, consequently, a human can be thrown several tens of meters away because of the so-called propellant effect of a blast wave. In the near-miss zone, the dynamic pressure can be as high as the excess pressure resulting complete destruction of a human body. As the distance from the epicenter increases, the pressure decreases in inverse proportion to the cube of the distance. In this zone, there are extremity avulsions, severe open and closed damages of a body, including internal organs, accompanied by hemorrhage and a shock. The power pressure in a blast front leads to the rapid compression of cavities and vessels, which is accompanied by the development of the general commotiocontusional syndrome, an injury of lung tissue (less often of heart tissue) due to its compression between the rising diaphragm, moving inward chest wall and the rigid backbone. Strong stimulation of extero-interoreceptors on the wide body surface results in the formation of the numerous and resistant excitation focuses in the central nervous system. Because of the pressure difference ahead of and behind a blast front, casualties receive the barotrauma with a dominating damage of hollow and ENT organs. In fractions of a second, the acoustic trauma has a strong impact on the cerebral matter and Corti's organ, subsequently resulting in their significant dystrophic and atrophic changes. It is determined that in 50% of observations the eardrum ruptures occurred at the pressure of 97103 kPa. The threshold pressure, resulting in the lung tissue damage, is 200-345 kPa. In the closed space, excess pressure caused by the blast wave complex impact, including reflected waves, can be five times lower. The injury of abdominal cavity organs by an air blast wave is much less frequent than the injury of lungs. Observations have shown that the majority of the casualties with such damages have died. Morphological changes (hemorrhages, perforations, etc.) were localized in the organs, containing gas. Besides the direct injuring effect of a blast front, body and internal organs damage can occur because of specific physical phenomena. Thus, due to a predominance of high frequencies in the
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blast wave spectrum it easily penetrates into a human body, resulting in inertial and splitting damages, accompanied with tissues fragmentation, organs edema and hemorrhages, in the interface of structures with different density. Compression of small air-bubbles leads to their warming and expansion, which is accompanied by origination of a new blast front and further tissue damage (an implosion effect). Structures of the central nervous system, the middle and internal ear, lungs, the gastrointestinal section are most sensitive to the specified factors. In two last decades a series of studies addressing primarily research of mine demolition mechanisms were published. For example, some foreign authors even introduced the mine foot term, meaning an aggregate of human foot injuries in the radius of blast effect as a result of an anti-personnel mine explosion [Owen-Smith M. S., 197. 1981]. To elaborate statements in the previous chapters, it is necessary to add that the ultrahigh and reflected pressures during an anti-personnel mine explosion, at contact form a united blast front with substantial destructive force, and most of energy goes to compress basic foot structures, or transforms into kinetic energy, defining the dynamic pressure of a blast wave. A damage aggregate, as a rule, is defined by an explosive device type, HE weight and a foot position while actuating a fuse. Thus, the character of damages at the anti-personnel mines demolition depends primarily on the excess and dynamic pressures impact, and at the fragmentation mines demolition it also includes the fragments impact. An experimental research of corpses aimed to reproduce the mechanism of basic explosion injuring factors showed that HE demolition under mid-foot often causes the avulsions of foot and shin at different levels. Soft tissues damage extent was regularly increasing with the HE weight increase. Using piezoelectric transducers implanted into the lower limb tissue at different levels, the researchers found out that the energy transmitted to biological tissues was registered throughout the bioobject with a minor lag, and the maximum energy output has impacted foot support structures with its subsequent linear wane throughout the limb. The blast wave excess pressure resulted in foot complete destruction and separation. Penetration of explosive gas jets and a blast wave under the skin and into the wound of a shin led to extensive tissue detachment. Demolition high-speed camera data have indicated that the light flash produced by heated gases and the blast wave were spherical, which defined traumatic and coagulative necrosis of protruding bones of a shin and soft tissues at the level of separation and also a specific fragmentation pattern. Dispersed in the form of a cone, they defined a typical topography of injuries, namely: fragmentation wounds of a contralateral limb, perineum, buttocks, front torso,
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and of arms and a face slightly bowed forward during walking.

4.2. DISTINCTIONS OF TECHNOGENIC EXPLOSIONS

Both in combat environment, when regular ammunition is used, and in peace time, when explosions have the technogenic nature, particularly a blast wave causes primary (commotiocontusional syndrome), secondary (fragmentation injuries) and tertiary (mechanical traumas as a result of body throwing-off and hitting the ground) injuries. Fragmentation wounds are worthy of special attention. If during combat these wounds are mainly inflicted by pre-shaped elements of an ammunition case (for example, a grenade ribbed case), then during peacetime by fragments of glass, stones, equipment parts, etc. With respect to an estimation of the most frequent and typical injuries inflicted by injuring factors of an ordinary explosion, it is necessary to distinguish three fundamentally different situations: a casualty is exposed to all injuring factors of an explosion, i.e. he is in the immediate proximity to the epicenter; a casualty is mainly impacted by fragments, and the effect of other injuring factors is either absent or considerably weakened; a casualty is exposed to the impact of collapsed buildings destroyed by an explosion (traumas due to rubbles, crush syndrome). Undoubtedly, according to a broad experience of specially performed experimental operations and the whole field medical practice of rendering medical aid to casualties, in the first alternative a primary types of injuries are plural, associated and combined traumas, while in the second and third options solitary and plural fragmentation wounds, open and closed compression traumas. A practice of rendering medical aid during technogenic catastrophes has demonstrated that during explosions of any origin, individuals in the first group are killed at once in overwhelming majority of cases. Thus, according to Shaposhnikov Yu.G. et al. (1990) and Anisimov V.N. et al. (1991), basing on a thorough analysis of irrevocable and sanitary losses patterns during large urban explosion, it has been established that survivors consisted mainly of individuals with plural and associated traumas (wounds of soft tissues, fractures, dislocations, skull and brain injuries, internal organs injuries), and also body compression under the debris of collapsed buildings. The researchers noted large number of glass fragmentation wounds; hence, the majority of casualties
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were injured only by one (mechanical) injuring factor. The individuals with injuries inflicted by two and more explosion factors were killed at once or died during transportation. E.g., at the anthropogenic catastrophe in Arzamas, casualties manifested, first, primary, secondary and tertiary mechanisms of a blast effect in their entirety, while temperature, chemical and other explosion factors had an effect at a rather small distance. The mentioned predominance of singlefactor injuries in sanitary losses is necessary to consider as essentially important to forecast a traumas structure at technogenic catastrophes caused by explosions. One more feature of peacetime explosions, which characterizes quantity of sanitary losses, i.e. a number of casualties requiring a medical aid, is as essential as the previous one. From the formal point of view, only those events are catastrophes that lead to mass casualties. Therefore, numerous accidental explosions, injuring only one or several people (a typical situation is an explosion of fuses or other devices in curious hands, especially, children; an explosion of small gas-cylinders, etc.) do not create catastrophes and are not considered in the mass explosion injuries patterns. Naturally, it does not lower standards of rendering the best possible aid to any casualty, but changes the mass injuries pattern placing predominance on the single-factor injuries. At the same time, it is necessary to emphasize that the single-factor explosive trauma is also characterized mostly by plural and associated injuries of many body sectors. Closing this section, it is necessary to note that wartime explosive and mine injuries and explosive traumas at technogenic catastrophes essentially differ from each other, though having much in common. The former, being one of the combat gunshot wounds varieties, are inflicted by specially designed weapon. In their origin, one can determine regular connection with an explosive ammunition type and yield, and also with a degree of personnel protection or shelter. They can be also classified in relation to particular injuring shells. A quantity and structure of sanitary losses for specific operations and during entire war are also known. Besides, these injuries occurred in homogeneous in sex and age military personnel, morally and psychologically prepared for a possible impact of combat weapon. In contrast to them, explosion injuries at peacetime technogenic catastrophes by their origin
are as infinitely various as sources and circumstances of wounds occurrence. Predominantly

casualties consist of women and children. Suddenness of an explosion, irregularity of this extreme event creates conditions of an inevitable panic and possibility of additional injuries. At last, it is important that while the aid to combat explosions casualties is rendered by the military doctors armed with predeveloped military-medical doctrine regulations with precisely regulated
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stages of medical aid, many civilian surgeons involved in remedial actions after technogenic explosions lack knowledge on the mentioned injuries.. Authors intended this chapter mainly for civil surgeons constantly involved in the civil defense structures or sporadically engaged by the Russian Federation Ministry of Emergencies and regions administration in remedial actions after natural and technogenic catastrophes, terrorist acts. Thus, we consider necessary to present a series of additional data from the theory and practice of explosions, but mainly only those, which are extremely important in covering of general questions of the explosive trauma pathogenesis. Namely due to their particular generality we did not include them into other chapters, covering questions of a pathogenesis and mechanogenesys of a typical but particular variety of explosion injuries, which is a mine trauma. But, because of infinite variety of wartime and, especially, peacetime explosive traumas, all doctors should be aware of general issues, pertinent to explosion injuries pathogenesis of a human. 1. One of the major common features of explosion injuries is the fact that injuring factors of
any explosion, unlike many other traumas, affect immediately. During micro- and

milliseconds, i.e. practically at once, all structures of a human body get exposed to the impact. It is proved that during an explosion to a greater or lesser extent there is generalized concussion of a body, causing changes at all homeostasis levels at once (organism, system, organ, tissue, cellular and sub cellular). 2. The fact that simultaneously with an impact of explosion basic injuring factors a human
body is affected by such components of the impact as an abrupt strong light flash and a sonic boom is not yet fully described in the scientific and especially in the educational

literature. Usually these injuring factors of explosion manifest as acoustic or barotraumas, flash or flame burns. Unfortunately, one more important component of an explosive trauma occurrence of psychoemotional stress is disregarded. Unprepared to a sudden explosion, people, often including women and children, even without exposure to major explosion factors, can get severely injured and will require proper specialized medical care. 3. The air blast wave impacts a body as a volume or one-way shock, abruptly changing ratio
of intracavitary, intertissue and intercellular normal pressure levels, resulting in primary injuries disruptions, sprains, organs displacement accompanied by haemorrhage and lymphorrhagia practically in all tissues [Odinak M.M., Kornilov N.V., Gritsanov A.I., et al.,

2000]. Certainly, a type and severity of such macro- and microinjuries depend on variety of
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factors, but first on physical parameters, as a level of the excess pressure, rate of change and oscillations frequency. On the other hand, it is necessary to consider that various organs and tissues possess both general and individual resistance to concussions, although mostly it appears to be insufficient to prevent injuries. Research of military specialists, reflected also in civil defense manuals, established so-called coordinate (depending on a distance from an epicenter) and parametric (according to indices of the excess pressure and the dynamic pressure) laws of blast injuries. Since they have been calculated mainly for nuclear weapons, it will be more appropriate to cite the generalized data for peacetime explosions according to Marshall V. (1989) (Table 4.2). Table 4.2 Human injuries dependence on the excess pressure Injury level The excess pressure, bar Unexceptional lethal injury 5-8 50% lethal outcome .5-5 Threshold of lethal injury 2-3 Severe lungs injury .33-2 2-.33 (till age 20) 50% eardrum rupture 1-.33 (age above 20) Advantage of this graduation is that the author has considered human age different resistance of children and adults. Again, this table do not reflect all regularities living organism injury, which not always can be estimated in comparison to explosion physical parameters. 4. Psychoemotional stress of casualty is supplemented with the pain syndrome with
undoubtedly psychogenic origin. Further, it is aggravated by such general pathogenetic

mechanisms of a shock, as haemorrhage and plasmorrhagia (external and tissue), disturbances of bioenergetics and metabolism of every kind (water and electrolyte, protein, carbohydrate, lipid exchange, etc.). The traumatic toxemia rapidly develops. Stress and anemia cause an acute depression of immune system function. Eccrisis disturbance and other dysfunctions of an entire organism assume great importance. Only considering this it is necessary to study simultaneous, but as though additional mechanical injuries caused by other explosion factors fragmentation wounds, throw-off traumas, concussions, compression, etc. This pattern allows offering a simplified, but, according to experience, practically acceptable formula of the explosive trauma (Figure 4.1).

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Figure 4.1. General scheme of explosion injuries

This formula in each specific case should be evolved up to definition of systemic and organ injuries, as subsequently they define the peculiarity of a traumatic disease clinical pattern and, accordingly, strategic, tactical and technical directions in organization of rendering aid to and treatment of casualties. Since explosive traumas, as a matter of principle, are multifactor, aside from general consequences (psychoemotional stress and commotiocontusional syndrome) every time one should define pathology forms with dominating injury of sectors or organs with certain localization. Thus, in the pathogenesis and clinical pattern, the leading role is played by the injuries to the central nervous system (brain and spinal cord, centers and conductors sympathetic and parasympathetic systems), lungs, heart and large vessels, hollow and parenchymatous organs and the musculoskeletal system. In special experiments, using mine wounds model of P.V. Rybachenko and N.N.Zybin (1991), developing and supplementing A.I. Gritsanov and I.P. Minnullin (1987-1990) research, it was demonstrated that at the explosive trauma the general severe commotiocontusional syndrome with the neuroendocrinal regulation disturbance and microhemocirculatory derangements that lead to generalized, registered by biochemical and histological techniques changes in brain structures, heart, lungs and other internal organs, should be considered as a basic pathology. Transient ischemia is accompanied by long-term (more than a day) lipid peroxidation activation, changes in the enzymes and other intracellular metabolism regulators content. Similar data have been published by Yu.G. Toropov and Yu.P. Roslova (1991) and N.F. Fomin et al. (1991). It confirms the data known earlier that at the explosive trauma the consequences of the general contusion lead in the pathogenesis and then in the clinical pattern, while peculiarities of the

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pathology and clinical pattern development define injury specific types soft tissues and bones wounds, and also internal organs wounds or their closed traumas [Nechaev E.A., et al., 1994; Odinak M.M., et al., 2000]. The novelty of the mentioned authors approach lies in emphasizing of the neurodystrophic process significant influence, grounding application of an effective medical measures complex in each clinical period of the explosive trauma. They are based on procaine blocks, ganglioplegics application, providing sympathectomy of autonomic nervous system, and of soporifics. Pyrroxanum, intraarterial spasmolytics infusions, blockage and epidural anesthesia were successfully tested.

4.3. BASIC EXPLOSION INJURIES TYPES AND THEIR CLINICAL MANIFESTATIONS

Past decade publications reveal the data that mental shock at catastrophes is experienced not only by casualties of direct explosion factors, but also by witnesses of an explosion who did not receive injuries, and also by the people, not present at an explosion. According to Yu.A. Aleksandrovsky et al. (1990), the generalization of the psychogenic impact of both natural (the hurricane in Ivanov city on June . 198. earthquakes in Khorog on July 3. 198. in Leninabad on October 1. 198. in Leninakan on December 0. 198. the flood in Georgia on January 3. 1987) and technogenic (the ship-wreck in Novorossiysk on August 3. 198. the Chernobyl disaster on April 2. 1986 and explosions in Arzamas on July 0. 198. in Sverdlovsk on October 0. 198. near Ufa on June 0. 1989) catastrophes it has been found out that numerous psychogenic responses can be divided into three types according to the period of their occurrence.
During the first acute period under threat to persons life and e life of relatives phenomena of a

panic and manifestations of vital self-preservation instincts predominate. They are termed as extrapersonal psychogenic reactions, based on fear.
In the second period, coinciding with the beginning of rescue operations and medical care rendering, the researchers noted mental disadaptation and psychogenic derangements, depending

on casualties personality characteristics and normal or perverted perception of a tragedy. Stressful situations occur related to the loss of relatives, loss of home, property, and especially to the character of a health disorder received by a victim. Neurosis, typical for the second period, is replaced by undue fatiguability and "demobilization" with astheno-depressive manifestations
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towards the end of the period. Psychiatrists emphasize that traumatized individuals require the qualified differentially diagnostic analysis of mental disturbances cause-and-effect relations both with psychogenias and with received injuries (the craniocerebral trauma, the trauma of internal organs).
In the third period, only after evacuation in a safe place and having escaped vitally dangerous situations, casualties have complex emotional and cognitive "rehashes" of a situation, stressing

mental activity all over again. Wounded exhibit "somatization" of many neurotic disorders, "neurotization" and psychopathisation, related to reflection on severity and consequences of traumatic injuries and somatic diseases. Described disorders vary from temporary defense psychotic reactions up to resistant and then subsequently to chronic pathological states. Authors put special emphasis on explosions during which psychotic reactions are intensified by visible, sensory catastrophe manifestations. Indirectly, the fact that after the explosion in Arzamas those women who witnessed the catastrophe without any injuries, had their reproductive function fully or partially impaired for up to 2 years and the number of involuntary abortions has sharply increased, testifies to the depth and duration of psychic traumas at catastrophes. [Potapov A.P., et al., 1990]. Basing on the above formula, it is necessary to note that for all practical purposes there is anamnestic data on short- or long-term loss of consciousness after explosions. Personal experience and published data convince authors to consider the explosive trauma in any case to be one of the types of closed or open craniocerebral trauma from brain concussion to severe bruises and compressions, including wound of medullar substance. Practice has shown that very frequent injuries of eyes and eardrums are the imperative demand to participation of a neuropathologist and a neurosurgeon, but also of an ophthalmologist, an otolaryngologist, and a dental surgeon in the patients examination. For the detailed description of all other injuries, it would be practical to use data on explosive and mine injuries of the military personnel. However, it would not coincide with the occurrence conditions of peacetime explosions. The data on wide explosives application by terrorists at mass people accumulation to destabilize political situation show better correlation with them, but all of them are worth overview in an individual chapter. In our opinion, the data published by domestic authors on explosion catastrophes in our country are the most interesting. V.N. Anisimov et al. (199. 1991) described an explosion of three freight
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cars with explosives (120 tons) at the railway hub Arzamas-1. Explosion resulted in a crater with a diameter of more than 50 m and depth of 26 m. 150 of nearby buildings were destroyed and 250 buildings were partially damaged. At the distance of 2 km from an epicenter the windows were destroyed in multistory buildings. It is possible also to predetermine the explosion yield by the fact that rails debris was found 800 m from the epicenter. The number and the character of the injuries inflicted to people was conditioned by the following: first, the explosion occurred on Saturday at 9:30 a.m., when people stayed primary at home; second, explosion area encircled mainly wooden houses;. third, presence of cars and buses on both sides of the railway crossing.

Approximately 500 casualties applied concerning plural skin-deep wounds by glass were administered ambulatory care; 240 people were hospitalized, and 91 did not survive; among them 20 people died in medical institutions (soon after admission to hospital 18; and within the next few hours after a surgery 2). According to the forensic medical examination in all cases of lethal outcomes at the place of a catastrophe and in medical institutions, received injuries turned out to be incompatible with life. Analysis of the situation and performed examinations showed the basic injuring explosion factors to be a blast wave, secondary injuring projectiles, body compression by heavy objects, psychogenic and temperature factors. The direct impact of a blast wave on a human came to the so-called propellant blast effect (body throw for a distance up to several meters), which leading to the closed traumas of a skull, chest, abdomen, limbs. Among secondary injuring projectiles (glass and metal splinters, slag pieces and wood chips), glass was of special importance. Because of the blast, the glass in buildings and cars was fractured. Splinters of various sizes received high kinetic energy. Traumas by glass splinters, as a rule, were plural and remarkable for injuries profiles; the part of a body facing a window at the explosion moment was injured more often. Body compression by heavy objects was recorded at buildings destruction when casualties were trapped under collapsed construction overlaps. Closed injuries to an abdomen, skull and limbs were noted more often. At the same time surgeons did not see any crush syndrome cases. Thermal injuries area, as a rule, was limited to several people and had no special traits. Distribution of casualties with regard to the injuring explosion factors impact was as follows; blast wave 131 people;;
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secondary injuring projectiles 158; body compression by heavy objects 73; psychogenic 50; thermal 5.

As evident from the given data, there was associated impact of several factors. From the analysis of dependence of injuries character on a distance from the epicenter, researchers found out that at the distance of 150-300 m closed injuries occurred more often, while 500-800 m distance led to fragmentation wounds by the fractured glass. Most of the casualties had head injuries. Closed traumas made up 21 cases, in combination with head soft tissues wounds by glass splinters 84 cases. Open head injuries were recorded in 12 people, head soft tissues wounds in combination with traumas with other localization in 27 casualties. Altogether, 144 casualties with head injuries were admitted. Limb traumas ranked second for injury frequency. They were recorded in 43 people. Earlier, addressing the same catastrophe, Yu.G. Shaposhnikov et al. (1989) revealed the definite dependence of the injuries character and severity on a distance from an explosion epicenter, a body position in relation to an epicenter and an extent of person protection. At the 60 m distance from the centre of the charge localization there manifested in full the combined impact of an air blast wave, the fragmentation and temperature fields. Dead casualties were seen to have laceration of lungs and abdominal organs, separations of limbs, extensive III-IV grade burns. The perished under debris were diagnosed to have the compression asphyxia. At the 600 m distance injuries resulted from throwing. For example, casualties in an autobus (100 m away from the epicenter, and the bus has been thrown at 15 m) were injured by glass splinters (96.6%), received craniocerebral traumas (89.7%), bone fractures (44.8%), plural body bruises (75.9%). The data on explosions at the Sverdlovsk-Sortirovochnaya railway station were approximately the same [Potapov A.I., et al., 1990]. It is typical that the publication authors have not recognized any difference in the character of recorded mechanical or thermal traumas, but repeatedly emphasized more severe general state of casualties, than it would be with isolated and solitary non-explosive wounds. Similar to other researchers, they indicated this peculiarity as the mutual aggravation syndrome. That emphasized the analogy of explosive traumas with mass injuries inflicted to casualties in Hiroshima and Nagasaki, where combined injuries combinations of radiation, a blast wave and luminous radiation effects constituted a dominating pathology type. It enables to refer the overwhelming majority of explosive traumas to the special type of the
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traumatic disease. Various data on the traumatic disease were published by many prominent pathophysiologists, surgeons and traumatologists (S.A. Seleznev, V.K. Kulagin, I.I. Deriabin, S.S. Tkachenko, I.A. Eriukhin, Yu.G. Shaposhnikov, et. al.).. Nevertheless, it is necessary to remind that a variety of peacetime explosions can be rather manifested by primary impact of the thermal factor, not mechanical. At 1:00 a.m. on June 0. 198. oil byproducts pipeline near Ufa exploded causing severe injuries of passengers on two trains. As the later investigation revealed, gas condensate leaked from a damaged byproducts pipeline, filling a huge natural trough on both sides of railroad. When the trains met, a spark initiated a powerful explosion, which is regarded by specialists as a fuel air explosion, comparable to an low-yield nuclear explosion. Practically all 1368 passengers were hurt. 408 passengers perished instantly, 806 were hospitalized with 196 children among them. Judging from the description of domestic and foreign specialists, who took part in rendering aid [Feodors V.D. et al., 1990; Sologub V.K. et al., 1990; Dedushkin M.L et al., 1990], 97.4% of casualties had their skin burned, 33.0% among them in combination with inhalation burns. 10% casualties suffered combined thermomechanical traumas. Only 2.6% of casualties had various types of traumas without burns. Every fifth victim had a burning injury not compatible with life by its extensiveness and depth. Insofar, the explosive trauma was manifested as the prior impact of the thermal factor, which is typical for so-called fuel air ammunitions explosions. Presented description of injuries required organization and treatment of burns mainly (intensive antishock therapy, necrotomies, necrectomies, amputations, in the mentioned cases various kinds of detoxication). The peculiar form of injuries caused by direct effect of all or nearly all injuring explosion factors deserves special attention. These situations are most frequent for closed circuit explosion injuries (in a building, inside of a combat vehicle or carrier, etc.).Naturally, they are of interest only if casualties do not perish instantly. Reported experience and published data suggest visual diagnostics of full or partial segments avulsion (foot, lower leg, upper leg, hand and forearm) or their extensive and plural fractures. In addition to crushed, ruptured muscles and tendons and plural comminuted bone fractures, burnt and fuliginous muscles are observed with tracks of a heated gases breakthrough into intermuscular and interfascial spaces. Often, there is no bleeding, though almost all wounded men arrive with bandages. Clinical practice and special morphological research proves that zone of immediate and visible mechanical injuries is more extensive. It spreads unevenly in the proximal direction. Zone of molecular contusion is also
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more extensive, comparing to a usual gunshot wound. Secondary necrosis areas after primary amputations within seemingly healthy tissues prove this fact. Despite transient impact of heated gases, it turns out to have enough energy to inflict III-IV grade burns, which influenced formation of both primary and secondary necrosis areas. It is necessary to remind once again that these severe local combined injuries in many casualties were associated with injuries of internal organs and other limbs. Moreover, all victims, almost without exception, had commotiocontusional syndrome. Occurrence of one more explosion injuries type called shielded deserves attention as well. An explosion under the bottom of a ship, vehicle and train, behind a wall or other shelter can cause severe injuries to any organ without visible surface lesions. Many surgeons could observe in their practice multiple bone fractures, injuries of vessels and internal organs under seemingly viable skin integument. The above can be quite typically illustrated not by a technical catastrophe, but with a terrorist act, committed by mujahedeens in August, 1985 at the Kabul airport. Powerful explosion in an airport building overcrowded with passengers and accompanying people caused more than 200 casualties, including many perishing instantly, and more than 120 victims with the most severe and complex types of wounds and injuries delivered to CMH. It was this moment, when the manual authors faced for the first time mass and practically simultaneous admission of wounded with the wide range of explosion human injuries, caused by the specific anthropogenous factor named as terrorism.

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Chapter V EXPLOSION INJURIES DURING TERRORIST ACTS

On April 1. 200. conference was held in the Taurian palace in St.-Petersburg International terrorism: sources and counteraction, organized by Inter-Parliamentary Assembly (IPA) of the CIS countries and by security and anti-terrorism services. Newspapers, referring to the conference material, informed that the international terrorism already became an objective reality for a long time. If in the eighties of 20th century the number of terrorist groups in the modern world varied from 500 to 80. now the number of such groups reaches up to 1000. Chechen republic of Russia transformed into the powerful generator of criminality and terrorism splashing out far beyond republic (The Saint Petersburg Vedomosti. 04.19.2001). Before uncovering characteristics of human explosion injuries during terrorist acts, authors considered necessary to cover at least briefly history of terrorism and present the problem of modern international terrorism. Members of the civil defense strategic research center of the Russian Ministry of Emergencies N. Dolgin and V. Malyshev are convinced with good reasons that the 20th century will go down in the history of mankind not only because of prominent scientific and technical discoveries and achievements, but also as a century adding many black pages, including one of the ugliest and tragically social phenomena (Principles of life safety #. 2000 p. 5-10). This big analytical article, which is worth of undivided attention, addresses terrorism, which during last century has: transformed into a global world problem; became one of the most dangerous challenges to international safety and cooperation, and by its purposes and types of manifestations became a multifaceted monster, extremely dangerous to a society, got an opportunity to employ scientific and technical achievements criminally; begun to be performed in some cases with participation of state structures, gaining the status of state terrorism. The term terrorism originated from a Latin word terror, meaning fear, horror. The concept goes back to the Great French Revolution. The Federal law of the Russian Federation Countermeasures against terrorism gives a legal definition of this phenomenon. Terrorism is

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violence or a threat of violence toward physical persons or organizations, also including destruction (damage) of property or other material objects, creating the danger of loss of life, causing significant property damage or other socially dangerous consequences which are committed with the purpose of violating of public safety, intimidation of population or putting pressure on authorities for decisions, advantageous to terrorists, or satisfaction of their unrightful property and (or) other interests; infringement on life of a state or public figure, committed with a view of the termination of his/her state or other political activity or revenge for such activity; an attack on the representative of a foreign state or the internationally protected member of an international organization, as well as on office or transport facilities of internationally protected persons, if this act is committed with a view of war provocation or aggravation of the international situation. N.Dolgin and V. Malyshev (2000), proceeding only from three classification criteria of terrorism, devised successfully consolidated classification of all manifestations of terrorism (Figure 5.1). Even a fluent analysis of terrorism manifestations shows widest range of its both possible purposes and methods: by purposes from physical elimination of political figures-opponents up to provocation of a military conflict or a change of regime; by methods from application of individual guns up to application of chemical and biological weapon or organization of large industrial accidents.
Possible purposes Physical elimination of political opponents Intimidation of population TERRORISM Scale of terrorism Crime against the person Methods of terrorism Firearms

Group murders

Acts of retribution Government destabilization Infliction of economic damage Exacerbation of interethnic and interconfessional relations Provocation of a military conflict Regime change

Explosions and arsons in cities Mass destruction of citizens Hostage taking Acts of sabotage all over the Nuclear explosives and country radioactive materials Large-scale actions against Chemical or biological the world community weapons Industrial sabotage

Destruction of transport infractructure Electromagnetic irradiation Informational-psychological pressure Fig. 5.1. Classification of terrorism manifestations

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The first question, arising with the classification of terrorism manifestations, is the one about its origination sources and basic stages of evolution; it is the question about cause-effect sources of the most complicated social phenomenon, known as international terrorism. In the frames of this manual, while addressing medical aspect of explosion injuries, the authors could not give this problem a proper attention, though it is a subject, first, for lawyers and historians, not doctors. However, deliberate approach to this problem is necessary and important at least because, when analyzing terrorism as a social phenomenon, it is very easy to get tempted to present everything (whether it is the struggle for national liberation, revolutionary movement, etc.) as plain terrorism. Is this a correct thing to do? There are several recent history facts. Therefore, the armed struggle of our country population against fascists in occupied territories was rightly termed as partisan warfare, while for Hitler troops partisans were just gangsters and terrorists. A similar situation developed in both Vietnam and Algeria. The second example is the PalestinianIsraeli conflict, burning in the Near East for decades. For Israelites, the methods and means of the armed struggle of Palestinians, fighting for the independent state, constitute terrorism, while for Palestinians it is intifada, the war of independence. Who is right? All efforts of other countries and authoritative international organizations somehow to perform a role of arbitration judges were unsuccessful for only one reason different understanding of the same events by conflicting parties.3 Terrorist acts in Northern Caucasus (Table. 5.8) brought into focus actuality of this problem and complexity of its solution once again. Only for the last three years (19982000) more than 10 acts of terrorism were committed using explosives. As a result, 834 persons have suffered in, 315 were killed (Argumenty i Fakty 1. 2001). Terrorist acts, committed in January-March 2001 in Chechen republic Stavropol Territory, open the list of mournful losses of Russia population in XXI century. And there is no end in sight. Table 5.8 Most significant terrorist acts, committed against (or in the) USA and Russia (1944-2001)4 Date City Event Casualties june 1944 Hartford, CT Circus building 168 persons killed by fire, 480 arson persons
3

Further discussion of terrorism history in Russian empire and earlier years of Soviet Union is moved to Annex 1 to preserve manual integrity. 4 Explosives-related terrorist acts committed in Russia during 2001-2004 include: blasts in Moscow subway, Beslan school siege, Blast of two airliners, blast of police quarters in Chechnya, siege of a concert hall in Moscow, and claimed over 2000 casualties (killed). 134

19.04.1995 Oklahoma-City, Car bomb explosion 136 killed, including 15 children, 60 USA near federal building missing, 200 wounded 16.11.1996 Kaspiysk, Russia 9-story building demolition 28.04.1997 Piatigorsk, Railway station Russia explosion august Nayrobi, Kenya, Car bombing of US 1998 Dar-Es-Salam, embassies in Kenya Tanzania and Tanzanya 19.03.1999 Vladikavkaz, Market explosion Russia 4.09.1999 Buinaksk, Russia 5-story building demolition 9.09.1999 Moscow, Russia 9-- story building demolition 13.09.1999 Moscow, Russia 8-story building demolition 16.09.1999 Volgodonsk, 9-- story building Russia demolition 8.08.2000 Moscow, Russia Explosion in subway station 24.03.2001 Mineralnie vody, Explosion on market Essentuki, Kizil- and in the police Togai, Russia quarters 68 dead, including 21 children 2 dead, 30 wounded 224 dead, including 12 US citizen, 300 wounded 52 killed, 200 wounded 60 killed 90 killed, 200 wounded 120 killed, including 13 children 18 killed, including 2 children. Total casualties 310 18 killed, more than 100 wounded 23 killed. More than 120 wounded.

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Chapter VI PECULIARITIES OF STRUCTURES AND TISSUES MECHANOGENESYS AND STRUCTURE-FUNCTIONAL DISORDERS FOR DIFFERENT TYPES OF EXPLOSIVE DAMAGES
6.1. MORPHOFUNCTIONAL PECULIARITIES OF MINE-EXPLOSIVE WOUNDS
Mine trauma is a special type of a combat-inflicted surgical pathology, which recently is drawing substantial interest of the specialists. Favorable tactical capabilities, relative cheapness and high damaging of the mine weapons promoted its wide use by the conflicting parties in the Republic of Afghanistan. Nowadays, proposed by us, subdivision of mine trauma into two classes, is gaining wide circulation. We separate mine trauma into two basic clinical varieties: mine wounds (MW), caused mainly by direct action of explosion on unshielded personnel and mine damages (MD), being characterized by the indirect (non-constant) explosion factors effects on the shielded personnel. Irrespective of explosion details, casualties of mine trauma suffer avulsions, plural wounds and tissue damage of the extremities, functional disorders of internal organs, determining evolution of the wound and treatment approach. These phenomena are observed on the background of severe contusion-commotio syndrome and loss of blood. Severity of primary damages and course of traumatic diseases in wounded, large number of wound infectious complications stipulated various studies of this battle surgical pathology aspect, which would allow putting forth effective system of pathogenetically proven medical provisions. A need to discover underlying factors and regularities of pathomorphologic disorders in an extremity, caused by the explosions of anti-personnel, anti-tank and anti-vehicle mines, stipulated the authors to conduct complex topographic-anatomic, pathohystologic and X-ray-dye angiographic studies of casualties extremities. Bottom segments of the extremities amputated from 42 wounded men during first 12-15 hrs after explosion were the study objects, along with biopsy material, taken at the edges of an amputation bone wound, taken from 19 wounded men . .
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. 10 and 14 days after a trauma. A number of questions, related to pathogenesis of mine-explosive traumas was complicated in the complex morphofunctional studies, performed with 32 animals (dogs and rabbits) using original model [Rybachenko P.V. et al., 1988]. Character and topography of damages, condition of vessels, blood microcirculation efficiency were estimated in acute (up to 6) and subacute (up to 24) experiments.

Fig. 6.1. Topographic-anatomical levels of tissues damages during the contact mine-explosion extremity avulsion Upon completion of experiments on animals, the researchers undertook topographic-anatomic and pathohystologic studies, coordinated with those studies, conducted with the material under the field combat conditions. Studies results have shown that a number of general laws can be discovered in character and topography of the structural and functional disorders, caused by explosive trauma. These general laws corresponded to the developed models. At the same time, the researched noted peculiarities of different traumas, which is mostly caused by the different mechanisms of the personnel damage by mines in open terrain (MW) and inside armored vehicles or objects (MD). Morphological studies of extremities after MW, undertaken with respect to the contained
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structure of feet, shins and femurs have shown the following. First, exceptional severity and abundance of the pathomorphologic damages, which sometimes go beyond torn segments. Second, there is multitude of surgical anatomy wound varieties. Differences include an extremity avulsion level, severity of tissues structural damages, topography of a wound. Polymorphic character of the discovered damages finds an explanation in multitude of applied ammunition, different position of a body and their position relatively to ammunition at the time of explosion. Irrespectively of contact demolition peculiarities, a number of laws can be distinguished in the severity of local and segmentary morphofunctional disorders. We have conditionally separated all explosive disorders in an extremity into three topo-anatomical levels (zones), with different qualitative structure characteristics (Fig. 6.1).
1st zone avulsion, crushing and layering of a tissue. The essence of changes in this zone is

reduced to destruction or full anatomic rupture at different levels of skin, tendons, muscles, bones, neurovascular formations, to stratification and mechanical separation of the most resistant tissues, an ascending pneumatization of "weak sites friable interstitial spaces of fascial container and subcutaneous fibers (Fig. 6.2). For this level one can also observe appreciable pollution of tissues, continuous hemorrhages and irreversible decomposition of the cellular structures. Its extent varies over a wide range from 5-10 up to 2535 cm, which is most likely determined, by an ammunition type, unequal magnitude an angle of the explosion shock wave forces, various position of an extremity during explosion. Avulsions of the foots front sections is accompanied by the preservation of heel bone integrity and more expressed direct damage of the front shin container, if compared to those, inflicted on the back shin container, which is protected by the bones

Fig. 6.2. Morphological indicators of fracturing shockwave damages of bone-fascial containers (microscopic layer, second third of a shin)
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If an extremity avulsion transgresses boundary line of an ankle joint the damage of all three shin containers always appears more uniform. It is noticed also that intermuscular slots, normally opened from below (forward group of shin muscles, group of fibular muscles), are damaged at the greater extent, than the intermuscular gaps closed from below (salens and gastrocnemius muscles). During any avulsion of a foot and shin, the least severe damages are suffered by the gastrocnemius muscles and most severe damages by the deep-layer muscles through the whole length of shin-popliteal channel). These data represent anatomic-physiological baseline for nonstandard truncations of extremities, amputations and covering the bonesaw line with the most viable muscle.

Fig. 6.3. Staircase muscles rupture

Fig.6.4. Fracturing damages of blood vessel

(microscopic level), inflicted by the shock wave

Fig.6.5. Ultramicroscopic level of the morphological indicators for the shock-wave rupturing

indicators in the nervous tissue

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The morphological artifacts, which we refer to the 1st zone, testify that the shock waves in tissues (compression and deformations) play the most important role in a genesis of explosive damages, as well as extremely high pressure of the heated gases. Bone-fascial architectonics of extremities, apparently, defines a wound anatomy.
IInd zone contusions of tissues in the remaining part of destroyed extremity segment.

Pathomorphologic changes in the given zone are based on the plural focal microruptures of muscles, known as "staircase" ruptures of fascicles and separate fibers (Fig. 6.3) along, with the ruptures of large and fine vessels walls, which may cause confluent and focal hemorrhages. Noted segmentary contractions and expansions of fine arteries, focal disappearance of a vascular picture on arteriogram suggest the persistent disorder of a blood flow in arteries within contusion zone (Fig. 6.4). In peripheral nerves of the remaining part of an extremity one can also find endoand epineural hemorrhages, the expressed edema of the cage, endo-and a perineurium. Discovered irreversible changes in tissues have, as a rule, focal character and stand out on the background of secondary circulatory disorders segmentary spastic stricture or a varices of arteries, venous plethora, a clottage of arterial and venous vessels, acute dystrophy of a muscular tissue, reactive changes of axons of peripheral nerves. All these changes (in depth and numbers) decrease in the direction away from the tissues avulsion zone. The maximum disorders are localized, as a rule, in the field of the basic neurovascular fascicles of the remaining part of an extremity segment (Fig. 6.5). At the same time through all extent of IInd zone, there are entirely unchanged sections of tissues, whose share grows in a proximal direction. It is important to emphasize that the presented changes to some extent are observed in all bone-fascial containers, opened by explosion. In a proximal direction, they regularly propagate to a level of the damaged muscles attachment, i. e. more proximally toward the join slot. However, contusion damages do not encompass the closed muscular cases of a proximal segment of an extremity. Alongside with defects of bones and their skeletization, the researchers observed using X-ray tomography in the Ist and IInd levels local explosive fracturing of bone structures with pulpous fragments, lines of multicomminuted fractures with ejection of fragments beyond the limits of layered skin flaps of soft tissues, longitudinal cracks of long tubular bones diaphyses. In proximal sections of the destroyed segment sometimes, they observed slanting or spiral diaphyseal fractures unrelated to the basic zone of bones and soft tissues destruction that, apparently, reflected rotation, ad-or abduction vector of shock effects on the damaged segment.
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So, basic important regularity is that condition that upper bound of a level of a soft tissues level for at mine-explosive wounds is not the line of the joint slot of the nearest intact joint, but anatomic boundary line of opened bone-fascial container. Muscles of an overlying segment of an extremity appear as though defended by the fibrous receptacles. Extent of tissues contusion level is defined by proximal boundary line of the containers, belonging to the intact part of the destroyed segment of extremity.

III zone commotio of tissues of a contiguous extremity segment and ascending circulatory disorders. Structural and functional disorders, discussed here, are characterized by avulsion of

collaterals from the main vessels, hemoinfiltration of the basic neurovascular fascicle, disturbance of a vascular tonus, decrease of drainage properties of the capacitor vessels, reactive changes of axons in separate peripheral nerves. The mentioned events redefine lasting disorders of macro -and microcirculation, mainly under-fascial issues. In a muscular tissue the focal granulous dystrophy of muscular fibers is noted. The maximum of these changes concentrates in the areas, directly adjacent to the basic neurovascular fascicle. In the fascicle, one can observe the edema of paravasal and paraneural fibers in the vasa vasorum site. By means of an angiography it is possible to find avulsions of fine arteries from the basic blood arteries with extravasation of contrast mass along the vascular slot and segmentary disappearance of lateral vessels picture. Thus, tissues of a extremity segment, which remained intact after mine explosion, undergo essential, though reversible, structural and functional changes which are localized mainly in the area of the basic neurovascular fascicle. Performed morphological studies give the basis to state that the fascial carcass of extremity is like the conductor of a shock wave in tissues of damaged segments. On the contrary, if the integrity of a joint-tissue carcass is intact the fascial apparatus serves as a shield for underfascial structures. Apparently, shock waves transform in the containers of the destroyed segment to the hydrodynamic waves, and propagate in a proximal direction first through the vascular lines, defining damages of the contiguous and remote segments. Proceeding from the presented data, it is possible to assume, that any amputation of extremity, caused by mine -explosive wound will not be radical from the standpoint of its accomplishment in the unchanged tissues. After a shin amputation, the stump will contain irreversible focal disorders in muscles and vessels (II zone). During the amputation of a femur, the operational wound will be in a zone of the expressed disorders of macro-and microhemocirculation (III
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zone). Unconditionally, the more distal is the level of extremity avulsion, the smaller is the quantitative expression of the discovered disorders. However, it is impossible to prevent their adverse effect on the further recovery processes in tissues of extremity. It is confirmed by the morphological studies conducted in the postoperative period. Studying of a biopsy material, taken from 19 wounded men, whose postoperative period proceeded without serious purulent-necrotic complications, has shown, that in a amputated stump wound for several days the predominant role is played by alterative-ecsudative processes. Alongside with an edema of tissues, a hemorrhage, within three day the regional necrosis is formed. This necrosis is more expressed spread in a muscular tissue. The demarcation line is expressed by the leukocyte infiltration, propagating along intermuscular and interfascial gaps far outside bone-saw limits. Nervous fibers in a wound lose myelin and many of them perish. By the end of the first week, the granulation tissue starts to be detected in the specimens. Necrosis region and a demarcation line to this term are more expressed, and the boundary line between them is more distinct. At 10-14th day the scar tissue starts to be formed. Necrotic tissues are expelled. Muscular fibers experience dystrophic changes, down to a full degeneration and destruction of some and an atrophy of others. In vessels of an amputating stump, the researchers can observe panvasculitis, onset of thrombosis, emptying of a vascular bed separate sections. For peripheral nerves, the growth of endo-and a perineural connecting tissue is characteristics, along with a hyperplasia of schwann cells, formation of traumatic neuromas and neurofibromas. Stump tissues during the proximal two weeks after amputation showed, on the one hand, appreciable volume of para-necrotic changes in a wound, and with another about a distinct delay of all inflammation phases from formation of sections of a necrosis to proliferative changes. Thus, even at rather favorable trend of a wound process in an amputated stump, results of biopsy studies testify to remaining resistant residual vascular and neurotrophic disorders in the extremity, damaged by a contact mine explosion. This circumstance has to be taken into account during treatment and in the post-treatment phase. The studies, conducted with desensitized research animals confirmed the same character of local and segmentary damages of extremities tissues. As a result of custom demolition under right jump joint of the animals, placed verticality on a board, the avulsion of the right shin in was caused in the upper third with skeletization of bones (Fig. 6.6). This situation was accompanied by the plural wounds of soft tissues of the right and left shins and a femur, and a perineum with rupture of a scrotum and fall of a testicle in a wound.
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Pathomorphologic disorders in tissues of the opened containers in shin appeared more serious than analogous tissue damages in the opened containers of a femur. Maximum of disorders was concentrated around forward and back neurovascular fascicles of a shin. The central questions of surgical and subsequent medical treatment, demanding the urgent solution when rendering assistance to the victims of MT at stages of the qualified and specialized surgical help, are finding optimum level of amputation during avulsions and damages of extremities and development of pathogenetically justified medical program in the postoperative period. Local and general complications, wound healing process in a stump, local and general complications, and finally, the recovery, depend on these questions correct solutions.

Fig.6.6. Zones of the hip extremity explosive damage, accompanied with two-thirds shin avulsion Based on the gained results, the most preferable level of amputation during the mine trauma is the zone of tissues, where the changes bear reversible character. According to the proposed classification, it is IIIrd level or proximal sections of IInd level (during distal avulsions of shin). Clinically these levels are differentiated by ability to muscular fibers contraction, moderately expressed traumatic edema of tissues, absence of confluent hemorrhages. Extreme complexity of topographic-anatomic mutual relations of tissues of an explosive wound dictates necessity to study of additional diagnostic methods and approaches. The important place among them belongs to a radiological method. Arteriogram analysis, executed at a stage of the specialized treatment, in terms from 12 up to 24
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hrs from the moment of a trauma, and their comparison to macro-and microscopic morphological changes of tissues of the damaged segment of extremity allow to draw a conclusion about feasibility of amputation, carried out at the level of lowered but preserved arterial and capillary bloodstream, matching II-III to damage levels according to clinico-morphological studies. Obviously, in battle conditions at stages of medical evacuation, under the mass influx of wounded personnel with MT there is no necessity to dilate the indications for angiographycal studies. In this connection, an attempt was undertaken to estimate usual survey X-ray shots of the damaged extremities. It was established in process that a reliable data about extent and frequency of damages can be obtained under condition of complex estimation of radiological processes (Table. 6.1). Most important of them defects of soft tissues (7.1 %), defects of a bone (6.3 %), puffiness and loss of soft tissues differentiation (7.1 %), multicomminuted character of fractures and bones cracking(7.9 %), bone fracturing with pulpous fragments (5.5 %), ejection of bone fragments beyond the soft tissue flaps (5.5 %), outstanding naked bone ends (6.9 %), etc. Cumulative presence of 4-5 and more of the named radiological attributes gives the basis to classify this damage section as MT zone I-II. As to IIIrd, zone it conditionally can coincide with upper bound of an edema of soft tissues which, more frequently embraces all extremity perimeter, encompasses skin, subcutaneous fiber, causes loss of a differentiation of intermuscular spaces, tendons and fascias. Thus, performed studies allow recommending methodical approaches, whose practical use enables to determine the optimal level of amputation during the mine-explosive extremity avulsions. In turn, choice of an optimum amputation level forms for strategy and tactics of optimal treatment.
At stage of the qualified surgical aid in view of developing battle and military-medical

conditions, it makes sense to truncate extremities, caused by mine-explosion avulsions, in the most sparing regiment;
At stage of a specialized medical aid, depending on character of a wound process, terms of

receiving and a condition of wounded personnel, the surgical treatment are performed, targeted on covering of a stump: delayed primary or secondary stitch of a wound; typical repeated truncations of a stump with formation of skin-fascial flaps; atypical sparing surgeries, in the form of expanded necrotomies and a secondary surgical treatment of a wound;
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skin cutaneous plastics of wound surface at the bonesaw line. All mentioned surgical measures can be combined.

For adequate therapy of wound sickness and effective treatment, directed on the prevention of purulently-necrotic complications, the chances of recovery surgical treatment increases conservation of functionally active parts of the damaged extremity with a capability to full scale prosthetic repair in the latter. Special attention was given to studying of internal organs conditions. It is known that the MW victims, along with avulsions and destructions of extremities in 24 % of cases suffered wounds and closed damages of a skull, in 21 % abdomenal wounds, in 18 % chest wounds, and in 36 % closed damages of internal organs [Habibi et. al., 1988]. For the express-diagnostics of topography and extents of internal organs damages in animals, researchers used intravenous injection of intravital coloring agent (10 % solution of dimifen blue). A staining of organs was controlled during thoracal -and laparotomies. For all animals in different terms after a trauma, researchers noted absence of painting of basal segments in right, and in some cases, left lung. During histological research of these zones, they observed the edema of interstitial tissue, the venous hyperemia, plural atelectases and paravasal hemorrhages were observed. In third of animals researchers found unpainted sections of heart on its phrenic surface, in some cases, histological studies pointed on accumulation of erythrocytes in microvessels and ruptures of muscular fibers Almost half of animals exhibited parenchimal sections (from 4 5 cm up to 1x2 cm) on a phrenic surface of a liver already 6 hours after experimental mine wound. Their histological research revealed ruptures of the central veins with extravasates, venous plethora. 24 hours later in such zones the destruction zones of parenchima with leukocytic infiltrates were found. Only 4 of 32 animals showed unpainted sections of thick and a small bowel. Microscopy usually showed loosening and stratification of submucous layer, ruptures of venules with small extravasates. Ganglias of nervous- muscular-intestinal plexus in the earlier terms after trauma showed noted argentophylia of neurons, a vacuolation of 2nd type Dogel cells which quite often had protoplasmatic offshoots. In the subsequent 24 hours besides, the noted reactive changes in nerve were complemented by the attributes of destruction: Ruptures of dendrites, disappearance of nuclei and nucleoluses etc, which testified to coarse disorders in system of local reflex arches of an intestine.

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Table 6.1. Character and structure of the X-ray symptoms distribution for mine-explosive wounds (groups %) X-ray observed symptoms Mine-explosive wounds Avulsions Mine wounds Mine wounds Mine wounds and with multiple with isolated with plural crushing of bone fractures bone fractures wounds of soft extremities tissue Metal fragments (primary projectiles) Fragments of nonmetal density (primary and secondary projectiles) Outstanding bone stumps Joint slot avulsion Bone defect Injection of air in soft tissues (5 to 15 cm above level of avulsion) Soft tissue defect Edema of soft tissues Bone fracture, lateral bone cracking Pulverizing of bone Ejection of bone fragments beyond soft tissues Penetration of fractures insides the joint cavity Anaerobic infection of soft tissues Closed fractures beyond the explosive damage zone Total 3.4 4.2 6.9 1.2 6.3 4.4 7.1 7.1 7.9 5.5 5.5 1.9 .7 1.3 104 6.1 2.2 1.1 2.7 2.2 5.5 6.6 6.1 1.1 1.6 1.6 1.6 18 8.2 1.6 .3 2.8 1.7 3.5 6.5 5.1 .3 1.5 1.6 1.5 32 46 9.4 .6 _ .5 .5 2.0

The conducted experiments confirmed selectivity of internal organs damages, inflicted by a mine wound: the lungs were damaged in all animals, liver 40 %, heart 30 %, and hollow organs of an abdominal cavity in individual observations. Thus, mine-explosive wounds are characterized by a number of morphofunctional phenomena at local and segmentary levels, as well as whole body. Discovered laws represent an organic basis of a wound sickness, accompanying this specific aspect of a gunshot trauma.

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6.2. CLYNICAL-MORPHOLOGICAL PECULIARITIES OF MINEEXPLOSIVE DAMAGES

Cornucopia of explosive ammunition forms, varieties of mine weapons tactical application, multiple grenade-launchers, rocket and artillery systems, different protection of personnel from their damaging factors, determine the multiplicity of explosion damages and their clinical forms. In this section, we shall address and generalize some questions of a pathogenesis, clinics, diagnostic and treatment. Pathogenetically mine-explosive damages represent combat-inflicted combined trauma, described by a number of specific features. As a rule, these are insulated and plural, mainly closed, sometimes open, bone fractures, combined with closed damages of internal organs, head and a spinal cord. Mine damage is usually inflicted on the personnel more or less protected from mine explosion or antitank mines by a transport or armored vehicles. Mine damage severity depends on many components, but first, ammunition yield, armor design, position of personnel in relation to the major part of shock wave accelerations impulse, produced by a shock wave. An essential role is played by the interior profile at the crew battle posts positioning of equipment, mechanisms and weapons. Influence of these factors is extremely important: the range of explosive damages for crewmembers of one armored vehicle can vary from damages incompatible with life to the insignificant insulated body bruises with easy contusional CNS and psychics disorders. The same features explain the desire of soldiers to be on the armor during convoys. In case of armored vehicle or tank demolition on anti-tank mine, the damages caused by a propellant blast effect appear incommensurably smaller, than those for crewmembers inside the armored vehicle. There is, however, a problem of efficiency increase of personal armor against bullets and fragments. Damages of a locomotorium and internal organs during the demolition of armored vehicles bear both quantitative and qualitative character. Vitally important ethiopathogenetic moment, defining character and severity of MD is the extent of armored protection destruction, caused by the mine or demolition munitions blast. In cases of armor protection remaining intact, the main part is played by the powerful beyond-armor impact and repeating oscillations of metal surfaces. As the result, there are damages of bones and internal organs, identical to "deck" traumas, inflicted on crewmembers by sea mine blasts (Fig. 6.7). To a certain extent, catatrauma (biological group of damages, resulted from a human fall from the high building) can serve as a remote analog of MD.
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Fig.6.7. Character and zones of primary and secondary contusion damages of bottom extremity at
MD

Fig.6.8. Localization of fractures, inflicted by MDs Leading component of MD are plural and combined fractures of skeleton bones of mainly closed and comminuted character. First of all, they originate in the body segments, which face an explosion point, and due to throwing of a body and a counter-impact with equipment detail from
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the other side. Fractures of the bottom extremities bones are diagnosed for 6.6 % of MD victims (Fig. 6.8). Fractures of top extremities bones (2.1 %) are characteristic for personnel, thrown from the military equipment to the ground, i.e. as a result of an explosive wave propellant effect. Predominance of the closed diaphyseal fractures of long tubular bones (Fig. 6.9) distinguishes M at the dry land from typical naval "deck" fractures, whose great share are fractions of heel and ankle bones, feet dislocations and fractures, compression fractures of spinal column. Wounds of extremities soft tissues in cases of intact armor are possible, but not typical.

Fig.6.9. Character of the most typical bone fractures, inflicted by MD (a,b,c,d) Developed understanding of MD pathogenesis is essentially complemented by the injection, Xray dye, hystotopographic and histological studies of the bottom extremities in victims, and the amputated bottom extremities when the matching indications for this surgery were present (20 observations). It is established that cover tissues and bone-fascial containers suffer extensive
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crushes of a fatty tissue and muscles with hematomas or blood imbibition within the limits of the damaged extremity segment towards main axis of shock impulse propagation.

Fig.6.9 (Continuation). Most typical fractures of bones, inflicted by mine damages (d,e,f,g)) Soft tissues of osteofibrous receptacles from the opposite side of the damaged segment are noted to have, as a rule, less serious contusional damages (see Fig. 6.7). Alongside with bone fractures in especially serious cases, the repeated disorders of main vessels (more often veins) with clottages and blood extravasation were noted. In the focus of soft tissues contusion, one can see the sharp depletion of a vascular drawing. Muscles of the damaged segments exhibit deep ischemic disorders as an acute granulous dystrophia down to evolution of a "waxy" necrosis. On the background of the reversible circulatory disorders, one could notice irreversible damages only in the application zone of the basic shock components of explosion. Disorders of a circulation had secondary character in all other sections of a segment. There is no exact zoning of pathomorphologic disorders, as was established during studies of MD and MW. Mine damages, when the armored protection is destroyed, have other character. As a rule, it is caused by higher yield or efficiency of a mine or demolition munitions. Closed damages of bones and soft tissues, are complemented by more serious and plural wounds of a body segments. These wounds are inflicted by primary and secondary wounding projectiles, avulsions and destructions of extremities with typical layering and pneumatization of friable tissues by explosive gases, deep impregnation of the tissue by fuel and lubricants and characteristic blueblack coloring. The maximum severity of these damages is usually localized from the explosion side and their severity sharply drops away from an armored vehicle penetration site. This condition defines also frequent asymmetry in extent and character of opposite extremities
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damages in the same victims. As a whole, this class of wounded personnel, by the character of local and segmented pathomorphologic disorders, reminds mine-explosive wounds. However, it is incommensurable in the severity of general condition and extensiveness of damages to various anatomic areas. The major pathogenetic part of MD is damages to internal organs, trunk and extremities by impulse impact. This damage is done by a blast wave, propagating through armor to human body in the form of a seismic wave with a shock acceleration. If armor is pierced by the shock wave direct effects, flames, high-temperature gases, throwing of a body and counter-impact inside armor. Thereof, wounded personnel suffers ruptures and bruises of hollow and chest and abdominal parenchymatous organs, bruises of lungs and heart, various extent of hemorrhages in subcutaneous layers of pelvis, retroperitoneal space and mediastinum. Casualties of mine explosions suffer macro-and microhemorrhages, clottage of head and spinal cord vessels several days after trauma. Disorders of the vital organs and systems, as a rule, are observed on the background of extremely severe shock and a hemorrhage, and also attributes of a fatty embolism. In especially serious cases of MD the multiorgan failure is leading and defines an outcome of a trauma. Diagnostic of the aggregate damages, inflicted on skeleton, internal organs and revealing of a leading pathology is the major part of medical treatment system during MD. Characteristic
clinical diagnostic attributes of the feet and shin bones fractures, damages of tissues during MD

are: expressed edema and stress level of integuments and deep tissues of the damaged segments; presence of deep and extensive hemorrhages; sharp weakening or full absence of an arterial pulsation; decrease of muscular activity; sharp decrease of cutaneous temperature of distal extremity segments (6-8C and more). In some cases the unbiased assessment of the injured segments tissues viability is possible only after semi-closed (subcutaneous) or opened diagnostic and decompression fasciotomies mainly on the feet, shin and a forearm. Presence of deep damages of a terminal vascular bed and decrease in a fabric blood flow in extremity during MD dictates necessity to restrict indications for X-ray dye studies to investigation of vessels, using it with careful subsequent flushing of a vascular bed.
At stages of the qualified surgical and specialized medical care this problem is solved by
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directed diagnostic study according to pathogenetic features of MD. Evaluation of the victim neurologic status is performed with comprehensive radiological diagnostic study of the damaged anatomic areas, electrophysiological diagnostic of bruises of heart and brain (electrocardiogram, EEG), and if necessary diagnostic laparo- and thoracocenteses. The MD basis is comprised by, as a rule, comminuted fractures of bones combined with a mine craniocerebral trauma of various severity extent and others distant damages of internal organs, as a rule, main place in the conditions of modern war is taken with following aspects of medical evacuation and treatment: classification; transport immobilization and transportation of victims; expansion of diagnostic opportunities during certain stages of medical evacuation, to find out the main damage; increasing practical significance in diagnostic and treatment of combined traumas by anaesthesiologists, therapists, neuropathologists; critical analysis of the available inventory, including drugs necessary for effective treatment, optimization of this.

6.3. MORPHOFUNCTIONAL AND CLINICAL PECULIARITIES OF CASUALTIES, INFLICTED TO NAVAL CREWS BY MINE WEAPONS AND EXPLOSIONS IN WATER
As noted, initial judgements that explosive damages in NAVY are mainly reduced to a problem of "mine-torpedo" and "deck" fractures, is simplified. US sources, dated back to WWII, testify that at sea, the number of survivors, which require treatment in hospitals, is much smaller than that on a dry land. It possible that it is that why deck fractures became the leading naval casualty during WWII [Punin V., 1954]. According to P.P.Rybkin's (1956) opinion, an appreciable number of naval operations casualties is not subjected to pathoanathomical study, which affects reliability of irrevocable and combat sanitary losses pattern. According to opinion of the majority of researchers, the ships crewmembers suffer damages of the bottom extremities 3.74.7 % [Punin B., 1943 predominate; Rybkin P.P., 1956; Evenstein Z. M., 1961]

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More than 50 % of cases deal with damaged shin. Special attention is attracted by the combined damages of other body segments and first of all skull damages 1.3 %. According to USSR NAVY medical service data, during the WWII the head wound share was from 1.3 % to 3.3 % that, most likely, was consequence of secondary trauma, inflicted by ships equipment and hull [Evenstein Z.M., 1961; Medvensky V.M., 1963]. Chest damages made .81.2 %, top extremities damages made 1.01.8 %, damages of spine and a pelvis made up to .51.0 % (as the appreciable share of crewmembers is sitting), damages of the other organs made .9 %. Statistical data of NAVYs medical service emphasize that the closed damages made 75 %, while open made up 25 % of surgical cases. In this connection, it is of interest to compare published NAVY casualties data with those, concerning mine-explosive damages land armored vehicles explosions. A.I.Gritsanov et. al. (1987) informs that at landmine demolition of armored vehicles mainly damaged bottom extremities, making 6.6 %. Top extremities were damaged in 2.8 %, a spine in .5 % of cases, while the damages to a skull and chest were even more infrequent. According to some authors the insulated damages of the bottom extremities in NAVY do not exceed 2030 % and by character match to classical deck fractures according to Magnus [Rybkin P.P., 1956; Pellicari P. et al., 1987; Lunn D. V., 1987]. The major part of casualties was hit by the plural and combined trauma with damage, to two and more anatomic areas [Rybkin P.P., 1956]. For the clear reasons, the combined mechanic-thermal trauma is formed more frequently in the naval conditions than on dry terrain. It happens more frequently to the crewmembers, being in the closed compartments, constituting up to 70-75 % of all damages [Lunn D. V., 1987]. Combustions were observed in 30 % of cases, poisonings by explosion products in 1518 % of cases. 50% of casualties in NAVY were diagnosed as contusion or craniocerebral trauma. According to USSRs NAVY medical service during WWII, the pattern of explosive trauma consisted of: 30 % critically wounded patients, 20 % wounded of average severity and 50 % crewmembers with light wounds. 60 % of critically wounded patients suffered shock and 40 % of them perished at pre-hospital stage. Of greatest interest are the published data, concerning severity of the victim conditions, who reached hospital stage of medical care. More than half of victims arrived to hospitals more than .5-2 days after reception of a trauma, and with damages of easy and average severity [Klyncevich, 1975; Pellicari P. et al., 1987]. Specialized treatment of the wounded men led to complete recuperation in 72 % cases, of which 25 % led to decommissioning. The lethality at this stage of a medical aid made up .3 %. . Predominance of the combined and plural trauma, late
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terms of hospitalization led to irrevocable losses for the crewmembers with severe and extremely severe damages. During explosion under the ships bottom with deck oscillations with 6-8 cm amplitude, usually 6 oscillations are commenced during 8-10 ms [Rybkin P.P., 1956]. Notwithstanding that oscillations transfer through the hulk armor reduces magnitudes of initial accelerations by a factor of 1. intensity of their effects on a body o remains such that it is comparable only to the damages, caused by the fall from a high building. Experimental data by Evenstein Z.M. (1961) have shown that magnitudes of shock accelerations on lower decks can reach 600g, battle posts and corridors up to 120g, upper decks up to 40g, the captains bridge 25g. Excision from an explosion enlarges duration an explosion effects. It is considered to be that light damages are possible for 15-20g, average severity at 25-40g, severe damages at 40-80g and the extremely serious at 130g [Zherbin E., etc., 1966]. Thus, features of explosive damages of NAVY crews and passengers are comprised of special conditions, timeliness and completeness of rescue and medical care. Considering all this, it is possible to consider established that damages during explosions at sea, by complexity and variety of options can be treated as more than the same ones at land. In the specific naval conditions, one can isolate other special aspects of explosive damages. Main distinction of these damages is that the explosion energy is transferred by water, which by density and other physical properties is close to person tissues. This circumstance concerns damages, inflicted on people who were underwater during underwater explosion, and mineexplosive wounds in shallow waters. Damages, inflicted by underwater explosions were for the first time described by Williams in 1917 [Timofeev N.S., 1944]. However the basic aggregate experience was accumulated by the military medical services of allied forces during the WWII. According to the professor B.V.Lunin, who analyzed experience of rendering of the surgical treatment in Soviet Northern fleet during WWII, damages by an explosive wave of submerged personnel were observed often enough. Severity of victims condition of victims beyond polar circle was undoubtedly graver, than at an analogous trauma in other regions. Lunin has noted that all these traumas have been bound to shock and prolonged expose to cold water beyond polar circle sharply reinforced its symptoms. Unfortunately, by analyzing records he failed to establish frequencies of these damages and levels of lethality. But, grave severity of the general condition of these victims in the North
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demands prompt anti-shock treatment and correct diagnostic as well as adequate therapy. According to P.P. Rybkin's (1956), 5.3 % of the seamen, present at deck at the explosion moment, were thrown in the water. Many of them, while in water suffer shock waves from explosions of bombs, torpedoes and also ship ammunition [Hara K.S., 1989]. Mine-explosive wounds in shallow waters have drawn attention of the researchers, studying organization of the surgical treatment in the NAVY in 90th of the past century (Ruhljada N., Minnullin I., Chernysh A.). Nowadays, it became clear that military-tactical priorities are shifted towards wider use of the mobile armed formations and, first of all, stormtroopers. Consequently, this lead to a necessity of more detailed studying of marine losses patterns as well as the medevac organization. According to A.A.Ermakov (1955), losses in landing troops will be characterized by mass nature, irregularity and suddenness. During the WWII the relationship of irrevocable and sanitary losses in landing operations reached 2:1. During landing, the sanitary losses averaged 10 % during the first day and 20 % during the next 35 days. During WWII greatest sanitary and irrevocable losses were inflicted on stormtroopers when landing in shallow waters. The subsequent armed conflicts with participation of marines exhibited the same regularities [Ramage J., 1982]. These regularities were caused by required landing under small arms and mortar fire and overcoming of barrages on the shelf and coast. The most vulnerable marines were those, involved in storming of obstacles near the waterline, as there is usually no slightest shelter from fire and a bottom topography is virtually unknown. As a consequence, sanitary losses during landing make 25 % of total losses. As a clear example of wounds localization, we will address Novorossiysk assault during September 10-16th of 1943: head 1.4 %, chest .8 %, belly .6 %, pelvis .4 %, top limbs 2.8 %, bottom limbs 3.0 %, other sites 4.0 %. According to Katochigov (1954) 18% of marines suffered shock. Appreciable share of losses, as noted, fell on the marine recon force with 33% of them being severe wounds. There is published data [Garrikk J. C., 1968] addressing analysis of 1st USMC battle sanitary losses during war in Vietnam. Of 2021 wounds treated in hospitals, maximal share (3.8 %) was caused by small arms. Damages, inflicted by boobytraps were less frequent, but more severe in their majority. Part of casualties failed to reach hospital stage of medical treatment. Of all treated 6.1 % required urgent surgical help, 3.3 % needed bandaging, 2.6 % of victims did not require any surgical help. As noted, large casualties during landing operations overburdens medical care facilities in immediate proximity from the battle field. Author proposed
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using rapid deployment field hospitals with small number of beds (200 beds), which should be deployed close to the landing sites. While there is enough published sources present, dealing with the patterns structure and character of personnel losses during landing operations, until recently there was no data about traumagenesys and morphofunctional disorders, inflicted by mines in shallow water. That is why, the department of naval and general surgery of Military Medical Academy executed a comprehensive study, supervised by the professor Ruhliada N.V. The study objective was to develop comprehensive understanding of bone and tissue damages in the segments of extremities and internal organs. The study also addressed mechanogenesys of mine-explosive trauma in shallow waters with experimental-anatomic studies (26 experiments). Mine-explosive wounds were modeled by demolition of 10. 50 and 25 g plastic explosive charges. Anatomic objects were blasted at land (control group five demolitions), and in shallow water with two levels of submergence to knee and coxofemoral joints. Thus, the most probable conditions were created, which can be developed during assault landing on a sea shelf, protected by the most-widespread landmines (Table. 6.2). The study was performed on 26 anatomic objects, of them 15 bottom extremity of corpses, cut off at a hip joint level, 6 unfixed male corpses. Explosions were carried out (including experiments with animals) in field conditions at the Leningrad area Ministry of Defense ranges. The test procedures strictly followed safety regulations. Experimental studies on anatomic material pursued the objective to define amount and character of damages of soft tissues and the bone-joint apparatus. Secondary objective was to find out the mechanism of mine-explosive wounds in shallow water. Selected corpse extremities and corpses were clad in soldier's boots. The plastic explosive with detonator was installed in the water tight bag under the boots heel. Corpse extremity or a corpse was stabilized in vertical position using special metal construct at the required depth in the pool, filled with water. Explosives were detonated by electrodynamic fuse EDP-N8a. The control group was represented by the anatomical objects, being demolished on land. Vitally important ethiopathogenetic moment, defining character and severity of MD is the extent of armored protection destruction, caused by the mine or demolition munitions blast. In cases of armor protection remaining intact, the main part is played by the powerful beyond-armor impact and repeating oscillations of metal surfaces. As the result, there are damages of bones and internal organs, identical to "deck" traumas, inflicted on crewmembers by sea mine blasts (Fig.
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6.7). To a certain extent, catatrauma (biological group of damages, resulted from a human fall from the high building) can serve as a remote analog of MD. Table 6.2 Distribution of the anatomical study objects HE charge, g Anatomical objects explosions Shallow water Land 100 50 25 Total 8 8 5 21 4
1

50 g plasti explosive charge caused full destruction of the feet tissues stops up to a Shopar joint level. Bone fragments and tendons protruded inside the wound. Gas-dust impregnation was spread 56 cm in a proximal direction. When studying morphology of damages destruction, authors found destruction of ankle and distal sections of a tibial bone. Soft tissues were layered and covered by explosion byproducts up to a level of an ankle joint. Overlying tissues of extremity remained macroscopically intact. Results of macropreparation of extremity segments after land demolition showed the produced damages to represent severe explosive damage to locomotorium, which correlates with the land blast observations, presented by many researchers, and therefore can be treated as a control series.

Fig.6.10. Damages to the bone and joint apparatus of extremity (control series). Topographical anatomic preparation. 100 g charge under the heel

Fig.6.11. Shallow water explosion wound. 100 g charge under the heel

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Fig.6.12. Extremity wound in shallow water. Charge mass is 100 g. The charge is close to the feet fingers

Fig.6.13. Knee joint damages of the same extremity. Angiography results. 100 g HE charge, installed under the heel

Plastic explosive charges with 10. 50 and 25 g weight were used in the series of experiments when the extremity was immersed in water up to a knee joint. The charges were installed under the heel and toe. The damages, inflicted upon the adjacent extremity were studied as well. Demolition of 100 g plastic explosive charge under the heel led to extremity avulsion at the foot level. No damage to soft tissues was noticed, i.e. no naked and protruding bones, which is characteristic for land explosions. However, elements of the foot tendons and ligaments did protrude in the wound. From 3 to 4 linear skin abruptions could be traced at the bottom third of a shin. These abruptions propagated radially from an explosion point and extended for 15-20 cm. Wound of extremity was contaminated by the bottom mud. Traces of a charring and fly ash were absent. Overlying sections of a shin and a femur were visually intact, skin integrity was not violated (Fig. 6.11). Palpation revealed pathological mobility and a crepitation of bone fragments of bones through an entire shin, in the knee joint area and the bottom third of femur. The second type of blast involves explosion of plastic explosives the foot fingers. The same charge in all observations yielded following external wound attributes: avulsions of fingers at a Lisfranks joint level, absence of soft tissues damages and naked bones at the level of avulsion, the wound is considerably contaminated by soil, destroyed sections of soft tissues on the salvaged tendons. The skin shows 1- 3 linear ruptures extending radially 15-20 cm from an explosion. Overlying sections of extremity are visually intact (Fig. 6.12). Bone crepitating and pathological mobility of a shin is revealed by palpation in the area of a knee joint and the bottom

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third of femur. X-ray images at both alternatives of explosion showed plural fine fractures of shin bones (virtually entire destruction of shin bones in the bottom third), shattering of knee joint bones, comminuted femor fracture in the bottom third. For more detailed analysis of extremity segments soft tissues conditions, angiographic studies were undertaken in four cases contrasting of a vascular bed by lead white. The main arteries were tracked through all extent. Defects of a vascular wall and leakages of contrast substance were not observed. All topographic-anatomic interpositions of vessels were kept. Fine arterial network was distinctly observable. As one can see on Figs. 6.13-6.16 closest 20-25 cm of tissues in a proximal direction from an avulsion are delaminated an disintegrated, the architectonics of their vascular bed is broken, distal sections of shin arteries are helically twisted.

Fig.6.14. Damages to foot and shin bones. Angiogram. 100 g charge. The charge is under the heel

Fig.6.15. Damage to the knee joint of the same extremity. Angiogram. 100 g charge under the foot fingers

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Fig.6.16. Foot and shin bones damages. Angiogram. 100 g charge under the foot fingers

Fig.6.17. Damages to bone and joint apparatus of an extremity segment. Topographicanatomic separation. Charge mass is 100 g, positioned under the heel

All shin vessels have lost linearity, due to soft tissues being shifted by the bone fragments. Air bubbles were found in the central arteries at a level of the lower and medial thirds of shin. Popliteal and femoral arteries in the lower third of a segment are considerably deflected from an initial direction. Through all traumatic damage section, the researchers failed to find leakage of contrasting substance beyond the limits of a vascular bed. The fullest and integrated pattern of damages severity was provided with dissectional extremity preparation. Apparently, as one can see from Fig.6.1. 100 g C4 charge, when placed under a heel, led to full fragmentation of the bone tissue remained sections, plural fragmentation of a tibial bone metaepiphyseal section with the heaviest fractures in the region of a knee joint. Thus, the medial third of tibial bone was damaged to a lesser degree, so one can notice individual large fragment fractures of a tibial bone. On Fig.6.17 the fibular bone is removed. The characteristic damages, inflicted by the similar blast were intraarticulate fractures of the bones forming a knee joint, ruptures of both meniscuses, with medial meniscus suffering the most serious damage. In the lower third of femur, the researchers observed multicomminuted fracture of a femur with fragments shifting and fracture of condyles. Preparation of overlying femoral sections revealed amotio of the soft tissues together with a periosteum up to boundary of the femur lower and medial thirds. Preparation of a
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knee joint revealed rupturing of cruciform ligaments and damage to the entire articulate cartilage and meniscuses. Integuments, subcutaneous cellulose and muscles were visually less damaged degree. Preparation of extremity after 100 g charge blast under the foot fingers (Fig.6.18) revealed subperiostal fracture of shin bones in the lower and upper thirds, intraarticulate fractures of tibial and femoral bones condyles. Amotio of a periosteum and muscles from a femur up to boundary of a segment medial third is clearly visible. The data on damages, inflicted by a 100 g charge with its location under a foot heel or fingers, have confirmed that while there is exterior difference of a wound character there are no differences in the extremity segments damage character. Consequently, the subsequent experiments were conducted with strapping a C4 charge to a heel, because at dry land blasts this charge localization causes heaviest traumas.

Fig.6.18. Damages of bone and tendon fragments of the extremity segments.

Fig 6.19. Damages of bone and tendons apparatus in the corpse. Anatomic-topographic preparation. 100 g charge immersion down to a knee

When the corpse is blasted on 100 g C4 charge the exterior macroscopic attributes of a wound are similar to those extremity blasts, described above: avulsion of the right foot, lack of the soft tissues damages in an avulsion zone, crepitation of bone fragments at a diaphysis level of a shin, a knee joint and the lower third of both extremities femur, lack of integuments damages more proximally than an avulsion place. Body-section anatomic preparation revealed virtually entire

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fracture of the ligamentous and bone structures of both knee joints and femurs in the lower third, amotio of muscles and periosteums from a femur on 1215 cm distance (Fig.6.19). Examination of overlying sections of a femur, hip joints, soft tissues of femur exhibited no obvious damages.

Fig.6.20. Damages of bone and tendon fragments of the opposite extremity segments. Anatomic-topographic preparation. 100 g charge placed under the foot fingers

Fig.6.21. Comparison of damages through the anatomic-topographic separation. Right explosion at the dry land. 100 g charge immersion down to a knee. Right extremity blast in shallow water.

The contralateral extremity (left in all the experiments) has suffered no damage to the skin as the result of a blast on the 100 g C4 charge. Pathological mobility and a crepitating of a tibial bone fragments was discovered by palpation. X-ray imaging revealed coarse fractures in medial and lower thirds of shin. Layered preparation revealed closed, subperiostal fractures in the middle and lower thirds of a shin. The fibular bone also suffered coarse fracture in its lower third, but without fragments shifting (Fig.6.20). Thus, comparing effects of topographic-anatomic preparation of extremities segments after mine blasts in shoal water the significant expansion of extremities damage zones after explosion in water was noted (Fig.6.21). Such inconsistence of damages severity demanded further experiments with decreasing explosive charges.
Blast of a 50g C4 charge. Blast of 50 g C4 charge in half of cases did not cause a foot avulsion.

The foot remained hanging on tendons with no damage to the soft tissues. Researchers found 2-3
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linear skin ruptures. By the palpation one could feel a crepitation of fragments and pathological mobility through the entire shin. X-ray imaging of both shin bones diaphyseal fractures proved to be true but the knee joint remained intact. Layered section preparation of extremities showed the full fracture of foot bone and soft tissues structures in the fornix area. From an ankle joint up to a medial third of tibial bone one can observe closed multicomminuted subperiostal fracture without bone fragments shifting. In the tibial bone metaepiphysis region, one could see a compression fracture of a bone spongiform substance with partial fracture of articulate surfaces of a knee joint, and the bone in a fracture area represented bellied pulpous mass. No visible damages to the knee joint ligamentous structure. Amotio of muscles in the lower third of femur with a periosteum protruding from at 57 cm. Femur is not damaged. The soft tissues of extremity did not suffer significant changes, except for hydraulic preparation of muscles and subcutaneous fatty tissue of the shin lower third of. The following damages were revealed after mine blasting of a corpse avulsion of the right foot, practically full subperiostal fracture of tibial bone metaepiphysises (pulp), a damage of ligaments and bone structures of both knee joints. The phenomena of muscles amotio with a periosteum from the lower third of femur (8-10 cm) were observed.

Fig.6.22. Damages of bone and tendon apparatus of an extremity, clad in the combat boot. Topographic-anatomic preparation. Charge mass is 50 g.

Fig.6.23. Damages of bone and tendon apparatus of an opposite extremity. Topographic-anatomic preparation. Charge mass is 50 g.
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In four experiments, addressing corpses with extremities, being blasted by mines, HE charges were positioned under the soldiers heels. Fractures of foot fornix tissues appeared to be less severe; a turn of a foot bone was less than 40 degrees. Linear skin ruptures were observed through 10-12 cm from an explosion point. Palpation and X-ray imaging revealed closed comminuted fracture of the tibial bone lower third, lack of femur and a knee joint damages. Preparation revealed virtual identity of damages, inflicted on skeletal bones (similar to blast of 50 g charge without a footwear) multicomminuted subperiostal fracture of bones in the lower third of a shin, fracture of proximal metaepiphysis spongiform substance in a tibial bone, amotio of the soft tissues with a periosteum from a femur in the lower third through 10-12 cm (Fig.6.22). Experiments showed the usual shoe to fail reducing severity of the inflicted damages during shallow water blasts. Damages to contralateral extremity, inflicted by the 50 g charge explosions were reduced to closed coarse fractures of a tibial bone in its middle and bottom thirds, which could be noticed by palpation, X-ray imaging and by dissection of a body (Fig.6.23). For more exact visualization of fracture character, the periosteum is removed from a tibial bone.
Blast of a 25 g C4 charge. Subsequent multiple reduction of explosive charge down to 25 g has

led to following changes of trauma character traumatic fracture of the foot fingers hanging on tendons; the calcaneus is suffered 20 degree turn after an explosion; there are two radial 10 cm skin ruptures starting from an ankle joint. Palpation and X-ray imaging proved that the closed comminuted fracture of the lower third of tibial bone took place. Layered preparation of extremity revealed virtually full fragmentation of the ruminating foot bones and the closed multicomminuted fracture of a tibial bone distal metaepiphysis. The ligamentous apparatus of a knee joint remained without visible pathological changes, but the intraarticulate fracture of a femur medial condyle can be clearly seen. The shin soft tissues are fibered and scaled at 8-10 cm distance from an ankle joint (Fig.6.24). When a corpse is blasted by the 25g C4 charge, it suffers fractures of a foot fingers and disintegration of a metatarsus bones. The radial ruptures of a skin till up to 8-10 cm were seen. By palpation, one could feel crepitation of fragments at a lower third level of the right shin and a medial third of left shin. After preparation, the researchers diagnosed virtually complete fracture of bones of the right foot and field of the ankle joint, closed subperiostal fracture of the right tibial bone lower third. Elements of the soft tissues ammotio were detected at 8-12 cm from the right ankle joint in a proximal direction.
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Contralateral extremity after blast of 25 g C4 charge usually suffered closed coarse fracture of a tibial bone in a medial third. Thus, the results of anatomic objects blast with the immersion to knee joints, the authors found out a series of the characteristic features and the features, specific to a similar trauma: in all experiments one could observe specific constant macroscopical attributes of contact mine-explosive wound on a shoal water; no extremity shin bones baring (soft tissues defect ) is found, contrary to the landmine blasts; two-four radial ruptures of a skin spread in a proximal direction on 15-20 cm distance cm from a level of an extremity separation; plural shattered or comminuted fractures of the bones diaphyses and fracture of the articulate extremities of and extremity, which was submerged during a blast; in all cases, there are closed fractures of bones of the opposite extremity. These fractures have stable features, characteristic for the certain charge mass. C4 charges with masse 10.. 5.0 and 2.0 grams were used for examination of damages character, inflicted on the submerged extremities up to a level of a hip joint.
Blast of a 100 g C4 charge. Damages to the extremities, caused by a 100 g charge with

immersion to a level of the hip joints revealed following trends the separation of an extremity took place at the foot base level, there was no damage to the soft tissues at the avulsion level and a skin damage was more proximal than this region. Nevertheless, one could usually see 23 linear skin ruptures at 810 cm beginning from a level of a separation and transgression in a proximal direction. Palpation revealed pathological mobility and a crepitation of fragments in the regions of the lower and upper thirds of tibial bone, and also in a medial third of a femur. X-ray imaging showed analysis fractures of bones in the specified anatomic regions. Effects of topographic-anatomic preparation allowed determining the complete fracture of foot bones and subperiostal fine fractures of a tibial bone virtually through the entire bone. There were no macroscopic damages of meniscuses and the ligamentous apparatus of a knee joint, but one could see exact amotio of muscles and periosteums from a femur through medial and upper thirds, comminuted fracture of a femur in a medial third without fragments shifting. Study of the extremity soft tissues has shown that visible morphological disordered were present only in the avulsion zone separation of fibers and ruptures of muscular bundles, but, they did not spread past 812 cm from a foot avulsion.

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Fig.6.24. Damages to bone and tendon extremity segments. Topographic-anatomic preparation, 25 g charge Another damage pattern was observed during blasts of corpses, immersed in water up to a hip joints level fracture and a separation of the right foot at a level of an ankle joint, lack baring and protrusion of bones, presence of fibres separation and soft tissues disintegration in the separation region, radial skin ruptures at 10-12 cm, attributes of containers hydraulic preparation at 7-9 cm from an avulsion level. In addition to that, researchers discovered the crepitation of fragments and pathological mobility at a level of both hip joints (Fig.6.25), crepitation of fragments in the both metaepiphysises of the right tibial bone and a proximal metaepiphysis of the left tibial bone. X-ray imaging revealed comminuted fractures of the right tibial bone metaepiphysises, left tibial bone diaphysis, intraarticulate fractures of both femoral necks with fragments shifting, cracks in the ischium from the right, propagating radially from an acetabular trough for 4-5 cm (Fig.6.26). Preparation of the corpses extremities segments confirmed the damages to be virtually identical to those, inflicted by the blast of separate extremities, immersed up to a hip joint level. There were no attributes of fractures in both knee joints and both femurs up to a femoral neck. Preparation of hip joints has allowed discover limited ruptures of a joint capsule and ligaments from both sides, fractures of femoral necks with shift of the fragments (Fig.6.27).

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Blast of a 50 g C4 charge . Explosion effects of 50 g C4 charge was reduced to an avulsion of

the right foot at the same level, as that in the experiments with separate extremities. One can also observe subperiostal fracture of both metaepiphysises in right and a diaphysis in left tibial bones. X-ray imaging revealed cracks in the ischium from the right, propagating from an acetabular for .52 cm. Separation of the soft tissues fibers with the full destruction of their topographicanatomical bonds was found in the separation region and was traced through 5-8 cm distance in a proximal direction

. Fig.6.25. Damages of cadavers bone and tendon apparatus. Topographic and anatomic preparation. Charge mass is 100 g. Leg is immersed down to hip joints.

Fig.6.26. X-ray image of bone and pelvis damages, along with the upper third of hip joints. Charge mass is 100 g. Leg is immersed down to hip joints.

Fig.6.27. Damages, inflicted on the hip bones and joints in the cadaver. Topographic-anatomic

preparation. Charge mass is 100 g, immersion to hip joints level. In the lower third of right femur, the investigators discovered amotio of muscles from a femur at the extent of 8-10 cm, but from the left side there was no such amotio. Another extremity

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manifested closed comminuted fracture of a tibial bone at the medial third with no damages to the integuments.
Blast of a 25g C4 charge. Blast of a 25g C4 charge caused full fracture of the right foot bones at

a level of a premetatarsus traversal joint. Foot fingers loosely hanged on separate tendons. The radial skin ruptures propagated from this level in a proximal direction for 48 cm. The foot fornix fracture caused a calcaneus to be displaced in relation to a shin axis of at the distance of 20-25 cm. Damages of integuments, more proximal than an ankle joint, were not observed visually. Palpation revealed crepitation of bone fragments through all extent of a foot and in the region of distal metaepiphysises in the right shin. While at the left, there was no exterior lack of skin damages, one could observe pathological mobility and a crepitation of a tibial bone fragments in its medial third. Macropreparation and an X-ray imaging confirmed presence of a proximal metaepiphysis macrofractures in right and diaphysis in left tibial bone.

Fig.6.28. Destruction of skeletal bones when modeling mine-explosive wounds in shallow water. Immersion down to a knee joint Comparing data, related to the experimental blasts of bioobjects at two levels of their submergence, it is possible to conclude, that contact blast in shallow water (Fig.6.2. 6.29) are more likely to cause the most typical attributes of explosive damages to extremities:

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Fig.6.29. Destruction of skeletal bones when modeling mine-explosive wounds in a shallow. Immersion down to a hip joint plural shattered (up to pulp) subperiostal fractures of metaepiphyseal regions of long tubular bones of the lower extremities, and in some cases with a damage of joints surfaces and elements, extending only through a level of body immersion in water; permanent diaphyseal fractures of the contralateral extremities, which have the multicomminuted or shattered character; frequent ruptures of joint capsules and permanent amotio of muscles and a periosteum from diaphyseal bone regions; heaviest damages to anatomic structures in the extremities were observed on a boundary of two media "air-water". Much greater volume of extremities segments damages, caused by the blast in shallow water allowed estimate probability of heavier distant damages, than those, inflicted by mine -explosive wounds on dry land. If character of extremities segments wounds in unstable corpses can be compared to damages, inflicted on the wounded personnel, then the correct comparative analysis of distant damages in corpses and wounded men is extremely difficult. According to experiments with corpses it was possible to estimate only frequency and severity of the distant damages. Lack of a circulation, nonreversible changes of the physicochemical properties of organs and tissues, losses of elasticity, mobility, other density of the soft tissues and a number of other conditions disallowed us to characterize reliably distant damages, inflicted on an anatomic material, and macroscopically defined ruptures of a scrotum, a sphincter of a

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rectum, mesenteries and regional liver tissue damages only confirmed an opportunity of their formation. Comparative analysis of the studied objects and specimens in a control series, judging only from X-ray imaging and topographic-anatomic preparation yields a pattern of the significant difference in character of traumas, judging from frequency and severity of damages of extremity segments. Proceeding from these observations, it is possible to speak with a high probability that damages to an extremity after blast by a charge of C4 25 g in water are comparable to damages, inflicted by 100 g C4 charge at land. At this investigation stage, one could find 4-fold increase of an antipersonnel mine yield during explosion in a shoal water. Experimental research with animals involved dogs with body mass of 19-25 kg (Table. 6.3). Mine-explosive wounds were simulated by the blasts of C4 charges with mass of 10.0; 5.0; 2.0 g. Of 16 executed experiments, in 12 experiments the dogs during the blast were immersed in water up to a level of a knee joint. The immersed technique was original and allowed to closely reproduce a situation of a human body blast, when the latter is partially immersed in water. Four experiments of 16 constituted control group where mine-explosive wounds were simulated on a land. Land Blasts. Mine wound image represented a classical example of a land contact blast. Damage to the soft tissues and thereof extremity bones baring, made up to 2-3 cm, with the wound coated by explosion products. Proximally departments of the injured segment and the next extremity do not show any damages visually. Skin of both extremities manifests individual confluent hemorrhage. The specimens exhibited the tachycardia around 110-115 bpm, a dyspnea did not exceed 2023 /min (Fig.6.3. 6.31). The state of animals was regarded as severe, but, from the standpoint of the prognosis during a shock (the proximal day), favorable. All animals after two elapsed hours after wound tried to rise and ramp that demanded additional injection of anesthetics. Response to infusional therapy was adequate, that allowed correcting and supporting the basic vital functions of an organism. Table 6.3 Distribution of field experiments HE charge, g Experimental enemies blasts In shallow water On dry land 100 1 3 50 5 1 25 6 _ Total 12 4

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Three dogs of four have been were terminated from the experiment after 2325 hrs. Severity their state was different, but there was no agony observed. During observations, the researchers found no disorders of the heart rhythm and convulsions. One dog has died from a building up cardiovascular and respiratory failure 22 hrs after the wound.

Fig.6.30. Dynamics of dogs heartbeat after explosion on dry land and shallow water (X m)

Fig.6.31. Dynamics of dogs breathing after explosion on dry land and shallow water (X m) Of all 12 experiments, the first and single blast on 100 g C4 charge, with the dog immersed to a knee joint revealed following set of damages rupture of a pelvis ring, fracture of a forward abdominal wall with an eventration of an intestine, ruptures of a liver and spleen, massive intraabdominal bleeding. The animal has died 3 minutes after explosion. The general state of a dog right after blast was regarded as agony: tachycardia more than 180 beats/min, apnea. Reanimation was not performed. This case convinced researchers that the further experiments with a 100 g charge are not warranted, since they produced damages incompatible with life (Fig.6.32).
Blast of a C4 50 g charge. In the following five experiments the charge mass was lowered to 50

g. One dog from this group perished on the seventh minute after blast (rupture of an abdominal
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wall, an eventration and a massive intraabdominal bleeding with tachycardia and a dyspnea). In apogee of a decompensation the Cheney-Stokes breathing was observed, with a death following 2 hours after an explosion.

Fig.6.32. Mine-explosion of dogs extremity, caused by the contact mine-explosion wound in the shallow water. Charge mass is 100 g
All dogs were rendered a primary surgical treatment of a stump at the right shin. The treatment

was performed under narcosis. The surgeons performed audit of a wound, a necrotomy, final staunching of a wound, a section of shin fascias to drain the formed hematomas. The surgical treatment was limited to these issues. Remaining three dogs from 50 g charge blast group were in a grave condition with slow subzero dynamics of a clinical pattern. The tachycardia gradually built up, and after 11 hours from the moment of wound comprised 150 and more beats/min. Breathing remained superficial with a dyspnea till 30-34 per minute. All animals were lying, the motoric performance was minimal. Lid reflexes were alive, as well as tendon reflexes. The dogs suffered increased tremor of extremities and after that, as a rule, through 1015 minutes the convulsive attack developed. Similar clinical developing processes only aggravated derangements of a hemodynamics and breathing. In a terminal phase of a wound, one can observe tachyarrhythmia, Cheney-Stokes breathing, followed by the death from cardiac arrest. The remained three dogs have perished within 12-13 hours after wound.
Blast of a charge of 25g C4 charge. Clinical course of a shock in this group of animals,

consisting of six dogs, was more favorable in comparison with the above. 3 hours after wound two dogs from a six attempted to lift a head and move legs. The state of animals was regarded as severe with a tachycardia 120125 beats/min, a dyspnea 2123 per minute. Damage to the extremities was less frequent in a proximal direction. All dogs manifested avulsion of the right foot, closed fractures of the right shin bones and the left foot with fragments shifting and massive
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hemorrhages in soft tissues, insignificant petechial hemorrhages in the perineal region were observed. In two cases of six, the researchers noted strips of petechial hemorrhages in extremities skin at a level of submergence. Infusional therapy stabilized a hemodynamic and breathing of animals in the interval 12-17 hours after wound. Slow subzero dynamics of a clinical pattern in these two animals began to be observed after the first day after wound. It was manifested by gradual aggravation of a tachycardia and a dyspnea. By the end of the day the cutaneous sensitivity decreased at back extremities. The phenomena of a circulation decompensation and breathing built up, accompanied with a tremor of extremities. After that, both dogs exhibited clonic-tonic cramps, a tachyarrhythmia, breathing Cheney-Stokes. Phenomena of a cardiovascular and respiratory failure on the background of cardio-vascular arrest caused death of the animals. Four remaining dogs had the characteristic exterior attributes, however dynamics of their state was a little different no motor performance was observed. Dogs reacted only to the strong pain stimulation with ambient heartbeat 130-150 beats/min, feeble, a dyspnea reached 24-26 per minute. Remaining four animals have survived evacuation from the field range to a medical facility (around 3 hours). There was no necessity to inject additional anesthetics. Of four animals in the surgical facility, 3 were in a grave condition: pulse 140-145 beats/min with feeble modulation, superficial breathing 2628 / min. The right foot was missing, both femurs are hydropic, palpation showed closed fractures of a shin bones in a medial third on the right and bones of a premetatarsus at the left. One of the animals developed generalized cramps 3.5hrs after wound, repeating each 1.5-2 hrs. The cramps developed on the background of a progressing tachycardia (140-160 beats/min), dyspneas (up to 32 /min). The cramps could not be corrected by means of conventional anti-cramps treatment. All animals were laying without lifting a head. Along with stabilization of the general state, the dogs manifested some motor performance in the form of an incoordinate motion of claws, and two of four dogs tried to rise. 68 hours after a trauma on the background of progressing tachycardia and dyspneas, two animals have developed clonic-tonic cramps with 40-45 s apnea, which were treated unsuccessfully with lytic mixtures. All animal were subjected to infusion therapy: reopolyglucinum, polyglucinum, glucose, an isotonic solution of sodium chloride, 3 % solution of sodium hydrocarbonate (soda). Hormones, analeptics, narcotics were injected based on manifestations. On the average, each dogs during observation was subject to injection of .52 l of fluids. Infusional therapy largely stabilized a
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state of animals; however it still remained severe. All dogs maintained sensitivity in the damaged extremities. 10 hours a trauma on the relative stabilization background for the state at all animals, the tachycardia attained 140-150 beats/min, a dyspnea more than 30/min. The state of a dog, suffering convulsive attacks after 3.5 hrs, was progressively deteriorating, the decompensation of a circulation and breathing was building up, accompanied by the tremor of extremities. 11.5 hours after wound cramps appeared twice during 35-40 min period, the dyspnea attained 32 35/min, the nystagmus was diagnosed. It followed by the disturbance of a heartbeat as a tachyarrhythmia, breathing became superficial and sped up, cyanosis of mucosas was observed. The cramps repeated twice, but less intensive, accompanied by 20-25 s apneas. For two animals, the cramps developed already 11.5 hours after wound. In the subsequent they repeated, and each time their intensity increased. One dog has died 5 hrs after trauma on the background of a convulsive attack, a tachyarrhythmia and Cheney-Stokes breathing. Precise trend of the symptoms aggravation began to be observed 10-12 hours after blast. The symptomatic therapy was undertaken, but gave only short-living effects. Harbingers of an agony, as well as in the previous cases, were disturbances of a heartbeat by a tachyarrhythmia type, convulsive attacks, Cheney-Stokes breathing. Animals died 21-23 hrs after wound. Gravity of dogs condition, dynamics of pulse and breathing, and also circulatory disturbance, as well as the degree of their neutralization, varied. This witnessed of natural differences in an individual resistance to a trauma and directly depended on a charge yield. As a whole, the clinical pattern of mine-explosive wounds in animals on a shoal water has a number of the important distinctive features from similar traumas on a land. The tachycardia and a dyspnea were more expressed, especially at 50 grams C4 charge blasts. The Motor performance was minimal. All 11 animals after blast on shoal water developed cramps of various expression and duration with the phenomena of breathing disturbance. As noted, after advent of the first cramps, animals conditions considerably deteriorated decompensation of a heart activity and breathing built up, the diuresis degraded down to anuria. Moreover, for the majority of dogs the cramp siterated, and more often became heavier and longer. In a terminal phase of traumatic sickness practically all animals experiences disturbances of a heartbeat like tachyarrhythmia and Cheney-Stokes breathing. The death resulted from a stopping of heart activity. Practically equal pattern of wound sickness clinical manifests development in animals has allowed presuming an additional factor, aggravating trauma and
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being manifested by equal neurological CNS derangement, that largely defined gravity of animals conditions and outcome of a wound. Thus, clinical course of traumatic sickness for the animals, suffering explosive wounds in shoal water, differed undoubtedly by a greater degree of severity from the same blasts on land. Observations over group of animals after their blast on a 50 g C4 charge allowed guessing that the successful prognosis for these wounds is extremely doubtful. Explosion of a 25g C4 charge in shoal water by a set of damages to the tissues and gravity of clinical course is comparable to 100g C4 charge blast on land. Blast in water creates one more link in a shock pathogenesis, manifested by the characteristic neurological symptomatology, which aggravates shock and makes improbable successful prognosis for a wound. This deduction has demanded more detailed studying of shallow water wounds morphology. After profound studying surgical anatomy of mine-explosive wounds to extremities of the experimental animals during the land and shallow water blasts, the following data are obtained.

Fig.6.33. Mine-explosion of dogs extremity, caused by the contact mine-explosion wound on the dry land. HE charge mass is 100 g
Land blast. During contact land blast (4 dogs, constituting a control group) a fur and skin of

animals in the region of extremity avulsion, femur and perineum is scorched and coated by the fly ash of explosion. Two of four dogs manifest focal intradermal hemorrhages, extending on a perineum and genitals. All dogs manifest the significant edema of the right shin and sponginess in the right femur up to a level of a segment medial third. Damage to the soft tissues of the right extremity with bones protrusion on 2-3 cm distance (Fig.6.33) is observed. Closed comminuted fracture of bones of foot was diagnosed by X-ray imaging and palpation in left hind extremity in one of four observations. When studying surgical anatomy it is revealed
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that during a land explosion under effects of a shock wave and other factors of explosion separation of the shin soft tissues at 68 cm from an avulsion level. Most expressed damages were positioned along neurovascular bundles, around a bone and in subcutaneous cellulose, the soft tissues are imbued by blood, their anatomic mutual relations are broken. Examination of the right and left femur muscular containers in hind extremities showed, that on the right in medial and back there are groups of hemorrhages in a depth of muscles from 58 to 1518 mm, without spreading on perineum and buttocks. Individual hemorrhages sites were found on the left femur, in medial and back containers, but their diameter did not exceed 57 mm. Confluent and focal hemorrhages concentrated along the basic neurovascular bundles. The greatest hemorrhagic imbuing of muscular elements was observed in the regions adjoining vascular bundles. Mosaic painting of femur muscles and individual sections of muscular fibrils dystrophy attracted attention. The phenomena of muscles and a periosteum amotion from a femur and a hemarthrosis of a knee joint have not been found.
Blast of 50 g C4 charge. In experiments with charges of 50 g C4 charges, in spite of individual

differences in a clinical course, for the five animals "the set" of damages was virtually identical. The researchers observed right foot avulsion at a hop joint level without baring of bones in the region of a separation, presence of 2-3 radial skin ruptures in 3-5 cm length, transgressing in a proximal direction (Fig.6.34). Destroyed muscular elements were found flush with a cutaneous wound of the right extremity, a bone and tendons. The right shin and a femur were hydropic, the circumference of an extremity segments increased by a factor of in .5 times from an initial level, puffiness of the left extremity was less expressed. The fur showed tracks of fumes and fly ash. Three of five animals had 36 ruptures of a skin with length of 7-8 mm on a skin of the upper third of femur, a perineum and an abdominal wall. All animals manifested plural intradermal hemorrhages in these regions. By palpation one could see closed coarse fractures of the right shin and left foot with fragments shifting. Movements in hip joints of all animals were limited, especially on the right. Pelvic bones damage was not detected by palpation. Other sections of a body showed no visible changes. The pulsation of the right femoral artery was found at an inguinal crimp, in the left femoral artery at the level of a medial femur third. X-ray imaging confirmed closed coarse fractures of the right shin in a medial third and fractures of the left foot in the upper third with the significant bias of fragments. Dislocation of the right femur has been additionally diagnosed along with the significant decrease in joint mobility.

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Fig.6.34. Contact mine-explosion dogs extremity wound in shallow water. Charge mass 50 g.

Fig.6.35. Layering of muscles with an epiphysis from the femoral joint, caused by the contact explosion in shallow water. Charge mass is 50 g X-ray imaging showed now pathological bone damages in the pelvis ring and lumbar section of a spine. Studying of surgical damages anatomy showed total hemorrhagic imbuing of all muscular arrays in the right femur and significant hemorrhages presence in left-hand femur. Both shins were imbibed with blood. Hemorrhages were spread to inguinal fields from both legs, and on the right down to the lower departments of an abdominal wall, a perineum. The wound side showed elements of the hydraulic tissues amotio up to a level of a shin medial third (on the right). Preparation of container spaces in both extremities showed the hemorrhages on the right femur to spread through an entire extent of bone-fascial containers. Neurovascular bundles of extremities

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are entirely imbued by blood. In three of five cases, the researchers noted separation of fibers through the lower third of femur. On the left-hand femur, the damage degree of the deep muscular layer was less expressed; only in two cases hemorrhages around of a femur in its lower third have been detected. Preparation showed damage to all container spaces in the hips. The hematomas on the back container of the right femur spread to a rump. For all dogs the hemarthrosis of the right knee joint was recorded, and in three cases fracture of a medial condyle of the right femur. In addition to that all animals showed amotio of muscles in the right femur together with a periosteum from a femur through 2/3 lengths of a femur, starting from a knee joint (Fig.6.35). On the left femur, the phenomena of amotio of a muscular array were found only in one section with the length no more than .5 cm in the lower third of the segment. According to the results of 50 g C4 charge on the dogs extremities, when the latter are immersed in water, the researchers found decrease of damages in comparison with a 100 g charge. At the same time, abundance of damages, the significant trauma of the bone apparatus and a vascular network of extremities puts under doubt viability of the injured tissues, mainly from the side, exposed to an immediate blast action (on the right).
Blast of 25 g C4 charge. Explosion of 25 g C4 charge led to a separation of the right foot, baring

of bones at a level of a separation, the significant edema from the right and the moderate edema of the left-hand femur. By palpation the closed bone fractures in the right shin and the left-hand foot were found. In four cases of six, the researchers found intradermal hemorrhages with smaller volume and abundances. Two dogs had the linear skin ruptures in length of 3-6 mm on a hips skin along with hematomas in the genital regions. X-ray imaging showed closed comminuted fractures of the right shin and the left-hand foot bones with shifting of fragments. Hip joints, pelvis, a lumbar region of a backbone were without a visible bone pathology. Confluent hemorrhages were localized in subcutaneous cellulose of the lower third of extremities, being most expressed at a level of submergence. In all observations, the essential damages to muscular and others soft-tissue femoral formations were seen. Hemorrhages on the right back extremity spread up to a level of the upper third of a femur. In three cases of six, the hematomas spread through the rump on the background of their significant presence in the back muscular containers. The amotio of muscles, found in four cases with a periosteum from the right femur on boundary of medial and upper thirds of segment supplemented a morphological pattern of the mine-explosive wound. The same damages were not found on the left femur. Greatest abundance hydraulic preparation due to a blast effect was
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observed at the extent of a right femur neurovascular bundles. In three cases of six the hemarthrosis of the right knee joint was noticed. Experiments with blast 25 g C4 blasts charge have shown, that at rather smaller volumes of wounds, their exterior attributes were comparable to those, inflicted by the charges with larger yield. Thus, comparing the effects of anatomic studies of control and observational series, it is possible to conclude that the explosive trauma of dogs extremities in shoal water is drastically different from those on a land. The morphological studies confirm the attributes of expansion of damage regions expansion in the soft tissues, inflicted during a shallow water blast. In whole, certain zoning of pathomorphologic derangements is seen. Examination of proximal extremity zones and morphological finds revealed significant disturbances of fabric architectonics exceeding analogous damages in a control series. In all observations the degree of damage of a femoral neurovascular bundle was closer to the right. Deep dystrophic and necrobiotic changes were noticed to the right of separation level up to the upper third of shin, involving a knee joint. Region of the lower third of right femur exhibited heavy disturbances of a microcirculatory bed, the fabric organization, necrosises of the significant muscular sections. Gravity of histological disturbances decreased in a proximal direction. The phenomena of an edema, individual confluent hemorrhages and necrosises of muscles, adjacent to a neurovascular bundle were predominating in the upper femoral third. Only starting from this level and comparing obtained data with those regarding a peripheral circulation, it is possible to speak about a satisfactory state of an extremity tissues. To the left, the maximum of histological pattern changes fell to a level of the upper third of shin with predominance of the hemoinfiltration phenomena in muscular elements and an edema of an interstitial tissue. For contralateral extremities it is practically important, that there were no irreversible changes in tissues, though individual sections of necrosis and the expressed spastic stricture of a vascular bed can lead to a disability in reactive and plastic capabilities of a vascular system. Distant damages of interior organs, when simulating a contact blast in shallow water were studied in sharp and chronic experiments with 37 mongrel dogs. 1st group contact mine blast on a land 17 animals, 2nd contact mine blast in shoal water (submergence to knee joints) 20 animals. An experiment was based on the above-described contact blast model with anti-personnel mines. The procedure allows to gain the fullest analogy to the mine-explosive trauma, caused by a
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contact with anti-personnel mine. Both groups of animals after mine explosive trauma showed retardation, deceleration of response to exterior irritants, disorders of impellent response and a sleep, animals refused to take food. In further, close to fifth day of observations, retardation of animals in 1st group was replaced by hypererethism, sometimes even aggressiveness. Depression of impellent response and retardation of animals in 2nd group was observed starting with 3rd through 10th day after mine wound injury. When analyzing obtained data it has been noted that tonus of a sympathetic branch of vegetative nervous system in the animals, belonging to 1st group was higher than that in animals of 2nd group. Mine-explosive trauma in shallow water caused drastic degradation of this tonus during the first three days after blast, which is manifested by disorders in functioning of the organs, controlled by this system. It can witness to a greater degree of suppression of an efferent path chain in a sympathetic branch of vegetative nervous system after the contact mine blast in shoal water. As a result, derangement of nervous system specific trophic functions is accompanied by the changes in the general adaptation syndrome. Presence of the local homeostasis system, reflecting brain condition, in the framework of the hemoencephalic defined necessity to examination biochemical processes, taking place in the local homeostatic system of an organism, termed as the intracentral homeostasis. Experiments were performed addressing a degree of disturbances of the intracentral homeostasis during contact mine blast on a land and in shoal water. When studying the cerebrospinal fluid (CSF) in the dogs, blasted on land, the researchers found statistically significant activity differences during the first day after wound in a biochemical spectrum of laninaminotranspherases (AlAT), creatine phosphokinase (KPK), gammaglutamate transpeptids (GGTP). Activity aspartate aminotransferases (AsAT), an alkaline phosphatase (AP), lactate dehydrogenase (LDG) did not change. Creatinine, crude protein and cholesterol showed no reliable changes in concentration after contact mine blast on land. ALAT and GGTP showed significant activity differences even three days after explosion. The biochemical composition of a cerebrospinal fluid for the dogs, suffered blasts in shoal water, was characterized by increase of virtually all studied indicators for 7 days after a trauma. Measurements of cytoplasmatic and mytochondrial ferments in CSF proved disorders of structural and functional integrity of CNS histohematogenous barriers, especially expressed for shoal contact mine-explosive trauma. The intracentral changes after contact mine blasts in a shoal water are caused by the direct primary damage, inflicted on CNS histohematogenous barriers can
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lead to amplification of activity synaptic enzymes activity, leading in turn, to change of a metabolism regulation. Hence, increase in activity cytoplasmatic and mytochondrial enzymes (AlAT, AsAT, KPK, GGTP) in CSF is an important set of indicators, witnessing a prime role of brain damage in contact mine blast on a shoal water. This set of indicators can also point on the biochemical developing processes of hyper expressed enzyme degradations. Structurally-metabolic intracentral disorders correspond to a change of the bioelectric characteristics of neurophysiologic processes. Time-spatial patterns of brain bioelectric processes are determined by the mechanisms of formation and propagation of rhythmical bioelectric activity of cerebral structures. These structures can temporarily merge and regulate various functional systems. Integrative function of a brain biorhythms is implemented by coordinated in space and time variation of neuron systems excitability, creating conditions for biorhythms formation. Composition and pattern of these biorhythms depend on interaction between various brain structures and the functional state of an organism. According to classification by E.A.Zhirmunskoj's and V.S.Losev (1984), they discriminate following types of electro encephalographic (EE) types 5
Type II (irregular) is characterized by substantially regular alpha-rhythm. At the same time there

are conditionally regular or conditionally pathological EEG components: slow theta and delta-activity with
Type III (asynchronous) is characterized by diffuse (expressed in all brain regions)

disorganization of all rhythms, i.e. formation of dominantless curve with low amplitude, less than 30-35 uV; alpha-activity is always irregular, and beta activity is irregular with interlacing high and low frequencies. Most typical indicator of Type III type is low-ampltidue slow activity, and quite often, fast asynchronous oscillations.
Type IV (hypersynchronous) is characterized by extremely underlined rhythms with amplitude

higher than normal. Zonal differences in rhythms are erased and dominating rhythm appears almost equally expressed in all brain regions. On can possible isolate three basic alternatives of this type: dominance of beta rhythms of low frequency (1425 Hz) with amplitudes above 25-30 uV; dominance of alpha rhythm with amplitude above 60100 uV (i. . mechanical-like and alpha rhythm without amplitude modulation);
5

Type is a so called ideal norm and is characterized by regularity of two EEG types: alpha frequencies with magnitude up 100-110 uV and beta with magnitudes up to 25-30 uV. These types are also 181

 dominance of theta-rhythm (4-7 Hz) with amplitude above 30-35 uV.

Type V (coarse-disorganized) as well as the third type, is characterized by disorganization of

rhythm of potential oscillations, occurring unlike III type at a high level and expressed by occurrence of the irregular and unconditionally pathological indicators of EEG in all or some brain regions; rough and irregular slow theta and delta -activity with an amplitude above 30-35 uV. Appearance of waves with short fronts and paroxysmal discharges. Comparative estimate of EEGs, recorded after contact mine blast on land and shoal water, is presented in Table. 6.4. For the animals, blasted in a shoal water, percentage relation of II , III, IV and V types of EEG constituted 9:31:38:9:13 % accordingly. For the animals, being the victims of land blasts this relation was 15:25:42:10: 8 %. For animals with a shoal mine-explosive trauma, the researchers noted decrease of communicative function or activity of a subdominant hemisphere (Table. 6.5). Total interhemisphere balance in EEG of the given group after . 7 and 21st day constituted:-.316;-.187;-.242. Usual rhythm relationships in EEG did not recover by 21st day. The researchers noted functional separation of time-spatial patterns of cortical zones interaction, reduction of interstructural interactions cyclic shapes, change EE amplitude-frequency characteristics. Table 6.4 Relationships of basic EEG types for animals of I and IInd groups Groups of patients Number of EEG types (%) patients II III IV V I (dry land explosion) 12 II (shallow water explosion) 25 25 31 42 38 10 9 8 13

Fig.6.36. Ultrastructural changes of neuron in a brain cortex 3rd day after contact blast on dry land. A submicroscopy (x26 000)

Fig.6.37. Ultrastructural changes of neuron in a brain cortex. 7th day after contact blast in shallow water Electronic microscopy (x26 000)

characterized by the certain spatial patterns in EEG components within different brain regions 182

General EEG characteristic of animals with a "land" mine-explosive trauma in many respects coincides with that of animals with a "shoal-water" mine-explosive trauma. Net interhemispheric EEG balance of the animals, suffered land blast, constituted.165;.123;.130 on the 1st , 7th and has accordingly made 21st day. Indicators of interhemispheric balance in separate structures testify to extremely low brain reserves in an initial stage of wound sickness with a slow trend to recovery (see Table. 6.5) in the time-spatial pattern of EE. Thus, during the "shoal" contact mineexplosive trauma, the researchers noted intensive degradation of a brain communicative function that leads to deeper neurovisceral disturbances, in comparison with a "land" mine-explosive trauma. These disturbances finally define victims state severity. Table 6.5 Hemispherical balance indicators for EEG of 1st and 2nd group animals Observation groups EEG balance I (dry land blast) II (shallow water blast) 1st day -.165 -.316 7th day -.123 -.187 21st day -.130 -.242

When an explosion pathological factors influence CNS, the ultrastructural changes in different neurons are different and in many respects are caused by the functional CNS state as a whole and separate neuron in particular. When an animal is subjected to a gas dynamic pressure because of contact mine blast on a land (25 g charge of C4), the researchers noted rise of infrastructures, responsible for a metabolism of nucleoproteins (Fig.6.36). Diaphragms of cytoplasmic reticulum ribosomes are often found at the outer diaphragm of a nucleus. The significant amount of polysoms, filling a cytoplasm was noted. Mitochondrias were swollen, with sharp intercrist vacuolation that testified to amplification of energy processes in a neuron. It was specified by a magnification of the lamellar complex quantity, as manifested by a thinning of diaphragmas, expansion of cisterns. In pyramidal cells, the decrease in ribosomes and polysoms, responsible for DNA, was noted. Mitochondria were seldom, sometimes with the changed exterior shape, swollen with a destruction of cristas. The researchers observed drastic cisterns expansion in the cytoplasmic reticulum with loss of ribosomes on diaphragmas surrounding them. In a number of neurons, the vacuolation of a cytoplasma was found. All this indicated towards a developing destruction of neurons. At the same time, simultaneously with destructive processes, the lysosomes were

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formed separately and in groups. At the same time, inhomogenities in their osmotic properties was found, which testified to their various functional states. Same changes were detected in the neurons, but with more distinct positioning of microtubes, which served an indicator of a more viable metabolism of nucleoproteins, than that in a neuron cytoplasm. It is necessary to note that the majority of neurons had a normal metastructure without any attributes of destruction. A study of structural changes in neurons was performed using various regions of CNS. When the animals were subjected to dynamic pressures as the result of contact mine blast in a shoal waters (25 g charge of C4), the researchers noted a build-up of destructive processes in neurons and diminution of the metastructures, responsible for a nucleoproteins metabolism. Destructive processes in neurons of a brain cortex, unlike those in neuron, belonging to a trunk structures, were less expressed. 3 and 7 day later a considerable proportion of neurons developed increasingly destructive processes in a cytoplasm: further diminution of ribosome quantity and virtually complete disappearance of polysoms (Fig.6.37) was noted. By 14th and 21st days, alongside with the full destruction of separate neurons, large number of polysoms was produced. Expansion of cytoplasm reticulum cisterns was observed, proving intensification of a nucleoproteins synthesis. Mitochondrias were swollen quite often; sometimes having exotic shapes with attributes of interior diaphragms fractures. This fact is an indirect indicator of energy processes intensification in a neuron due to compensatory response. During this period, nanotubes were generated in a cytoplasm. Quantity of lamellar complexes with diaphragms, exhibiting vesicular hypertrophied formations, grew visibly. The mitochondrias, positioned in lamellar complex proximities, were maintaining its energy function.

Fig.6.38. Neurology. Bypolar olygodendrocytes and pseudopolar neurons. Gray matter. Electronic microscopy (x 18 000)

Fig.6.39. Electronic microscopy of the endoplasma network for the olygodendrocyte, 3th day after land explosion (x 33000)

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Alongside with the above described changes, part of neurons exhibited lipid and liopfuscin bodies, with the characteristic structure, occupying essential part of a cytoplasm. In some cells, they were encircled by the diaphragms, transmuting, thus, in a phagosoma. The defective unit of neuron looked as a section of the localized degeneration, while its other section was represented by normal ultrastructure elements. This fact testifies reparative neogeneses of neuron after damage. Action of shock accelerations on an animal organism led to essential changes of a nuclei metastructure starting from reactive up to degenerate. In the first days after traumatic action, the researchers found raised density and osmosis capability of nuclei and their eccentric bias. Quite often, the nuclei exhibited increased size, ribonucleic granules propagated through a nuclear membrane. Nucleus fragmentation was observed, causing extension of the nucleus diaphragm. Ribonucleic granules lost usual structural clarity and were grouped in a karyplasm in conglomerates of various shape and size. Nuclear envelope was considerably thickened around a whole nucleus. It is also necessary note the presence of reactive nucleus changes, characteristic for neurons of a brain cortex. For the trunk structures, neurons and a spinal cord these changes combined with a pattern of destructive process. Nuclei in this case changed the structure with the significant condensation of ribonucleic granules. Nuclei changes were accompanied by a lack of receipt pores, which indicated disorders in the functional state of the neurons related to a nucleoprotein synthesis (Fig.6.38). Cellular elements of a neuroglia, including microglia, are known to carry out differentiating, basic, trophic and secretor functions. Close morphological and biochemical link between neurons and a neuroglia was established. The link is maintained both by immediate contact energy conjugacy [Manina A.A.., 1978]. According to L.I.Yevseyev (1961), A.Greten (1963) glial elements weakly participate in metabolic CNS processes and have feeble oxidative ability. However, there are also opposite opinions. E.g. Rogers (1960) and L.Z. (1964) consider that glial cells do not yield to neurons both on activity of the enzymes majority and intensity of oxidative processes. According to A.A.Manina (1978), glial elements have inhomogeneous metastructure and functional activity and, in many respects, their structural features are conditioned by functional accessories of a neuron. Besides, neuroglia cells, in particular oligodendrocytes, large amount of polysoms, responsible for synthesis of ribonucleic acids.
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As seen from the illustrations, the cytoplasmic network of an oligodendrocyte is represented by wide cisternas and channels, which are encircled by the diaphragmas carrying ribosomes (Fig.6.39). Mitochondrias are spread virtually through the entire cytoplasma and have various shapes and are oversized. Regarding glia cells of a mitochondrion, they are concentrated in the regions of grouped polysoms, which can be explained by the energy expenses resulting in the synthesis of nucleoproteins. Drastic osmosis increases of cellular appendices draw a special attention, in particular that of oligodendrocytes, since they also are rich in ribosomes, polysoms and mitochondrias. In all glia cells, one can clearly see the hypertrophy of lamellar complexes. Glia cells in nuclei often look swollen, the outside diaphragma formed invaginations in a cytoplasma. For some oligodendrocytes of a neuroglia the significant amount of lysosomes of various sizes was noticed, which serves as an index of the destructive processes. These changes were characteristic for the first 7 days after trauma being inflicted on an organism. By 14th day, the cells, which avoided complete destructions, showed lysosomes extinctions and cytoplasma elements acquiring normal structure. When a trauma is inflicted on an animal organism, it causes evolution of both reactive and degenerate changes in the synaptic NS apparatus. Fissile regions of synapses exhibited pastose conditions and swelling of diaphragmas with elongation of membranous surfaces, changes of synaptic vesicula, caused by their significant accumulation in certain synaptic regions. A number of synapses lost clear boundaries of pre-and postsynaptic diaphragmas, making synaptic slot virtually indistinguishable due to high osmosis. In a number of axodendritic synapses, one could find attributes of degenerate process (proved by a small numbers of the synaptic vesicula), part of which was subject to lipid degeneration.

Fig.6.40. Axomuscular synapse (motor plaque). Electronic microscopy (x 26 000)

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The membranes, surrounding a synaptic contact, were blurred and without precise contours. The vacuolation of an axoplasm is clearly seen along with lipide degeneration of mitochondrias. CNS vessels underwent certain changes as well. Changes of endothelium and an adventitia cells were also observed in the form of organellas bloating, down to their full fracture. Quite often, the cytoplasma of an endotheliocyte showed vacuolated mitochondrias. Endotheliocytes nucleis looked swollen, with the central brightening and condensation of a chromatin at the nuclei periphery (Fig.6.40). Thus, ultrastructural changes of neurons for the observational animals after mine trauma are in a wide gamut: from functional, inflicted by the contact land blast through the rough dystrophic changes, caused by a contact mine blast in shoal water. Organellas of a cytoplasm and the nucleus complexes participating in a synthesis of nucleoproteins are subject to the most essential changes. Studying CNS neurons metastructure dynamics has shown their high plasticity. The destruction of separate neuron constituents causes formation of the lysosomes, summoned to remove perished metastructures from the cell and create conditions for regenerative processes restitutions of the lost organellas. With introduction in a clinical practice in 1996 methods of a central hemodynamics complex estimation by means BIOMED PD-03 device new opportunities in studying of blood circulation were opened in studying of blood circulation disorders, caused by a mine trauma: as less invasiveness, simplicity, repeatability, accessibility and high information yield. This device was intensively applied in the field surgery, naval surgery and expeditionary forces conditions. Within the first week (. . . 7 days) after wound, the device allowed to perform 185 studies in 37 dogs. As normative and control series of experiments, the researchers used central hemodynamics indicators of 40 healthy animals and the data, accumulated when studying experimental dogs for 24 hrs prior to the beginning of experiment. Results of circulation system studies during contact mine blast at land and in shoal water are presented in Table. 6.6 and 6.7. 1st group ( contact mine blast at a land ) showed reliable increased of pulse, systolic and diastolic blood pressures during first week after the explosion. Pulse dynamics increased on average by 4.7 % and after . . 5 and 7 day of observations, constituted accordingly 139 . 155 . 165 1. 168 8. Rise of diastolic blood pressure happened in average of 6.7 % of animals . . 5 after an explosion, constituting after 7th day of experiment accordingly 87 . 93 . 98 2 and 100 2 .

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Table 6.6 Central hemodynamics in 2nd group of animals (contact land blast, 25g C4 charge) Indicators (normal) Days after mine trauma 1 Pulse (95 25 )6 Arterial Pressure (SYST)(125 15) Arterial Pressure (DIAST)( (55 15.) Arterial Pressure (AVG) (85 113 .5 15) SBW (8.5 3.5 ml/kg) GPR (.9 .9 Dyn * s * cm5

3 155 7 148 8 93 3 12.5 .5 7.0 .2 12.4 .5 .0 .7

5 165 13 140 10 98 2 119 6 8.4 .6 11.6 .3 .2 .4

7 168 8 140 5 100 2 120 4 8.3 .3 12.5 .2 .6 .3

139 9 139 6 87 3

9.2 .8 .3 .5

BCPM (150 30 ml/min/kg) 12.0 .5 /kg)

In the 2nd case ( contact mine blast in a shoal water ) through all observations the only the pulse and pressure increased essentially. However, the highest pulse rate increase was (1.6 %) was noted only during the first day after the wound. The pulse during the experiments had a decreasing trend and by the end of 7th day exceeded normal value only on .8 %. During .. . 7 day of observations, pulse rate averaged 143 . 134 . 127 . 132 5 accordingly. Rise of average BP occurred due to a rise of diastolic BP and constituted made 110 7. Diastolic blood pressure showed steady increase and after on . . . 7 days of experiment it constituted (81 6), (92 6), (98 8), (96 4) accordingly. When analyzing of changes of the central
hemodynamics, the researchers used division of a circulation system responses into hyper-,

normal-and hypodynamic types [Samohvalov I., 1984]. The hyperdynamic type, characterized by a heartbeat and BP increase, was caused by the light damages caused by the contact mine blasts on a land (wounds of the soft tissues, right back extremity foot avulsion without the significant hemorrhage). A normodynamic type behaved similarly, showing lack of essential hemodynamics
6

BCPM blood circulation volume per minute, SBW strike blood volume, GPR general peripheric resistance. The table also contains unrecognized abbreviations, unknown to the general circle of medical researchers. These abbreviations are omitted. 188

deviations from the norm. Hyperdynamic type indicated compensation of a cardiorespiratory system functions, disturbed by the wound. Hypodynamic type of circulatory system operation, in turn, testified to its decompensation, despite increase of a BP. Classification of animals in the 1st and 2nd groups depending on the functioning of a circulatory system after MW is reflected in Table. 6.8. Table 6.7 Central hemodynamics 2nd animal group (contact shallow water blast, 25g C4) Indicators (normal) Days after mine trauma 1 Pulse (95 25 ) Arterial Pressure (SYST)(125 15) Arterial Pressure (DIAST)( (55 15.) Arterial Pressure (AVG) (85 15) SBW (8.5 3.5 ml/kg) BCPM (150 30 ml/min/kg) GPR (.9 .9 Dyn * s * cm5 /kg) 143 9 139 11 81 6 1108 8.6 .0 1155 .7 .8 3 134 2 130 5 92 6 111 5 7.6 .6 94 8 .4 .9 5 127 3 122 4 98 8 110 6 6.0 .2 76 8 1.6 .8 7 132 5 124 6 96 4 1105 4.8 .3 72 6 1.5 .4

Compensatory capabilities of a myocardiumcontractory function were experimentally studied by using loaded auscultator test with apnea (according to Sharabrin). These test results showed two groups of animals 1-3 days after explosion to generate inadequate response with the delayed recovery and occurrence of oxygen backlog attributes. Adequate responses of a circulatory system to the test was noted only form the animals of 1st group after 7 days. In 2nd group impairment of 2nd tone at the aorta and pulmonary artery indicated decompensation and a buildup of the oxygen backlogs (Table. 6.9 and 6.10). Table 6.8 Distribution of animals in 1st and 2nd groups depending on the circulatory system operation type after a mine wound Circulatory system functioning after Group of experimental animals Total a mine wound I II Hyperdynamic Normodynamic Hypodynamic Total 9 (75%) 2 (1.7%) 1 (.3%) 12 2 (8%) 5 (20%) 18 (72%) 25 11 (2.7%) 7 (19%) 19 (5.3%) 37
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Table 6.9 Response of 1st group of animals to loaded auscultator test with apnea (by Sharabrin) Indicators Days after explosion 1st 3rd 5th 7th 2nd tone at aorta Tone up Tone norm Tone down Tone down nd 2 ton at the lung Tone norm Tone up Tone norm Tone up artery Note: Tone up elevated done, Tone norm normal tone, Tone down weakened tone.

Table 6.10. Response of 2nd group of animals to loaded auscultator test with apnea (by Sharabrin) Indicators Days after explosion 1st 2nd tone at aorta 3rd 5th Tone down Tone down 7th Tone down Tone down Tone norm Tone down 2nd ton at the lung artery Tone up Tone up

Studies of the central hemodynamics, carried out by us, testify, thus, to more difficult character of a trauma at blast in shoal water. Results of the spirographic studies after the contact mine blasts on land and in shoal water are presented in Tables. 6.11 and 6.12. Table 6.11 Spirographic indicators for the 1st group of dogs after contact mine blasts at land (25g C4 charge) Indicator (normal) Time after wound (days) 1st 3rd 5th 7th Breath rate(15-25 /min) 34 2 37 2 41 1 39 1 Breath volume (200 10 ml) 165 10 144 8 123 5 120 5 Lung vital capacity (850 15 ml) 800 16 770 14 692 10 684 8 Breathing volume per minute (.0 .0 l) .6 .3 .3 .2 .0 .2 .7 .3 Oxygen usage factor (OUF) (3.5 .5 3.8 .2 3.5 .6 3.0 .6 3.8 .2 ml/l) Through the entire observations period, the researchers noted statistically important differences in the exterior breathing system dynamics. Therefore, the effects are presented for each group and represent averaged values over the entire period. In 1st and 2nd groups of the observed animals after a mine trauma, we noted reliable increase ( <.05) of breathing rates on the average of 20 % in comparison with normal. We also clearly saw average 7 % reduction volume of breathing per minute in animals of the 1st group, occurring on the background of breather volume per minute reduction (33 %) and lung vital capacity reduction (18 %). The OUF reliably decreased ( <.05) by 4 % on average to the 5th day of observation. Reduction of oxygen intake
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per minute in 1st and 2nd , as well as breathing volume per minute was well within normal margins. However the entire series of experiments in 2nd group showed the trend to decrease of per-minute ventilation. Reduction of breath volume per minute and vital lung capacity by 40 % and 20 % correspondingly in the animals of 2nd group occurred on the background of OUF drop. Table 6.11 Spirographic indicators for the 2nd group of dogs after contact mine blasts in shallow water (25g C4 charge) Indicator (normal) Time after wound (days) 1st 3rd 1st 3rd Breath rate(15-25 /min) 31 4 37 3 40 2 41 3 Breath volume (200 10 ml) 145 22 111 15 93 15 86 7 Lung vital capacity (850 15 ml) 785 23 728 32 670 25 615 15 Breathing volume per minute (.0 .0 l) .5 .4 .0 .4 .7 .5 .3 + .2 Oxygen usage factor (OUF) (3.5 .5 3.0 .3 3.0 .4 2.3 + .3 2.7 .7 ml/l) Thus, spirographic data show activation of the compensatory mechanisms supporting ambient indicators of the exterior breathing. Increase of breather volume occurs on the background of steadily decreasing breath volume per minute and lung vital capacity. Changes to the functional state of the exterior breathing system after a contact mine trauma are by diminution of this systems functional reserves. The greatest depletion of the of exterior breathing system functional reserves is observed after a contact mine explosion in shallow water, which is caused by the deeper pathological changes in lungs. Contact land blast corresponds to the hyperdynamic type of exterior breathing regime, which is manifested by increase of breathing volume per minute in the first day after a wound. Contact in shoal water causes more adverse clinical prognosis, related to the normodynamic type of lung ventilation with growing oxygen backlog, tending to evolve into a hypodynamic regime, as a consequence, of exterior breathing decompensation. This combat pathology causes the disorders of protein exchange. The disturbances are most expressed after a shoal-water contact blast. Decrease of crude protein down to critical numbers in animals of 1st and 2nd groups occurred 5 day after experiment. Apparently, as one can see from Tables 6.13 and 6.1. losses of protein occurred, first, due to the albuminous fraction, responsible for the colloid pressure in vessels. The significant decrease of albuminious fraction in blood created conditions for the fluids removal from the vascular bed to interstitial regions. Excitation of sympathetic nervous system of was accompanied by the activation of glycolic processes in tissues and increase of blood gulose content. Starting from the 3rd day, one could notice the trend
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to a glucose level drop. However in the 2nd group normalization of the blood glucose content was happening slower than in the first group. Disorders of an electrolytic exchange in animals of both groups were manifested by a higher than normal content of potassium and lower than normal content of sodium through the entire observation cycle. Hypoosmotic state was expressed most strongly in 2nd group of animals and was manifested by flabbiness, retardation, trend to decrease of a arterial blood pressure and evolution of hypodynamic circulatory system regime with suppressed intestinal peristalsis. Inappreciable but reliable increase of calcium level in a blood as (as calcium is the antagonist of potassium) was of compensatory character. At animals of II group, despite of a higher degree of a hyperpotassemia, a level of calcium in a blood was below, than in I to group. Low cholesterol content proved the significant disorders of a lipid exchange, which started since the 1-st day after MW. It proved, that the resources of lipid exchange was employed as an additional source of a plastic material. The changes in levels of the general bilirubin, creatinine, urea and alkaline phosphatase in the blood of animals, belonging to 1st group tended to be unreliable. However, increase of these indicators in the blood of 2nd group animals by a factor of .5-.5 pointed out the presence of the posttraumatic hepatorenal syndrome. The enhancement aminotransferases activity (except for AlAT activity in a blood of 1st group), aldolases, LDH, MDH, muscular, muscular alkalate phosphate in blood of all animals was steady and caused by an accumulation of the specified enzymes in tissues due to a crisis of microcirculation and their further entering vascular bed after removal of a peripheral block. The level of enzymes in a blood of 2nd group through all the observation cycle was higher than that in the 1st group by a factor of 0.7-1.3 Performed studies testify to gross infringements of virtually entire metabolism in animals of both groups. Contact blast in a shallow water produced more severe degree of metabolism disturbances. Presented data underly consistent approach to the treatment of mine trauma casualties. Thus, generalization of these studies allows to reach a conclusion, that mine-explosive wounds in a shoal water should be isolated in a special class of an explosive polytrauma. It is necessary to underline once again that this kind of trauma has specific origination conditions causing special local, segmentary and distant damages, with extremely adverse clinical course of wounds treatment. Table 6.13 Metabolism analysis report (dry land) Indicator Units Normal Elapsed time after a trauma,days

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Crude protein Albumins Globulins Bilirubin Sugar Cholesterol AsAt (Aspartam aminotransferase) AlAt (Alanine aminotransferase) Aldolase Alkaline phosphatase MDH LDH Creatine phosphokinase Muscle hemoglobin Sodium Potassium Calcium Urea Creatinine

g/l g/l g/l mkmol/l mmol/l mmol/l nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) ng/l mmol/l mmol/l mmol/l mmol/l mmol/l

72 9 3.5 .5 2.5 .5 .4 .1 .05 .45 .1 .5 .46 .26 .35 .22 1.0 .5 .6 .7 .49 .1 .590 .001 .45 .05 3.5 3.5 13.7 .3 .6 .8 .85 .60 .25 .25 .06 .034

6.6 .6 3.9 .1 3.7 .0 .2 .6 .2 .3 .9 .4 .38 .03 .91 .06 1.0 .2 .7 .3 .47 .04 .87 .04 1.6 .8 712 30 12.7 .7 .5 .3 .86 .34 .1 .2 .128 .03

5.4 .4 2.3 .6 3.0 .8 .7 .23 .5 .6 .3 .25

5.8 .6 2.2 .7 2.6 .4 .5 .23 .7 .4 .5 .2

5.5 .3 2.7 .0 3.8 .0 .4 .27 .5 .6 .7 .18 .62 .04 .75 .05 1.4 .4 .8 .35 .8 .12 .74 .05 .3 .6 221 61 12.0 .8 .2 .25 .9 .22 .3 .4

.74 .04 .65 .05 .82 .07 .48 .05 1.6 .7 .8 .34 .6 .05 .96 .03 .0 .7 1.5 .3 .9 .31 .7 .07 .82 .03 .5 .7

626 42 494 30 12.3 .1 .0 .3 .7 .28 .6 .2 .099 .007 12.7 .2 .65 .2 .2 .12 .3 .7

.101 .003 .048 .015

Table 6.14 Metabolism analysis report (shoal water) Indicator Units Normal Elapsed time after a trauma,days 1 3 5 Crude protein g/l 72 9 6.9 .3 5.5 .8 5.5 .8 Albumins g/l 3.5 .5 3.7 .2 2.5 .8 2.3 .2

7 5.6 .4

2.8 1.2
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Globulins Bilirubin Sugar Cholesterol AsAt (Aspartam aminotransferase) AlAt (Alanine aminotransferase) Aldolase Alkaline phosphatase MDH LDH Creatine phosphokinase Muscle hemoglobin Sodium Potassium Calcium Urea Creatinine

g/l mkmol/l mmol/l mmol/l nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) nmol (s)(l) ng/l mmol/l mmol/l mmol/l mmol/l mmol/l

2.5 .5 .4 .1 .05 .45 .1 .5 .46 .26 .35 .22 1.0 .5 .6 .7 .49 .1 .59 .001 .45 .05 3.5 3.5 13.7 .3 .6 .8 .85 .60 .25 .25 .06 .034

2.4 .5 .0 .6 .5 .4 .8 .3 .54 .04 .42 .12 1.7 .6 .1 .2 .57 .16 .99 .02 .2 .5 899 35 12.8 .4 .6 .5 .66 .30 .0 .7 .130 .012

2.9 .6 .6 .6 .4 .5 .0 .3 .05 .07 .08 .15 1.2 .5 .3 .2 .72 .09 .34 .05 .5 .9 811 87 12.7 .2 .2 .3 .57 .15 .1 .4 .120 .016

2.8 .0 .3 .4 .1 .3 .2 .3 .92 .04 .16 .11 1.8 .7 .5 .2 .82 .22 .17 .04 .5 .9 688 25 12.6 .0 .0 .7 .97 .31 .6 .5 .114 .008

3.0 .3 .1 .3 .6 .3 .4 .2 .88 .05 .34 .09 1.4 .6 .45 .15 .87 .09 .89 .03 .9 .4 480 172 12.0 .5 .9 .7 .76 .3 .8 .0 .092 .005

6.4. CLINICAL-MICROBIOLOGICAL ASPECTS OF WOUND PROCESS, CAUSED BY EXPLOSIVE DAMAGES 6.4.1. Microbiology of explosive damages
Despite the achievements of the modern medicine, the prophylaxis and treatment of purulentseptic complications, accompanying combat surgical trauma remains one of the main field medical surgery tasks. Underlining a urgency of this problem for military-medical service. N.I.Pirogov wrote in well known book Basics of the general field medical surgery (1865): ... Majority of wounded perishes not from mechanical injuries and surgeries, but from hospital infections, transmitted from one wounded man to another... Of extreme importance in rational antimicrobial prophylaxis and therapy of a wound fever at explosive damages are the data on clinico-microbiological aspects of a wound process. According to the modern views, one should separate concepts of microbial pollution , microflora of a wound and pathogen of a wound fever. Microbial pollution (contamination) is fathomed as plurality of the microorganisms, which entered a wound tissue at wound
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origination( primary microbial pollution ) or during treatment at the stages pf medical evacuation, if the antiseptics rules are broken ( secondary microbial pollution ). A degree of microbial pollution is determined during bacteriological examination of a pathological material (slices of the defective tissues, ooze) and is expressed in colony-forming units (CFU/g or CFU/ml). The bacteria, which entered a wound, do not manifest the invasive properties immediately. Within several hours they are adapting to new conditions and remain in the region of entering. This fact makes very clear why it is necessary to reduce the time from the moment of trauma to the time of wound surgical treatment.It is also of utmost important to remove carefully unviable tissues, being a good nutrient medium for many representatives of a primary microbial pollution. Under the favorable conditions (disturbance of blood supply, necrotic regions etc.) microorganisms are promptly multiplying up to 102-104 CFU/ml and shape wound "microflora", vegetating on its surface and is not capable to infiltrate the intact tissues. The increase of bacteria level in 1 ml of wound contents up to 105-106 CFU/ml and more is accompanied by infiltration of the infectious process deep into the viable organic tissues and causes evolution of a wound
fever. With the advent of an inflammation clinical attributes, the wound is considered "infected".

The microorganisms, causing infectious process are termed "pathogens" of a wound fever. As follows from the data presented in the Table 6.1. the wound fever during explosive damages is caused by a wider group of microorganisms, which can be separated into the basic and minor pathogens. The basic pathogens (golden and epidermal staphylococci, streptococci, enterococci, enterobacteria, non-enzyme Gram-negative bacteria, clostridiums and anaerobic bacteria incapable of spore-forming) possess the ability to cause a self-sustaining infectious process, are pronouncedly virulent and can be found in large numbers (106 CFU/ml and higher) in a pathological material.. The minor pathogens (saprophytic staphilococci, micrococci, corinebacteria, propionibacteria, microorganisms, belonging to the class of Bacillus etc.) are capable to cause wound infectious complications only if an organism resistance drops essentially below normal level or if the dead tissues are massively present in a wound and there is no adequate antimicrobial therapy. They are are infrequently separated from the clinical material, their concentration is usually small (less than 105 CFU/ml), are very sensitive to the majority of 1st generation antibiotics and possess feeble invasive properties.
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Right after a primary surgical treatment, frequency of detection of microorganisms in tissues of a wound and the microbial contamination degree falls considerably. At the same time, a surgeons scalpel is not in condition "to sterilize" a mine-explosive wound and completely kill primary microbial pollution. On the other hand, during diagnostic manipulations and surgery, the hospital strains of bacteria can enter a wound. These strains are highly virulent and resistant to antimicrobial drugs. In the last decades the increasing share of infections in surgical hospitals is taken by the combined infections. It is characterized by a heavy clinical course and is difficult to treat. As follows from the data gained by us, microbial associations play the significant role in a pathogenesis of a wound sickness, caused by different combat surgical traumas. High rate of multi-infection (5066 % of observations) is, apparently, not a coincidence, as associations of microorganisms are more resistant to adverse medical factors (a surgical treatment, systemic antibiotic therapy, application of local antiseptics, etc), than the bacterial monocultures. Of great value during the explosive damages is variation of the pathogens significance of purulent-septic pathogens through a wound process. For example, if pathogens of a gas gangrene are important before a primary combat wound surgical treatment, their postoperative importance drops and 3-10 days after these microorganisms are seldom detected in a pathological material. On the contrary, defermenting Gram-negative bacteria {Pseudomonas aeruginosa, Acinetobacter spp., Alcaligenes faecalis etc.) are usually not detected in wounds before a primary surgical treatment, but 3-10 days after their occurrence rate goes up 4172 %. It is necessary to note that severe violations of the field medical surgery regulations (an inadequate primary surgical treatment, primary seams on a bullet wound, etc.) can cause the etiological role of clostridial pathogens to essentially increase. N.N.Elansky (1945) distinguished three stages in the evolution of a microflora in bullet wounds during. In the first stage (1-7 days after wound), the pathogens of clostridial infection and streptococcuses predominated. In the second stage (8-20 days after) there were many non-sporeforming bacteria (E. coli, vulgar proteus Etc.) on a background of gradual clostridia disappearrance. During the third stage, the researched witnessed mainly staphylo-and streptococcuses. Slightly different pattern of microbial "landscape" in the bullet wounds was described by V.M.Melnikova (1915). In the beginning of wound process evolution, the clostridiums and streptococcuses predominated. They were followed by E. coli and the hemolitic staphilococcuses, present to the end a wound process.
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Table 6.15 Classification of wound fever pathogens, related to explosive damages Ethiology Oxygen relation Morphology and Gram Pathogen list factor Basic wound Aerobic Gram-positive coccui Staphylococcus spp. pathogenes Enterococcus spp. Streptococcus spp. (facultativelyGram-negative bacteria Escherichia spp. Enterobacter anaerobic) and coccus-bacteria spp. Citrobacter spp. Klebsiella microorganisms spp. Senatia spp. Providencia spp. Proteus spp. Pseudomonas spp. Acinetobacter spp. Alcaligenes spp. Etc Anaerobic Gram-positive, sporeClostedium spp. microorganisms forming bacteria Gram-positive , sporePeptococcus spp. forming cocci Peptostreptococcus spp. Gram-negative bacteria Bacteroides spp. Fusobacterium spp. Etc Secondary Aerobic Gram-positive cocci Micrococcus spp. wound (facultativelyStaphylococcus saprophyticus pathogenes anaerobic) microorganisms Gram-positive bacteria Bacillus spp. Corynebacterium spp. Fungus Candida spp. Etc Anaerobic Gram-positive bacteria Propionibacterium spp. Etc microorganisms Gram-negative cocci Vefflonella spp. Clinico-microbiological studies carried out by us showed the patterns of wound microflora, caused by the modern combat damages to change radically. Performed analysis has allowed isolating three stages in the dynamics of wound sickness pathogens. First ("pre-hospital") stage
(from the moment of wound before a primary surgical treatment of a wound) was characterized

by predominance of a "primary" ("street") microflora in a wound tissue: clostridiums, staphylo-, strepto-and enterococci, spore-forming aerobic bacilli, corinebacteria and certain enterobacteria (Eschericia coli, Citrobacter spp., Proteus spp.), appearing after long-term (above 24 hrs) delay of wounded personnel at a pre-hospital stage.
For the second ("transitional") stage (12 days after a primary surgical treatment of a wound), occurrence of a secondary ("hospital") microflora in a bullet wound on the background

of primary ("street") microflora elimination.

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The basic content of the third ("hospital") stage (three days after a primary surgical treatment) was the dominance in a wound of polyresistant " problem pathogens, including o

Pseudomonas aeruginosa, Acitenobacter spp., Alcaligenes faecalis, Staphylococcus aureus, Enterobacter spp.., Citrobacter spp., Serratia marcescens, Klebsiella pneumoniae, Providencia spp., Enterococcus spp. as well as some other microorganisms. As the experiments of massive troops losses treatment, capabilities of the laboratory facilities in military hospitals and field medical establishments are limited. Labor content, duration and massive amount of casualties do not allow conducting high-level microbiological survey of each wounded. In this connection, the knowledge of pathogens evolution laws helps the physicians to prove competently tactics of rational antimicrobial prophylaxis and therapy of purulent-septic infections, caused by the modern combat surgical trauma.

6.4.2. Antibiotic prophylaxis and antibiotic therapy of wound sickness, caused by explosion damages
As our studies showed, infectious complications in the wounds, caused by explosive damages, can be caused by two groups of pathogens. Their qualitative composition and biological properties essentially differed: "non-adapted" ("non-hospital", "wild", "street") and "adapted" ("hospital") strains of bacteria. The first group of microorganisms appeared sensitive to antibiotics of 1st generation, contaminated wounds at the moment of a combat trauma, was not overly virulent, caused purulent-septic complications only after the lengthy delays of wounded personnel treatment at a pre-hospital stage and can be promptly eliminated from a clinical material by a primary surgical treatment. The second group of microorganisms enters the wounds in medical facilities and is presented by more virulent strains. These strains are hardened by a long-term adaptation in hospital medium, possess expressed resistance to the many antibiotics and causes hospital infection. In connection with the above, the modern concept of a "wound sickness", caused by the combat surgical trauma is subdivided into two groups.
Non-hospital wound sickness . The organic substrate is preferentially primary necrosis. It is

caused by non-adapted strains of bacteria (a clostridium, streptococcuses, penicillin-negative staphilococcuses, E. coli, etc.) and usually happens after the long-term (above 24 hrs) delay of
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wounded personnel at the pre-hospital stage of medical aid.

Hospital wound sickness, whose organic substrate is preferentially secondary necrosis, is caused

by strains of microorganisms (enterobacteria, penniclinase-forming and oxacillin-resistant staphilococcuses, enterococci, non-fermenting Gram-negative bacteria, anaerobes incapable of spore forming etc.) and can be formed at the stage medical treatment. Prominent features of a hospital infection, caused by the combat damages are polymicrobial character, the leading part of the microbial associations, prevailing local complications and an insufficient expression of local symptoms. In view of these etiological and pathogenetic features, characteristics for these two types of a wound sickness, prophylaxis of these complications also should be differentiated. Application of antimicrobial agents at a pre-hospital stage and early primary surgical treatment of combat wounds do not guarantee uncomplicated course of a wound process in a postoperative period. They are just the standards of prophylaxis for non- hospital infections (arrested development of "street" strains of microorganisms in combat wounds and removal of primarily-necrotic tissues, serving as the organic substrate for multiplying "non-adapted" pathogens). As "street" strains of bacteria have appeared sensitive to antibiotics of 1st generation, the prophylaxis of non-hospital wound sickness does not involve modern expensive antibiotics. For prophylaxis of a hospital wound sickness, it is necessary to use active surgical tactics (well-timed removal secondary necrotic tissues), an adequate intensive aid and application of the modern antibacterial drugs. It is necessary to underline especially, that one of basic principles of prophylaxis, during purulent-septic complications, caused by a combat surgical trauma, is the priority of surgical treatment over antimicrobial therapy. The reason for that is that modern high-speed projectiles, interacting with tissues of an organism, promptly release the energy and cause "intratissual explosion. As a result, the tissue in the diameter of 10-15 mm from a wound channel is destroyed, at 30 40 mm is subject to the functional derangements. In addition to the wound channel, the majority of surgeons isolate region of tissues with full loss of tissues viability and evolution of a primary necrosis and a region of tissues with the lowered viability (capable of recovery or the subsequent evolution of a secondary necrosis) [Rudakov., 1984; Lytkin, etc., 1995; Gumanenko E., 1997; Konecny B., 1982; Jacob E. et al., 1989].. Similar changes in wound tissues are observed at explosive damages. Since antimicrobial agents badly penetrate into the impractical tissues, being organic substrate of a wound sickness, this case
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mostly requires surgical removal of primarily and secondary necrotic tissues. Thus, the highgrade surgical treatment creates favorable conditions for the effective application of antimicrobial agents and a prompt recovery of fire and explosive wounds. In our opinion, prophylaxis and treatment of the purulent-septic complications in casualties with a combat trauma at stages of medical evacuation demands from simple to complex usage of antimicrobial agents. I.e. from antibiotics of 1st generation to 2nd-5th generation. This tactics is quite justified, cost-effective and allows using all antimicrobial resorts. Application of highpower modern antibiotics of 3rd -4th generation for preventive purposes creates resistant media and, thus, significant difficulties at the subsequent stages of treatment. According to the majority of field surgeons, the greatest danger at early stages of medical evacuation is represented by a gas gangrene and a streptococcal infection [Trueta X., 1947; Coakley A., 1986; Wouters R., 1986; Bellamy R. F. el al., 1991; Krause A, et al., 1996]. Choice drug for prophylaxis and treatment of these terrible complications of a combat trauma is penicillin G. This antibiotic used to treat primary wound sickness in major armies, as reflected in the appropriate field medical surgery manuals (Directions on the field medical surgery, 1988; Field Surgery Pocket Book, 1981; Emergency war surgery NATO Handbook, 1999). As the wound ballistics studies show, penicillin G besides the antimicrobial activity possesses properties to prevent warn secondary necrosis evolution in the tissues of a bullet wound damaged by a trauma [Dahlgren et al., 1982]. Therefore, this antibiotic should be prescribed to wounded personnel as early as possible after a combat trauma. The earlier penicillin G is injected, the more effective it is against wound sickness pathogens and the defective tissues of a wound. To expand of a spectrum of antimicrobial activity and enhance antibacterial activity of the penicillin G it should be combined with 1st generation aminoglycosides (strepto-and Kanamycinum), providing synergetic effect. Such combination of antibiotics "overlaps" entire spectrum of the basic pathogens, causing non-hospital wound sickness: clostridiums, strepto-, staphilo-and enterococci, anaerobs, incapable of spore-forming, enterobacteria. As spectrums of antimicrobial activity for penicillin G nd aminopenicillins are close, the latter can be used as alternative drug. Yielding to penicillin G in anticlostridial activity, Ampicillinum is more active agains enterococci, some streptococcuses and enterobacteria. In presence of allergy to the penicillin, physicians apply cephalosporins of 1st generation (Cefalotinum, Cefazolinum). When the explosive damages are combined with the penetrating stomach wounds, the "starting" plan of
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antibiotic treatment includes a combination of Ampicillinum with gentamycin, in cause of severe damages a combination of ampicillinusulbactam (amoxicillin-clavullan acids) with gentamycin As follows from our data gained, at a stage of the qualified surgical help, the combat wounds are entered by the pathogens of a secondary ("hospital") infection, most frequently isolated from a clinical material in the structure of aggregates and are very resistant to antibiotics. Change of etiological structure and resistance to antibiotics for the pathogens, causing a wound sickness at a hospital stage entails respective change of the list of the antimicrobial agents, used during prophylaxis of the purulent-septic complications. Prophylaxis by antibiotics of the wound sickness at the first stage of the medical treatment is based on two alternative approaches. Principle of maximally broad spectrum is based on the suppression of major pathogens in the wound infection sickness, due to using more active and expensive antibiotics. The principle of reasonable sufficiency is based on growth inhibition of the most often encountered pathogens. It seems that the last principle is more preferable in combat conditions, because its antimicrobial prophylaxis is efficient, yields smaller probability of polyresistant strains of microorganisms production and is more cost-effective. As the analysis of wound sickness pathogens sensitivity to antimicrobial agents shows, at a hospital stage of medical aid the most rational resorts of purulent-septic complications prophylaxis are cephalosporins of IInd generation and "protected" Penicillinums (ampicillinsulbactam, etc.). They are the broad-spectrum antibiotics, characterized by the expressed effects on the penicillin-forming staphilococcuses, many strains of enterobacteria and the majority of obligated anaerobs. These antibiotics have bactericidal effects on the microbial cells, tolerance by the patients and cost-efficiency. A blank spot in the spectrum of IInd generation cephalosporins and ampicillin-sulbactam is taken by not fermentative Gram-negative bacteria (Pseudomonas aeruginosa and Acinetobacter spp.) and, partially, enterococci. As the frequency of a wound sickness evolution increases proportionally to the combat trauma severity, the wounded with sever wounds are treated as high-risk group. These wounded require more expressed antimicrobial protection at a hospital stage. This issue makes necessary to apply combinations of analysis IInd generation of cephalosporins to prophylaxis of a wound sickness,ureidopenicillins or "protected" penicillinums with amynoglycoside antibiotics. These combinations have synergistic effects on the staphylo-, enterococci, pseudo-monads and enterobacteria. If penicillinum allergy is present, it is necessary to use combinations of IInd
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generation cephalosporins with aminoglycosides. Development of uniform recommendations for the empirical antimicrobial therapy of a wound sickness at a hospital stage is a difficult problem. Studies show that the etiology of a wound sickness and sensitivity to antimicrobial agents for the microbes, cultured from combat wounds at various stages of a medical aid differ considerably, which allows to formulate the concept of etiological patterns and mechanisms originality for the antibiotic resistance of a wound sickness pathogens. According to this concept, rational antimicrobial therapy is impossible without taking into account data, gathered in microbiological laboratory. At the same time, the data on the pathogens of wound sickness sensitivity to antibiotics in most cases can be gained only at the 2nd or 3rd day after sampling pathological material. Consequently, strategy of antibiotics treatment applications, during the evolution of wound infectious complications includes two stages (empirical and targeted antimicrobial therapy).
At the first stage (empirical antimicrobial therapy) antibiotics are prescribed on the basis of the

objective information analysis, available to the clinician clinical features of a wound sickness, effects of the express-bacterioscopy of the wound cultures, local (intrahospital) data about mechanisms of pathogens resistance to antibiotics, and the data about what class the pathogens
are belonging to. staphylococcal infection shows a trends to localization of the inflammatory nucleation site for

(formation of abscesses), dense, jelly-like odorless pus of yellowish etc.; streptococcal infection shows a trend to generalization of infectious process (in the form of flows, phlegmons), presence of fluid pus of flavovirent color, etc.; pyocyanic infection shows specific odor and color of wound content; putrefactive process of enterobacterial etiologies shows presence of plural necrosis sections, flaccid grains, brown painted wound content; non-clostrydial infections the wound contents are of dirty-grey color with foul odors and inserts in the form of fat droplets and other pathognomonic attributes. The results of express-bacterioscopia can be obtained 4060 mines after its delivery in bacteriological laboratory. Simultaneously, the researchers use several methods of coloring (Gramm, Cill-Nielsen, Burri-Gines), allowing to find Gram-category of microorganisms and their morphology. During combat operations, these data are of great value as they allow surgeon to perform competently and timely prescription of etiotropic medical products (Table. 6.16). For each medical facility, the features of etiological pathogens structure of a wound sickness and
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their sensitivity to antibiotics are different. Knowledge of these features helps the attending physician to select confidently, the necessary antibiotic for treatment of purulent-septic complications. 18-24 hours after culturing of the cytological material, the data are generated on the pathogens and if necessary, needed corrections to an antibiotic therapy (Table 6.17). Table 6.16 Choice of antimicrobial agents depending on Gram coloring of a wound content Microscopy results Antimicrobial agents I. Aerobic (minor-anaerobic) bacteria Staphilococcuses: solitaire Gram-positive coccuses, in Isoxasopenicillins Cephalosporins of pairs or in the f aggregates III generations the "protected" Penicillinums Glycopeptids Strepto-and enterococci: solitaireGram-positive Natural Penicillinums, coccuses pairs or those forming amynopenicillums or their combinations with gentamycin Enterobacteria and not fermentative bacteria: Gram- Cephalosporins of IIIV of negative clostridia , size 2 4 microns, single bacteria generations Monobactams. and aggregations; can sometimes form a capsule Aminoglycosides IIIII generations Karbapanems. Fluoroquinones Polymyxins Acinetobacter spp.: short and thick Gram-negative Cephazidim combined with coccus bacillas, placed solely, pairs, aggregations aminoglycosides IIIIIrd ungeometrical; some strains form a capsule generations. Carbapenems. Fluoroquinolones. Polymyxins II. Obligatory-anaerobic pathogens Spore-forming anaerobs (clostridiums): large (410 * 1 .5 microns) the Gram-positive bacilla forming the central, subterminal or terminal spores, whose diameter exceeds traverse sizes of a cell peifringens form in vivo well expressed capsules Non-spore forming anaerobs: bacterioids, prevotella and porphomonads: Gramnegative polymorphic bipolar colored bacyllas with the rounded extremities fusobacteria: thin, double-edged Gram-negative fusiform bacteria often shaped as mesh aggregations peptococcuses and peptostreptococcuses, morphologically identic to staphilococcuses and streptococcuses Natural Penicillinums Amynopenicillins Metronidazolum . Lynkosamid Cephalosporins III of generations Lynkosamid. Metronidazolum. Protected Penicillinums Cephoxytin Natural Penicillinums Amynopenicillins Cephoxytin Metronidazolum Natural Penicillinums Amynopenicillins Cephoxytin Metronidazolum

At the second stage (targeted antimicrobial therapy) , the antibiotics are prescribed after taking

data on sensitivity of pathogens to chemotherapy 4872 hours later from the beginning of microbiological study. Thus, the algorithm of antimicrobial treatment, rendered to the wounded man with explosive
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damages includes: 1) Preventive application of antibiotics at a pre-hospital stage and upon acceptance in medical establishment; 2) empirical antibacterial therapy, during the evolution of wound infectious complications, based on the analysis of a wound sickness clinical signs, results of express-bacterioscopy of a wound content, data on the pathogens strain, and local (intrahospital) data on the pathogens resistance to antibiotics; 3) targeted antimicrobial therapy after elimination of wound sickness pathogens and studying their sensitivity to antibiotics. Table 6.17 Antibacterial drugs recommended for empirical therapy of a wound sickness (with available data on the specific pathogens origin) Microorganisms Front-line therapy Alternatives Oxacillinum-sensitive Isoxasopenicillins. Cephalosporins Macrolyds. Lynkosamyds. of I-IInd generations the Aminoglycosides II-IIIrd Staphylococcus spp. Protected Penicillinums generations Oxacillinum-resistant Glycopeptids Fluoroqynones. Ryphampicin Staphylococcus spp. Natural Penicillinums Cephalosporins I-IInd Streptococcus spp. Aminopenicillins generations Macrolyds. Lynkosamyds. Rifampicinum Amynopenicillins (natural or Glycopeptids Enterococcus spp. ureapenycyllins) in a combination to aminoglycosides Cephalosporins II-III generations Cephalosporyns of IV Enterobacteriaceae Aminoglycosides II-III of generation, Carbapenems, generations Urea penycyllins the Fluoroqynones, Polymyxins Protected Penicillinums Monobactams Carboxypenicillins. Carbapenems, Pseudomonas Ureapenicillins. Monobactam. Fluoroqynones, Polymyxins aeruginosa Ceftasidim. Aminoglycosides IIIII generations Ceftasidims in combination with Carbapenems, Acinetobacter spp. aminoglycosides of II-III Fluoroqynones, Polymyxins generations Bacteroides fragilis and Lynkosamids. Metronidazolum Protected Penicillinums close Cephoxytin Other anaerobs, incapable of spore forming (prevotellas, porphyromoands, fusobacteria, Natural Penicillinums Amynopenicillins Lynkosamids. Cephoxytin Metronidazolum

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peptococcuses, peptostreptococcuses

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Chapter VII FEATURES OF PATHOGENESIS DURING THE TRAUMATIC SICKNESS, CAUSED BY EXPLOSIVE DAMAGES
Collective experiments of surgeons, traumatologists, reanimatologists and the therapists, who directly treated patients, suffering from the mines, convinces that pathological responses of an organism developing in reply to a specific explosive trauma are complex and interdependent, volatile and are changing with time. Their plurality shapes a series of the characteristic syndromes and creates a specific pathological complex, specific to a traumatic (wound) sicknesses, caused by the explosions. Successful treatment of these patients is impossible without understanding all of the compensatory-adaptive and pathological responses, their interdependencies and features of evolution. Careful analysis of a natural clinical material and effects of scientific experiments has allowed us to offer and prove scientifically the general approach pathogenesis of an explosive damage (Fig. 7.1).

Fig. 7.1.Pathogenesis of an explosion damage

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The damaging factors of explosion, acting on a human simultaneously, are represented by the blast wave, jets of flame and heated gases, debris, secondary projectiles. Combined damages, inflicted by the specified factors of explosion are implemented by the release of high amount of energy. With reference to casualties on the open terrain, the general vector of damaging factors of explosion in all cases points upward. As a result, there is a specific gunshot trauma, whose pathogenesis can be divided into two groups of damages, giving birth to a stage of homeostasis systemic disorders: 1. Extensive fractures and damages of tissue structures in the extremities, trunks and even heads. 2. Blanket contusion-commotio syndrome, usually manifested by the closed craniocerebral traumas with various degrees of severity and distant damages to the interior organs of chest and stomach.

Fig. 7.3 . X-ray image of an abdomen after a Fig. 7.3 b. Mesentery root haematoma after a fragmentation wound fracture penetrating gunshot wound

Fig. 7.5. X-ray image of a shine after a mine wound. Dual projection image

Fig. 7.6. Arteriogram of a shin after an antipersonnel mine blast

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Examples of these damages are illustrated on Fig. 7.2-7.7 (Fig. 7.. 7.. 7.7 see color insert). Consequence of fracture and damage to the extremity and trunk tissue structures are a traumatic shock, a hemorrhage caused by external, interstitial and intracavitary bleedings, a posthemorrhagic anemia, endogene intoxication initially due to massive injection of metabolites to a vascular bed of tissue from an explosive fracture of the soft tissues. The trauma is accompanied by expressed painful and pathological trophic (eisodic and efferent) impulsation, which later, jointly with microcirculatory derangements, significantly influences character and features of a wound process course. Extremely serious and little-known component of the complex damages, caused by a mineexplosive trauma is the fatty embolism which, alongside with other factors, defines depth of systemic disorders of homeostasis, especially at the early stages of a wound sickness. Clinical diagnostics of the fatty emboli is complicated by shock, hemorrhages and primary intoxication. The second triggers of the formation and evolution of homeostasis systemic disorders are distant damages of brain and interior organs, shaping gamma of matching functional derangements. Systemic disorders of microcirculation, a trophicity, an immune and endocrine regulation, in turn, not only aggravate clinical course of the general contusion-commotio syndrome, but are also oppressing compensatory-adaptive mechanisms and responses in the tissues, suffered from explosive damages. Thus, at an explosive trauma two basic independent pathological circles are formed. Communication between these circles is obvious due to the formed systemic disorders of a homeostasis: 1. Blanket contusion-commotio syndrome-> <- systemic disorders of a homeostasis. 2. Extensive damages of tissue structures-> <- systemic disorders of a homeostasis. In various alternatives of an explosive trauma we do not see major differences in pathogenetic mechanisms. Moreover, in some cases, even the classification explosive trauma (MW or MD) poses some difficulties. For example, during blasting armored vehicles by the anti-tank mines or IEDs, one can witness avulsions and other direct fractures of the extremities segments. These damages are caused by blast wave and other explosion factors penetrating beyond the armor. In turn, contact blasting of a soldier at open terrain always exhibits a propellant effect, causing both insulated and plural closed fractures of bones. Hence, any explosive damage manifests basic mechanisms presented on the general scheme of a pathogenesis. However, the degree of their expression (and expression of clinical processes) varies depending on a combat trauma type, a munitions yield and, at last, elapsed time after
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explosion, time of initiation and efficiency of medical treatment, functional state of an organism at the blast moment etc. Essential influence on the mechanisms of an organisms protectivelyadaptive, compensatory and pathological responses after a mine-explosive trauma is exerted by the climatic and geography of the operations region. In particular, in the conditions of hot dry climate and a mountains-desert Afghanistan landscape, both government troops and 40th Soviet Army personnel, suffered the state of chronic ecological-professional stress. A degree of its expression for these representatives of different ethnic groups was different, and, therefore, it is necessary to consider this factor in a clinical treatment of wounded. The studies, especially conducted by us, illustrate a variety of disorders of an organisms interior medium after a mineexplosive trauma and are the best proof of this issue. Modern theories of an organism adaptation to extreme factors of an environment, shock, functional systems of an organism underlie the concept of traumatic sickness, by K.Anokhin. Heavy mechanical trauma of a peace time is governed by these concepts as well [Seleznev S.A.., 1984; Nasonkin O.S., 1987]. Treatment Experiments of casualties with a heavy mine-explosive trauma allowed to isolate two factor groups, responsible for evolution of traumatic (wound). First group, encompasses damages from the modern projectiles, first of all mines and IEDs. This group is characterized by unprecedently high severity of plural and combined wounds. This group is not limited to heavy gunshot wounds, but also includes closed and open simultaneous damages of extremities and interior organs of several anatomic regions, in combination with blanket contusion-commotio syndrome. In this connection, specific morphofunctional changes of tissues develop in immediate proximity from a damage site and in the remote regions. Secondly, influence of medicogeographical factors on an organism, e.g. in Afghanistan of: mountain-desert terrain, strong winds and sandstorms, lowered pressure of oxygen, deficit of potable water, adverse epidemiology. Survey of healthy military men of the Afghani army discovered overstressed basic life-support systems of an organism circulations, breathing, a metabolism, excretion. Special place is taken by the psychoemotional stress, caused by combat and action of adverse factors of environment on the organism, also the special circumstances, developing immediately after a large-scale terror act. Combat stress , and in case of the longterm combat circumstances combat fatigue , should be viewed as an adverse background in case of a wound Thus, heavy local and segmentary disorders of tissues, contusion-commotion damages of CNS and internal organs are the powerful triggers for many compensatory-adaptive and pathological
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changes in all leading functional systems of an organism. Effects of clinical and pathophysiological studies testify to the expressed phasal nature in evolution of systemic disorders, which allows viewing them as a developing traumatic (wound) sickness. During traumatic sickness after an explosions we separate five stages (Fig. 7.8).

Fig. 7.8. Traumatic sickness during the explosion I a stage reactive -toxic (up to 1 day). Within the first day after an explosive trauma,

casualties developed intensive nonspecific response, manifested in exaltation of neurohumoral system with sharp stress: hormone level rise in blood and urine. Concentration increase of endogene toxins, enzymes, insufficiently oxidized products (a myoglobin, molecules of average mass, transaminases, yields of glycolisis, etc.) takes place. Hemorrhage and shock are accompanied by the expressed systemic changes in macro-and microhemocyrculation whose main features are hypovolemia, interlocking of a circulation, spastic stricture of peripheral vessels and increment of vascular resistance to a blood flow. The full decompensation of the vital functions in this stage was developed by 2.4 % of dead casualties.
II stage toxemia (2-3 day) is characterized by the reinforced endotoxins injection from

peripheral tissues on a background of the expressed complex general hypoxia of tissues hypoxic, circulatory, hemo and hystotoxic. Clinically, it is expressed in a build-up of attributes of a cardio-pulmonary and renal-hepatic failure with morphological changes in kidneys, liver,

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myocardium. The share of those, who dies at this period is 2.3 % of cases.
III stage infectious-toxic (from 4-6 days to several weeks). In this stage, casualties show

acute oppression of cellular and humoral immunity factors with evolution of local and blanket infectious complications a pyesis of wounds, pneumonia, tracheobronchitises, sepsis, etc. Character of toxemia changes. Mioglobynemia is followed by the bacteriemic toxemia. The infectious-toxic stage does not happen in all casualties. The combined antimicrobial therapy and active prophylaxis of complications allow refining course of traumatic sickness. However, if this stage develops, it frequently proceeds with a failure 3.3 % from all dead are due to IIIrd stage. Thus, for all first three stages of traumatic sickness the toxemia is characteristic, but its nature through disease stages essentially differs. If right after explosion, the intoxication is caused by an autolysis of the destroyed tissues, and in the subsequent days underoxydized metabolism, in the subsequent it is caused by infectious factors.
IV stage regenerative (up to 2-4 months), is characterized by the delayed restitution of the

broken physiological functions and metabolic processes in an organism. Casualties show slow healing of the wounds, long-term anemia, slow normalization of albuminous and lipide exchanges. Consequently, it is possible to terminate a medical treatment only later 2-4 months, i.e. in the next stage
V stage aftereffects. The following effects are characteristic: manifold anatomic damages to

extremities, the consecutive conjugate biomechanical damages to extremities, the consecutive conjugate biomechanical changes of a locomotorium. Major factors are shown in the Table. 7.1. Table 7.1 Major factors of MW traumatic sickness Periods Pathology I reactive-toxic (several "Overexcitation" of CNS, primary painful syndrome; entry of hours to a day) endotoxins in a blood channel; low BPV on a background of a massive hemorrhage II toxemia (2-3 days) Presence of endotoxins; hypoxia of the mixed type with redundant quantity of unoxidized metabolites; dystrophic changes in a myocardium, a liver, kidneys and other organs III infectiosly toxic (4 Diminution of quantity of endotoxins; evolution of wound and other 6 days to weeks) infectious complications on a background of decrease immunobiologic resistance of an organism IV regenerative (2-4 Gradual restitution of the broken functions (red blood indicators, months) general fiber and fractions of blood serum, imunologic indicators etc.) V aftereffects Anatomic defect of an extremity and the functional disorders
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Thus, the damaging blast action is characterized by severe polytrauma damages to 2-4 segments of extremities, as a rule, combined with blanket contusion-commotio syndrome (a craniocerebral trauma and damages to interior organs). Mine wound, is characterized by extreme extensiveness, depth and specificity of fractures of extremity tissues that distinguishes it from the typical bullet wounds, caused by bullets and debris. Summarizing, it is possible to reach a conclusion that explosive damages to the person should be considered as a polytrauma demanding special system of pathogenetically proved medical provisions. The deduction that scales and features of structural damages to extremities and organism as a whole in the majority of casualties do not allow to aim the surgeon on initially radical and early primary surgical treatment of wounds and damages. Principles of savory treatment of casualties with traumas of extremities, which are pioneered in XIX century by N.I.Pirogov, should consider the certain evolution probability of local and blanket complications of a wound process due to the deep residual functional-morphological derangements.

7.1. MICROCIRCULATORY DISORDERS

Among general pathology problems of theoretical medicine, the special attention of clinicians is involved with microcirculation (MC).It is extensive field of a biological and medical science concerning regularities of biological fluids circulation (blood,tissue fluid,lymph) at a microscopic level. Of greatest value are studies othe role of disorders of microcirculation in a pathogenesis of separate diseases and pathological states [Alexeev P.P., 1975; Kaznacheev V.I., Dzizinskij A.A., 1975; Chernuh A.M,, 1979]. Studying of a pathogenesis of a combat trauma has drawn attention to a problem of interrelation between character of vascular responses in the bullet wound tissues and course of a wound process. An originality of vascular and microvascular disorders were attributed by I.V.Davydovski (1952) and S.S.Girgolav (1956) to the complicated course of bullet wounds. They considered pathological changes in tissues as a consequence of hemodynamic disorders, leading to a hypoxia and hypotrophia. This direction was evolved the studies of E.A.Dyskin's and L.P.Tikhonova (1979), E.A.Dyskina (197. 1981), A.N.Berkutova and E.A.Dyskina (1979), I.I.Derjabin and I.Lytkina's (1979). Of the great importance is studying blanket organism responses to a gunshot trauma. In particular, E.A.Dyskin (1981) and employees had been noticed and studied morphological changes in nerve cells parts of a reflex arc, and the mostly
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expressed, its eisodic unit. Changes of a microcirculatory bed and nervous nodes in organs, even without an immediate exposure to a gunshot wound. As M.Chernukh considers (1975), disorders of microcirculation and, finally, perfusions of organs and tissues by a blood play an essential role in a pathogenesis and outcome of a shock syndrome and traumatic sickness in general. Probably, microcirculatory disorders play the major part of that vicious circle which eventually leads to failure of compensatory and adaptive responses and opportunities of an organism (Fig. 7.9). Studies of microcirculation were carried for 37 casualties with mine-explosive avulsions and fractures in distal segments of the inferior extremities, inflicted by anti-personnel mines. Immediately, after delivery of casualties to the surgical help facility, physicians undertook complex MC estimate of . Brief description of casualties by a degree of shock and terms of hospitalization is presented in Table. 7.. which testifies to the severity of their conditions. About half of casualties to some degree lacked qualified surgical help, rendered at the battlefield and pre-hospital stages of medical evacuation. Some of them were forwarded after incorrectly rendered medical aid. Infusional therapy and high-grade anesthesia, considered by us as the basic antishock provisions, were carried out only after casualties delivery to the medical facility. Thus, the surveyed contingent of casualties in the Afghanistan was placed in substantially adverse conditions. Table 7.2 Degree of shock and terms of MW casualties hospitalization Diagnosis Entire Hospitalized in number of shock wounded Stage Stage IV II-III 37 5 19 Hospitalization time after Died during 1st a wound (hrs) day 1
17

2-3 4-6 > 6

12 5 3 6

Mine-explosion wounds with avulsions of distal segments of the lower extremities

Multicomponent character of the microcirculatory systems and a multiplicity of influencing factors predetermine the complex approach to its study. To estimate state of casualties and efficiency of medical provisions in field and hospital conditions, we developed and used system of a MC complex estimation. Certain directions of scientifically-clinical search were separated. Their aggregate results allows to represent functional state of microcirculation and its dynamics
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at the posttraumatic stage including influence of the rendered medical aid. The following parameters are of value for estimating microcirculatory disorders: 1. Clinical manifestations coloring of integuments and visible mucous, an expression and character of vasculomotor responses, pastosity and puffiness of tissues, a hourly diuresis.
2. Microvessels conditions and blood flow was visually estimated by the microscopy of an

eyeglobe conjuctiva with the subsequent estimate of changes and calculating general conjunctival coefficient (GCC). 3. Viscosymetric blood properties were estimated from the changes of a viscometric coefficient (VC) a a viscometry on a paper, according to A.F.Pirogova and V. D.Dzhordzhikija (1963). 4. The general image of microcirculation was attained by a method of an integrated electrothermometry with calculation of axial (OG) and rectal-skin (RG) gradients. Biomicroscopy of eyeglobe conjunctiva (EC) allows conducting a detailed estimate of arterioles, precapillaries, capillaries, postcapillaries and venules, a blood flow in separate microvessels and perivascular spaces [Bloch, 1954].

Fig. 7.9. Self-perpetuating hemodynamics disorders circle (by A.M. Chernyh, 1985) High descriptiveness of these methods in a clinical practice is confirmed by studies by

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E.I.Daktaravichene's data (1966). He confirmed high correlation with effects of scleras bioptates studies at volunteers. The method has is widely applied in NAVY medical service7*. The process utilized improved optical portable microscope MBS-2 installation. Changes in microvascular bed of a bulbar conjunctiva was analyzed using a system of qualitative-numerical microcirculation analysis. According to this approach, devised on the basis of published data and observations, all changes of microvessels of a bulbar conjunctiva can be isolated into three groups: vascular, intravascular and extravasated (perivascular). Each attribute of microcirculation change was given one point it expressed weakly, and, one point higher for any increase of each pathological attribute (Table. 7.3). The method of a paper viscometry on a paper, used for studying rheologic blood properties, is based on unequal leakage of fluids with various viscosity through a filter paper. The soaked area is the smaller, the higher the viscosity is. The viscometry coefficient (VC) is estimated by an equation:
2 VC = 2 ( R12 R2 ); ,

where R1 is an average diameter of water spill spot; R2 is an average diameter of a blood spot. Our experiments testifies to outstanding descriptiveness of this method and possibility to apply it in the field conditions

Fig. 7.10. Distribution of the skin and rectal temperature ( normal; B 12 hours after a mine trauma after treatment)

Microcirculation studies in the practice of NAVY medical services and facilities (Physicians manual Kaliningrad, 1986).

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Table 7.3 Analysis of microvascular bed in the bulbary conjuctiva Character of changes Vascular Degree Venules Arteriolas Capillars Aneurisms Venules Arteriolas Capillars Curvitude Venules Arteriolas Capillars Choroid glomus Functional capillars Elevated number Deteriorated Emptied Artierolic-venular anastomosis Arteriola-venular ratio 1 : 3-4 1 : 5-6 1 : >7 Vascular change index Intravasc Blood flow changes ular Slowed Retrograde Stopped Intermittent blood flow Phenomenon Clotting in venules Clotting in venules and capillars Clotting in venules, arteriolas and capillars Total aggregation Intravascular changes coefficient (ICC) Paravascular changes Foggy background Lipidos,pygmented spots Hemprrhages Paravascular changes coefficient (PCC) Total conjuctival coefficient

Points 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1

2 3 21 1 2 3 1 2 3 4 5 21 2 2 2 6 48

The integrated body thermometry with calculation of axial gradients of extremities and skinrectal gradient can be a very descriptive method for estimating a peripheral circulation, especially

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in early terms after wound, can be [Fishkin V.I. et.al., 1981; Malov oM.N.., 1985].For this purpose, physicians used thermistor multichannel electrothermometer, developed by N.F.Fomin. Cutaneous and rectal temperatures were taken in the certain points immediately after accepting wounded man for medical treatment. Originally, the researchers considered that absolute temperatures are not that important as and their allocation and a relationship between thermal kernel of an organism (temperature in a rectum, in an auxiliary trough, in the field femoral delta) and "shell" (distal departments of extremities, in particular, points in interdigital gaps on a brush and stop). Temperatures distribution was characterized by using axial gradients over the extremities and on a rectal-skin gradient. It was represented by a different in the temperatures in an auxiliary trough and in interdigital foot gaps, in rectum and in inguinal field. Elevation of temperature gradients between "kern" and "shell" is a manifest of a circulation interlocking and disorder of microcirculation at the periphery (Fig. 7.10). The most severe changes of microcirculation are noted in wounded in a terminal state (AD SYST < 60 mm.hg.col). For this category, the researchers noted rise of the general conjunctival coefficient up to .27 .35 points (NORMAL .75 .26 was observed; <.01), decrease viscometric coefficient (VC) down to .17 .36 (NORMAL .51 .23; <.05), sharp rise of axial (up to .57.49) and skin-rectal (.41 .59) gradients. These data confirmed interlocking of a circulation and peripheral blood flow disorders in the first hours after a heavy gunshot trauma. Rendering of an effective antishock therapy in the first 612 hours, necessary with bleeding stop and a replenishment of the CBV, anesthesia and an immobilization of the defective extremity, lead to stabilization microcirculation factors: GCC decreased to .89 .2. OG to .29.17, rectalskin gradient down to .56.17. No essential changes in VC were noted. Through the end of the first day, the indicators of microcirculation virtually did not change. These numbers, describing microcirculation dynamics after active antishock provisions within the first day after wound, were similar for the wounded with less severe trauma (II-III stage of shock or without it). Thus, studies of microcirculation in casualties with a mine-explosive trauma showed that within the first hours after a wound, severe disorders are noticed and their expression completely correlates with severity of wound and shock. It is proven that even after successful anti-shock therapy, the majority of microcirculation indicators is preserved for a lengthy period. This implies, that the further course of traumatic sickness with favorable and unfavorable outcomes is related to appropriate changes in microcirculatory background.

7.2. ARTERIAL AIR EMBOLISM

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Arterial embolism, well-known to NAVY doctors heavy, and sometimes fatal complication of a barotrauma of lungs in submarine crews, draws more and more attention of the military doctors, involved with treatment of explosion damages. Interest to this problem, in relation to an explosive trauma grows due scientific studies in the last decades, which allowed to explain misfit of casualties states severity and amount of noticeable damages [Phillips Y. et al., 1991]. German researchers T. Benzinger, H. Desaga, R. Rossle (1947) were first to have found that the arterial emboli is responsible for lung damages during explosions. With experiments on animals they proved the damage of alveolar walls and pulmonary vessels after explosion can lead to formation alveola-venose fistulas and to penetration of alveolar air into pulmonary veins, left heart sections and systemic arteries. According to R. Rossle, air embola were detected in brain and heart arteries in 33 dogs of 42 casualties after underwater and air explosions. The nature of pathophysiological and anatomic changes during air and underwater explosions turned out to be the same. It was found that the explosive wave damages lungs not due to the rise of pressure in respiratory tract, but by combined external action on thoracal and abdominal walls. The shock front, being spread in air with the velocity close to 3000 m/s causes strong and rapid compression of lungs between rigid spine and a thorax displaced towards pleural vacuity and a diaphragm [Chalisov I., 1957; Buffat J., 1988]. Lung damages are aggravated due to propellant effect of the explosive wave, expressed by the action of positive and negative accelerations on different organs and a body as a whole [Nekludov V.S., Stepanova N., 1966; Kudrin I.D. et. Al., 1981]. Additional physical phenomena, accompanying blast wave propagation through nonuniform structure of lungs parenchima also constribute. These phenomena are termed "the effects of atomization, "fracturing ", "inertia" and interior explosion ("implosions"), cause heavier damages of lungs in comparison with other mechanisms of a pulmonary trauma and more frequent arterial air embolism [Buffat J., 1988; Sharpnack D., Johnson A., Phillips Y., 1991] The least studied question till now is a role of an arterial air embolism in a pathogenesis of a mine-explosive trauma. Despite that the air embolism was detected only in 26 % of cases among casualties from MW in Afghanistan [Velichko M.A., Lihachev L., 1991], mechanisms of its origination are treated speculatively, to a certain extent. E.g., air detection in a right heart ventricle in casualties, caused by the mine explosions, was explained either its being sucked through the defective veins of a head and a neck, or pressure-injection by an explosive wave
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through vessels of torn extremity. If first of the given mechanisms, is well-studied and, perhaps, there is no proof of the second mechanism in the literature. Moreover, neither that, nor another mechanisms do not explain detection of air emboluses in arteries of heart and brain in casualties without any external damages. Though mechano-and pathogenesis of lung damages and the subsequent evolution of an arterial air embolism after thorax being effected by a blast wave of a high is well-described in the foreign literature, it would not be entirely correct to use these data as a substantiation of the derangements caused by anti-personnel mine blasts. Rather small yield of anti-personnel mines (from 10 up to 500 g HE) causes short radius of damaging blast effects and only transient effects. The longitudinal axis of a casualties body in a typical blast situation is oriented perpendicularly to an excessive pressure front, therefore air blast has the tangential direction. It is also important that the lung position is remote from a contact mine blast center. In the experimental studies, conducted by the operative surgery department of Soviet Army medical college, it was shown that anti-personnel mine blasts causes the main damages not through the air blast wave, but the blast wave (compression and stretching), propagating through a victims body [Fomin N.F., Rybachenko P.V., 1988; 1989; Chernysh A.V, 1996; Lipin A.N, 1997]. The major part of a blast energy, because of large body inertia, is spent on the fracture of distal extremity segments, only minor part is spent on the shock oscillations of organs and tissues, shock accelerations and propelling of a body. Similarly to an air blast wave, propagation of a tissue blast wave [Nechaev E., etc., 1994] is accompanied by cavitational, inertial and fracturing effects in various organs, and, first of all, in the lungs. Modeling of contact blasts on anti-personnel mines at land (9 experiments) and a shoal water (16 experiments) showed that the majority of the observational animals suffered the typical set of local, segmentary and distant damages, well described in the publications. Their severity was defined by exterior conditions of blast (at land or shoal water) and mass of used charge of HE (2.50 or 100 g). Depending on the severity of MW clinical manifestatations and life span, all experimental animals were separated into three subgroups: with the heaviest (8), heavy (5) and a medium degree of severity (12) traumas. In each series of experiments (blasting on a land or on a shoal water) the attention was attracted by the lack of direct correlation between mass of HE charge and severity of MW. At the same time, irrespective of modeling, the exact law was revealed greater severity of mine-explosive trauma corresponded to more expressed manifestations of an
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arterial air embolism, as well higher frequency of intravital and postmortem detection of air emboluses. The cause of air penetration in a systemic blood flow in all observations, similar to well-known from the foreign literature cases of blast wave effects on people and the observational animals, is the damage to the lungs, manifesting as ruptures of alveolar bafflers, walls of bronchioles, pulmonary veins and arteries created morphological substrate for plural routes between pulmonary vessels and pneumatic tract. This mechanism of an air embolism, is supported by the observations in the majority of dogs, perished and rendered unusable after the blast experiments. These dogs exhibited emboluses in a vascular bed, frequently, in pulmonary veins, intravital air bubbles, circulating in the main arteries, found by doppler imaging. Additional argument in favor of the pulmonary cause of an air embolism can be an experiments, regarding MW in a shoal water, causing death of the observational animal in three minutes after blast, on the apnea background. Despite wounds to large arterial and venous vessels in extremities and pelvis, the dog showed no intravital and postmortem attributes of an embolism. Most likely, the arterial air embolism in this case did not develop only because the dog did not have respiratory excursions of a thorax, and, consequently, conditions for air penetration into vessels of lungs. Otherwise, if there is no breathing after a blast, then there is no arterial air embolism. For refinement of lung damages mechanogenesys, the biophysical studies on 4 dogs were performed, included measurements of shock accelerations and excessive pressures in tissues of various extremities and trunk segments in the observational animals. Measurements of excessive pressures were performed in an esophagus, muscles of a femur and external chest surface. Measurements of intraesophageal pressure were performed by the 8103 model hydrophone, manufactured by Brul and Kier (Denmark). A was inserted into esophagus to a level of heart using X-ray imaging. The maximum level of a excessive pressure of the air blast wave affecting a thorax in dogs at the distance of 65-70 cm from charges of C4 50 and 100 g, did not exceed 243 kPa for .7.8 ms. Meanwhile, according to Lovelace research center, threshold value of an excessive blast wave pressure causing a trauma of human lungs (positioned head or legs to a wave front) is within the limits of 710-994 kPa during .7.0 ms [Sharpnack D., Johnson A., Phillips Y., 1991]. Abundantly clear, the damage of lungs noted in all experimental animals, is caused by a mechanism, other than a barotrauma. Same factor explains absence of subpleural hemorrhages, shaped as impressions of ribs , characteristic for a morphological pattern of an air blast wave
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[Chalisov I., 1957]. For a human, having greater linear dimensions, the damaging blast effect on lungs with the similar mechanism and anti-personnel mine is even less probable. Macro- and micro-scopic pattern of lungs in experimental animals completely corresponds to the description of morphological changes in lungs in MW casualties [Habibi V et.al. 1988; Bisenkov L., Tynjankin N., Said H.A. 1991] and is a typical process of a blast wave effects on an integrated organism. A human is known, to be capable of surviving shock accelerations not exceeding 15 g in the head-legs direction [Nechaev E.A et.al., 1994]. Biophysical measurements, performed on MT model showed that contact blasting on a land (2. 50 and 100 g C4) caused a dogs shin to suffer acceleration of 47-107 g, while the thorax 55-150 g. Duration of shock accelerations was 2.5 ms. The human or animal body is known to respond to the shock accelerations with duration of 1-8 ms as rigid quick-response system, with the leaging role played by physical processes [Kudrin et.al., 1980]. Protective reflex responses (redistribution of a muscular tone, damping movement in joints) have not effects at such velocities. Mechanically homogeneous structures of an extremity, first of all, bones, and a blood column are main conduits of the blast waves in a proximal direction [Fomin N., 1994]. Lungs, whose protection against gravitation and shocks is performed by an entire body, possess feeble support structures, like bronchuses and blood vessels. Besides, they are in the suspended state relative to a mediastinum inside hard skeleton of a thorax. Therefore, typical blast on an antipersonnel mine causes lungs to displace from its roots and suffer an impact with a rib cage (interior propellant effect). Such mechanism explains the evolution of all observational radical hemorrhages in the animals, spread in parenchima of lungs along blood vessels, and also more expressed morphological changes in basal segments of the left-hand lung, exposed to shock from the side of heart. Prominent feature of an explosive trauma is a presence of pathohystohystologic changes (an emphysema, perivascular and peribronchial hemorrhages, dystelectase) in all departments of lungs, even when macroscopical changes are lacking. Obviously, such totality of lungs microtrauma is caused by evolution of cavitational, fracturing and inertial effects in parenchyma, after a shock wave passage. The interstitial emphysema, observable in those lung sections, in Rossles (1947) opinion, interferes with decrease of pulmonary vessels, promoting air entering these vessels. Besides, in real conditions, blasting of a human on an anti-personnel mine is accompanied by a propellant effect and strike with a firm subjects. Bruises of a thoracal wall, caused by it, and additional damages of the superficial stratums of a pulmonary tissue, pneumo221

and a hemothorax, contribute to increasing severity of MW [Bisenkov L., 1993]. Experimental studies and clinical observations of an arterial air embolism, caused by a barotrauma of lungs in submarine crews showed that the nonlethal air embolism is manifested by general brain and focal neurologic symptomatology, and various disorders of heart pace [Shestunov A., etc., 1991 Spenser F. et al., 1965; Gillen H., 1968; Evans D. et al., 1981; Pearson R., Goad R., 1982; Gorman D., Browning D., 1986]. From these positions, of great interest are inferences of the domestic neurosurgeons [Hilko V.A., Shulev Ju.A., 1994] on the leading part of an explosive lungs trauma in evolution of "secondary" (classifications of authors) cerebral derangements, caused possibly by local occlusal damages and as a result of systemic hemodynamic disorders. Among pathogenetic mechanisms of secondary brain damage in those, suffering from explosions , the authors give the first place to an air and fatty embolism of cerebral vessels. These standings correspond to those of L.N.Bisenkov and N.A.Tynjankina's (1992), isolating special group of casualties with MW, for whom circulatory and respiratory derangements led to disorders of CNS activity at lack of direct craniocerebral trauma clinico-morphological attributes. The data, cited by authors, in our opinion, in many respects are similar to known clinical and morphological development of a cerebral arterial air embolism. Authors forgetting to mention of this complication speaks, most likely, of extraordinary difficulty in its clinical and postmortem diagnostic. Accepted by a majority of surgeons opinion, that anti-personnel mines blasts cause air embolism by air penetration into vessels of the torn-off extremity is based on the seemingly evident facts, like presence entry gates for air in the form of the defective extremity veins, insufficient to cause lungs damage, pathoanathomical examination of air bubbles in the right heart chambers and large veins, characteristic for a venous air embolism. Pulmonary air embolism, and its most dangerous form arterial, usually does not take into consideration and often remains hidden for clinicians and pathologists, which is confirmed by the published literature, especially domestic. More frequent evolution and heavier course of an arterial air embolism after an explosive trauma in comparison with other mechanisms of lungs damage of lungs speaks is explained by the multifactor explosive effects. So, one may refer all casualties with clinical and radiological manifests of an explosive lungs trauma of lungs to a hazard group for arterial air embolism. Presented data on the role of an arterial air embolism in a pathogenesis of traumatic sickness, caused by explosion damages define necessity to study application of a medical compression and
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other forms of a barotherapy as an important component of complex treatment at the stages of medical evacuation. Nowadays, medical literature displays observational substantiations of a medical compression treatment of the arterial air embolism, evolved owing to blasts on antipersonnel landmines [Ruhljada N., 2000; Homchuk I.A., 2000].

7.3. CHANGES OF BLOOD ACID-BASE BALANCE AND THE GAS COMPOSITION

The most informative method of an oxygen failure study in clinical conditions is measurement of blood oxygen content. This method underlies identification of a hypoxia stages [Efuni S.N., Shpector V.A., 1986]. Studies of blood oxygen indicators and related acid-base balance (ABB) during traumatic sickness provide and insight into functional disorders of the life-support systems and metabolism rate in the defective tissues. Of significant interest are the study results, regarding functional state of the system, responsible for supporting optimal levels of respiratory indices ,pCO. pO2 in wounded with explosive avulsions and fractures of extremities. The control group for defining normal indices for the given region and was made up of 26 healthy Afghan army soldiers. 18 casualties are surveyed. Studies were carried out in dynamics (. . 5 and 7 days after wound). Blood from a radial artery and ulnar vein was sampled in the mornings by punctur method: from an artery, using special syringe "Radiometr " (Denmark), from a vein, using disposable plastic syringes. Studies were conducted by Astrup micromethod. The study results are presented in Table. 7.4. In the first days after wound, wounded developed combined hypoxia on the background of a shock and a massive hemorrhage. The hypoxia can be described by accumulation unoxidized products of tissues metabolism, build-up of bases deficit (up to .57 mmol/L). However, developing metabolic acidosis (with pH < 7.37) bears compensated character due to a stressed exterior breathing function. This is being confirmed by an active removal of CO2 from blood and its decrease in arterial and venous blood, increase of O2 content in an arterial blood in the first day due to the hyperventilation. In the subsequent time, the following changes were noted. At 34th day after a mine-explosive trauma distinct attributes of a hypocapnia are maintained, alongside with a continuing pO2 decrease in arterial blood and diminution of an arteriovenous oxygen differential ( O2). These indicators testify to a spastic stricture of a peripheral vascular bed and an arteriovenous
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bypassing. Continuing vasoconstriction in turn causes microcirculatory hemodynamic disorders and a decline of tissues perfusion. Table 7.4 Dynamics of acid-base balance and blood gas content for MT casualties Indicators Normal (26 Wounded(14 persons.) persons.) Days after wound 1 3 5 7 * .36 .01 .39 .01 .43 .02 .41 .01 .38 .02 * .30 .02 .31 .01 .36 .02 .34 .01 .35 .02 .06 .08 .07 .07 .03 * BE (base deficit), -.75 .28 -.03 .79 -.33 .87 -.7 .61 -.52 .9 mmol/L -.59 .77 -.57 .61 -.87 .31 -.82 .44 -.76 .86 -.84 -.54 -.54 -.12 -.24 . mm.Hg. 3.2 .77 3.55 .94 3.14 .77 3.5 .0 3.15 .36 4.2 .67 3.15 .81 37.14 3.02 .94 3.92 .92 .18 1.0 .6 .0 .52 .77 . mm Hg.. 6.79 .21 7.12 .18 6.54 .05 6.85 1.2 6.95 .76 3.59 .36 3.24 .69 2.76 1 .22 4.18 .07 4.24 .0 39 4.88 3.78 2.67 2.71 * Note: A artery, B vein, ABP arterial-venal differential The response to complex pathogenetic changes is the further progress of metabolic disorders. The tissue hypoxia expressed in incremented indices of " base deficit, especially in an arterial blood (two and more times above normal) is maintained. Maintenance of within the normal range is maintained due to hyperventilation, a hypocapnia, an overstress of respiratory system. Low ABP levels without normalization trend (22 mm hg at seventh day with 39 mm normal value) confirms deep disorders of oxygen regime in the wounded with MT. This, in turn, testifies to derangement of microcirculation and presence of histotoxic hypoxias through an entire observation cycle. Probable mechanism of the noticed oxygen disorders in an organism, due to mine-explosive and other heavy gunshot traumas are the oxygen transport disorders at the section cellular membrane mitochondrias. It manifests as membrane transmittivity disorders, cells overhydration and other changes caused by a trauma. According to the data by S.N.Efuni and V. A.Shpektor (1986),
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these disorders can be classified as hypoxia of a peripheral bypassing in its interstitial and intracellular (cellular-mitochondria) varieties. Thus, the heavy mine-explosive trauma and traumatic sickness is accompanied by the pronounced hypoxic syndrome with presence arteriallyhypoxemic, hemic, hemodynamic and peripheral components. As known, ultimate function of a cardiorespiratory system is supply of oxygen in tissues, necessary for their vital activity and removal of a carbon dioxide and other metabolism products from tissues [Navratil etc, 1967]. Prerequisites of this task accomplishment are: First, normal lungs function (sufficient ventilation, uniform distribution ventilating, intact diffusion); Secondly, normal capability of blood to transport respiratory gases and circulation system ability to provide a sufficient blood flow; - Thirdly, undisturbed ability of tissues to remove oxygen and deposit a carbon dioxide into the flowing blood.

Fig. 7.11. Pathophysiological mechanisms of breathing disorders at the mine-explosive trauma (by Cournand, M.Navratyl et.al. 196.) Consequently, breathing disorders and evolution of a hypoxia can be observed even at the normal functioning of lungs. Knowing a pathogenesis of a mine-explosive trauma, one can describe pathophysiological mechanisms underlying a hypoxia, developing after gunshot wounds. Figure 7.11 shows schematics of pathophysiological disorders of breathing, taking into account characteristic anatomic-physiological states [Cournand et.al.]. Three primary states are isolated,
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as observed after heavy mechanical traumas. Detailed estimate of breathing function after gunshot trauma demands rather complex and detailed, which is not always feasible in field conditions. In this connection, of a substantial value is development of the syndromic approach to the respiratory failure diagnostics, which is feasible only on conditions of substantially accurate understanding of a mine-explosive trauma pathogenesis.

Fig. 7.12. Pathogeneses of hypoxic syndrome and basic treatment directions Approaches to elimination or relieving of hypoxic syndrome after combat damages is determined by treatment of its basic components (Fig. 7.12). Arterially-hypoxemic component of hypoxic syndrome is caused by exterior breathing decrease. A treatment, which raises efficiency of exterior breathing, will promote elimination of this factor. The anemic form of hemic component can be liquidated by the oxygen increase in an arterial blood. For this purpose, it is necessary to raise hemoglobin concentration, or increment oxygen share, dissolved in plasma. Cardiogenic and hypovolemic forms of a hypoxic syndrome hemodynamic component can be arrested by raising an overall performance of cardiovascular system and CBV increase. The peripheral bypassing hypoxia (in particular, its intersticial and cellular-mitochondrial forms) can be reduced by normalization of intracellular metabolic processes in the injured cells. Thus, acute stage of MW disease is characterized by the evolution of the expressed combined hypoxia with disorders at all levels of an oxygen system (with hypoxic, hemodynamic, hemic and

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histotoxic components). This conclusion demands respective planning of treatment. This issue gains the special practical significance in mountain conditions on the lowered oxygen partial pressure background.

7.4. METABOLIC DISORDERS

Multiple disorders of a homeostasis after a mine-explosive trauma are manifested and implemented through the changes in metabolism indices in an injured organism. Study of these changes is extremely important for development of the rational pathogenetically proved treatment plan and revealing hidden mechanism mechanisms of a wound sickness pathogenesis in its dynamics. The chapter addresses metabolic disorders studies, performed on the biochemical indices. These indices reflect dynamics of water-electrolytic, carbohydrate, albuminous and lipide metabolism. The survey encompassed 23 persons with mine-explosive avulsions and crushed extremities. Studies of blood serum were conducted using automated biochemical analyser "Technicon ". Such indices of a blood serum, as aminotransferases (AsAT, AlAT), an alkaline phosphatase, general bilirubin, creatinine, urea nitrogen, glucose, sodium and red muscular pigment - myoglobin were studied in the traumatic sickness dynamics. Study results are summarized in the Table. 7.5. In the subsequent time, the following changes were noted. At 34th day after a mine-explosive trauma distinct attributes of a hypocapnia are maintained, alongside with a continuing pO2 decrease in arterial blood and diminution of an arteriovenous oxygen differential ( O2). These indicators testify to a spastic stricture of a peripheral vascular bed and an arteriovenous bypassing. Continuing vasoconstriction in turn causes microcirculatory hemodynamic disorders and a decline of tissues perfusion. Heavy explosive trauma and the related stress are characterized by exaltation of sympathetic nervous system. This, in turn, is accompanied by energized glycolycolitic processes in tissues and rise of the glucose content immediately after wound. In the subsequent time, starting from the third day, glucose level decreases to normal indices. Certain elevation of urea nitrogen testifies to enhanced catabolic response to a trauma in the first three days of a wound sickness.

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Table 7.5 Metabolic disorders after MT

Index SI Units Normal range 1 3 5 7 10 15 Days after wound

AlAT AsAT Acid Phosphatase Bilirubin Creatinin Urea nytrogen Glucose Cholesterol Crude protein Potassium Sodium Myoglobin

mmol/(g L)) .1-.68 mmol/(g L) .1-.45 mmol/(g L) .5-.3 mmol/L mmol/L mmol/L mmol/L mmol/L g/L mmol/L mmol/L ng/L .55-2.5 .66-.32 .78-.55 .64-.76 60-80 .5-.0 135-145 10-80

.2 .79 .05 1.3 7 .1 .81 5.3 .8 128 831

.68 .3 .1 .3 .09 .37 .5 .28 5.0 .6 120 793

.59 2 .2 .2 .95 .5 .42 5.0 .3

.59 6 .05 .3 .47 .7 .62 5.5 .9

.55 .87 .35 .4 .94 .8 .94 6.6 .5

.59 .78 .62 .8 .076 .53 .3 .6 6.5 .0 350

.044-.088 .12

.095 .075 .08

125 126 131 130 549 394

Mine-explosive traumas are characterized by the deep disorders of an albuminous exchange. During the first 10 days of a posttraumatic stage the patients exhibited expressed hypoproteinemia with decrease of the crude protein content to critical quantities (50 g/l) during 3-rd and 5-th days. It was proven that losses of protein are caused first of all by albuminous fraction loss. Considering that the albumin preferentially provides the colloid pressure in a vascular bed, it becomes obvious that its significant decrease leads to redistribution of a fluid in the tissues. This creates conditions for transition of a fluid from a vascular bed into the interstitial space. Clinically this phenomenon is manifested by attributes of interior organs edema, first of all lungs, and brain. Noted albuminous exchange disorders in casualties (hypo and a disproteinemia) stipulate necessity of permanent crude protein level monitoring. The treatment should also include oncotically active transfusion agents (plasma, albumin, protein), and if they are not available artificial colloid solutions (Polyglucinum). Disorders of an electrolytic exchange are manifested by a hyperpotassemia (. . 10 and 15 day) and a lowered sodium level through an entire cycle of observation. Developing hypoosmotic state is manifested by flabbiness, retardation, hypotension, decrease of intestinal peristalsis. Using
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concentrated solutions of sodium chloride in similar situations is pathogenetically justified, and the raised content of potassium is the indication to infusion of its pharmacological antagonist the ionized calcium in the form of gluconate or chloride. Essential disorders of a lipid exchange are confirmed by the lowered cholesterol content during 15 days from the moment of a wound infliction. Apparently, it is a consequence of unbalanced feeding, excess of energy expenses over ingestion of a plastic and energy material, wound depletion of various degrees. Normal indices of the general bilirubin and creatinine testify to lack of rough hepatonephric pathology in this class of casualties. However, elevation of an alkaline phosphatase in the end of and observation cycle witnesses about some disorder of a liver function in these terms. In the first and subsequent day after wound, the attention of researchers was attracted by the sharp rise of the myoglobin level (by a factor of 8-10) in comparison with the normal. Injection of high muscular pigment amount in a vascular bed, which is endogene poison (similar to free hemoglobin during hemolysis of erythrocytes), largely defines severity of a casualtys state and can be a principal cause of renal failure. Raised myoglobin level is maintained during entire cycle of observation though tends to decrease. It defines, accordingly, necessity to conducting disintoxication therapy not only in the first days after wound, but at the later terms as well. Performed studies testify to severe metabolism disorders for all casualties. Metabolic disorders bear phased character, they are found not only in early, but also in the later terms after a trauma. The presented data underlie the plan of pathogenetically proven treatment of MT casualties.
7.5. CHANGES OF THE CENTRAL HEMODYNAMIC

With introduction of a body integrated rheography technique into clinical practice by I.M.Tishchenkos (1971), new opportunities were formed in studying disorders of a circulation and breathing, caused by MT. They include non-invasiveness, simplicity, repeatability, accessibility and high descriptiveness, allowing applying this method in field conditions. 150 rheograms were taken within three weeks after wound for 38 wounded persons. The control group consisted of 22 healthy persons. Casualties were separated into three groups: with uncomplicated course, with the complicated course and a success outcome, with the complicated course and adverse (lethal) outcome. The degree of breathing disorders can be significant in the first phase of observation (1-5 days after wound). In particular, during these time, the breathing rate exceeds normal by 1.5 % on the
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average, stress level of breathing factor exceeds normal by 3.7 %, coefficient of respiratory changes by 1.7 %. In the second stage of observations (7-10 days) gradual decrease of these indices to a normal level with insignificant oscillations was noted. During those observations, when the casualties developed purulent-septic complications (usually by 6-8th day of a posttraumatic stage), stress level and breathing changes coefficient remained elevated, which confirms breathing system being overstressed in the complicated cases. When analyzing changes of the central hemodynamics, the researchers used separation of circulation systemic responses into hyper-, normo- and hypodynamic types [Hasandinov E., 1970; Samohvalov I., 1984]. Our studies confirm interrelation between character/ severity of an explosive trauma and response of circulation system. In particular, in the group of slightly wounded (gunshot wounds of the soft tissues with a hemorrhage < 10 % of CBV), the circulation system operates in hyperdynamic regime, achieved by a heart pace increase. When performing a load test, inadequate response was noted with the delayed restitution and oxygen backlog. Adequate character of circulatory system response to load was noted only 7-8 days after a trauma. In mine-explosive wounds with avulsions of lower extremities distal segments, with a hemorrhage < 30 % CBV, the hypodynamic circulation was noted (coefficient of a reserve .82 .0. stress coefficient 2.5 .3 ml/m2 with normal .54 .31 and 69 15 ml/m2 accordingly). In the subsequent days, this group of wounded with the uncomplicated course of traumatic sickness eventually showed normalization of circulation indices. If the general or local infectious complications evolved to the 7-8th day, the hyperdynamic circulation was noted. The group of wounded with combined MT, characterized by massive hemorrhage and high lethality in the first day after wound, the hyperdynamic circulation type developed. It is regarded as compensatory response of an organism to a heavy trauma. In the subsequent days, circulation changed to a hypodynamic regime with simultaneous decrease of breathing stress level. Despite the treatment, wounded frequently developed decompensation of cardiorespiratory system. Analysis of heart electrical activity in casualties with a mine-explosive trauma according using electrocardiography testifies that in the majority of observations, in the first three day after trauma there is sinus tachycardy (12020 /min). Also, the researchers noted a protraction of an electrical systole and a shorting of an electrical diastole. Considering that blood supply of a myocardium comes in a diastole, it is possible to confirm decline of blood supply and a cardiac musle trophicity in the first day after wound. Casualties with a mine-explosive trauma showed local decline of a myocardium circulation preferentially in the post diaphragm and lateral regions
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of a left ventricle. It was manifested by decrease of altitude or inversion of T-finger in derivations III, aVF, aVR, V5 and V. and in some observations (2.6 % of casualties) depression of S-T interval according to subendocardial ischemia. These signs can testify to heart bruise during a wound. In further in the majority of observations, researchers noted gradual heart pace reduction, shortening of an electrical systole, improvement of a local blood flow in a cardiac muscle. However, in some cases they were noticing disorders of electrical heart activity through an entire observation cycle. These casualties showed certain electrocardiogram parameters degradation 510 days after wound. The tachycardy was building up, myocardium ischemia regions were spreading along with the attributes of a hypopotassemia and diffuse changes of a cardiac muscle. Usually these symptoms coincided with evolution wound infectious complications. Analysis of heart rate changes, according to variation pace-metric data by M.Baevsky (1979), testifies to the following. During first three days of a posttraumatic stage, the wounded showed preferentially synpaticotonic character of variation curves with a mean .53 .017 with, deviation (AH) .16 .3. amplitude 9.3 .52. Vegetative rhythm indicator averaged 615 64. 5-7 and 1014 days after wound indices . 0 did not change, at the same time variation total amplitude considerably increased (.28 .03 with on 5-7day, <.05 and .24 .027 with on 10-14day, <.05). Favorable course at the majority of wounded proves that such character of heart pace changes is rational and manifests gradual normalization of homeostasis indices [Kiselev S.O., 1986; Tsipis A.E., 1986; Lesnyh M., Baishev I.S., 1987]. In cases of complications, there was no change in variation amplitude It is expedient to isolate hyperdynamic, normodynamic and hypodynamic type of circulation system operation. The hyperdynamic type is characterized by elevated heart pace, certain rise of MBV (blood volume per minute), high reserve coefficient and coefficient of integrated tonus. All these factors are observed for light damages (soft tissue wounds, feet avulsions without the significant hemorrhage). Similar to normodynamic type, corresponding to essential circulations indices abnormalities, hyperdynamic state testifies to neutralization of the functions upset by the wound of cardiorespiratory systems. Hypodynamic circulation system operation, in turn, testifies to decompensation and is characterized by low CBV (despite elevated heart pace). In a clinical practice, the hypodynamia testifies to a decompensation of life-support system functions and in the most expressed cases is an attribute of irreversible pathological changes. Dynamics of
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traumatic sickness shows that the circulatory system operation type is not permanent. For example, during evolution of purulent complications, activity of infectious process factors and protective mechanisms can cause the failure of life-support system compensation. In clinical conditions, the special attention should be paid to casualties with labile compensation of the cardiorespiratory system function. Corrective treatment in these cases should be directed toward prevention of decompensation of the upset functions and circulation transition to a hypodynamic type. This class of wounded includes patients with uncomplicated course of a posttraumatic stage. Labile compensatory function is justified only having with regard to the following facts: the significant diversions of an integrated rheography initial indices in the first stage of observation (1-5- days after wound), a resistant trend to normalization of major indices after three-week observation, lack of the statistical significance in differences of indices. Comparative analysis of the central hemodynamics indices for those, who perished in the first days and those, who died from complications, provides extensive information. E.g., despite that heart pace for those with lethal outcome was 20 % higher and a systolic coefficient (SC) 10-12 % lower than for wounded with favorable course of a posttraumatic stage. What attracts attention is identity and unidirectional changes of integrated rheography indices in casualties during first days after wound and. Probably, hypodynamic operation of cardiorespiratory system with decompensation is common for these groups of wounded. Thus, dynamics of the functional indices of the basic organism life-support systems after a mineexplosive trauma is characterized by the greatest disorders in the first days after a trauma with normalization in the subsequent days, provided the course is uncomplicated at the posttraumatic stage, but with gradual buildup of all studied disorders.

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Part II
Chapter VIII MEDICAL TREATMENT OF THE EXPLOSION DAMAGES

8.1. MEDICAL TREATMENT EXPERIENCE OF THE AFGHANISTAN WAR

Starting 1979 until 1989 in Afghanistan, Soviet military physicians performed large amount of operations, involving medical support of combat operations and daily troops activities in the complicated medical-geographical conditions, pertinent to hot mountain-deserted terrain. The main conclusion, military physicians came to after ten years of war is as follows: permanent medical personnel readiness with respect to specifics of a battlefield, applied weapons and operations planning. This thesis should become a baseline for military medical theory and practice. It should find reflection in special scientific studies, conducted for possible future conflicts at specific battlefields. These studies may stipulate sufficient deviations from the standard approaches, concerning organizational structures of medical service, its mobilization and the organization of operations. Combat experience testifies that achievement of organizational questions resolution requires such state of affairs that regular military medical services are ready for independent deployment, despite the problems, related to a partial or complete isolation. This statement is valid for entire medical service operations and for separate medical service units. We recognize that existing military medical service infrastructure of 40th Army was not flexible enough and did not allow timely adaptation to quickly changing environment. Hasty setup of military hospitals without planning of probable flows of casualties, patterns and amounts of medical losses, leads to failure of adequate personnel treatment during the first year of war. Means of medical evacuation lacked adaptation to the regional conditions. Initial experience of medical provision has shown that mobilization and the combat readiness of medical service during a peacetime is the mainstay of success, especially in an initial stage of war.

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What are the basic medical lessons of war in Afghanistan? First, it is necessary to note that some positive results were achieved in solving medical issues. This is reflected on timely rendering of medical aid to combat casualties and successful operation of large-scale medical centers, belonging to USSR MoD and Ministry of Health. As known, during 1979-1989 Soviet Army losses in Afghanistan, according to USSR Joint Staff, comprised 64148 persons, of those 13 833 killed, 49985 wounded and 330 MIA. Table 8.1 shows comparison with US casualties during a Vietnam War Table 8.1 Personnel losses during Afghanistan and Vietnam wars Casualties Afghanistan war 1979- Vietnam War 1964-1973. 1989. % Number. Number . % Dead 13833 2.6 57685 1.9 Wounded 49985 7.9 303175 8.6 MIA 330 .5 1678 .5 Total 64148 10.0 362538 10.0 Table 8.2 summarizes sanitary losses for entire Afghanistan war Table 8.2 40th Army losses dynamics Years Total Damages/wounds total Incl combat
# Diseases Total #

% .6 .6 1.8 .3 1.0 1.6 1.6 .3 .2

% .9 .7 .3 1.7 1.4 1.7 1.7 1.4 1.2

Including infections % #

19791980 1981 1982 1983 1984 1985 1986 1987 19881989 Total

31790 .0 39224 31361 47300 57826 63661 67019 59022 57246 .6 .9 1.4 1.7 1.0 .8 1.0 1.6

3799 .6 3842 5975 4127 7737 8219 7696 4915 3675 .7 1.0 .3 1.5 1.4 1.4 .8 .3

2372 2686 4342 2600 5661 5201 3631 2954 1930

27991 35382 25386 43173 50089 55442 59323 54107 53571

18922 16176 21786 32097 38641 39527 41545 34899 34429 278 022

.8 .8 .9 1.5 1.9 1.2 1.9 1.6 1.4 10.0

45444 10.0 49985 10.0 31377 9

10.0 404464 10.0

Insofar, the combat damages comprised around 10 % of all losses. The majority (about 90 %) is represented by non-combat sanitary losses. Of special interest for medical services are sanitary

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losses, not caused by any weapons which, depending on casualty involvement in combat, are referred to as combat (7.3 %) or non-combat (3.7 %). Combat sanitary losses peaked during 1984-198. due to stirred military operations and improvement in guerilla weapons supply. Combat damages pattern analysis warrants to term Afghanistan war as "mine-war", because such massive application of engineering mine ammunition is unprecedented. Share of sanitary losses, resulted from mines and demolition munitions attained 2530 % of the total casualties. This allows to treat explosion trauma as the independent combat pathology. The structure of sanitary losses is shown in Table. 8.3. Table 8.3 Sanitary losses pattern from the conventional weapons as a function of damages type,% Total Damage type Sanitary losses Combat Non-combat Wounds 7.5 2.4 6.5 Damages 2.1 5.4 3.2 Contusions .4 .5 .4 Other .0 1.7 .1 From the in Table 8.3 it follows that 6.5 % of damages was falling on wounds and 3.2 % on damages. Rendering medical for casualties with such pathology burdened the medical service as a whole. Quality of medical service operation in medevac area was impaired by the frequencies of combat traumas, which peaked during 1985-89. Traditional characteristic of a combat traumatism is distribution casualties by localization of damages, which predetermines medical service infrastructure (Table. 8.4). When comparing presented data, similarity of discussed structural indices is noted. Key factor of military-medical service efficiency is the number of casualties, returned to ranks. In Afghanistan, medical service returned to ranks 7.9 % of all casualties (Table. 8.5) , which exceeds WWII factors (7.3 %). Returned to ranks index peaked in the second period of war (1985-1988) 8.4 %, in comparison with 7.1 % for the first period (1980-1984). For the casualties these indices were the following: first period 8.2 %, second period 9.4 %, and on the average 8.0 %, which practically corresponds to WWII data. Treatment of the casualties, referred to the combat and non-combat sanitary losses, is presented in Table. 8.6. It is necessary to underline that recovery rise was achieved on the background of the heavy and extremely severe casualties increase 4.4 % in 1985 1989 , if compared to 3.3 %

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during 1980-1984. These data show tremendous efforts on the improvement of medical treatment in the military service. Timely rendering of medical aid was still the crucial factor. Sufficient to tell that an average term of medical aid rendering was reduced almost by a factor of . from 7.8 down to 4.5 hours. Table 8.5 Wound outcome during XXth century wars, % War Average time before Dead at the medical aid is rendered, battlefield hrs 1.8 2.0 WWII 1941-1945. Afghanistan war: first phase second phase entire war WWII 1939 1945. (USA) Korean war 1950-1953 (USA) Vietnam war 19641973 (USA) .8 .5 .1 1.5 .3 .3 1.5 1.0 2.0 1.0 Lethality Decom Returned mission to ranks ed .7 2.0 7.3 .0 .9 .5 .5 .5 .6 2.9 1.7 1.6 2.8 2.8 1.4 7.1 8.4 7.9 7.7 7.7 8.4

Table 8.6 Treatment outcomes depending on the damage character, % Outcome Sanitary Wounds Damages Contus Other damages loss ions Returned to ranks Combat 8.3 9.5 9.2 9.9 Non8.5 9.9 9.8 9.3 combat Decommissioned Combat 1.8 .7 .0 .4 Non1.8 .5 .9 .3 combat Dead Combat .9 .8 .8 .7 Non1.7 .8 .8 .7 combat

Total

8.0 9.6 1.5 .1 .5 .3

Casualties were routinely airlifted at Afghanistan territory. Almost 90 % of casualties (in 1980 7.0 %, in 1987 9.4 %) were airlifted directly from a battlefield. Share of battlefield deaths is generally accepted to be an adequate indicator of efficiency and timely medical aid at the battlefield. According to our data, it is lower than that during WWII and is close to a level of analogous indices in XX century local wars. Table 8.6 is shows sample set of the indicators, which became a standard in a world practice of an estimate of medical service operation performance. Analyzing a share of battlefield casualties,
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lethality, number of returned to ranks, terms of medical aid rendering one can conclude that efficiency of the Soviet troops in Afghanistan medical support was at the level of American army in Korea and Vietnam. In our opinion, low level of irrevocable losses (1.0 %) during war in Vietnam points on methodical approaches, characteristic for US military surgeons, namely, this indicator includes very light casualties (otherwise, filed for the sake of statistics ) where the casualties even missed hospitals. Medical provision system for the Soviet troops in Afghanistan, as a whole, were predetermined to solve three problem classes: medical support of Soviet troops during operations, directed on extermination of mujahedeens; medical support of troops, involved with protection of infrastructure; medical support of garrisons. Of special scientific interest is medical support organization during combat. The battlefield factors, influencing medical treatment, include: specific operation tasks and units staffing; combat tactics (operations in the mujahedeens-controlled territories by self-contained units remotely from main forces); lack of a continuous frontline, possible flank strikes by mujahedeens; extremely complicated medevac conditions; restricted transportation opportunities. Among other factors are: Specific medicogeographical conditions of Afghanistan; small numbers of casualties, entering medical units (on the average 5-10/division ,46/brigade); high infectious morbidity and a labile sanitary-epidemic troops conditions; sufficient medical resources. In view of these organizational methods of troops medical support were based on the following principles: enhancement of the combat units with medical personnel; rendering the major medical aid by the qualified medical personnel, and only the minor injuries should be treated by fellow soldiers; direct evacuation of casualties from the battlefield to a hospital
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 reduction of transit time by using medevac helicopters; - deployment of stationary medevac facilities, broadening the range of treated injuries and returning casualties into ranks within 30 days, whenever possible; Implementation of these guidelines helped effective organization of surgical and therapeutic treatment. Medical service command was continuously improving medical treatment organization through an entire war, actively applied modern treatment methods, preventing of dehydration, wound sicknesses and other complications. The medical treatment infrastructure was based on 8 military hospitals, deployed in Afghanistan. These hospitals had dedicated units, specializing in hemosorption, a hyperbaric oxygenation, hemotransfusion, vascular surgery, artificial kidney. Since first years, experienced medical surgeons, anethesiologists and intensive aid specialists were redeployed . Since 1987-1988 the methods of extracorporal detoxication, plasmapheresis, liquosorpbtion, UV blood irradiation etc, were intensively applied. The basic regional centers of specialized medical aid were the 40th Army Central Military Hospital in Kabul and Region Military Hospital of Turkmenistan Command in Tashkent. More than 50 % casualties 35 days after surgical treatment in their units were evacuated to these facilities. During operations in 40th Army, medical aid was sometimes rendered at the evacuation stage, especially during massive operations. For this purpose, special medical battalion or hospital was enhanced by necessary physicians, nurses and medical equipment. At the same time, the war required echeloning of the specialized aid for casualties, requiring advanced treatment. So, the important organizational decision was made to create special units in central military medical academy by V.M.Kirov, central and regional medical hospitals (Table. 8.7). Before, the specialized casualties treatment was rendered in the regional hospitals, where the casualties were enlisted or based. Essential element in rendering specialized medical aid is scientifically proven recovery therapy. Personnel with heavy wounds aftereffects was directed from military hospitals and clinics to medical rehabilitation in Sakskiy, Sochinskiy and Piatigorskiy military health centers. In 1983 special rehabilitation division was organized in Sakskiy military health center. More than 5500 casualties underwent rehabilitation treatment. It is necessary to underline that during this war, the medical services acquired valuable experience in airlift medical evacuation at tactical and strategic levels. Note that annually 1500 2000 casualties and the patients were airlifted, if they required complex or specialized treatment. The airlift was performed within first 10 days directly from Kabul to MMA clinics, Burdenko
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NMH and regional military hospitals. Table 8.7 Specialization of medical hospitals and Military Medical Academy clinics in treating Afghanistan casualties Localization Military hospital Foot SMH8 Hand RMH Leningrad region Skull and brain MMA, Burdenko NMH, RMH Odessa region, NMH Caucas region Spine and spinal cord RMH Moscow, Leningard, Baltics region, Black Sea Fleet NAVY hospital Peripheric nervous system MMA, Burdenko NMH, RMH Leningrad, Krasnodar regions Eyes MMA, RMH Leningrad region, Odessa region, Krasnodar region, Moscow region ENT-organs MMA, Burdenko NMH Dentofacial region MMA, Burdenko NMH, RMH Leningard region, Transcaucaus region, Baltic region When developing large-scale medevac measures using airlifts, a number of organizational and medical problems were solved. Clinically proved optimal evacuation terms for basic groups of casualties were established, equipment of transport aircraft by necessary medical equipment, professional training of attending medical personnel. Specially equipped aircrafts and helicopters were deployed, as AN-26 " Spasatel", IL-76 "Scalpel", helicopters MI-8 MT "Bisectrix ". The effectiveness of undertaken measures is proven by favorable outcomes for many casualties with various wound localization. It can be seen from Table 8.8 that the favorable outcomes level was much higher than that during WWII. Table 8.8 Casualties outcome depending on the wounds localization, % Localization Afghanistan war 1979-1989. WWII 19411945. Returned to ranks Death Returned to ranks Head 8.1 .4 7.3 Chest 6.1 .3 8.4 Stomach 4.5 1.8 3.5 Pelvis 8.4 .2 8.6 Upper extremities 9.9 .1 7.2 Lower extremities 9.2 .2 6.5 I Intensive development and R&D is required, directed on the development of new bandages,

Dead .4 .5 4.0 .6 .0 .6

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immobilization means, medical polymers and new non-inhaling agents for general anesthesia. Medical evacuation airlift means need an improvement, in view of latest experience ("Spasatel", "Scalpel", "Bisectrix", etc.). Casualties transportation equipment still requires intensive R&D works. Rehabilitation treatment of casualties in 40th Army required special attention. This, in turn, allowed developing new manuals on medical rehabilitation *. Of special interest is search for new adaptogens, drugs for improvement of combat performance. Treatment of psychoneurological disorders for casualties needs significant improvement as well. Medical logistics system needs improvement and medical reporting documentation approach needs revision during wartime. Considering medical aid organization for casualties in the Republic Afghanistan army, we note it to be defined by a nature of combat operations, medicogeographical conditions of region, organizational structure and material capabilities of medical service, available to the country. Without taking influence of these factors into account, diagnostic and efficiency of mineexplosive wounds are difficult to estimate. The medical aid infrastructure in the Afghan army practiced Soviet military medical doctrine about staged rendering of a medical aid. Besides central military hospital, Republic of Afghanistan (RA) Army (110 000 personnel) was services by two garrison hospitals (Jelalabad, Kandahar) and four medical battalions (Host, Gardez, Herat, Mazar-i-Sharif). Continuing, although slow, improvement of staged medical aid system is indisputable achievements of RA medical service. It has to be noted that RA medical service successfully managed treatment of casualties, and finally managed to achieve 2/3rd casualties returning to ranks. Central Military Hospital was unique in its way diversified medical facility. This hospital was capable of deploying 11001200 beds (annual load 10501070 beds) and was staffed by well-trained national medical personnel and equipped with modern medical equipment. It was very important that more than 80 % casualties started and finished treatment in the RA Central Military Hospital (RA CMH). Through an entire war, RA CMH functioned as not only a medical treatment stage, but also performed wider and diverse functions, as physical examinations, blood supply maintenance, recovery therapy and returning to ranks. It was a unique situation when a single physician supervised the whole cycle of medical aid. If the medical aid is organized correctly this leads to essential improvements in clinical outcomes and
8

RMH regional military hospital, MMA military medical acadeny, NMH national medical hospital 240

eliminates multiply errors and assumptions. RA CMH was a final stage of medical evacuation. Mountain terrain, intensive guerilla warfare, lack of adequate roads or impassable roads, along with understaffed medical service in advancing troops are responsible for central military hospital being the first medical aid facility for 2/3 of all casualties. Even in view of evacuation peculiarities (more than 90 % of casualties were airlifted), they entered central military hospital of Afghan republic army incredibly late (Table. 8.9). Table 8.9 Delivery of mine-explosion casualties to RA CMH, % Evacuation time Years Biannual average 1983 1984 < 6 hrs .5 .5 .9 6-12 hrs 2.4 2.8 2.5 12-24 hrs 1.6 2.3 2.9 2-3 days 5.5 5.4 5.7 Total 10.0 10.0 10.0 Justified uneasiness about the existing medical aid infrastructure was caused by massive influx of casualties without any paramedical help or any help on the pre-hospital stages (no aseptic bandages, transport immobilization or enclosed medical documents). Only 4 % mine-explosive trauma casualties were rendered adequate paramedical anesthesia; 60 % MW casualties entered CMH in severe condition (Table 8.10). Cause for this severity, along with massive extremity damages and delays in hospitalization, is defects in paramedical treatment and massive hemorrhages. Table 8.10 Severity of MT casualties, entering RA CMH, % Severity Years Biannual average 1983 1984 Satisfactory 4.5 3.5 3.1 Moderate 2.6 2.5 2.1 Severe 2.4 2.0 2.3 Extremely severe 1.5 2.0 1.3 Total 10.0 10.0 10.0 Organizational measures (deployment of support medical teams to garrison hospitals and medical battalions), undertaken during 1986-1987 resulted in certain improvement of MT casualties, crushed extremities and avulsions treatment at pre-hospital stages. At the same time, such a mandate measure as an extremity amputation during the explosive avulsions and damages was performed for only 50 % of required number. Medical aid at pre-hospital stages for casualties
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with the plural and insulated mine-explosive bone fractures does not even deserve a comment, due to the unavailability of qualified specialists, drugs or medical equipment. Anatomic and functional outcomes of treatment, lethality, number of local and general complications, number casualties returned to ranks, terms of treatment, disabilities all these categories directly depended on: severity and extents of primary tissue fractures; depths and abundances of the microcirculatory and trophic derangements, leading to evolution of extensive and drug-resistant purulent-necrotic processes; timeliness, completeness and quality of medical aid at all medical evacuation stages, terms of evacuation and military-medical logistics. If the first set of factors is beyond medical service control, the second and third one depended not only the specific medevac stages, but also on the entire system organizational mobility. Considered aspects can be compared against the same factors for Soviet army. During Afghanistan war, many factors were identical for medical services of Afghanistan and Soviet armies: the same opponent; same warfare, same battlefield climate and geography; equal intensity troops involvement in combat operations; the uniform concepts of medical aid organization. At the same time, there are vast differences in medical infrastructure, as substantiated in the Table 8.11 Table 8.11 Effectiveness and shortcomings of MT casualties treatment at pre-hospital stages, % Category Army RA 40th Army USSR

Casualties entered stage of specialized healthcare without: aseptic bandages 3.0 1.0 transport immobilization 4.0 .0 documentation 3.0 1.0 anesthesia 9.0 .0 Airlift 8.0 8.0 Tourniquet placement defects 1.6 1.0 Casualties with developed purulent-necrotic complications 2.0 Development of purulent-necrotic complications after two days in 2.0 hospital Terms of casualties delivery to the stages of qualified and specialized medical aid proved

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efficiency of medical aid infrastructure (Table 8.12). Shortcomings in medical aid, caused by the objective and subjective events, led to essential difference in the condition of wounded and development of local complications (Table 8.13 and 8.14). Table 8.12 Terms of evacuations, % After explosion Army RA < 6 hours .9 < 12 hours 2.5 < 24 hours 5.7 More than a day 5.7 Total 10.0

40th Army USSR 7.8 1.2 .5 .5 10.0

Table 8.13 MT casualties conditions upon entering specialized medical aid stage, % Condition Army RA 40th Army USSR Satisfactory 3.1 3.0 Average severity 2.1 3.8 Severe 2.3 2.7 Extremely severe 1.5 .5 Total 10.0 10.0 Table 8.14 Local complications for MT casualties, % Character Army RA 40th Army USSR Skin and muscles necrosis 1.1 1.4 Surface festering .4 2.2 Deep festering 3.3 2.2 Osteomyelitis 3.4 2.3 Anaerobic infection 1.8 .6 No less important, Mine Traumas exhaust medical supplies due to the extremely severe and complicated character of damages. Treatment of MT requires 3 times more supplies than a typical bullet wound. Presented data stipulate the authors to come to the following conclusion. Successful medical support of an armed conflict, natural or man-made disaster, is possible only with respect to specifics of situation armed conflict character, anthropogenic or natural cataclysm, basic damaging factors of explosions, losses pattern, climate conditions, material and economic capabilities.

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8.2. SURGICAL TREATMENT DURING NORTHERN CAUCASUS CAMPAIGN IN 1994-1996 AND 1999-2000
This section is based on the analysis of 319 mine-explosive trauma casualties treatment during the operations in Chechen Republic. Mine-explosive wounds were mainly caused by the contact blasts of non-shielded personnel (217 casualties (68 %). Mine-explosive damages, caused by indirect blasts, resulted in 102 casualties (32 %). Isolated MT, caused by a single damaging factor (often a blast wave or single fragment) was observed in 45 casualties (14 %). Combined wounds were noted in 36 % (115) of cases. Most often, head and extremities (27 %) wounds were noted, followed by plural wounds of top and bottom extremities (15 %). 788 surgeries were executed for these casualties. Their largest share was executed at the qualified surgical help stage (67 %), with urgent surgeries making 69 % . The last circumstance confirms severity of the inflicted damages. Surgical interventions under secondary indications made up only .9 %, as complications did not have enough time to develop at this stage (1-5 days). 31% of surgeries were performed at the specialized surgical aid stage, with scheduled (reconstructive-regenerative) surgeries taking the main place (48 %). Developed complications were related to 40 % of surgeries. 220 casualties were delivered in the state of shock (69 %). Objective analysis Russian Army medical service during Chechen republic operations is impossible without estimating enemy warfare, operations specifics and climate-terrain conditions. First, it was an internal confrontation with Russian Army utilizing high economic potential of entire country. At second, there was no traditional front line, and operative conditions were changing continuously, which demanded application of novel medical aid approaches. Federal troops carried out operations in cities and other settlements, as well as in mountain-forests terrain. Troops suffered from a permanent lack of potable water, high rate of infectious diseases, which aggravated casualties clinical course. Conflicting parties were armed with similar small arms. With continuing war, the share of mine casualties started to grow, which implied multiple and combined wounds. By the end of 200. veterans of Afghanistan campaign started to voice an opinion that the conditions becomes to resemble mine war in Afghanistan. Returning to analysis of 1994-1996 campaign events, it is necessary to note three phases in this armed conflict: deployment of troops and assault on Grozny, assaults on Chechen cities and

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towns. It is these periods, responsible for escalation of combat, increase of casualties influx, which required improvement of urgent medical aid. Mine damages constituted 12.5% through a first period, 18.3% through the second period and 20.4% through the third period. Small share of damages during the first period related to predominant use of small arms. In addition to that, intensive sniper warfare during Grozny assault prevented timely evacuation of casualties, causing death of many heavy casualties. These casualties perished when vainly waiting for medical help. More than 40 % of mine casualties during the first period were mine damages. These damages were inflicted by the mechanized convoys demolitions by guerrilla minefields and IEDs. Additionally, during the urban combat, tanks and APCs are almost perfect target for the grenade launchers. The least share of mine damages was noted during the second period, when operations were conducted mainly by small units in the terrain almost impassable for heavy armor. During 1994-1996 qualified surgical help to casualties was mainly rendered by the special medical units (SMU), deployed around Chechnya. These units demonstrated their high mobility, efficiency and completely accomplished their tasks. Medical support experiences during the armed conflicts and local wars convincingly showed that outcomes of combat damages are appreciably defined by adequacy and terms of urgent medical aid at a pre-hospital stage. First and paramedical aid after explosive damages are based on closing wounds with aseptic bandage, external bleeding stop, transport immobilization of damaged extremity by improvised means, injection with analgesics. Performed analysis testifies that 70 % of casualties were delivered to qualified surgical aid facility after first and paramedical aid. For 49 % casualties the paramedical help was rendered as self-help or by other soldiers, as well as paramedic personnel. Since these numbers really reflected situation on the battlefield, commanding officers paid special to training of personnel and paramedics in the first aid principles. Each soldier was supplied with two individual wound packages, two injectors with promedol (trimeperidine hydrochloride), one tourniquet for two soldiers. During initial stage of operations with, military surgeons were assigned at the company level, and anesthesiologists and reanimatologists at the regiment level. However, as the military operations continued, it became obvious that a military surgeon without necessary equipment or infrastructure is inefficient and bears little difference from staff paramedic specialists, responsible for first medical aid and evacuation. In first 30 minutes after wound, the first aid was rendered to 7.3 % casualties, during the second
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30 minutes to 2.9 more % casualties. Improvement of first and paramedical aid, fast evacuation of casualties allowed to deliver 7.3 % of MT casualties to a stage of the qualified surgical help within first three hours. Later evacuation would have led to substantial number of MT casualties deaths at a pre-hospital stage. Analysis of the medial operations support allows to come to a conclusion that the basic condition of optimal organization of medical aid for MT casualties at the pre-hospital stage is reduction of time to qualified medical aid. Quality of the first aid is defined by a medical training of personnel and military paramedics. Special attention should be paid to a tourniquet placement. Experience of Chechen war confirmed earlier ideas that medical-evacuation infrastructure for different combat theaters will have different features. In particular, during Grozny assault in 1994-199. the qualified surgical help stage was deployed 2-5 km away from battlefield. Evacuation of casualties to this stage was carried out, as a rule, by specially equipped APCs. This allowed avoiding secondary damages. Later, during elimination of guerilla units in the mountain areas, the evacuation leg was at least 40 km and airlift was main evacuation tool. This allowed maximal reduction time to a stage of the qualified surgical help. According to our data, 4.6 % MT casualties received the qualified surgical help within first three hours. Airlift evacuation also allowed reducing terms of evacuation from qualified surgical help stage to regional hospitals, away from the combat theater. Criterion of evacuation in these hospitals was successful completion of anti-shock therapy. Mandatory condition of successful evacuation was transportation of all heavy casualties, accompanied by the medical personnel with supporting therapy en route to eliminate consequences of massive hemmorhage, coma, heart-lung failure.

8.3. ORGANIZATION AND PRINCIPLES OF LIGHT WOUNDS TREATMENT

A peculiarity of mine damages casualties pattern is the significant number of casualties with light wounds. This circumstance attracted attention of many medical experts. Alongside with necessity to solve some specifically surgical issues, the following questions need answers as well. The modern concept of medical support of walking wounded as a special casualties group, provides: earliest separation of walking wounded and rendering of exhaustive medical aid;
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 optimal distribution of walking wounded through the medical aid stages; earliest possible rendering of specialized medical aid, if required; early start of rehabilitation therapy to provided earliest possible returning to the ranks. Complete implementation of this approach is possible only in case special infrastructure for treating walking wounded, including evacuation stages, starting with the first aid and through the specialized aid. If organization medical aid questions (including qualified aid) are resolved, the defining stage of the specialized aid demands research and discussion. Nowadays, walking wounded are defined as personnel, received uncomplicated gunshot or mechanical trauma, and temporarily incapacitated. The treatment of walking Walking wounded do not include casualties with cavity wounds, joints and an eyeball wounds, fractures of long tubular bones, damages of the main blood vessels and nervous trunks. Among the factors determining light wound, it is necessary to note that: low kinetic energy of a projectile (penetration of bulletproof vest, armor, ricochet, initially small velocity and weight); light wound, inflicted by a fragment with high kinetic energy is possible only in case of gutter wound or surface wound; large distance from an explosion center, causing isolated damage by a single factor (fragment) and not involving blast wave, fire etc The attention to this casualties class is caused by their massive presence (51-5.2 % in casualties pattern during Chechen republic campaign 1995-199. and 5.3 % during anti-terrorist operation in Dagestan in 1999), a potential for fast recovery and returning to ranks. The share of walking wounded in the general casualties pattern during the different operations period can differ. If made up, e.g., 58 % during initial stage of fighting and went down to 43 % at the final stage of armed conflict. One of the trends observed in the comparison of light wounds structure in two armed conflicts on Northern Caucasus is the decrease both in general number of casualties who suffered from the explosive ammunition and reduction of the multiple and associated fragmentation wounds part (Tables 8.15 and 8.16).

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Table 8.15 The structure of battle injuries and traumas in the slightly wounded by the wound form and type (the 1995-1997 Chechen campaign data) Type of wound (%) Form of wound and trauma Total isolated multiple associated combined Wounds, including: 30.7 29.9 25.7 86.3 19.9 0.7 20.6 bullet wound 9.7 28.2 25.7 63.6 fragmentation wound 1.1 1.0 2.1 mine wound Trauma, including: 8.8 2.1 0.5 0.2 7.1 4.3 2.1 0.5 0.2 7.1 mechanical trauma 3.7 1.1 1.0 5.8 burn trauma 0.8 0.1 0.9 frostbite Total: 39.4 32.0 27.3 1.3 100.0 Table 8.16 The structure of battle injuries and traumas by the wound form and type (The Chechen campaign of 1999-2000) Type of wound (%) Form of wound and trauma Total isolated multiple associated combined Wounds, including: 41.8 4.3 5.6 1.5 53.2 15.1 0.4 0.2 0.4 16.1 bullet 26.3 3.9 5.4 1.1 36.7 fragmentation 0.4 0.4 mine Trauma, including: 33.5 2.2 9.4 1.7 46.8 29.7 1.6 3.8 1.2 36.3 mechanical 2.9 0.4 1.8 0.5 5.6 burn 0.9 0.2 3.8 4.9 frostbite Total 75.3 6.5 15.0 3.2 100.0 These facts can be explained by different military operational tactics of federal forces in the second campaign, better preparation of combat operations, and an attempt to reduce inevitable losses of personnel by every possible means. In the structure of slight wounds by localization, the wounds to limbs and head are rated first, i.e. those body parts not protected by personal protective equipment or armor. The comparison of the two last confrontations in the Chechen republic data testifies to the relative decrease of slight wounds of a head and the number increase of limb wounds (Table 8.17). Clinico-morphological peculiarities of slight fragmentation wounds feature the following: the wound channel is, as a rule, tangential, superficial perforating or superficial nonperforating;

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there are damaged preferentially soft tissues, less often short tubular bones (marginal, perforating, slightly comminuted fractures);

Table 8.17 The structure of slight wounds by localization The Chechen The Chechen Wound localization campaign of 1995-1997 campaign of 1999-2000 (%) (%) Head (including a skull and brain, an organ of 27.8 9.9 sight, maxillofacial area and an ENT organs) Neck 1.3 0.3 Chest 5.9 5.1 Abdomen 2.5 2.4 Upper extremities 24.0 36.9 Lower extremities 34.7 45.4 Total: 100.0 100.0 There are no symptoms of the circulatory disorder and innervation of places localized more distally than the injury spot or in its area; stable satisfactory state of the wounded through the first hours and days after wounding. The experience of medical aid and treatment of the slightly wounded in regions of combat operations and at technological disasters during explosions confirms that the first aid in the cases of slight wounds is rendered as a self-care (17%), mutual aid (22%) or by a paramedic and the surgeons assistant (15%). As a rule, during the first contact, a doctor checks applied bandages, homeostasis, and reinjects analgesics. The data presented in the Table 8.18 testify that more than 90% of the slightly wounded received the first aid in the first 30 minutes after being wounded. At the stage of medical aid the slightly wounded personnel receive aid in an evacuation or sorting tent. After examination, in the first place the expediency of homeostasis tourniquet application is estimated and, if necessary, continuing external hemorrhage is arrested by compressing bandage or other indicated method. Pain syndrome being severe, narcotic analgesics are introduced. Transport immobilization is performed using standard facilities All manipulations with the wounded are performed without removal of a bandage, and only if it is necessary the applied bandages are changed or corrected. To prevent of wound infection broad-spectrum antibiotics and tetanus toxoid are parenterally administered.
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Table 8.18 Distribution of first aid measures by terms of its rendering to the slightly wounded (%) First-aid treatment terms, minutes Accomplishment of measures in the specified periods (%) application of an aseptic dressing (first aid dressing kit) 15.4 68.0 8.2 2.3 0.8 5.3 100.0 injection of narcotic analgesics 17.8 55.6 23.8 0.3 0.8 1.7 100.0 homeostasis by application of a tourniquet 6.7 38.5 54.3 0.2 0.3 100.0 immobilization 1.5 10.3 38.1 28.0 13.2 8.9 100.0

Less than 10 10-20 20-30 30-40 More than 40 Terms are not indicated Total:

The slightly wounded personnel with the surface puncture, tangential and perforating wounds without signs of other injuries and with up to 5 days planned treatment terms can be left in the medical aid post of a combat unit. Such casualties do not require the solution of expert questions and having received medical assistance are sent to a rehabilitative team or dismissed for an inresidence outpatient treatment. The rest of the slightly wounded are administered with the following stages. Capable of moving slightly wounded personnel is usually among the first who arrive without assistance on the stage of the qualified medical aid. However, in connection with the strict requirements of triage and medicotactical environment they are last to receive the qualified surgical aid. One of the factors, protracting rendering terms of the qualified and specialized surgical assistance to the slightly wounded, is the priority evacuation of the seriously wounded and seriously ill patients. Regarding the slightly wounded, field surgeons apply the principle of their accumulation up to the ambulance transport capacity, and this can delay the evacuation of the slightly wounded by 8-10 hrs. According to the conflicts experience in Northern Caucasus, about 55% of the slightly wounded are delivered for the stage of the qualified assistance within 6 hours after being wounded, and 30% more within the first day. Medium terms of the qualified assistance for this class of casualties made 7 hours. It is necessary to mention that the first to be delivered to the qualified aid stage (within first 6 h
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after wounding) included casualties wounded in a head (82%), neck (65%), abdomen (85%), chest (57%) and spine (45%). Wounds of these localizations allow the slightly wounded to move without assistance, but cause the greatest anxiety to the first contact doctors and require the intervention of functional specialists (the ophthalmologist, the ENT-doctor, the maxillofacial surgeon, the neurosurgeon). This is followed by the arrival of slightly wounded with limb injuries (hand and foot), requiring traumatologic aid, arrived. The third turn line, though being the most numerous, included casualties with slight wounds of limb soft tissues. 48-52% of the wounded of this class were delivered for the stage of the qualified assistance 24 h after receiving a wound. The qualified surgical aid starts from triage, when the slightly wounded are divided into the following groups: the wounded with tourniquets, continuing external hemorrhage, severe pain syndrome (this group is the first to be sent to a dressing room); those, who require the qualified surgical aid (initial surgical debridement, final arrest of external hemorrhage, etc.); the slightly wounded with an injury of a hand, foot and a head require, respectively, the traumatologic and neurosurgical help, therefore they only have hemorrhage arrested and are sent for the stage of the specialized assistance; the wounded with up to 10 days approximate treatment terms should be sent to a rehabilitative team or for the outpatient treatment. This group consists of patients with surface wounds of soft tissues without injury signs of large blood vessels and nerves. The contingent of slight-wounded can partially increase due to patients under 23-day observation in case of not penetrating wounds to a chest and a abdomen. After field surgeon is certain that the wound is not penetrating and the closed damages to internal organs are present, the wounded can be classified as light wounded. The obligatory requirements for the qualified surgical aid to the slightly wounded are bandage removal, wound examination, estimation of surgical treatment needs. This requirement can be neglected only due to mass load of the wounded, severity of other casualties state and confidence in the possibility of surgical treatment delay for some slightly wounded. According to the medical provision experience of combat operations in the Chechen republic during 1995-199. about one third of the slightly wounded was evacuated for a following stage without initial surgical debridement (ISD).
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Table 8.19 Description of the qualified surgical assistance to the slightly wounded (%) Wounds of The qualified surgical help measures soft tissues bones Initial surgical aid debridement terms Less than 6 h 15.5 18.7 6-12 h 61.1 71.4 More than 12 h 23.4 9.9 Initial surgical debridement 48.5 68.7 Anesthesia Local 84.7 74.6 General 15.3 25.4 Foreign bodies removal 38.4 87.7 Paravulnary introduction of antibiotics 41.1 67.4 Wound drainage Rubber stripe 58.3 35.4 Rubber tube 9.3 28.4 Gauze wick drain 32.4 36.2 Method of wound closing Open management 71.3 84.2 Stitching 3.3 3.4 Combination 25.4 12.4 Immobilization A dressing-cloth 64.7 41.5 Plaster bar 35.3 58.5 Table 8.20 Specialized surgical assistance to the slightly wounded Organizational measures of the specialized surgical aid Term of delivery for the next stage: Less than 3 days 3-5 days 6-10 days More than 10 days Conservative Operative Combined Neurosurgical Dental ENT Ophthalmologic Trauma surgery Surgical Purulent Other Soft tissue wounds (%) 87.2 5.8 4.6 2.4 58.7 37.0 4.3 2.4 11.0 6.7 1.2 10.1 58.7 2.8 7.1 Wounds with bone injuries (%) 75.9 21.4 2.7 8.2 67.3 24.5 1.2 6.4 1.2 0.5 68.7 8.2 12.0 1.8

The specialized surgical help measures: Departments, where the specialized surgical help were rendered:

The analysis of the specialized surgical assistance to the slightly wounded with explosion injuries

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have shown that they were divided into two groups: the first group consisted of casualties with soft tissue wounds, the second one included those with gunshot fractures. It is necessary to mention that within the first three day about 90% of all slightly wounded were sent for the stage of the specialized assistance and distributed between departments regarding wound type (Table 8.2. 8.21). Thus, practically 70% of patients with mine and fragmentation wounds were located in the Trauma surgery department. More than 40% of the wounded with soft tissue injuries and 90% with gunshot fractures had surgeries performed. Soft tissue wounds required preferentially initial surgical debridement with blocking anesthesia. In cases of gunshot fractures, general anesthesia was preferred. Surgeons used general anesthesia to plastic and reconstructive operations. For the most part, they performed free skin grafting, rough scars excising, neurolysis, tendon grafting and stitching, various kinds of osteosynthesis in cases of fracture, etc. Among peculiarities of operative interventions at this stage, it is worthy to mention the necessity of the instantaneous exhaustive surgical aid. 24.7% of wounded with soft tissue injuries and 5.4% with gunshot fractures did not have ISD performed on them at previous stages. These patients, as well as the other wounded, having respective indications, received various types of wound surgical treatment. Table 8.21 Range of specialized measures for the slightly wounded
List of specialized measures Wounds with Soft tissue a bone injury wounds (%) (%) 24.7 5.4 13.2 21.8 5.3 7.2 22.9 7.4 71.4 23.2 5.7 69.4 72.3 42.4 21.1 38.7 6.6 18.9

Type of operative intervention: Anesthesia: Type of operation: Specialized measures:

Rehabilitation:

Primary Secondary Repeated local block general ISD Plastic Reconstructive intravenous introduction of antibiotics under two cuffs lymphotropic introduction of medicines laserotherapy oxygenobarotherapy medical physical psychological

61.7 25.3 13.4 7.4 100.0 71.0 32.4

81.4 48.5 18.7 38.4 100.0 68.5 34.1

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60-80% of cases, particularly at hand injury, required intravenous introduction of antibiotics retroactively. 25-50% of the wounded were administered endolymphatic introduction of antibiotics. All wounded, regardless of a state and admission terms, had rehabilitation measures administered on the stage of the specialized surgical aid, including physiotherapy and exercise therapy with gradual increase in load and the work therapy. Among all available methods of temporary hemostasis the tourniquet application was favored quite often for no valid reason. Thus, it led to ischemia of distal limb segments that prolonged wound healing and contributed to the development of some complications. Reduction in efficacy of initial surgical debridement or failure to execute it in proper period also had an adverse effect on wound treatment terms and outcomes. At the same time, ultraradical extent of ISD has to be admitted as irrational. For the observed class of casualties this kind of approach led to formation of skin defect, requiring further plastic operations. However, these defects were rare enough due to experience accumulation by surgeons of early stages and introduction of common treatment policy of casualties with gunshot and explosive wounds. Among complications, at the stage of the qualified surgical assistance wound abscesses predominated, developing in 26.2% of wounded after surgical treatment and in 31.5% at conservative wound management (Table 8.22). One of the arguments in favor of early ISD execution are numerous wound abscesses in casualties wounded in hand and foot. Renunciation of surgical wound debridement with only hemostasis execution and application of aseptic dressing followed by immobilization resulted in significant increase of suppurative complication in comparison with wounds of other localizations. The second most frequent complication was improper or unreasonably protracted
immobilization of limbs. In 38.4% of cases, three-week straighten fingers fixation caused joint

stiffness. Early immobilization of the wounded with an ankle joint fixed with plaster boot in 18.5% of cases doubled terms of joint movement full recovery. Complications occurrence after treatment at the stage of the specialized surgical assistance is noticeably rarer (Table 8.23). At the same time, soft tissue wound abscesses and osteomyelites at gunshot fractures dominated the structure of complications at this stage 10.2% and 13.4% respectively. At the formation of the hypertrophied scar, main efforts were aimed at its softening
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in combination with therapeutic exercises. Table 8.22 Distribution of complications in the slightly wounded at the stage of the qualified surgical assistance Wound Wound abscess Wound ncorrect and Suture Skin localization in after dehiscence, its protracted sinuses defect soft tissues immobilization Wound marginal necrosis ISD sanitation Head Neck Chest Abdomen Pelvis Spine Upper extremity Lower extremity Average values: 14.1 8.7 25.7 32.4 30.7 24.4 35.4 38.1 26.2 20.4 9.9 38.1 34.5 35.6 28.7 41.8 43.2 31.5
1.8 2.1 3.8 4.5 3.8 12.1 4.4 4.0

0.2 0.1 0.3 0.2 0.4 2.8 1.7 0.7

7.3 1.5 1.1

38.4 18.5 7.1

42% of the slightly wounded completed treatment at the stage of the qualified surgical treatment. Average treatment period without wounds complications in all localizations was 21 days; complications occurrence resulted in treatment protraction up to 30.1 days on the average. Upon treatment completion the assignment status of all wounded was not changed. Table 8.23 Complications occurred in the slightly wounded after treatment at the stage of the specialized surgical assistance Type of complication Soft tissue wound (%) Gunshot fracture (%) Wound abscess 10.2 7.2 Suture sinus 2.3 4.1 Osteomyelitis 13.4 Hypertrophied scar 2.7 2.4 Total: 15.2 27.1 Other slightly wounded completed treatment at the stage of the specialized assistance. In the absence of complications terms of treatment turned to be analogous, while in their presence reached 27.3 days. The majority of the wounded (98.6%) also completed treatment at this stage without change of the assignment status. Thus, mass scale and perspectives of complete recovery and rehabilitation of military and vocational efficiency fully justify common practice that includes the allocation of the slightly wounded to a special category and special attitude to their treatment.
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Chapter IX DIAGNOSTICS AND TREATMENT OF EXPLOSION INJURIES

9.1. BASIC PRINCIPLES OF PRE-HOSPITAL EXPLOSION INJURIES TREATMENT
One of the main requirements of life-sustaining treatment in casualties with explosion injuries and their subsequent effective medical aid is proper and timely assistance at the pre-hospital stage. Treatment-and-prophylactic measures at the pre-hospital stage consist of the first aid measures rendered at the scene of an accident, and the measures rendered by medical or paramedical emergency teams at the accident scene. We will not now distinguish these two groups of treatment-and-prophylactic measures, but we should only mention that, according to our data, treatment and traumas outcomes were invariably better, if first aid at the scene of an accident was rendered by properly prepared medical personnel. First aid aims on the temporary elimination of causes, threatening casualtys life, and prevention of severe complications. The extent of medical aid rendered to casualties with explosion injuries at the accident scene, covers: termination of explosion to injuring factors and consequences impact on a casualty (removal from under the debris of a building, burning clothes extinguishing); temporary arrest of external hemorrhage by means of digital occlusion of main vessels, compressing bandages, tourniquet or a garrote from improvised means; elimination of asphyxia by clearing of upper respiratory tract from mucus, blood, foreign bodies, elimination of tongue falling back by changing of a body position or fixation of a tongue by pinning the tongue to the lip, artificial ventilation; anesthesic injection; application of protective bandage on wound or burn surface and occlusive dressing application at penetrating wounds of chest; limbs immobilization at fractures and massive tissue injuries with elementary methods, using standard or improvised means.
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Though competently and fully executed first aid measures are the indispensable condition of casualties successful treatment at the pre-hospital stage, however, first aid medical measures take priority. The reason is that timely elimination of factors, causing traumatic disease (massive hemorrhage, respiratory metabolism disorders, toxemia, severe pain syndrome, mental shock, vital organs injuries), and resulting disorders of the basic life-support systems constitutes one of the major treatment problems of victims with explosion injuries. It can be solved only with complex approach, undoubtedly starting at the pre-hospital stage. It is necessary to emphasize that intensive care division into preoperative preparation, anesthesia and postoperative intensive care is conditional. All these stages are subordinated to one purpose, merged by a common plan of treatment and are parts of complex resuscitation aid directed on delivering casualty from critical condition. While executing intensive care, stabilization of circulatory and breathing systems activity is reasonably given special attention. At the same time, it is necessary to consider that the level of arterial pressure, considered so far by many as a basic exponent of shock severity, does not completely indicate extensiveness of pathological changes, occurring in an organism at mine trauma. In Afghanistan, for example, in case of timely and high-grade emergency treatment at the pre-hospital stage and early evacuation, many casualties, including those with quite serious wounds and injuries and subsequent unfavorable clinical course of traumatic disease, were delivered to medical establishments with normal or insignificantly lowered level of systolic arterial pressure. And on the contrary, marked hypotension was quite often caused by severe cardiac failure due to heart contusion rather than by hemorrhage. This fact sometimes led to serious mistakes in selection of terms and extent of operative intervention, in substantiation of preoperative preparation and anesthetic management tactics. For victims with mine trauma their duration and particular content depend upon localization, character and severity of damages, the phase of shock (compensation, decompensation), level of hemorrhage and specific characteristics of an organism (age, associated diseases, mental and physical state, etc). The main task of this period lies in execution of most effective measures on improvement of central and peripheral circulation, gas exchange in lungs, normalization of acid-base balance. Irrespective of external respiration character, casualties in the state of shock always have hypoxia of the circulatory, respiratory or combined character. Therefore, all of them have inhalation of oxygen through mask or nose catheters indicated. At stage III shock and terminal state the
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spontaneous breathing should be replaced as soon as possible by artificial ventilation. It is necessary to exercise special care, as at multiple injuries there sometimes can be missed rib fractures and small lung lacerations, which clinically may not be manifested against spontaneous breathing. Adequate anesthesia, especially at chest and abdomen wounds, allows to take away breathing pain brake and to enhance lung ventilation. To relieve painful syndrome it is more preferable to use various alternatives of nerve block anesthesia with local anesthetics. At this, transmission of afferent input into the central nervous system is decreased effectively enough without suppression of the central neurohumoral regulation system. However, in connection with hypersensitivity of the wounded in stages II-III shock, in addition to the local anesthetics activity it is advisable to reduce a general dose of Lidocainum (Trimecainum) by 15-20% to prevent hypotension. Injured limbs wash and tourniquet control or removal is executed only after the onset of sufficient anesthesia. Note that, depending on a situation, to arrest hemorrhage at explosion injuries one of the following known methods can be used: compressing bandage application, hemostat application on a bleeding vessel in a wound, hemostatic garrote application. The hemostatic garrote at mine avulsions and fractures of limbs should be applied as close as possible to the place of injury. Compliance with this requirement allowed expecting better functional results after limb amputations. Experience showed that, as a rule, usually at first (in first minutes and even hours) after demolition there is no excessive arterial or venous external bleeding. Performed by us topographic- and pathoanatomical examinations of the amputated limb segments both in the wounded and experimental animals have allowed to detect significant vessel injury polymorphism at every studied level. Directly in the zone of avulsion there were observed bloodvessels ruptures, intimae detachment and torsion of large and medium arterial trunks, appearing like vessels damages at the traction mechanism of limb separation in peace-time practice. Morphological substrate of vessel damages in the injured limb, presence of shock with persistent vascular spasm, and circulating blood volume decrease in aggregate explains a phenomenon of excessive bleeding absence in the casualties with mine avulsions of limbs. From these positions, it is possible to explain the point of view of surgeons, arguing against hemostatic garrote
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application on similar wounds or imputing to a garrote ability to isolate an organism from the entering of tissue decay products into the general circulation. However, observing a big number of the wounded with mine limb avulsions and fractures in dynamics practically from a battlefield up to the determination of treatment outcome, we came to the conclusion, that application of a regular or improvised hemostatic garrote at prehospital stages of medical evacuation should become a rule rather than an exception. A timely and correctly applied garrote in such wounded has the following functions: safely isolates an organism from decayed tissues, which contributes to decrease of intoxication by their decay products; provides complete arrest of all kinds of external bleeding arterial, venous, capillary (two last kinds play the leading role in the formation of profuse hemorrhage in casualties with mine wounds); guarantees non-renewal of bleeding in the subsequent (during evacuation and transportation) as a result of central hemodynamic exponents normalization with the adequate antishock treatment background. Hemorrhage control in victims with mine wounds cannot be limited to hemostatic garrote application. In the majority of cases, the contact wounds inflicted during explosions are accompanied by extensive wounds of soft tissues of another extremity, perineum and pelvis. Combinations of one limb avulsion and the other limb gunshot fractures were quite frequent. Extensive wound surface with specific multiple lacerated skin wounds, injuries of subcutaneous cellular tissue and subjacent muscles is a source of continuous capillary and venous bleeding, which exceeds bleeding from the separated limb by duration and intensity. Due to this, it is problematic to achieve hemostasis by such well-known and safe methods, as dressing of the bleeding vessel in a wound or hemostatic clamp application. Therefore, at the pre-hospital stage the compressing bandage and the hemostatic garrote were used most frequently. Enforced high tourniquet application, including wounded with no arterial bleeding, provided complete exsanguinations of a limb and safe hemostasis, but it was paid sometimes by a high price. Consequently, during late rendering of the qualified surgical assistance to the wounded they quite often have lost also another damaged but not avulsed extremity. Efforts to save it in 36 hours and later after the tourniquet application were, as a rule, unsuccessful, and for some wounded man cost lives. At the same time the compressing bandage applied on a damaged but not avulsed limb (as a rule,
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with a grip of two segments) increased general hemorrhage, rather than provided arrest of the bleeding, absorbing blood from extensive wound surface. Medical service had no other means and methods to fight against external bleeding in victims with mine wounds. Assisting such casualties, every time it was necessary to solve the same question: Is it better to apply a tourniquet or to use a compressing bandage? seeing that the tourniquet provides a better chance to save the life of a wounded man, but also practically deprives him of his second lower limb in real circumstances. Meanwhile, the compressing bandage creates only illusion of the fight for the rescue of a wounded man and the other extremity not avulsed by an explosion. Thus, considering the special mechanism and character of mine avulsions and wounds, at presence of relative conditions it is necessary not only to monitor, but also remove applied tourniquet, while hemostatsis should be provided at relative possibilities and favorable circumstances by the ligation of bleeding vessels in a wound or hemostatic clamp application. However, these methods are practically impossible in the fight against hemorrhage in many victims. As a consequence, there can be administered repeated, but medically correct tourniquet application. Later, such victims are subject to urgent evacuation directly on a stage of specialized medical care, where the important problem, consisting of two indissolubly united purposes rescue of a wounded man and second, not avulsed limb should be solved. Basic antishock therapy, besides the fight against hemorrhage and provision of injured limbs complete immobilization, at the stage of pre-hospital treatment should constitute circular and other kinds of procaine block with antibiotics. In some cases at the significant damages of an extremity a field surgeon, assisting the victim with mine wound, should solve so-called transport amputation problem. This term is commonly defines a separation of the extremity hanging on a soft-tissue flap. Renunciation of this medical assistance or impossibility to execute it deprives a wounded man of effective transport immobilization, while the safe wound closing with an aseptic bandage transforms into a challenge. There is one of main field medical surgery provisions of the major importance in the pre-hospital stage measures system: each victim with bone fractures, avulsions and extensive limb soft tissues wounds should be transported with the safely immobilized extremity. There were such basic means of transport immobilization as Cramer's ladder splint (97%), Diterichs' splint (2%), and improvised means (1%). Efforts to achieve complete immobilization of all limb injured segments with multiple bone fractures due to mine injuries and wounds were unsuccessful. Due to extreme
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urgency this problem requires further development and prompt solution. Presented in this chapter data, conclusion and recommendations are based on personal experience of authors in treatment of explosion injuries in the local war circumstances, and on results of specially performed clinical-experimental investigations. It allows making the following conclusion. Explosion injury is a special form of the polytrauma with specific mechanisms of pathogenesis. Recommendations on assistance rendering and treatment of victims based on their concepts prefer the complex pathogenetically proved treatment-and-prophylactic measures, which are mostly accomplished at the pre-hospital stage. This fact tasks medical authority with precise organizational problems and their complete accomplishment is a possible key to a successful treatment of these victims.

9.2. PECULIARITIES OF THE INTENSIVE CARE AND ANESTHESIA IN EXPLOSION INJURIES CASUALTIES
Mine injuries, as mentioned earlier, are characterized by severe anatomic disorders. Character of morphological changes in tissues is rather diverse, but specific, which allows, in particular, to allocate the zone of an avulsion, crushing and tissue separation, the zone of contusion and the zone of commotio. From the anaesthesiologist-resuscitation expert position it is important to accentuate that if in the first zone destruction of tissues is irreversible, then in the second one focal irreversible changes occurs as a result of secondary circulatory disorders progression. The essence of changes in the third zone is reduced to the collateral structural damages of main vessels and peripheral nerves axons, accompanied by corresponding functional disorders, which, ultimately, aggravates morphofunctional disorders outside of the wound channel [Nechaev E.A., et al., 1994; Gumanenko Ye.K., 1997; Phillips Y.Y., Zajtichuk I.T., 1991]. In other words, if the zone of primary necrosis is characterized by presence of tissues that completely lost viability and, consequently, are a subject to removal during surgical treatment, then origination and prevalence of the secondary necrosis zone is affected by consistency of systemic and local defense reactions in many respects. Unfortunately, extensiveness of tissue destruction, significant hemorrhage which usually accompanies them, and the polymorphism of internal organs injuries cause the development of complex pathophysiological changes and the increment of the functional component importance
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in the general estimation of trauma severity. The so-called professional-ecological stress syndrome, developing in the casualties, participating in operations, significantly influences the adaptive mechanisms development and the wound clinical course [Novitsky A.A., 1994]. Listed aspects show that while treating such victims it is impossible not to go beyond the elimination of gross disorders in breathing and circulatory systems. Overall, efforts of the anaesthesiologist-resuscitation expert should be directed: on the one hand, on functioning optimization of all life-support systems, their functional failure elimination or prevention, normalization of postaggressive responses at the systemic level; on the other on the correction of microcirculatory disorders and metabolic processes, the damage prevention of cells and intracellular structures in the tissues, adjoining with the primary necrosis zone or the surgical treatment area. Certainly, the second problem cannot be solved before the first one. Moreover, this solution on the whole is based on the complex of measures directed on the leading of the wounded out from a state of shock. Nevertheless, today there is an opportunity to purposefully apply some methods, facilitating blood circulation and tissue trophism in a particular region (epidural and nerve blocks, regional infusion of solutions and agents, influencing vascular tone and blood flow or providing protection of a cell and intracellular structures from free oxygen radicals and various biologically active substances). The first problem can be optimally solved based on the traumatic disease concept, allowing to chain shock and pathological processes, developing in the postshock period [Erjuhin I.A., Tsibulyak G.N., 1996; Gumanenko E.K., 1995]. Value of such concept consists in the fact that it accentuates the so-called functional component of a trauma and aims the doctor not only on the particular anatomic injuries elimination, but also on the overall victims treatment, underlining the importance of resuscitation aid. It is necessary to note that experience in the war in Afghanistan raised a question about expediency of the wound disease allocation within the traumatic disease framework as its special form [Shanin Yu.N., 1989]. Although in the basis of body vital activity changes both in postwound and posttraumatic periods there are universal, nonspecific reactions, and differences in the functional state of casualties with a heavy mechanical trauma are quantitative rather than qualitative, such point of view has a right to exist. Nowadays, although not everyone shares it, the practice shows that the special homeostatic background in victims received a wound in combat circumstances, leads quite often
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to unusually severe postwound clinical course inconsistent with the character of present injuries. It is especially peculiar to the mine trauma. Such reaction is shaped by many pathogenetic factors, with basic of them being the nociceptive sensory input from plural focuses, hemorrhage from several sources, hypoxia of mixed genesis, early endointoxication, structural damages of various organs [Gritsanov A.I. et al., 1987; Shanin V.Yu., et al., 1993; Polushin Yu.S., 1995]. Specific factors of explosion injury lead to the faster and more intense clinical course of traumatic (wound) disease with a tendency toward quick emaciation and failure of compensatory mechanisms. The key moment of a shock for the observed class of casualties is the combination of circulatory, hemic (due to anemia) and pulmonary hypoxia. Namely, hypoxia and tissue hypoperfusion define disorders of metabolism, immune status, and hemostasis, lead to intoxications and, ultimately, cause the formation of the traumatic disease treatment program [Nechaev E.A., et al., 1994]. Resuscitation aid to the wounded from explosive devices can be effective, if a peculiarity of MT etiopathogenesis is considered. To suppress the severity and transience of pathological processes, it is very important to begin rendering this assistance as soon as possible, observing sequence and continuity at all treatment stages: while rendering first aid in a critical state at the pre-hospital stage, during preparation for anesthesia and operation, while executing intensive care during an operative intervention and in the postoperative period. And it is important to understand that division of intensive care into preoperative preparation, anesthesia and postoperative intensive care is quite conditional. All these stages are subordinated to one purpose, unified by one treatment plan and are parts of complex resuscitation aid directed on leading a victim out from a critical state. Basic first aid measures at the pre-hospital stage which can prevent development of disorders or facilitate temporal stabilization of life-support systems functionality at a critical state, are reduced, first of all, to the decrease of external respiration and circulatory disorders, and also to the pain elimination [Levshankov A.I., et al., 1993; Steward R.D., 1990]. Life-threatening respiratory disorders at MT can be caused by various factors. Most often, especially with accompanying craniocerebral wound or trauma, they are related to respiratory obstruction (falling back of tongue, accumulation of the blood, mucus, and vomit in oral and pharyngeal cavities, pharynx, larynx or trachea injury by explosive device fragments), brain compression by a hematoma. There is possible the occurrence of both open and closed pneumothorax . But basic damages are not necessary localized in the chest region all the force
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of an explosion can be directed, for example, on legs, and the hit of a small fragment can be enough to cause pneumothorax . With the purpose of the respiratory disorders elimination, depending on their cause and circumstances of assistance rendering, there can be applied simple (for example, Safars triple airway manoeuvre) and more complex (oxygen inhalation, trachea intubation, mechanical ventilation) maneuvers. Principles of their use are traditional. Circulatory disorders at the given stage are related, first of all, to hemorrhage, which can be quite extensive in mine blast victims. It is necessary to remember, however, that the external arterial bleeding, including the main vessels bleeding, at the extremity separation is usually stops soon. Therefore, it is necessary to control periodically a tourniquet and whenever possible exchange it with a compressing bandage. At the same time during the transportation of a wounded man the arterial bleeding can recommence. In this connection the tourniquet should be always within reach; usually it is applied on the injured extremity provisionally. This question is covered in the previous chapter. Whenever it is possible, intravenous introduction of crystal and colloid plasma-substituting solutions should be provided, at least in volume of 400-1200 ml (in proportion 1:. 2:1). It is better to avoid the use of vasoconstrictors that lead to disorders aggravation of microcirculation and tissue metabolism. Pain syndrome is usually treated by 2% Promedolum solution. However, wide experience of its use at the pre-hospital stage showed that this medication should not be considered as the agent of choice. Its intramuscular injection with a heavy shock background is, as a rule, ineffective, which requires repeated (up to 3-4 times) introductions. At the Promedolum intravenous use there often develops the significant respiratory depression. Analyzing effects of the other agents use with the purpose of anesthesia, we think that in the trauma place or during transportation it is expedient to use medications of the agonist-antagonist of buprenorphine type or one of inhalation anesthetics (trichlorethylene, methoxyflurane), delivered to a wounded man by means of portable analgesics injector (Trilanum, Tringal). If rendering assistance in a specialized vehicle or in a medical aid station (ambulatory), it is possible to additionally increase inhibition nociceptive afference with local anesthetics (nerve block anesthesia), considering hypersensibility of such wounded to their hypotensive effect (the cumulative dose should not exceed 200-300 mg of Lidocainum). During arrival of the wounded in the admission room of a medical establishment it is necessary to continue assistance (puncture and catheterization of the peripheral and, in some cases, even main vein; infusional and respiratory therapy, anesthesia, etc.) together with initial
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diagnostic activities (examination, physical examination, blood sampling for clinico-biochemical examinations, radiographic analysis, etc.). It is especially important for casualties in serious and extremely grave condition. Injured body segments wash, inspection or removal of a tourniquet applied on a limb can be performed only after the sufficient analgesia onset. According to our data, 52.4% of victims with MT required intensive care [Polushin Yu.S., et al., 1998]. It is very important that the anaesthesiologist-reanimator participates in the treatment of such casualties from the very beginning, especially in hospitals where there are no special antishock wards or reanimation ward in the admission department. Polymorphism of anatomic injuries (according to our data, every second victim with MT, requiring intensive care, can have fractures of the sternum and the costal skeleton of the thorax, every fifth heart hemopneumothorax or contusion, injuries of eyes, visceral and cerebral cranium bones, abdominal cavity organs, etc.) urges timely estimation of the functional condition severity. Unfortunately, practice shows that inexperience of the personnel and typical frightening view of damages quite often lead to bustling and hasty delivery of a wounded man to the operating-room without any examination and assistance, which is a gross error. On the other hand, there is also unjustified delay of the wounded in the admission department, execution of traumatic manipulations without the elimination of the pain syndrome (for example, removal of bandages, wound examination, frequent shifting from trolley to trolley). That is why the anaesthesiologistreanimator should get involved into treatment of such victims right after their arrival to the admission department and from his positions to participate in the definition of a leading injury, coordination of succession and terms of operations. If necessary, he may and should insist on the allocation of a wounded man in the intensive care unit, rather than in the operative-room to lead him out from shock and prepare for a surgery, or, on the contrary, on the temporary termination of detailed examination and performance of urgent surgical interventions (elimination of tense pneumothorax, arrest of heavy bleeding, etc.. Timing of the surgery beginning should be reasoned from the effect of a forthcoming intervention on further clinical course of functional and metabolic disorders. If a surgery cannot eliminate or considerably reduce pathogenetic factors, causing severity of patients state, then it should be performed after liquidation of shock manifestations or at least after hemodynamic and kidney function normalization. Continuing internal bleeding and the necessity of restoration of blood circulation in extremity main vessels are the only grounds for the urgent surgery with a shock background. In these
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cases, the wounded should be immediately forwarded from the admission department to the operative-room (or to the shock-ward, if it is available in the establishment). Although the time for preparation in such situation is limited, nevertheless, it is necessary to use it effectively for the preoperative preparation, continuing treatment started at the pre-hospital stage and in the admission department. After hemorrhage arrest and restoration of vascular potency it is expedient to suspend the operation to continue the antishock therapy, if necessary. Surgical treatment of wounds should be completed after stabilization of the state or at least as soon as a wounded man is out of critical condition (stabilization of the arterial pressure at a safe level). It is important to accentuate that simultaneous performance of surgeries in different body regions by several surgical teams in such casualties is objectionable. Surgery on majority of MT casualties should be performed after arterial pressure normalization and spontaneous restoration of diuresis. Usually, it takes from 1.5 up to 4 h. Only in certain cases, the preoperative preparation takes longer time. It is better to perform it on a warm bed in the intensive care unit, rather than on a cold operating table. It is possible to check a tourniquet here too and, if necessary, to start general anesthesia (to switch on the mechanical ventilation, to introduce an adequate dose of an analgesic, ataractic, etc.). It is important to note that for the wounded in general and especially for this class of the wounded the general anesthesia may and even should be applied long before the beginning of operative intervention. Duration and particular content of intensive care in a preoperative period in each specific case are certainly individual and depend on localization, character and severity of injuries, phases of shock (compensation, decompensation), source and level of hemorrhage, specific features of an organism (age, concomitant diseases, mental state, physical development, etc.). However, overall they are defined by leading symptom-complexes, and, first of all, by circulatory and respiratory disorders. Therefore, the preoperative preparation is directed, first, on the improving of central and peripheral circulation, gas exchange in lungs, and normalization of acid-base balance. Its main purpose consists in the maintenance of urgent adaptation mechanisms and increase of victims organism resistance to forthcoming surgical intervention. Though a surgery in the wounded allows reducing and in some cases absolutely eliminating the activity of the pathological nociceptive input focus originated due to a trauma, it is necessary to understand that it is itself an additional trauma. Its infliction with the background of the significant stress of functional systems and, in particular, regulation systems, can lead to the compensation reactions deterioration and condition aggravation.
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Basic elements of the preoperative preparation are infusion/transfusion therapy, respiratory support (oxygen therapy, mechanical or assisted lungs ventilation), anesthetizing and sedative therapy. All victims in the state of shock, irrespectively of its degree, should be treated with catheterization of the subclavian vein in order to provide, if necessary, high space velocity of infusion on the one hand, and on the other to have an opportunity to check the central venous pressure (CVP). CVP, as a result of complex interdependence of heart activity, vascular tone and circulating blood volume, allows to estimate adaptive abilities of cardiovascular system and thereupon to control the infusion/transfusion therapy pace. Favorable course of shock accompanied with gradual CVP increase with the arterial pressure normalization and tachycardia decrease background. Its sharp rise, especially in combination with persistence hypotension, testifies to predominance of venous return over cardiac output and development of acute heart failure. The latter can be caused by the impairment of contractile myocardium function due to metabolic disorders, originating in it at severe shock, and diminished myocardium response to catecholamins, circulating in blood. Moreover (and it is a distinctive feature of mine injuries), amyocardia is quite often related to heart contusion. It is important to bear in mind that myocardium injuries, distant or originating at a fall on stones, due to a hit against armor prominent parts at an explosion, sometimes accompany non-extensive wounds too. At the CVP increase up to 7-8 cm of water the infusion/transfusion therapy pace should be slowed down (if the arterial pressure allows), over 15 cm of water column cardiotropic agents should be added (dopmin, dobutrex, adrenaline). Whenever possible, heart function estimation should be supplemented with the examination of the central hemodynamics. Low circulatory minute blood volume or its prompt decrease during treatment despite volemic load (during 2-6 h) should alert, as it can be the manifestation of cardiac function decompensation. The retrospective analysis of the available data showed that, on average, preoperative preparation a victim in grade I shock requires 0.8-1.6 l of blood substitutes transfused, grade II shock 1.63.2 l, grade III shock 1.2-4.0 l. However, polymorphism of mine injuries manifestations urges an individual approach to the question on infusion/transfusion therapy amount. In some cases (for example, at the lower leg avulsion) it can be enough to transfuse 0.8-1.2 l, while in others 4-6 l. Ultimately, at shock in general and in this class victims in particular it is important not so much to restore proper volume of circulating blood, as to bring it in correspondence with the
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bloodstream capacity, to liquidate life-threatening hypovolemia, to provide the necessary level of vital organs blood supply and to reduce thereby the sympathoadrenal system stress. The content of infusion/transfusion therapy in each particular case is also individual. As a rule, it is possible not to go beyond the infusion of crystalloid and colloid solutions in the ratio 2:. 3:. plasma and protein agents. Hemotransfusion during preoperative preparation is warranted by standard criteria: decrease of hemoglobin concentration below 80 g/l, and of hematocrit below 30%. In this situation it is quite difficult to restore hemodynamic only by plasma substitutes infusion. At this stage of treatment it is important not only to solve a problem of circulating blood volume urgent restoration (the donated blood has no serious advantages over plasma substituting solutions), but also to influence its physicochemical properties to decrease viscosity, improve fluidity and conditions of capillary circulation. It is important to maintain plasma oncotic pressure; to prevent the phenomena of intravascular aggregation and microthrombotization; to enter pool erythrocytes into the active blood flow; to maintain water-electrolytic and acid-base balance. Hemodynamic disorders correction along with hypovolemia and microcirculation disorders liquidation provides enhancement of heart pumping ability and elimination of vascular dystonia. Strike blood volume rise due to preload increase is attained, first of all, by means of infusion/transfusion therapy. Heart rate decrease has certain significance too. Pulse fall is accompanied by bradydiastole that leads to better filling of ventricles by the blood and cardiac output increase due to the Frank-Starling mechanism. In this connection, coping with psychoemotional stress in such victims and elimination of pain syndrome contribute to the cardiac efficiency ascension. Vasodilators (alpha-adrenoblockers, ganglionic blockers) are administered to eliminate blood circulation centralization and to afterload decrease at the compensated shock (at the systolic arterial pressure of at least 100 mm Hg in the normotonics). Their doses and injection schedule are determined individually, proceeding from the cardiovascular system response to the medication test-doze introduction (2.5 mg of Droperidolum, 2.5-5 mg of Pentaminum). The systolic pressure decrease or tachycardia increase at this is manifestations of latent hypovolemia and specify the necessity of the infusion pace and volume amplification. If there is no hemodynamic response, an agent dose should be gradually increased to achieve the peripheral vasospasm elimination.
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At decompensated shock, when the arterial pressure drops below critical level and infusional therapy does not increase it, vasoconstrictors should be used. They, however, improve only external presentation, whereas microcirculation and metabolic disorders still increase. Therefore, vasoconstrictors should be used only as a last resort to support with their help the arterial pressure by 10-15 mm hg.col. above a level necessary for vital organs blood supply. There is a necessity of cardiotonic agents introduction to enhance myocardium contractile ability, mainly, at severe forms of shock, and at the deterioration of heart failure due to heart contusion. From the beginning, the prescription of beta-adrenoceptor agonists in small doses (for example, 2-5 mkg/(kg*min) of Dopaminum), providing cardiotonic and vasodilating effect, is more preferable. If necessary, drug dosage is increased, and in case of apparent tachycardia it is combined with adrenaline or completely replaced by it. For the wounded with grade II-III shock and in a terminal state it is expedient to inject glucocorticoids (Prednisolonum in a dose of 120-300 mg at once) to stabilize cellular and lysosomal diaphragms, decrease permeability of the vascular wall and kinins production, and also to increase sensitivity of adrenoreceptors to endogene catecholamins. On the principle that respiratory distress is observed at every stage of gas exchange, the oxygen therapy should be assigned a vital part at the stage of preparation for an operation. It is necessary to provide oxygen inhalation through a mask or nose catheters, and at the grade III shock or a terminal state to switch a wounded man on artificial or assisted lung ventilation. Before switching to artificial pulmonary ventilation (APV) in this class of the wounded it is especially important to make sure that there is no pneumothorax, because at multiple injuries it is easy to miss a chest penetrating wound with a lung injury which is not always clinically manifested with the spontaneous respiration background. Switching to APV, which is accompanied by the rise of the peak intrapulmonary pressure, can lead promptly enough to the increase of a tension pneumothorax and acute aggravation of wounded man condition. In this case even before APV it is necessary to drain the pleural cavity on the side of the injured lung or to transfer a valvular pneumothorax to open pneumothorax at least by the pleural cavity paracentesis with a thick needle. When the main injuries area is localized in the limb region, it is expedient to arrest pain syndrome with nerve block anesthesia. However, at extensive damages it does not seem always possible to completely eliminate pain. First of all, in this situation it is dangerous to introduce a full dosage of a local anesthetic, considering the danger of hemodynamic disorders aggravation
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after it is resorbed into the blood. Hence, it is better to use at once no more than 50% from the local anesthetic rated dose (300-500 mg of Lidocainum), potentiating its effect by non-narcotic analgetics. Second, sometimes it is difficult to obtain paresthesia while searching a nerve due to psychic excitement of a wounded man or, on the contrary, due to his depression caused by shock and numerous introductions of drug analgetics at the pre-hospital stage. It hampers identification of the nerve trunks localization and reduces efficiency of anesthesia; therefore, to simplify the search of nerves it is expedient to use special devices or electrical stimulation of nerve trunks, for example, with the ordinary portable pacemaker EKS-15-3 (frequency 90-120 Hz, current from 1.5 to 5 mA). In our practice of upper extremity wounds and traumas, we preferred to block the cervical plexus. For the lower extremities we blocked the sciatic nerve through an anterior approach not to traumatize a wounded man again while turning him on his side, and also the lumbar plexus via an inguinal approach. At extensive and associated injuries, even localized exclusively in the region of extremities, it does not seem possible to eliminate effectively pain by means of nerve block anesthesia. In these situations, prohibitively large dose of local anesthetics is required to block adequately all nerves, innervating this area. In such cases we selectively provide a local (nerve block) anesthesia of areas, originating the most powerful nociception stream, combining it with the intravenous introduction of non-narcotic (of Stadol type) or narcotic analgesics, despite danger of development of respiratory depression and other unwanted side effects of these drugs. Acidosis is corrected according to the standard rules, monitoring the acid-base balance. As various biologically active substances and, in particular, simple and complex peptides, nucleotides, glycopeptides, and humoral regulators have a vital part in the pathogenesis of shock; a protease inhibitor is injected (100-300 kIU of Gordox(aprotinin). Due extensive wound contamination, the antibacterial therapy needs to be started. It is rather important to saturate the blood with an antibiotic prior to the beginning of the surgical wound treatment. Restoration of diuresis should be achieved, first, via microcirculation enhancement, spasmolysis of renal vessels and increase of filter pressure. At this treatment stage it is expedient to refrain from diuretics use. Introduction of Lasixum is recomended only at the threat of acute renal failure due to long-duration circulatory disorder and massive crushing of soft tissues, and also at the apparent overload of lesser circulation. However, all of them are still introduced only after hemodynamic improvement. Spontaneous restoration of diuresis is one of the major signs of the
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adequate antishock therapy. Other criteria of treatment correctness include the increase and subsequent normalization of the arterial pressure, tachycardia abatement, positive, but not exceeding 10-15 cm of water CVP values, gradual decrease of general peripheral resistance, accompanied with color change and warming of skin, white spot symptom reduction up to 1-3 sec. The choice of an anesthesia method in casualties with MT is defined taking into account the injuries localization, severity of functional disorders, character and duration of an operation, and urgency of its execution. Depending on these conditions, various methods of the general and regional anesthesia are used. In our observations (1109 casualties) the initial surgical debridemenet of limb wounds was performed most often (68%), while laparotomy (14%), craniotrypesis (10%) and a thoracotomy (8%) were executed considerably less. In most cases there was only one operation, in 17% of cases two operations. In 2% of the wounded there were executed three operations one after another. Average anesthesia duration was 199 30 min [Polushin Yu.C., et al., 1998]. A variety of operations has defined the application of various anesthesia methods. General multicomponent anesthesia, providing intense selective analgesia by Fentanylum and maintenance of the neurovegetative component of protection by joint or separate introduction of benzodiazepine and small doses of the neuroleptic, is applied most frequently (4%). It was used for urgent operations irrespectively of injuries localization (except for drainage of the pleural cavity), during surgery in the region of visceral and cerebral cranium, on the larynx and trachea, during non-abdominal surgery, lasting more than 1 hour, provided there was unstable compensation of hemodynamic and respiratory disorders. Often enough (26%) surgeons applied general intravenous anesthesia with spontaneous respiratory, mainly ketaminic (96%). In 50% of cases Ketamine was combined with Seduxenum, in 26% with Droperidolum, in 24% with Fentanylum. The main drawback of the ketaminic anesthesia was frequent psychomotor agitation and lasting depression of consciousness in the postoperative period. At large numbers of the wounded it created certain difficulties for medical personnel. During a surgery, the motor activity of a wounded man impeded surgeons, and after that quite often caused negative reactions in neighboring casualties, especially when several people were delivered from the operational room simultaneously. Besides, in depressed consciousness the wounded could not coordinate their moves, and it impeded their transfer from a trolley on a bed, especially in wards with narrow passes.
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Regional anesthesia, complemented with systematic action drugs, was used only in 14% of the wounded. Mainly it was applied during operations on limbs, and not in the acute period of wound disease. It seems that there are no grounds to expect wide application of this method in casualties with MT, despite the recent appearance of some new local anesthetics. Epidural anesthesia at urgent surgeries was applied totally rarely (approximately in .5% of the operated), as it was very unsafe. And mainly it was used as a component of the general anesthesia in the wounded with associated abdomen wound. Epidural anesthesia practically was not applied as an independent method, unless there were small injuries of extremities. At extensive damages it was absolutely avoid not to add up to traumatization with consequent increase of pathological sensory input while turning a casualties on his side to install a catheter. Quite often, such casualties responded with the arterial pressure decrease even to their transfer from a trolley to a surgical table. Regarding the surgery as an additional aggression, it is important to emphasize that adequacy of the anesthesiology protection during any surgical manipulations in these patients should be irreproachable. Present-day notions about pain pathophysiology and formation of stress-reaction at the gunshot trauma determine regulations which are of fundamental importance for the substantiation of anesthesia tactics [Shanin V.Yu., 1993; Polushin Yu.S., 1997]. First, main efforts of the anesthesiologist should be directed on the afferent part of the reflex arch and to avoid additional activation of the mechanisms responsible for efferent input. Second, prevention of subjective sensations of pain does not mean the block of nociception with its pathogenic effects. Sense of pain elimination should be combined with the blockade of vegetative neuronal and motional components of nociception. Therefore, simultaneous management of deafferentation with the antinociceptive system activation can be considered optimal (combination of general and local anesthetics with analgesics). Third, throughout anesthesia it is important to avoid the depression of antinociception physiological mechanisms, which usually occurs while trying to achieve an adequate anesthesia due to its amplification by means of, for example, one inhalation anesthetic. Fourth, since actions of the surgeon in an operative wound are an additional trauma, it is necessary to achieve deafferentation and the antinociceptive system initiation before inflicting traumatic action (preventive approach to the patient protection). Thus, it is expedient to use a range of measures, facilitating the prevention of excessive overexcitation of peripheral pain receptors (prevention of the primary hyperalgesia), and also spinal and supraspinal nociceptive structures CNS (prevention of the secondary hyperalgesia). Hence, while executing anesthesia in
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the wounded, it is important to inject the next dose of an analgetic before the most traumatic stages of an operation, and not as hemodynamic signs of anesthesiology protection inadequacy occur, to use nonsteroidal antiinflammatory drugs before operation, to inject in the very beginning of anesthesia antikinin and antiprostaglandine agents. Fifty, it is necessary to emphasize once again that anesthesia during an operation in a critically wounded patient should logically continue the intensive care begun in the preoperative period. During anesthesia it is important not only to reduce or eliminate hemodynamic disorders and provide antinociceptive protection, but also to continue executing a plan of therapy planned after primary examination. This rule, on the one hand, determines applicability to anesthesia of all intensive care principles, and on the other accentuates once again the unity of the anesthesiology-reanimatology profession, at least regarding the traumatic surgery field. Among methods of a multicomponent anesthesia at surgical procedures in the wounded in the state of shock or at unstable compensation of hemodynamic disorders it is expedient to prefer the following modified kind of ataralgesia. Anesthesia begins with oxygen inhalation during 5-10 min and precurarization. Then, there are injected Seduxenum (10-20 mg), mixture of Fentanylum (8-10 ml) with Ketamine (100-150 mg); switch on artificial pulmonary ventilation (after neuromuscular] relaxants introduction). Analgesia maintenance is provided with Fentanylum (0.1-0.2 mg before traumatizing stages of a surgery, and also when signs of insufficient depth of anesthesia occur). During a surgery (after the bloodstream capacity is brought at least in relative correspondence with the circulating blood volume) Droperidolum is additionally applied (fractionally by 2.5-5 mg). At this, there are intended elimination of the vasospasm and enhancement of the peripheral circulation rather than neurolepsia achievement. Last introduction of Ketamine (which is usually added by 50 mg every 30 min) and Fentanylum should not be later, than 40-50 min before the end of a surgery. To decrease the kininogenesis activity and prevent primary sensitization right at the beginning of anesthesia the protease inhibitors are introduced (kontrikal at the dose of 30-50 kIU). Undoubtedly, this kind of anesthesia is not dogmatic. Some anesthesiologists, for example, prefer to induce anesthesia with barbiturates (1%-solution of thiopental sodium), to inject the basic dose of Fentanylum after the trachea intubation before the beginning of a surgery, and to provide the unconscious state with inhalation of nitrous oxide and oxygen (under the condition there are no apparent hemodynamic disorders). However, we assume this kind of anesthesia to be optimal, especially when there is no mass delivery of the wounded.
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It is necessary to consider that in most cases there are metabolic acidosis and hypovolemia in casualties. Therefore, even standard doses of barbiturates can inflict dangerous hypotension. In this connection they should only be slowly used in the form of 1% solution together with the supporting therapy. Despite the settled opinion on efficiency of Ketamine for initial anesthesia in patients with hypovolemia, it is necessary bear in mind that with the hemorrhage background, especially massive, it can abruptly decrease arterial pressure, dilate vessels, and have depressive effect on the myocardium. For initial anesthesia it is possible to use Sodium oxybutyrate too. In such cases anesthesia should be somewhat delayed. To avoid the hemodynamic impairment after the switch to the APV, it is necessary to remember that the excessive hyperventilation leads to hypocapnia, and the redundant respiratory volume impedes venous return. It can result in acute decrease of the arterial pressure. Provided there is non-compensated shock, the unconscious state can be produced with Sodium oxybutyrate (2-6 g) or Ketamine (50 mg every 15-20 min) instead of nitrous oxide apply. Moreover, such doses of Ketamine allow enhancing the adequacy of antinociceptive protection due to the excitatory amino acid receptors block (NMDA-receptors). It is expedient to provide the muscular relaxation with nondepolarizing muscle relaxants. At present there is a quite large selection of these relaxants. But it is necessary to remember that at severe shock the renal excretion of such relaxants is sharply retarded. Thereof, the muscular relaxation can be considerably prolonged. Multilevel character of anesthesia is provided not only by applying pharmacological means with different points of their influence. Optimizing effect on the anesthesia course is rendered by various kinds of local anesthesia (infiltration, regional). Consequently, it is not necessary to use maximum doses of local anesthetics, so the arterial pressure would not decrease. The premedication necessity depends on the general patients condition, the time passed since the introduction of the analgesic last dose, and a sedative agent used at the pre-hospital stage and during preoperative preparation. In case of need it is expedient to inject intravenously an analgesic in combination with a small dose of Atropinum (considering the pulse rate) before the beginning of anesthesia. Proceeding from the new data on pain formation mechanisms, it is reasonable to prefer nonsteroidal anti-inflammatory drugs to reduce primary sensitization intensity due to decrease of the activating influence of pain mediators and edema and inflammation modulators on peripheral nociceptors. Considering the high risk of vomiting with the subsequent aspiration of gastric contents into the
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tracheobronchial tree, all the wounded before a surgery should have their stomach emptied with a thick gastric tube. After that the tube is removed and installed again only after the intubation of a trachea. In addition, it is necessary to remember that the tube installation does not release from other measures to prevent a regurgitation (Sellick's maneuver, lowering of the surgical table head end). Recovery from anesthesia is executed according to a common procedure. Since the residual action of injected drugs is manifested in shock much more often and stronger than in common practice, forcing the restoration of spontaneous respiration cannot be allowed in such casualties. Extubation can be performed only when a wounded man in clear consciousness, he is able to execute simplest commands (to hold back breath, to squeeze a hand, etc.), when the muscular tonus is restored and spontaneous respiration is effective. When by the end of a surgery it is not possible to normalize the arterial pressure or heart rate exceeds 120 beats/min, marked anemia is maintained (the level of hemoglobin less than 100 g/l, hematocrit is below .30 l/l), it is better to wait a little with extubation. For such casualties the prolonged APV in the intensive care unit is indicated. During routine operative interventions or at the stable condition of a wounded man the method of the general anesthesia is selected on a common basis. During In the postoperative period, main efforts are still directed to liquidate the most dangerous systemic disorders and their sources, to eliminate tissue oxygen debt, to optimize metabolic manifestations of body stress-response to a trauma. At the same time, prevention and treatment of acute period complications of traumatic disease, like shock lung, of fat embolism, cardiac, renal and hepatic failure, disseminated intravascular clotting, and early sepsis gain special significance at this stage. Namely, at this stage the principle of disorders advance (preventive) therapy begins to play an extremely important part. For example, at the mine trauma, accompanied by the brain injury, the intensive care is aimed to prevent the development of meningocephalitis, diencephalo-catabolic syndrome, to timely normalize the cerebral blood flow. In casualties of this class, the possibility to reduce the secondary necrosis zone is also very important. Provided there are chest wounds and trauma, it is impermissible to let the acute respiratory failure progress, and the traumatic pulmonitis transit to the pneumonia. The major problem of intensive care in the patients wounded in the abdomen with internal organs injury consists in breaking the peritonitis pathological program as soon as possible, during its primary formation. Provided there is extremities injury, it is important to influence purposefully regional
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blood flow reducing the secondary necrosis zone and probability of suppurative complications. It means that resuscitatory tactics should be more active, than in selective surgery, and criteria for application of one particular intensive care method in some cases should be simply different, not only milder. While implementing the intensive care program in such casualties one cannot allow the functional systems stress to reach maximum; intensive care methods should be applied not only when there are signs of apparent illness, but earlier. Certainly, treatment should be conducted with regard to the leading pathogenetic syndrome and also to all other traumatic disease manifestations. As a whole, it provides further correction of circulatory system disorders, prevention and elimination of acute respiratory failure, reduction of traumatic toxicosis, correction of hemostasis disorders, prophylaxis of enteral failure, normalization of metabolic response to the trauma, prevention and treatment of wound fever. Considering this and vast diversity of mine injuries, high percentage of associated and multiple wounds among them, it becomes clear that the standardization of postoperative intensive care is impossible in this casualties class. Although always based on traditional approaches, it is always individual as applied to a particular situation. The intensive care program is constructed by the most rational combination of means and methods considering the leading pathogenetic syndrome and all manifestations of traumatic disease resulted from the mine injury. By the moment of the patients admission to the intensive care unit from operating-room the task of the life-threatening hypovolemia urgent liquidation, as a rule, is already solved. In the nearest postoperative period the necessity of qualitative hemorrhage compensation, maintenance of heart pumping ability, and enhancement of microcirculation is brought to the forefront. It is important to timely perform correction of water-electrolytic balance and colloid osmotic pressure. The failure of systemic hemodynamic in this period testifies usually to the development of irreversible shock, presence of the severe heart contusion or the injury of vasomotor brain centre. It is necessary to persevere in trying to restore of globular blood volume by the end of the first three day, as in later terms the possibility of donor blood rejection is raised because of the immunobiological status inversion. At the same time it is necessary to avoid whenever possible massive transfusions (more than 2.5 l of the blood per day), maintaining the necessary level of oxygen delivery to tissues during marked anemia by using the prolonged APV with high-oxigen mixture. Since the second day it is expedient to add Trentalum, heparin (klexan, fraxiparin) to enhance the blood fluidity. Cardiac glycosides are indicated to enhance contractile heart ability. However, if the heart is
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wounded or presumably contused, they can be dangerous to apply, so it is better to use small doses of -adrenoceptor agonists (Dopaminum, Dobutrex). If necessary, adrenoceptor agonists are combined with the drop-by-drop introduction of nitro drugs to decrease the afterload. To this end in the several wounded we applied the long-term epidural block (with the puncture level of Th5-6) by the introduction of the 2% Lidocainum solution at the dose of 5 ml every 2 h. Monitoring of the central hemodynamic via integrated body rheography (according to M.I. Tishchenko) has detected at this the distinct raise of the cardiac index as well as the decrease of the general peripheral resistance. Unlike direct, the distant heart injury at MT is extremely difficult to diagnose clinically, especially in the state of shock. During electrocardiographic examination there are usually detected only diffuse metabolic disorders. It is possible to suspect it because of the prompt heart failure development and its more severe clinical course, than it may be expected proceeding from injuries character, expansion of the heart border at radiological examination. Occurrence of various arrhythmias is also facilitates the diagnosis. In our practice we had to diagnose the heart contusion twice only after detection of small blood amount in the pericardium cavity (during auscultation in the heart region the "splash" noise could be heard). It is typical that at this the electrocardiogram had no serious changes. Thus, considering specific character of mine weapon injuring factors, there always should be suspicion concerning the probability of the heart contusion development, an especially provided there are upper extremity avulsions. Peripheral vasospasm decrease is achieved via introduction of neuroleptics, vitamin RR. To the same end, especially there are abdomen, pelvis and lower extremities wounds, it is possible to use the prolonged epidural block. Introduction of a comparatively small Lidocainum dose (5 ml of the 2% solution every 2-4 h) or another contemporary local anesthetic allows to achieve quite resistant regional sympatholytic effect without the arterial pressure decrease even in the most serious casualties. Gas exchange disorders can be caused by the direct injury of the external respiratory apparatus (the thorax skeleton damage, lung contusion, etc.); by derangement of its regulation central mechanisms (brain wound or trauma, the residual action of narcotics); by pain-related restriction of the chest excursion. Hypoxemia can be also the manifestation of microcirculation derangements in lungs due to circulation centralization; due to the embolia of pulmonary capillaries by demulsified fat particles, microaggregates and microclots from the transfused donor blood; due to perialveolar edema. Respiratory muscles atonia, resulting in the gradual
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deterioration of sputum drainage, microatelectasis due to the surfactant regeneration impairment, is also of great importance in the acute respiratory failure development. In this connection, measures directed on the prevention and treatment of gas exchange derangements are conducted in all victims with MT with or without thoracic traumas. In general, these measures provide mandatory oxygen inhalation during 2-4 hrs after extubation; respiration under the positive pressure; respiratory gymnastics, vapor and aerosol inhalations; stimulation of the cough reflex by the introduction of the mixtures, diluting sputum, into the trachea through the microtracheostomy. Assisted lungs ventilation sessions through a mask by means of usual APV machines (15-20 min every 2-4 h), also have a good effect, especially if there are lung contusions. More severe cases require permanent high-frequency lungs ventilation (using special equipment or FAZA-5 device) through the microtracheostomy with the background of maintained spontaneous breathing and, certainly, the APV. Ventilation regimen and parameters are selected proceeding from technical capabilities of apparatuses, the hypoxemia degree and subjective sensations of a patient. The research we have conducted in recent years [Polushin Yu.S. et al., 1998] has shown that, provided there is developing the acute lungs injury (distress-syndrome) in the wounded of this class, it is necessary to revise administrations for some artificial ventilation regimens use. Particularly, obtained data have demonstrated that the APV with the positive end-expiratory pressure allows enhancing gas exchange in lungs only temporary. At the same time, as it turned out, this regimen possesses obvious adverse effects, manifested especially clearly in casualties with the heart contusion. It results in the irregularity aggravation of ventilation, ventilationperfusion relations, and in the central hemodynamic deterioration, and sometimes in the development of lung barotrauma. All th above questions the expediency of this method application in the treatment of the acute lungs injury (ALI) in the severely wounded. The inverted APV regimen has certain advantages over the APV with the positive end-expiratory pressure. It facilitates the enhancement of gas exchange in lungs due to increase of ventilated and perfused alveoli number and decreases the quantity of those that perfused, but not ventilated. It is known that the lung injury at acute lung damages injuries is non-uniform: sections of edematous alveoli with compromised elasticity neighbor with functioning, but atelectatic ones, and on the way to them there are obstructive bronchi. It is considered that ventilation of such sections enables adequate gas exchange and allows gaining time. At the ordinary APV and with the positive end-expiratory pressure too, the gas mixture, owing to a short inspiration, does not go
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further than the obstruction and gets in its bulk to the edematous, emphysema-like inflated alveoli along bronchi that were not obstructed. Having extended the inspiratory phase, it is possible to expect the restoration of functioning of those lung sections which played the shunt role before, causing ventilation irregularity. Moreover, it is necessary to choose ramp-like (descending) shape of the gas insufflation stream curve, when the insufflation speed is maximum at the beginning of an inspiration. At this regimen, it is better not to use periodic double inflation of lungs, as during the inspiration in double volume the indices of medium and maximum pressures in respiratory tracts are sharply increased. Considering that at acute injuries of lungs the pulmonary tissue is already compromised, the excessive pressure rise increases the risk of lung barotrauma development. It is necessary to mention that this regimen, at first, is accompanied by temporary and insignificant deterioration and only then by enhancement of the central hemodynamics, and in the patients with the heart contusion too. Due to this, it differs favorably from the previous regimen, which leads to the progressing cardiac output decrease. At the same time, considering short-term aggravation of respiratory and hemodynamic disorders after the connection of respiratory cycle phases inversion, this regimen of ventilation should be used when breathing and circulation reserves are still sufficient. The criteria of abandonment of ordinary pulmonary ventilation during acute lungs injuries are: the oxygenation index is less than 150 at the APV with the 50% content of oxygen in respiratory mixture; lungs compliance is less than 40 ml/cm of water col.; the respiratory index increase is more than 1.0 and the alveolar dead space growth is over 35%. Transferring on the APV in the inverted regimen can be executed when the cardiac index is greater than or equal to 2.5 l/(min*m2) (even if it is provided by inotropic agents). The criteria for the transfer into spontaneous respiration are: normal levels of the oxygen partial pressure in the arterial blood at FiO2=0.35; heart rate drops below 120 beats/min; lack of hypotension and marked anemia (the level of hemoglobin is greater than or equal to 80 g/l, and the one of hematocrit 0.30 l/l). To eliminate the pain syndrome the prolonged epidural blockage is used. Provided there are chest and lower extremities wounds, Morphinum can be introduced into the epidural space along with local anesthetics (30 mg 2-3 times per day).
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In such patients, the pain threshold often sharply decreases. It necessitates to increase anesthesia, combining various methods (regional blocks, narcotic and non-narcotic analgesics); to resort to psychotherapy. It is important to exclude the hypopotassemia development, leading to the respiratory muscle weakness, to eliminate stomach and bowels swelling early. Normalization of metabolic response to trauma is attained in many respects by medical measures, providing enhancement of oxygen transportation to tissues, increase of its utilization by cells, optimization of tissue metabolism. Actually, these tasks achievement is provided with the entire course of previous treatment. Everything above-stated has to be supplemented with the importance of correction of acid-base balance and adequate energy provision (enteral and parenteral nutrition); it is also advisable to use agents, affecting the intracellular processes biotechnology (actoprotectors, antioxidants). To optimize local adaptive processes in the wounded with massive soft tissues and lower extremities bones damages it is possible to use the partial perfusion method along with regional anesthesia. For that purpose the femoral artery on the injury side is catheterized according to the Seldinger's technique, distally directing the catheter. Intra-arterially there are injected antibiotics, spasmolytics (complamin 10 ml of the 15% solution, Nospanum 2 ml of the 2% solution, Trentalum 5 ml of the 2% a solution); rheologically and osmoticly active agents (400 ml of rheopolyglucin, Mannitum 100 ml of the 30% solution), and also crystalloid solutions (200 ml of the Ringer's solution in 6 h). Moreover, great importance should be attached to the drugs order and infusion rate. Usually, we began with antispasmodic infusion, and then we injected plasma substitute, and finally an antibiotic. Almost all agents were transfused slowly (up to 20 drops per minute), only Mannitum was infused faster (but not in jet), trying to create the osmotic gradient and involvement of the fluid from hydropic tissues in vessels. Experience of such technique usage in 79 patients with extremities avulsions has shown its sufficient effectiveness. Efforts to solve partially the same problem were made using the hyperbaric oxygenation (HBO). At first there were attempts to place the wounded in the pressure chamber as soon as possible. However, as experience was gained, it became clear that usually, provided there is massive noncompensated blood loss and hemodynamics is unstable, casualties condition suddenly worsened in 10-15 min after a session. It was manifested as aggravation of respiratory and cardiovascular failure. Henceforth during the first day after heavy wounding this method was used rarely, unless the wounded had an injury of the main arterial vessels, after their wholeness restoration. Mostly
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it was used after the casualties condition stabilization, if extensive fractures were observed, and the risk of purulent-putrefactive and anaerobic infection development was very high. In most cases after 2-3 HBO sessions the necrosis zone was confined, the wound got clean and granulation tissue formed. The purulent-putrefactive infection, if present, was arrested. A special section of this manual is dedicated to this technique. While gaining experience in this class casualtys treatment, we also ambiguously solved a question on the extracorporal detoxication methods application (hemosorption, hemoultrafiltration). Considering the traumatic endotoxicosis role in the traumatic shock pathogenesis, at the beginning we attempted to use them as soon as possible within the next few hours after surgery. We did not obtain positive results, but the bleeding from tissues, exposed to surgical treatment, have always resumed. Later on, extracorporal detoxication methods were used only if late purulent complications have developed, accompanied by marked endogenous intoxication. Only those wounded were excluded who had along with extremities damages a penetrating abdomen wound with the injury of the large intestine. In this case, considering the high probability of adverse inflammation course in the abdominal cavity and aggravation of endotoxicosis due to the combination of causes, we conducted detoxication after 2-3 days. At this time moment, on one hand, protective-compensatory mechanisms have not exhausted yet, and, on the other, the post-shock toxemia has been aggravated by intoxication from the abdominal cavity and intestine, being in a state of paresis. We are far from thinking that our treatment experience of casualties with explosive injuries is exhaustive. At the same time, we suppose that it can be of use for everyone who even once will face the necessity to render assistance to mine casualties.

9.3. GENERAL DIAGNOSTICS AND TREATMENT PRINCIPLES OF MUSCULOSKELETAL SYSTEM INJURIES IN SOLDIERS WITH BULLET, FRAGMENTATION AND EXPLOSIVE WOUNDS
The military-medical statistics of world wars and large local armed conflicts, which took place in the XX century, convinces in invariable predominance of extremities wounds in the structure of battle sanitary losses of surgical profile from 54.1% up to 70.8% and more (Figure 9.1)

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Figure 9.1. Frequency ratio of extremities gunshot wounds in the XX century military conflicts, %. (1 World War II; 2 local wars abroad; 3 Afghanistan; 4 the Chechen Republic) The same statistics distinctly shows a stable growth tendency for wounds, inflicted by explosive ammunition (80%) and ratio decrease for bullet wounds (20%). Even taking into account further evolution of warfare (precision weapons, maximum time decrease of troops engagement or even complete renunciation of it), and also military personal protective equipment upgrading (helmets, body armor, footwear) the specified regularities will hardly change in the next one-two decades. Some decrease in the share of the wounded with extremity injuries in operations in the Chechen Republic (1994-1996) can be explained by the significant improvement of the entire medical care system, which allowed to lower sharply battlefield lethality among the wounded with head, chest, abdomen and pelvis injuries. As mentioned, during large local confrontations in the second half of the XX century, due to large-scale explosive ammunition use, development of warfare and other trends in armed struggle conducting, the rate of associated (25%) and multiple (26%) wounds has increased considerably. Isolated gunshot extremity bone fractures were observed in less than a half of the wounded (Figure 9.2). Therefore, the wounded with extremities injuries after their recovery constituted and will constitute the basic reserve of fresh forces, especially in a long-term or large-scale war. It is well known that the ultimate mission of the Armed Forces medical service during war years is to bring back in the shortest possible time the maximal number of wounded personnel - trained and experienced soldiers. Achievement of this interiorly integrated task is possible only via life
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rescue of the wounded and recovery of their health. To provide namely these three tasks achievement, the entire system of treatment-and-evacuation provision of the Army, Navy and civilians was created and operates now, both during war years and in various emergencies. That is why, merits and demerits of existing treatment methods should be estimated regularly, there should be held military exercises and scientific conferences on military medicine particular problems, where the new technologies efficiency in diagnostic and treatment of the wounded and patients has to be evaluated. The more profoundly and comprehensively the questions on medical care organization, combat traumas diagnostic and casualties treatment in peacetime are elaborated on, the lower costs the belligerent army medical service will be and its tasks will be accomplished more effectively.

Figure 9.2. General characteristic of bullet, fragmentation and other explosive wounds kinds in the wounded with gunshot fractures of extremity long bones during operations in the Chechen Republic in 1994-1996 [Ivanov P.A., 2002] Thus, the urgency of the extremities combat trauma problem is defined by the high frequency of gunshot fractures, which does not tend to fall; increasing frequency of associated and multiple wounds; recent marked trend to broaden indications to apply osteosynthesis current technologies in the of step-wise treatment system in the wounded; persistent relatively high frequency of unsatisfactory treatment anatomic and functional effects despite modern advances in treatment of the wounded; and also by lack of common and statutory application standards in external fixation of bone fragments in the wounded at medical evacuation stages (Figure 9.3).

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Figure 9.3. Mine wound with the avulsion of the left lower extremity at the knee level, gunshot fractures of the femur and lower leg on the right side, abdomen and scrotum wounds. The state of the wounded man after left femur amputation, laparotomy, external fixation of bone fragments by the Ilizarov device It can be proved with the following data: only 19.7% of the wounded with femur gunshot fractures returned to the ranks during World War II after the long-term and laborious treatment. Final effect of such casualties treatment was a little bit better in American surgeons during the war in Korea. It was facilitated by following factors: staffing all surgical assistance stages by specialists with the experience of treatment of the wounded during World War II; advent of intramedullary metal osteosynthesis among methods of treatment of the wounded and patients with bone fractures; wide practical application of antibiotics and endotracheal anesthesia in medical institutions; sharp reduction of the wounded evacuation terms from the moment of wounding to specialized assistance rendering; reduction in the number of medical evacuation stages. In the middle of the seventies, members of the Military Trauma surgery and Orthopedics Faculty of the Russian Medical Military Academy carried out the retrospective analysis of treatment outcomes in casualties with open, gunshot and closed extremity bones fractures aftereffects in the Armed Forces for 10 years (1961-1970). These results are presented comparatively in the Table 9.1.

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Table 9.1 Summarized results for wounded with bone fractures (%) Fracture site Returned to the ranks Decommisioned USA WWII USSR (peacetime) WWII USA (Korea) (Korea) Shoulder 33.8 69.0 44.0 52.8 27.5 Forearm 54.2 56.3 40.0 44.6 41.4 Femur 19.7 69.5 25.0 56.2 19.3 Lower leg 50.8 60.3 50.0 44.1 33.7 Average rate 39.6 63.7 43.2 49.1 30.4 The final treatment results of the wounded with gunshot extremity bones fractures during postWWII period (even corrected to the fact that the majority of them received close-distance gunshot trauma) appeared better than during World War II, but much worse than the data of American authors. Analysis of treatment anatomical results demonstrated that correct healing in optimal terms was achieved only in 50% of the wounded during treatment; false joints, delayed consolidation and fractures healed in an incorrect position were registered in 22.7%. Treatment functional results in the wounded with defined outcome were studied in two casualties groups: with infectious complications and with with no complications during wound process. They appeared to be unfavorable in the wounded of both groups, and frequency of significantly limited or failed function development was higher in patients with infectious complications of wound process, and, naturally, it affected the expert solutions results. The final treatment results in soldiers with open and closed multifragmental and comminuted extremity bones fractures were somewhat better, but still unsatisfactory. Broad-spectrum medical-statistical analysis of a considerable medical histories number stimulated the necessity of army surgical service reorganization and new medical technologies practical application in hospitals. The Trauma surgery service in the Armed Forces structure led by the Chief trauma surgeon professor S.S. Tkachenko was founded in 1970-1971. Its creation perfectly matched the onrush of this speciality in the country in the post-war period. Methods of an internal and external functionally stable osteosynthesis began to be intensive applied in the Trauma surgery practice. High emphasis in the trauma surgeons vocational training system was placed on the extrafocal transosseous osteosynthesis method. Scientific research and technical creativity resulted in development of several multipurpose and special external fixation devices; various appliances, gadgets, guiding equipment, wire fixators, reposition devices and field orthopedic tables, providing reposition and safe fixation of fracture
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fragments, a necessary degree of wire voltage, facilitating the optimal course of osseous tissue reparative processes. Fundamental research was of special important when preparing trauma surgeons to use external osteosynthesis during treatment of casualties with gunshot fractures of limb bones (bullet, fragment, explosive damages). The research encompassed the following areas: studying of wound ballistics peculiarities during gunshot fractures of a shin and femur, wounds of the patellar and talocrural joints inflicted by high and low velocity projectiles; defining indications and developing of general and specific requirements to exterior osteosynthesis devices; determining pathoanathomical and pathophysiological regularities in origination and course of a wound process during gunshot wounds of the soft tissues and fractures of limb bones, including their treatment; studying biological and ballistic features of extremities explosive wounds, inflicted by ammunition with new generation HE (plastic explosives); biomechanical and biological regularities of combat-related long tubular bones fractures formation and healing. Defining optimum areas and levels of spokes installation. By the end of 70th, i.e. when USSR intervened in Afghanistan civil war, extrafocal osteosynthesis took special place in the system of medical provisions for casualties with fractures of extremity bones. Advantages of an extraofcal osteosynthesis over other methods of casualties treatment are clear: small traumatic action, high level of fragments bracing stability, real opportunity to control fragments during a postoperative period and carry out the dynamic monitoring of wound healing process, opportunity to carry out reconstructively-regenerative surgeries and early activation of casualties while maintaining mobility in adjacent joints and faster regional blood flow and microcirculation. Faculty of military Trauma surgery and orthopedics department in the military medical academy has the clinical material amounting to treatment of more than 11000 casualties with gunshot fractures of long tubular bones in extremities. This clinical array is comprised by the casualties of operations in Afghanistan and Chechen Republic during 1st nd 2nd antiterrorist campaigns. Studying infrastructure of gunshot fractures has shown, that during these conflicts fractures of shin bones (4.1 %) predominated, fractures of femoral and humeral bones (2.8 % and 2.3 % accordingly) were twice less frequent; fractures of forearm bones compounded 1.8 %. Diaphyseal fractures dominated all segments, intraarticulate fractures were noted in 1.1 % of casualties.
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Frequency of large joints wounds was practically equal: patellar at 2.0 % of casualties, ulnar at 2.3 %, coxofemoral at 1.0 %, humeral at 1.4 %. Wounds of talocrural and radiocarpal joints (in .9 % and .4 % accordingly) were somewhat less frequent. Modern concept of extremity wounds treatment is based on all factors, influencing the general state of an organism, a wound process and military-medical outcome. Nevertheless, the wound process was and remains major dynamic component of a gunshot wound, influencing anatomical and functional effects of casualties treatment outcome. Performed studies showed that the major factors influencing a wound process are: Volume and character of segment tissues damages; initial health condition of casualties in the stressful circumstances of combat operations and organism response to a wound; medical care organization in the specific local conflict, rendering of a pressing medical care at the forward stages and final casualties treatment in hospitals at the stage of a specialized medical care; scientifically proven complex programs of casualties rehabilitation depending on wound sickness course and reorganizations of an osteal tissues with respect to specific features of an organism. The volume and character of tissues damage are preprogrammed design features of the modern projectiles and explosive ammunition, laws of wound ballistics and anatomical constitution of a human body. They form under action of a projectile kinetic energy, transmitted to tissues, or a damaging blast effect. As the mankind did not come up with individual means of limbs protection, physicians can not influence this component of a bullet wound.

Fig. 9.4. Typical wounds extents Established laws of wound ballistics allow to isolate following clinically significant parameters
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of modern gunshot osteomuscular wound. 1. Zoning of morphofunctional disorders including: wound channel; zone of primary traumatic necrosis; zone of molecular contusion (a bruise of tissues) or microcirculatory derangement. 2. Microbial contamination of wounds all bullet wounds are initially microbially polluted. So, Gram-positive aerobes were isolated from wounds in 6.1 % of observations (mainly staphilococcuses and a fecal streptococcus). Gram-negative aerobes were diagnosed for half of casualties, predominantly enterobacteria (2.4 %) and Proteus (1.8 %). 3. Extensiveness of soft tissues wounds, preferentially in the exit zone during perforating bullet and fragment wounds. Extensive primary damages to soft tissues (up to 200 cm2), were noted in 1.6 % of the casualties, limited wounds (up to 20 cm2) in at 4.3 % of casualties (Fig. 9.4). 4. Higher frequency of direct and distant damages to the main vessels and nerves. E.g., during operations in the Chechen Republic (1994-1996) 1.1 % of casualties suffered gunshot fractures of bones, accompanied by the damages to the main arteries and 3.6 % damages of large nerve trunks [Ivanov P.A., 2002]. More often, damages to arteries were diagnosed during gunshot fractures of forearm bones (2.4 %), almost twice less often during fractures of shin (1.1 %) and a femur (1.8 %) bones. 5. Essentially important parameter describing a gunshot osteomuscular wound, is a comminuted character of gunshot fractures with intraosteal and periosteal vessel network disorder. Study of fractures character showed that 7.0 % of the gunshot fractures gained at wounds by the up-to-date views guns were of comminuted (3.4 %) or fractured (4.3 %) character. Primary damages to the bones were registered in 1.9 % of casualties, and 4.7 % of them exhibited damages to diaphysis during longer than 3 cm, and 3.6 % longer than 5 cm. At the same time, experimental studies stated and confirmed in a clinical practice, that the majority of osteal fragments maintains communication with the soft tissues. Moreover, their high biological fastness and preservation of potential ability to an osteanagenesis of even free osteal fragments [Gololobov V.G., 1999]. It would be contradicting to historical facts to state that during last 50 years military surgeons managed to depart from a preferential value doctrine in evaluating final outcome of bullet wounds treatment of bullet wounds, inflicted by the ballistic projectiles and anatomical damage to tissues. Since the middle of XIX century, rapid progress in natural sciences and industrial production, modernization of weaponry using novel small arms and artillery, have seriously
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improved warfare and character of inflicted gunshot wounds. Perennial and multifactor study of a bullet wound led to determination of its two principal features, which distinguish a bullet wound from all other wounds. It is necessary to underline that both of these features: each bullet wound is primarily microbial polluted; presence of a bruise region or the molecular percussion of tissues have strongly pronounced biological substance, including a timed response of a wound repair processes to infectious wound complications. The gap between two world wars resulted in development of a leading medical methodprimary surgical treatment of bullet wounds for the majority of casualties. If exercised correctly, this method reduces sharply microbial contamination of a wound and maximizes helping organism in biological purification from the foreign subjects and the dead tissues. At the same time, the same historical truth, forces to recognize that only during local wars, pertinent to second half of XX century (Korea, Vietnam, Afghanistan, Chechen Republic, etc.) military surgeons and other medical specialists started to pay attention to biological aspects of a problem: physiopathology of bullet wounds, general derangement of a homeostasis and, in particular, circulation in the injured extremity segment, i.e. varying factors, characteristic for the gunshot wounds. Technical search in this direction was favored by the economical and technical conditions and organizational innovations in the medical-evacuation infrastructure, characteristic for large countries involved in local conflicts. Countries like USA (wars in Korea and Vietnam), USSR (war in Afghanistan, antiterrorist operations in the Chechen Republic). Involvement of powerful armed forces allowed realizing for the first time a bicentennial dream of all military surgeons providing specialized medical care to casualties in the shortest terms. The goal was attained by the diversified methods and forms of military medical service operations: 1. Maximal possible use of the medical ships, operating as versatile specialized hospitals where casualties were delivered by helicopters immediately from operations regions (Vietnam). 2. Staffing qualified medical aid stage, especially during large-scale combat operations, by specialized teams from the stage of specialized medical aid stage. Conversion of main 40th Army hospital in Kabul in multiprofile specialized medical care facility, accepting wounded airlifted from the frontline (Afghanistan). 3. Placement of hospitals and special medical teams at the operations theater perimeter, enhanced
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by the specialized teams from Central Military Hospital and Military Medical Academy. Large flow of casualties during first Chechnya War (1994-96), after rendering first aid, was airlifted to Mozdok, Vladikavkaz, Buinaksk. Overload of front-line medical facilities of a specialized medical care stage was eliminated by well-timed evacuation of casualties. Echeloning of a specialized medical care stage was enacted. Armed forces used these tactical approaches in Vietnam and Afghanistan as well as on Northern Caucasus. Local wars of last 30 years provided a real opportunity to ultimately preserve casualties lifes by rendering specialized medical aid to majority of casualties during the first hours (not days) through the primary surgical treatment of gunshot extremities wounds. Prerequisites of this approach are: 1. Early airlift of casualties after immedicate medical assistance from a frontline to the specialized medical care stage, bypassing a stage of the qualified aid. 2. Comprehensive diagnostics of all damages and functional derangements, including X-ray imaging and laboratory examinations, involving qualified specialists. 3. High-grade anesthesiology and resuscitatory casualties provisions, transfusion and infusional therapy, adequate drug usage. 4. Adequate supplies of orthopedic and traumatologic devices and devices for a repositioning and bracing of fragments. 5. An opportunity to hold certain number of casualties in the first stage hospitals in order to monitor course of a wound course and accomplishment of necessary surgical treatment. Zone of gunshot wound molecular concussion, naturally, drew close attention of field surgeons, trauma surgeons-orthopedists and other specialists, involved in modern military medical care. Successful treatment of tissues in this zone influences course of a wound process and treatment outcomes. Consequence of an extremity gunshot wound, even with no damage to large vessels, is well known to be disorders of hemocirculation and hypoxy in the paravulnary tissues, injured segment and an entire extremity (Fig. 9.5). In aggregate, they lead to ischemia of mainly muscular tissues and necrotic processes acceleration in gunshot osteomuscular wounds (Fig. 9.6).

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Fig. 9.5. Posttraumatic adapted (pathological) response of system of a circulation (redesign by A.N.Erohov, 1999) Using adequate immobilization after removal of pain syndrome and administering proper drugs, directed on local circulation and microcirculation correction, surgeon can significantly reduce zone of microcirculatory derangements. Studies and experience proved that every casualty needs this kind of treatment.

Fig. 9.6. Local microcirculatory derangements diagram[Shapovalov V.M., Erohov A.H., 1999] The general health state of casualties in extreme conditions, during of real operations in Afghanistan and Chechen Republic was characterized by overworking, malnutrition, psychological stress, unsatisfactory sanitary conditions and functional hormonal disorders. These
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factors manifested in decrease of resistance to infectious diseases and predisposition to evolution of a surgical wound infection. General condition of a wounded essentially affects the wound process as a whole, in addition to local adaptation and pathological processes. These factors include hemorrhage, a hypovolemia, an endointoxication, various alternatives of coagulopathies, and for heavy wounds multiorgan failure. Character and depth of systemic hemodynamics derangement is basically determined by hemorrhage volume and pecularities of neutralization. Insulated gunshot bone fractures are known to be accompanied by the significant medial hemorrhage: femurs to .5-.0 l, shin bones up to 800 ml, brachiums up to 500 ml. In multiple fractures, wounds to the main vessels and limb segments avulsions it can exceed .5.0 l. At the same time, the decompensation of circulatory system of a circulation and clinical shock do not develop in all extremities wounds. In case of isolated femur gunshot fractures, shock was observed only in 40 % casualties, shin bones in at 24 %, humeral bone in 18 %, and for multiple fractures in at 4950 % casualties. These issues determine wound sickness course in these casualties, mainly, in three functional body systems: detoxication, an immunogenesis and hemostasis. Thus, hypoxia plays a key role in all of the above processes. The state of patients with extremity wounds without shock attributes is characterized by a systemic hemodynamics instability. Any additional trauma, including surgical intervention provokes decompensation of both local peripheral and a systemic circulation. This pathogenetic factor is rather important. It should be accounted and corrected in system of casualties complex treatment. Treatment provisions of casualties with gunshot fractures are as follows: 1. Early and adequate shock treatment and other manifestations of wound sicknesses (final stop of an external bleeding, liquidation of a hypovolemia and anemia, correction of metabolic disorders and endointoxication). Surgical interventions are counterindicated for casualties in severe condition because of massive hemorrhage and labile hemodynamics. 2. Correction of regional circulation and microcirculation disorders, including a decompressive fasciotomy, dehydration of tissues by osmotic means, infusional, including endarterial, therapy by specialized medical equipment, full-scale drainage. 3. Conducting, when indicated, preserving primary surgical treatment of an osteomuscular wound, meaning low-traumatic removal of large foreign bodies and obviously nonviable destroyed tissues.
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4. Inhibition of pathogenic microflora in a wound. 5. Full-scale limb immobilization, local hypothermia, treatment by antyhypoxants and stimulants. These positioned comprise mainstay of modern concept for preserving surgical treatment in casualties with gunshot fractures of bones of extremities. Studies of medical aid at the stages of medical evacuation revealed essential influence of wound sickness prevention on general outcomes of treatment. Primary surgical treatment was and still is basic medical provision preventing evolution of a wound sickness in osteomuscular wounds. This surgery is directed on removal of nonviable tissues and foreign bodies, diminution of wounds microbial contamination maintenance of optimum requirements for congenial course in a wound process. Note that from general biology standpoints, considering dynamics of necrotic processes in the molecular shock region, it is not always possible to attain congenial wound healing by conducting early, exhaustive and single-time treatment an early primary surgical treatment, as the rule, appears shallow and is usually performed 4872 hrs after the wound, which is too late. Moreover, the primary surgical treatment is counterindicated for 40 % of casualties with extremity wounds, in particular, in case of: plural point and larger wounds (with no foreign bodies) with no hematoma build-up and disorder of peripheral circulation; uncomplicated traversal, frequently comminuted, gunshot fractures of bones without shifting fragments and small wounds to the soft tissues; perforating wounds of large joints without damage to jointed bones. In these cases wound and integuments are sanitated by antiseptic solutions, paravulnary infiltration by antibiotics, adequate infusional therapy and a full-scale extremity immobilization. The primary surgical treatment is shown for the extensive wounds to the soft tissues, including gunshot fractures and explosive wounds, wounds of large joints with damage to jointed bones, avulsions and destructions of extremities, wounds to the main vessels, punctual wounds in main vessel projections, accompanied by a hematoma build-up and peripheric circulation disorders, as well as during the evolution of early contagious complications in bullet wounds. Primary surgical treatment is conducted at the stage of qualified (specialized) medical aid after anti-shock therapy and under full-scale anesthesia through narcosis with conductory or, less frequently, local infiltration anaesthesia. Basic stages of a primary surgical treatment for a gunshot osteomuscular wound are:
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 wide dissection of a wound, but mainly exit point, with economical excisionng defective skin edges; decompressive fasciotomy of the basic bone-fascial containers through entire damaged segment: through a wound and subcutaneously; revision of wound channel and all pockets with removal of clots, foreign bodies, fine osteal debris which not related to the soft tissues; excising only the tissues destroyed and deprived of blood supply, preferentially subcutaneous fatty tissue and muscles, accounting topography of neurovascular formations; multiply irrigation (flushing) of surgical wound with an aspiration of flushing fluid; maintenance of all large osteal debris, and fine osteal debris, if related to periosteum and the soft tissues; main blood flow recovery during wounds to large arteries by their temporary prosthetic repair; full-scale wound drainage by accomplishment of counterapperture slits with introduction of drainage tubes to create a natural sink for wound contents; careful hemostasis, paravulnary infiltration of tissues with antibiotics; friable wound tamponade by the napkins moistened with antiseptic fluids and sorbents with osmotic activity; adequate to a damage (fracture) immobilization of the defective segment by splint plaster bandages or transport frames. Deaf wound seam, osteosynthesis of fragments and bone-plastic amputations are prohibited at the stage of the qualified medical care. Exception for osteosynthesis can be only the casualties with heavy combined wounds, being rendered medical-transport immobilization single-plane rod devices and casualties with plural and isolated fractures under condition of Trauma surgery experts from the enhancement team are present at the stage. Plaster bandage remains basic osteal fragments immobilization technique. Digressing on the role and a place of an external osteosynthesis in the staged treatment system for casualties with extremities wound, it is necessary to underline stable trend during last 20 years. The share of transosseous osteosynthesis in the pattern of treatment methods grows. For example, during war in Afghanistan external fixation was used only in .5 % of casualties with gunshot fractures of long extremity bones while during counterterrorist operations in the Chechen Republic transosseous osteosynthesis was applied in 6.5 % of casualties.

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9.3.1. Place of bones fragments exterior osteosynthesis in the system of extremity wounds treatment
Estimating retrospectively efficiency of transosseous osteosynthesis in treatment of extremity wounds during entire war in Afghanistan, it is necessary to isolate 3 phases: Primary empirical accumulation of clinical experience and primary scientific generalizations. It completely confirmed theoretical experience, reinforced basic advantages of this method, allowed to complete indications for using external fixation devices for casualties treatment. It has been proven that 2025 % of casualties require application external fragments fixation methods in casualties. At the same time due thoughtlessly broad indications to the method use without taking into account gravity and complexity of the modern battle trauma and, first of all, soft tissue component in gunshot wounds and explosive damages pathogeny, frequent complications called into question efficiency of using this method in field conditions. The second period defined a role and a place of this method in the staged medical aid system. It was characterized by more restrained attitude to thoughtlessly wide application of external fixation devices and more weighed approach to estimating general state of casualties and regional blood flow. In the organizational plane, decision was made to stop using transosseous osteosynthesis at a stage of the qualified surgical help. Evacuation plan for casualties with extremity wounds was changed as well. Need to delay casualties with transosseous osteosynthesis performed, in the 40th Army Central Hospital was proved. Mechanic and functional deficiencies of certain compression-distraction devices (CDD) undergoing clinical trials in Afghanistan (insufficiently strong bracing of fragments, unjustified weight of devices, low repositioning capabilities and their restricted universality), shifted priority to Ilizarov devices. This time period is responsible for drastic changes in military trauma surgeons understanding. During treatment of casualties with gunshot fractures, the problem of fragments fixation becomes priority when organizational problems along whith antishock and antihemorrhage therapy are solved, posttraumatic edema is liquidated, general regional blood flow and microcirculation is restored, prevention measures for evolution of wound contagious and general complications are taken. Tthird period is characterized by systematization, accumulation of experience and propagating
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strategy and tactics among military trauma surgeons. Distinctive features of the las Afghan war period was seamless operation of the flexible and thought over medevac system with active recruitment majority of military district hospitals throughout an entire country, Army Medical Academy and central hospitals, setting up modern rehabilitational center, based on the MoD Sakskiy Military Resort. This resort operated based on the scientifically proven concept of casualties rehabilitation, as well as using transosseous osteosynthesis only under rigorous indications and only at the specialized medical care stage. Use of optimal transosseous and, less often, than the submersed functionally-stable osteosynthesis under protection of selective endarterial infusional therapy in local war conditions allowed to bring the field medical surgery community to the issue of preserving primary surgical treatment of osteomuscular wounds, inflicted by the gunshot fractures. In particular, on the background of regional medicinal and surgical dehydration, restitution of a blood flow and microcirculation without removing majority of free and inhibited osteal debris. Moreover, as studies addressing reparative regeneration showed, the processes of regeneration during gunshot fractures, major part of this debris is transformed into newly formed bone (Fig. 9.7 and 9.8). These measured resulted in wide exterior osteosynthesis application in the system of complex staged treatments of casualties with gunshot bone fractures in Afghanistan and it allowed to lower frequencies in shortings and incorrectly healed fractures by 3.6 %, the delayed consolidation 4.7 %, decommissioning by 2.6 %, treatment terms reduction on average of 21 .2 days. Introduction of exterior osteosynthesis in osteal purulent surgery allowed achieving the significant successes in treatment of gunshot osteomyelitis casualties, in particular, liquidating osteomyelitic nucleation sites, consolidation of fragments and restitution of an extremity length. In some cases, stable fragments fixation led not only to bone consolidation in pseudoarthrosis zone, but also provided resistant remission of osteomyelitic process without interfering in the bone damaged zone. Accumulated years of Afghanistan war experience allowed to define requirements for using devices of gunshot fractures external fixation: it is desirable to apply delayed option of nonfocal osteosynthesis, i.e. apply it after antishock treatment, restoring hemorrhage, normalization of hemodynamics and microcirculation or before the peak of neurotrophic derangement, or, on the contrary, after normalization of trophicity regulation through adrenergic and cholinergic channels;
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 repositioning of bones fragments should be conducted on a stationary or field orthopedic table or use devices for a bone repositionining in inferior extremities and superimposition of plaster bandages (RG-. RGU-1), shin and forearm bones by using of compact repositioning devices; in case of primary or secondary bone damage, which is shorter than 3-5 cm, single-time fragments adaptation is possible by compressing face surfaces before bone is regenerated; more extensive damages are to be replaced using arrested bone plastics using one ore more transverse osteotomies (corticotomies) , thus avoiding acute regional circulation disorders and evolution of resistant contractions; compression-distraction devices should provide strong, but not entirely rigid bracing of osteal fragments, that in a combination with damping, allows to reduce treatment of casualties with the shattered and multicomminuted fractures by 2731 %. Chechen republic war was an important stage in evolution of external fragments fixation in casualties with gunshot limb bones fractures. It is necessary to underline that casualties treatment in this local conflict was conducted using qualitative different organizational, material and medicinal principles, than war in Afghanistan: First, the system of casualties evacuation has undergone changes, a specialized Trauma surgery aid to casualties was rendered in permanent district Northern Caucasus instead of the field conditions (echeloning); Secondly, field medical surgeon and other surgical profile specialists were supported by the Afghanistan experience and developed standards of surgical aid;

(a)

(b)

(c)

Fig. 9.7 Gunshot fractures of the left shin bones ((a) X-ray images before and after a wound primary surgical treatment; (b) fragments positions after extrafocal osteosynthesis using Ilizarov device; (c) adnation of fragments with inappreciable angle strain in a sagittal plane.)
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 Thirdly, military trauma surgeons were not only equipped with Ilizarov devices but also with Field Kit for a spoke-rod fixation, developed in Medical Academy and adapted for the field requirements. The kid development due to the difficulties related with difficulties to use Ilizarov devices for external osteosynthesis in treatment of casualties with gunshot fractures of a brachium, femur and forearm. These fractures rarely require transosseous steosynthesis as use Ilizarov devices was difficult and led to numerous complications.

Fig. 9.8. Gunshot fracture of right shin bones in inferior third: (a) position of fragments during transport immobilization; (b) an arteriography of anticnemion vessels, damage to forward tibial artery at the fracture level; (c) position of fragments after primary surgical treatment of a bullet wound and external fixation of fragments by Ilizarov device; (d) correct adnation of the fragments. The exterior osteosynthesis by spoke and spoke-rod fixation in this onflict has been applied in 350 casualties. Same to Afghanistan war, preferential treatment method with gunshot bone

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fractures was transosseous osteosynthesis Ilizarov devices (Table. 9.2). Table 9.2 Frequency of spoke and spoke-rod fixation devices use at Northern Caucasus Injured segment Fixation Total Spoke-rod Spoke Shoulder 7.9 2.1 10.0 Shin 10.0 10.0 Femur 3.6 6.4 10.0 Total 7.8 2.2 10.0 Spoke-rod devices owing to a successful combination of rod and spoke devices advantages have a number of advantages: Device installation demands less time as the most labor-consuming stage, namely insertion of spokes in the upper third of femur or a brachium, is circumvented; Devices are .53 times less traumatic during osteosynthesis due to reduction of wound channel number and areas of; Frequency of contagious complications decreases around immobilizing elements by a factor of 3-4 due in the insertion areas; Achieving substantial stiffness in bracing of proximal device base, fragments can still be repositioned by using spokes and attaching spokes to the distal base of the device. If necessary to a spoke-rod the device can be remounted either in spoke or rod varieties; - Use of support segments instead of bulky arcs in Ilizarov devices eases patients time in bed and travel with crutches, simplifies wearing clothes (Fig. 9.99.12) More frequent application of this method in Chechen Republic was achieved due to cardinal changes in the organization of specialized medical aid, to increase qualifications of military trauma surgeons in the issues of external osteosynthesis. Gigantic experience, accumulated by military trauma surgeons on application of exterior osteosynthesis has convincingly confirmed that it is better than other methods of fractures treatment. It influences congenial course of a wound process and matches bullet wound pathogenesis. It can be used in presence of a wound infection contaminations and damages to the soft tissues. This method, per se, is least invasive technology of the fragments stabilization and allows to supply extensive bones damages, perform fragment positions correction in stages, carry out a medevac immobilization, protect and immobilize the soft tissues in case of the extensive damage to free and non-free skin flaps.

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Stability of bone fragments bracing, reliably achieved by the external fixation devices, should be a mandatory element of preservational treatment for casualties with gunshot long limb bones fractures. Another important point is that technology of an external osteosynthesis applied at stages of medical evacuation, should evolve along with the specialized aid level increase. This point was implemented during 2nd Chechen campaign in 1998-2000. First specialized medical aid stage applied preferentially external devices of medical transport immobilization. Second echelon, responsible for treating 7.2 % casualties with gunshot wounds of long extremity bones, utilized complicated osteosynthesis techniques. Casualties, requiring correction of gunshot wounds aftereffects and those who received heavy intraarticular fractures were concentrated in highly-specialized Trauma surgery centers, belonging to III echelon of the specialized aid.

Fig. 9.9. Spike-rod fragments fixation during the gunshot wound of humeral bone

Fig. 9.10. Spike-rod fragments fixation during the gunshot wound of femural bone in upper third

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Fig. 9.11. Spike-rod fragments fixation during the gunshot wound of femural bone in midshaft

Fig. 9.12. Spike-rod fragments fixation during the gunshot wound of femur bone in inferior third

Estimating anatomical effects of limb casualties treatment, as a whole, it is necessary to underline that to achieve fractures adnation in short terms was feasible for 6.8 % victims. Shortening of an extremity and deformations were observed in 2.6 % of casualties, the chronic osteomyelitis evolved in .3 %, nearthroses evolved in .6 % of casualties. Functional treatment effects when using plaster bandages and devices of exterior bracing were less impressive: virtually all casualties manifested muscle atrophy, temporary restriction of motions and resistant contractions in 7.6 %, vascular disorders were noted in 6.4 % and fibrous degeneration of muscles in 1.9 % casualties. Resistant contractions in patellar, ulnar and talocrural joints were oftenly observed in exterior fragments fixation by the devices, when fixation time average on 50 %. Defects and mistakes in rendering medical aid at medevac stages played important role in formation of unsatisfactory anatomical and functional treatment effects. Insufficiently high functional effects of casualties treatment in case of gunshot bone fractures stipulated technical search for the ways to improve medical rehabilitation. This search in academic community is conducted fore more than 30 years and includes following directions: gunshot fractures consolidation optimization, early restitution of anatomy and functions of muscles, tendons, vessels and nerves, early restitution of joints function and negative
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consequences minimization for the transosseous osteosynthesis method. Optimization of regeneration, maintenance of tissues vitality in a state of a parabiosis and a hypoxia, especially osteal, requires considering highly effective medical provisions, including prolonged endarterial drug infusions in combination with dampened extrafocal osteosynthesis, hyperbaric oxygenation and other physiotherapeutic provisions. Currently, the perfusion of oxygen-carrying media through a wound region, for example, perfluorocarbons, allows not only to survived osteoblasts in fine osteal fragments during a hypoxia, related to vascularization disorders, but also raising oxygen supply for other tissues in the wounded region, and lower frequency of contagious complications. Propagation of the soft tissues complexes with axial blood supply from the wound uncompromised regions permits not only substitute defects, for example, cover shin tissues but also optimize requirements for a gunshot fracture consolidation. Least invasion procedures were clinically developed for insertion of a false joint in the wound area, slowed consolidation or regeneration after wound flap coverage by Ilizarov by using spongiform bone autotransplants. Nowadays, medical researchers are completing experimentally-clinical work on development and studying of flap coverage efficiency for skin and broken fragments of shin bone by using muscular-subcutaneous and muscular-skin flaps. Original devices, based on the spokes, rods and their combinations, are developed to minimize negative side effects of exterior osteosynthesis method. Using these devices through the neutral lines of a segment does not interfere with sliding apparatus function. Sequential osteosynthesis proved to be very effective for the contractions prophylaxis in large joints, with replacement of external functionally stable osteosynthesis by internal functional-stable osteosynthesis, if needed in conjunction with tenolysis, a myolysis, an arthrolysis and a redressment. Experimental studies showed high efficiency of sequential osteosynthesis using least invasive technologies of internal fixation. Wounds of patellar, less often than other joints, requires wide use of artroscopy for removal of intraarticulate bodies, arthrolysis and occluded least-traumatic repositions and bracings of fragments. Primary internal osteosynthesis during gunshot fractures can be used for no more than 4 % casualties, and exclusively, in highly specialized hospitals, after a healing soft tissues wound and at least 3 weeks 2 months after a wound. It is desirable to use this method under the protection by medicamental intraarterial infusion. Aftereffects and complications of gunshot wounds in the specialized Trauma surgery centers of
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Russian Federation MoD can be treated by an entire spectrum of reconstructive and regenerative surgeries on a spine, joints, bones of extremities, tendons, nerves, vessels with application of the modern technologies and prosthetics. Modern rehabilitiation technologies allow raising considerably the functional effects of casualties treatment with gunshot bone fractures.

9.3.2. Transosseous osteosynthesis in treatment of casualties with perforating gunshot wounds of upper extremities large joints
Treatment of large joints gunshot wounds is one of most challenging problems of military Trauma surgery. Its complexity is predetermined not so much by the hight frequency but frequent unsatisfactory anatomic and especially functional treatment outcomes. Causes for unfavorable treatment effects, in opinion of numerous domestic and some foreign trauma surgeonsorthopedists, are special complexity of joints anatomical constitution, variety of their functions, severity, extent and multifaced character of joints gunshot damages. High frequency of wound contagious complications contributes as well, starting from an empyema to joint phlegmon to an osteomyelitis of the bone articulate fragment and a panarthritis. Unfavorable treatment outcomes depend on the long-term medical immobilization of the defective extremity, general treatment of casualties, necessity to perform significant number of reconstructive and regenerative surgeries to refine the injured extremity functioning. Another task during war in Afghanistan was to justify indications for using transosseous osteosynthesis methods and define their significance in the treatmen system of victims with gunshot wounds to joints of the upper extremity. Trauma surgery departments of Afghanistan MoD Central military hospital treated 756 casualties with gunshort penetrating wounds of upper extremity large joints. The faculty members (V.A.Averkiev, A.I.Gricanov) supervised this treatment. 4.3 % casualties had ulnary joint wounds while 3.2 % had humeral and 2.5 % spray joints wounds. Bullet wounds (7.1 %) prevailed in the general pattern of an upper limb wounds. Majority of them were penetrating wounds of joints by different caliber bullets. Outcomes of limb gunshot wounds treatment, as demonstrated by past wars experience, largely depend time to evacuation, amount and character of medical care at pre-hospital stages. Objective and subjective errors, omissions and deficiencies of the medical support infrastructure
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or shortage of doctors, especially surgeons, nurses shortage, rather limited logistical and supply capabilities of the Afghan Armed Forces did not allow to organize effective pre-hospital medical aid. Along with late delivery of casualties to the specialized aid stage, this affected quantity of wound complications and on general treatment outcomes. Perforating of the upper extremity joints without bone damages are diagnosed in 2.3 %. Oftenly this type of of damages is observed in humeral joint bones (3.7 %), less often during perforating wounds of a radiocarpal joint (.2 %). Thus, majority of casualties manifested intraarticulate fractures from inappreciable (regional, foraminous) through extensive fractures of the articulate bone joints, frequently with primary damage to a bone tissue. Latter type of gunshot fractures often accompanied wounds of ulnar and radiocarpal joints. Considering unfavorable background in view of hospitalization terms, amount of paramedical, medical and surgical aid, the most important role now belongs to quality and amount of orthopedic and traumatological aid. This includes determining indications to such surgical provisions as a puncture of a joint, drainage, irrigation, arthrotomy, a resection of one or both articulate ends and osteosynthesis. The important pecualrities of surgical aid in Afghanistan army is rendering primary surgical aid to 91.5% of casualties in case of upper limb wounds. Arhtrotomy is and will be a leading surgical provision for primary surgical aid to casualties with the gunshot wounds. This provision is executed for 70% of casualties. Depending on character, extents and severity of the soft tissues and the articulate bone ends damages, an arthrotomy surgeons conducted atypical arhtrotomy, along the wound channel and through the typical access points. Latter is preferable for minor soft tissues damages. Arthrotomies were performed with careful revision of a joint, detritus removal, removal of free foreign bodies, fine and even of large osteal fragments, flushing out and drying a joint, stitching of a synovial membrane and joint capsule. Arthrotomies with local a-application of antibiotics, drainage and irrigation were performed for 6.3 % casualties. .5 % patients with severe bone fractures, extensive damages to the soft tissues required resection of the articulate bone ends in the injured joint, preferentially ulnar. Basic medical immobilization methods included; plaster splints, replaced 34 times day a plaster bandage with a window or deaf plaster bandage. Transosseos osteosynthesis of gunshot intraarticulate fractures was applied for 95 (1.6 %) casualties. For 13 person synthesis completed primary surgical treatment of a gunshot wound. Amputations and exarticulations were performed in 16 casualties due to irreversible ischemia of an extremity during wounds to the main arteries,
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gaseous wound infection or in case of severe infectuous complications. Partilular problem - frequency and causes of wound complications requires special attention. The gaseous wound fever was noticed in .3 % casualties, other contagious complications in 2.3 %. Wound contagious complications (Table. 9.5) equally often accompanied wounds of ulnar and humeral joints, less often radiocarpal joint. The most frequent type of wound contagious complications included necrosis and pyesis of the soft tissues (5.9 %), empyema (25 %) and joint phlegmon (1.2 %). The articulate bone end osteomyelitis and panarthritis were observed less often. Lesser frequency of these compications is related to radical surgical treatment of the wounds, including a resection of the destroyed articulate bone ends. Of the total contagious complications number 4.1 % fell to an ulnar joint, 3.8 % to humeral joint and 2.1% to radiocarpal joint. All casualties with contagious complications were moved for further treatment to the departments of bone purulent surgery. These departments used all accessible to Central Military Hospital means of conservative therapy (fresh-cytrate blood tranfusion, whenever possible specific antibiotic therapy , infusions of disintoxicating solutions) and surgical treatment provisions, including a secondary surgical treatment of the wounds, arthrotomies, baring of abscesses and flows, secverectomy, resections of the articulate bone ends, amputations and reamputations. Complex, long-term, and sometimes dramatic fight with wound infection contamination preserved lives for the majority of casualties and in 95.4% cases allowed to liquidate these complications the killing number of casualties managed to maintain life, and at 9.4 % from them to liquidate the specified complications. Difficulties, related to a treatment of occluded, open and furthermore gunshot fractures is reduced finally to a three-pronged problem: restitution of articulate bone surfaces congruence, strong fragments fixation, maintenance of early recovery of the defective joint. In open and gunshot intraarticulate fractures, one more side of treatment acquires an essential value the prevention or struggle with wound contagious complications. However, solution of the main objective, i.e. recovery of injured extremity lost function is possible only using peak preservation of anatomical (structural) elements of the defective joint. Until now, traditional treatment methods did not allow to combine, pull together or merge the solution to the oppositely directed private problems. Therefore, the immobilization of an extremity by a plaster bandage after the open fragments reposition solves one of them (fragments immobilization) and automatically prevents another one provision of an early function. In
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gunshot fractures, it is frequently impossible to perform the immersion metal osteosynthesis in view of the articulate bone ends fracture and due to the elevated danger of contagious complications evolution. In addition to that, the majority of casualties, even after fixing fragments by a metal structure, still require external (additional) immobilization by a plaster bandage. Only with evolution of transosseous osteosynthesis and external fixation devices, for the first time an opportunity appeared for many casualties with gunshot intraarticulate extremity bone fractures to solve succesfully a complicated problem of the intraarticulate damages. Teamwork of the Soviet and Afghani trauma surgeons and orthopedists representing the Central Military Hospital of the Republic Afghanistan MoD and Military Trauma surgery and Orthopedics College of Military Medical Academy by S.M.Kirov allowed to achieve successful treatment for such casualties. Table 9.5 Frequency of wound infection complications for the top extremity wounds (%) Complications Joint Total Humeral Cubital Radiocarpal Necros and suppuration of soft tissues Joint empyema Osteoarthritis and panarthritis Joint phlegmon Frequency of infectous complications (of total penetrating wounds) 3.1 3.1 .4 1.4 2.2 6.0 2.3 .7 1.0 2.2 7.3 .7 .7 1.3 1.2 5.9 2.0 .9 1.2 2.3

Recovery of the defective joints function was based on the original method of surgical treatment of joint diseases and damages (Authors Certificate 1147373 of 4/08/80) and hinghe distraction devices (HDD) constructions by V.A. Averkiev, A.I.Gritsanov and A.V.Gaas (Authors Certificate 91584. 95976. 95976. 986405) for ulnar, radiocarpal, metacarpophalangeal and other joints. The devices design account for mechanical pecularities of a specific joint. Their difference from Volkov-Oganesian HDD is a lack of an axial spoke. HDD function is to fixate separately articulate bone ends by usual spokes in the device arcs. The arcs are interconnected by the distractors. The latter have a hinged joint, aligning according to a spin axis of a joint. HDD devices decrease load on articulate surfaces of jointed bones, and then allow to perform forced (by means of the threaded rods) and, later, active motions (Fig. 9.13).
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Fig. 9.13. Gunshot bone fracturers to the bones of right elbow joint. Fragments fixation by the Averkiev-Gritsanov-Gaas hinge-distraction device For casualties with gunshot intraarticulate bone fractures of the upper limb bones, upon primary surgical wound treatment, conventional spokes and spokes with the support faces are inserted through the bone fragments. The spokes with support faces are strung in the device arcs. For the time of wound healing, the distractors hinges are closed to maintain joint rest. The device arcs are temporarily connected by the auxiliary rod. After wounds are healed and inflammation subsided, strain is removed and the joint is being moved forcibly, at first, then freely. Authors have successful experience in treating 28 casualties with gunshot intraarticulart fractures of ulnar and radiocarpal joints using HDD device (Fig. 9.14). Hinge-distraction devices were used for 22 patients with wounds aftereffects (ankyloses, resistant contractions, incorrectly healed fractures). Hinge-distraction devices allowed to execute successfully a number of complicated reconstructive and regenerative sugeries an arthroplasty, replacement or restitution of the articulate bone end, elimination of rigor contractions, liquidate deformations, strains and circumarticular pseudoarthroses in jointed bones and, at the same time, develop motions in the defective joint.

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Fig. 9.14. Gunshot shoulder wound with multicomminuted humeral fractures Primary surgical treatment and external osteosynthesis by Averkiev device Treatment of casualties with extensive single-bone damages to the joint bone ends and entire joint defects deserves special attention. Based on the treatment experience of 14 casualties with damages to humeral (3), ulnar (7) and radiocarpal (4) joints, we can state that hinge-distraction devices, for the first time, provided an opportunity for a casualty to perform basic and selfservice functions even lacking a shoulder blade and proximal third of humeral bone. With a purpose to compensate inevitable bone shortening, 1-2 traversal subperiostal osteotomies are conducted, followed by the distraction osteosynthesis. This treatment targets restoration of an optimal segment length. The second problem is arthrodesing achievement in a former joint region for the functionally convenient extremity position. Experience in rendering specialized orthopedic and traumatologic aid to casualties with gunshot perforating wounds to joints of the upper extremity showed that the only way to achieve treatment outcomes is to improve quality of paramedic, field surgeon, qualified and specialized medical aid, reduction of medical evacuation time, using external osteosynthesis, especially new generation of hinge-distraction devices. Successful treatment of casualties with fresh intraarticulate gunshot fractures and serotinal terms of the complex reconstructive and regenerative surgeries became possible owing to indications
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improvement for and arthrotomy, resections of the articulate fragments of jointed bones or extremities amputation depending on a wound severity, terms of hospitalization, presence of wound complications. Deployment of special hinge-distraction devices, functional and rehabilitation treatment system by the Afghanistan MoD Central Military Hospital also contributed positively to the successful treatment of casualties. These measures resulted in reduction of general treatment types and improverment of treatment outcomes.

9.3.3. Neurotrpophic disorders correction after mine-explosive trauma

Taking as a basis the irrigational theory of neurodystrophic evolution by I.Pavlov and taking the latest published data into account [Anichkov S.V., 1974; Pshenicniy I.P., 1978; Berger E.N., 1980; Azhipa Ja.I, 1990] and having analysed original research results, Nechaev E., Gritsanov A., etc., 1994 put forth a framework for neurodistrophic derangements, inflicted by a severe combat mechanical trauma (Fig. 9.15). So, the etiological factors, which trigger entire stage of neurotrophic changes during MT) are heavy mechanical injuries to histic structures at the regional (e.g. extremity avulsion) and general (contusion-commotio syndrome) levels. Injury to histic receptors and the excitatory conductors leads to origination of inadequate eisodic impulsation from periphery and upset of regulatory mutual relations in nonspecific CNS frames. Thereof, the balanced interaction of ergotropic and trophotropic hypothalamus regions is upset, which is peripherally manifested by acute activation of the adrenergic regulation channel. Simultaneously, cholinergic channel of regulation is activated. However, this channel is incapable to support the compensatory function. For this reason, negative (damaging) adrenergic signal keeps coming to the tissues. Excessive sympathetic pulsation at the periphery leads to circulation disorder, including microcirculation, activation of inflammation mediatory systems and derangement of mutual relations in the cyclic nucleotides system. Accompanying changes serve as the histic trophism secondary stimulating factors, whose action on the receptors damages them again. As the result, excessive sensory input, coming from primarily defective histic receptors, is complemented by the inadequate sensory input from structures, which underwent secondary damage. It, in turn, leads to even greater upset of regulatory mutual relations, and, consequently, to amplification of trophic processes disorders in tissues. The vicious circle is created and leads to constant buildup of dystrophic changes in
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tissues.

Fig. 9.15. Pathogenesys of neurotrophic disorders during mine-explosive traumas Analysis of published literature was performed, regarding the concepts of acute and chronic neurodystrophic processes, interacting adrenergic and cholinergic channels of vegetative nervous system in a regulation of a trophism of tissues in trauma patients, natural clinical and experimental data concerning existence of a certain special period. This analysis enabled us to formulate a working hypothesis about the presence of specific critical period during traumatic sickness and accompanying neurodystrophic processes. During this period, the disorders from regulatory mechanisms of trophism, and other homeostatic systems (immune status, microcirculations, et. al.) are manifested to the strongest degree. If all these disorders of a homeostasis during trauma (wound) sicknesses are liquidated by an organism or by purposeful and adequate therapy, the favorable background for patient healing is created. If both self-regulation, surgical and therapeutic provisions fail to correct this disorders, which is observed preferentially in casualties with severe, but compatible with life mechanical
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injuries, a patient either dies from various contagious, necrotic, thromboembolic and other complications, or acute pathological process changes to chronic one (delayed consolidation, formation of a pseudoarthrosis, evolution of purulent-necrotic complications in a bullet wound, to include posttraumatic osteomyelitis) is observed. Cholinergic nervous system is well known to be more ancient, than adrenergic in phylogenetic sense. Therefore, it is more resistant to various disturbing factors. We consider this resistance to be defined by a lower response through the cholinergic regulatory channel, than through the adrenergic one. Consequently, activity of ergotropic regulatory channel dominates during the moment of a trauma and later over trophotropic cholinergic regulation, which leads to derangement of the balanced binary regulation of tissues trophism of tissues. The latter causes an evolution of neurodystrophic process. For the same reason, total depletion of the adrenergic system, due to later phylogenetic evolution, will precede the depletion of cholinergic part of the vegetative nervous system. Continuing from the above, we propose the graphic model of ergotropic and trophotropic regulatory channels activity during different periods of the neurodystrophic process evolution (Fig. 9.16). Wide horizontal strip with skew shading represents balanced interaction of two regulatory channels, arrow points at the moment of disorder action. Solid line maps activity of the adrenergic channel, dashed line cholinergic. Detailed consideration of each regulatory channel activity in different time periods of traumatic sickness allows to make a series of important practical and theoretical deductions, underlying the concept of neurodystrophic derangements corrective therapy. Adrenergic (ergotropic) channel. From the moment of damage, ergotropic regulatory channel of vegetative nervous system is activated in tissues. This leads to change of histic and vascular components of trophic processes. But, this channel cannot remain activated perpetually and is subject to depletion of histic catecholamines (HC) reserves. The adrenergic part of the nervous system activity peaks then. It matches to the diagram peak maximum of a solid line. At the time scale the peak activity matches to point K1. After that the acute decrease of its activity, related to the functional depletion, begins. The latter continues until restoration of histic catecholamines depots is achieved through the mechanism of axoplasmic flow. This moment matches to peak minimum, and point K2 at X axis. Then again, pathological activity of ergotropic regulatory channel starts to increase.

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Fig. 9.16. Graphic model of regulatory channels activity Cholinergic (trophotropic) channel. This part of trophicity regulation also undergoes functional changes. The maximum of this channel activity matches to the peak of the dashed line and to the point K. while the point K4 corresponds to the minimum. Presented diagram more or less truly reflects the essence of processes in the vegetative nervous system and can serve as a reference point in understanding pathogenesis of neurodystrophic derangements and in development of the medical provisions plans. There are many reasons to assume that neurodystrophic process includes a time span, responsible for the most expressed morphological and functional changes of ergotropic and trophotropic systems, histic substrate in the damaged region, regional circulation and microcirculations in the damaged tissues and entire human body. It is this period which decides a "fate" of the subsequent neurodystrophic process course. This fate depends mainly on the activity of ergotropic ("damaging") and trophotropic ("canceling") channels of regulation. If cholinergic effects cancel pathological activity of ergotropic channel, the involution of neurodystrophic process happens. Consequently, the process of wounds healing and fractures union will proceed in optimum time and without complications. Otherwise, one should expect transition of the acute neurodystrophic process into a chronic one. For this reason, this stage of traumatic (wound) sicknesses is the most decisive. During this stage, physicians should provide maximally intensive organizational and medical provisions, required to sustain or raise activity of compensatory responses of an organism and lower activity of damaging factors, and, first of all, ergotropic action of adrenergic system. Based on the published data, results of experimental research, clinical observations, pathomorphological and histochemical research, authors concluded that during traumatic sickness there is a critical period, corresponding to 5-7th day from the moment of trauma and peaking pathological activity of sympathetic-adrenaline system, evolving on the background of a depletion of cholinergic trophicity regulation mechanisms. At the diagram this period
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corresponds to the first shaded block. Pathogenetic essence of a critical period is that maximal pathological activity of sympatheticadrenaline systems is observed on the background of compensatory cholinergic mechanisms depletion. This depletion is caused by excessive injuring agents effects. So far, there are no data to prove that this time period is universal for all people and all types of mechanical injuries. Further purposeful studies and reliable statistical data will allow improving its duration, terms of the beginning and ending, and also its peculiarities for different types of mechanical injuries. It attracts attention that during neurodystrophic process one more dangerous period is noticed. As noted already, unfavorable factors for tissues trophism are not restricted only to the peak activity of the sympathetic nervous system, but also extreme degree of its depletion. For this reason, there is another critical period in course of neurodystrophic process, functionally matching to an extreme depletion of adrenergic and cholinergic regulatory channels. Consequently, one can assume that the course of any chronic neurodystrophic process is wavy, i.e. includes interleaving periods of exacerbation and remission. Consequently, surgeries will be most pathogenetically proved outside the acute period, whereas conservative treatment should be most active during critical (acute) periods of sickness. Present considerations prove three points: First, surgical methods of gunshot damages treatment are remaining leading provision, because they target elimination of an immediate cause of pathological changes evolution in the damaged organ; Secondly, when dealing with prophylaxis wound contagious and purulent-necrotic complications, contemporary antibiotic therapy in the pure form, i.e. without surgical support and liquidation of "capillary-trophic failure syndrome [Dyachenko P.K., 1982], is senseless; Thirdly, continuing from the modern level of physiology understanding of the homeostasis regulation and evolution of trophic disorders, and neuropharmacology achievements, there are several paths to correct trophic disorders. The basic objects of medical treatments of Mine Trauma (MT) are leading components of a gunshot polytrauma pathogenesis commotio-contusional syndrome and extensive damages of tissues, preferentially extremities. In an initial stage of treatment these casualties face provisions against a shock and hemorrhage, require early and radical primary surgical wounds treatment and high-grade fragments immobilization. Physicians should render proper aid against a posttraumatic edema of the damaged extremity and reduce pathogenic action of emotional stress
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by using psychoactive drugs, boosting adaptation capabilities of the nervous system. It is extremely important to conduct additional provisions, directed on protection of vegetative organism systems in casualties with gunshot combined and plural damages. Heading for the preferential activation of adrenergic structures for these casualties, physicians should apply vegetolytic drugs, quenching transmission of redundant input to the receptor units of vascular system. Hemodynamic changes during mine traumas are one of the permanent components, pertinent to crisis of microcirculation, and, therefore, local provisions, directed on vascular apparatus cannot provide their complete normalization. Vegetative blockage (shown on Fig. 9.17) is basis for one of the corrective therapy varieties, successfully used in Afghanistan.

Adrenergic system CNS Reticular formation of brainstem Vegetative ganglia Presynaptic end of adrenergic neuron Adrenoreceptors of an effector organ blockers

Drugs Central alpha adrenergic Central -cholinergic blockers N-cholinergic antagonists and ganglia blockers Presynaptic adrenergic blockers and sympatholytics Postsynaptic alpha adrenoblockers

Fig. 9.17. Vegetative blockage in the medical provisions system Medical shapes of vegetative blockage in the anesthesiology manual are currently the following provisions: stem soporifics (barbiturates) in preoperative preparation; novocaine blocks of a sympathetic trunk in combination with conductive or peridural anaesthesia or narcosis; fractional introduction of strong gangliolytics with short and medium action terms to provide sympathectomy of the vegetative nervous system at the level of vegetative ganglions.

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Majority of personnel with MT manifested whole gamma of mental disorders, including anxiousdepressive syndrome. These casualties required injections of Pyrroxanum in initial stage of a disease, which renders prompt therapeutic effects. Pyrroxanum is a drug of choice for treatment and prevention of diencephalic crises of sympathicotonic character, hypertonic crises with hyperadrenalism (1st type). Pyrroxanum is prescribed for the states with predominance of sympathetic tonus. Useful property of Pyrroxanum is possibility to combine it with other drugs cholinolytics and antihistamines. Recommended doses for intramuscular injection are from 1 up to 3 ml of 1% solution 1-3 times/day or 1-2 ml of 1.5% solution 2 times a day. Peroral prescription is 0.015 g 3-4 times a day. For MT casualties under scheduled operative treatment, authors suggest the following drug schemes: a) night any (better barbiturate) soporific; b) 15 min prior to anaesthesia peroral 250 mg of meprobamate, 100 mg of Benadryl and 100150 mg of Etamynal-sodium or other barbiturate soporific to boost organism resistance in case of local anesthetic overdose. Authors fully share point of view of T.M. Darbynian (1980), that the advanced combined endotracheal narcosis cannot replace local anaesthesia in surgical practice. According to our belief, that during a wound process, casualties with MT with narcosis only manifested following negative trends: delayed rejection of necrotic masses; late terms of graining; ambient deep neurotrophic derangement.

During 1984-1987 in CMH MOD RA the conductive and peridural anaesthesia remained the basic method of for MT casualties (19 %), providing not only appropriate anesthesia but serving one of components of antishock therapy, as well as trusty vegetative blockage, which is important for prophylaxis of microcirculatory derangements and purulent-necrotic complications. The endotracheal narcosis using ether or Halothanum was still applied for the main share (17.3 %) of casualties with plural and combined damages. Therefore, physicians used conductive anesthesia of large nervous trunks in an extremity, peridural anaesthesia and novocaine block of the sympathetic trunk, pharmacological sympathectomy by fractional injection of gangliolytics, conducted in a complex of the anesthesiology provisions (Fig. 9.18). These provisions allowed to decrease pathological efferent
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input in vessels and tissues of a damaged region. That eliminates one of the leading reasons of histic and vascular neurodystrophic changes.

Fig. 9.18. Pathogenetically justified therapy for MT wounded However, it is not sufficient to apply single vegetative block for the complete normalization of histic trophicity disorders in a postoperative period. Therefore, it is necessary to conduct the provisions directed on further normalization of histic homeostasis. Primary goal of these provisions is to eliminate the disorders, which are caused by the trauma of a histic trophicity regulation, microcirculation and liquidation of existing disorders. Casualties with severe wounds of the inferior extremities require use of spasmolytics as regional intensive drug therapy, executed by the prolonged infusions through catheterization of a femoral or external iliac artery. Introduction of drugs begins already at the surgery table. Primary goal of intensive regional therapy is not so much antibacterial drug activity, but improvement of microcirculation due vessels spacmolysis, normalizations of trophic disorders in tissues, boosting their vitality and reparative capabilities. These problems also define a composition of infusion substance, which includes anesthetics, spasmolytics, anticoagulants, vitamins, and, if necessary, hormones, enzymes and their inhibitors, biological stimulators, antihistamine and anti-inflammatory materials, antibacterial drugs. For casualties with mine-explosive avulsions of the inferior extremities and the gunshot fractures,
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accompanied by extensive soft tissue damages, infusion solution were based on Novocaine or Trimecainum 0.25% solution. Mixture of drugs for intra-arterial introduction should be designed with respect to compatibility and pharmacodynamics of each component. The fraction method of introduction is more effective in an initial stage of treatment MW casualties, while drop method is more preferable when treating purulent complications. Intra-arterial application of Complamin, Halidorum and Trental is indicated because they interfere with evolution of possible relapse of regional circulations disorders and microcirculations disorder. When conducting complex therapy of trophic and microcirculatory derangement for MW casualties (according to S.V. Anichkov), authors used series of newest and highly effective drugs Trental (Yugoslavia), Halidorum (Hungary) and ampullaceous Complamin (Yugoslavia). Ganglioblocker of choice was domestic Benzohexonium or Pachycarpinum. Drugs were prescribed with respect to their pharmacokinetics, so that effects are maintained through an entire day. E.g., Benzohexonium (0.1 g first day and 0.2 g subsequent day), for example, was prescribed three times a day as it is pharmacologically active for 6-8 hrs. Pachycarpinum 0.1 g pills were prescribed 4 times a day. Myotropic spasmolytic of choice was Complamin pills, prescribed 4 times a day. Thus, application of combined peridural anesthesia with Tetracaine with Morphine, fractional introduction of Diazepam during inferior extremities surgeries provides neurovegetative protection of an organism against operational stress, adequate analgesia and lockout of psychoemotional responses in an early postoperative period, which is, finally, powerful provision in prophylaxis of neurodystrophic and contagious complications onset. Anticoagulant Heparin therapy, applied since the second day, targets prophylaxis of a clottage. Inhibiting activity of Hyaluronidase, raising fibrinolytic blood properties and promoting recanalization of the thrombosed vessels, Heparin possesses appreciable anti-inflammatory activity (usually 100 ml infusion solution contained 1000 Heparin units). When applying Complaminum, with independent significant fibrinolytic activity, proportioning of Heparin can be reduced to 500-700 Units per 100 ml. Application of vitamins is expedient and necessary, as they, being coenzymes, participate actively in metabolism. Of special value is vitamin B. boosting Novocaine effects. As the cocarboxylase is an effective ingredient of Thiamine chloride or Bromide, vitamin B1 presence in infusion solution promotes improvement of carbohydrate metabolism. Due to these reasons, it is mostly
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indicated for renal and hepatic failures in casualties with extensive crushes and avulsions of extremities. Daily dose is 2 ml. Casualties without catheterization of a femoral artery, were injected vitamin B1 intramuscularly (1 ml of 5% solution). Since the ascorbic acid participates in redox processes, first in a synthesis of a collagen, base material for connective, in infusion solution for intra-arterial introduction is complemented by vitamin C (5 ml of 5% solution). Of the drugs improving regional circulation and independently introduced intravenously or intraarterially it is worthy to note Polyglucinum, Rheopolyglucinum, Haemodesum 500-800 ml /23 times a day. To speed-up processes of necrotic tissues rejections, physicians apply enzymes of a proteolysis Trypsin and Chymotrypsin, introduced intra-arterially. Inhibitors of a proteolysis are introduced intravenously. Prophylaxis of purulent complications requires introduction of antibiotics into infusion solution Penicillin, Streptomycin. Targeted usage of antibiotics with respect to seeded microflora is preferred. Thus, interrupting a vicious circle neurodystrophic process, revolving its clinical manifestations in a postoperative period, revolving or eliminating attributes of capillary-trophic failure syndrome, hydropic and pain syndromes, it is feasibly to achieve optimum course of a wound process to avoid evolution or manifestations of purulent postoperative complications.

9.3.4. General principles of hyperbaric oxygenation (HBO) in treatment of explosion damages

Under conditions of wide usage of mines and other modern explosion ammunition in modern wars, the number of wounds grows, whose outcome is defined, in addition to adequate surgical treatment, by the effective correction of multiple disorders of life-support systems of an organism. Explosive wounds include those with avulsions of extremities segments and extensive damages to the soft tissues; surgically untreatable plural fragmentation, combined damages, etc. As noted above, an explosive wound represents specific gunshot damage. Their prominent features are tissues with a various degree of vitality disorders. After a surgical treatment, possible radical, wound inevitably contains injured tissues with the lowered vitality. Problems of postoperative treatment of casualties with such wounds consist in creating conditions for their fastest healing, hopefully without suppuration. Reduction of wound fever probability is promoted by normalizing histic homeostasis in periwound tissues. All known and approved in practice
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methods should be targeting this problem. Treatment of any disease or trauma assumes presence of exact data on the substance of pathological responses, evolving in an organism. Analysis of our own and published data allows making the inference about presence of the characteristic microcirculatory disorders syndrome for explosive wounds. Metabolic and functional changes immediately related to this syndrome are hyperenzymemia, hyperproteinemia, azotemia, disorders of acid-base states and gas composition of blood, changes to the central hemodynamics. As noted already, nearest posttraumatic period for explosive wounds educes mixed hypoxia syndromes. Published data testify that the hyperbaric oxygenation a method of elevated pressure oxygen treatment is of high medical efficiency for severe peacetime traumas. However, there are virtually no published data on application of HBO for treatment of casualties with bullet, fragmentation and explosive wounds in early terms after damages. Authors have clinical experience in HBO application HBO within complex of medical provisions for 172 casualties with various combat damages. We consider it necessary, in view of insufficient published data to review general indications and contraindications for this method. As known, now medical indications for HBO can be separated into three groups: I sicknesses and traumas for which HBO is the basic medical factor (unconditional indications); II sicknesses and damages for which HBO is considered as an effective resort within system of complex treatment (relative indications); III sicknesses, for which advantages of HBO are unclear in comparison with other medical factors, or are still being studied (doubtful indications) Generalization of clinical experience and analysis of performed studies allows to conclude that indications to HBO within a system of complex treatment of gunshot wounds can be classified as a IInd group, i.e. HBO can be considered as an effective method. Use of a syndromic principle to estimate of trauma character and state of a casualty allows formulating following general indications for HBO treatment of gunshot and explosive wounds at the stages of the qualified and specialized medical care: postshock and postresuscitation periods in presence of the significant microcirculatory and metabolic disorders; manifested overstress of cardiorespiratory system; posthemorrhagic anemia (hemoglobin less than 70 g/l);
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risk factors of severe wound contagious complications or their evolution.

Based on general indications, it is obviously possible to isolated following classes of casualties requiring HBO by localization of damages: Perforating wounds of chest with a hemopneumothorax at presence of risk factors of purulent complications; Perforating wounds of a abdomen in a toxic stage of gunshot-induced peritonitis, preferentially with damages to colon; Bullet, fragmentation and explosive wounds of extremities with fractured and crushed large soft tissue regions, with avulsions of distal extremities segments; Plural and combined gunshot soft tissue wounds of the various localization, accompanied by the expressed disorders of homeostasis. Under conditions of mass casualties entering stages of medical evacuation, there can be a mismatch between needs and capabilities of the method. For these situations, it is necessary to provide HBO usage only under absolute indications. As a rule, these are the cases of extensive gunshot and explosive wounds with damages to the soft tissues, bones and neurovascular bundles. Application of HBO in such cases is pathogeneticlly justified first of all to prevent evolution of severe cases of gaseous wound fever. Isolation of prime indications for HBO during gunshot wounds treatment prevented overburdening material resources and capabilities of HBO. Contraindications for HBO in treatment of casualties with gunshot pathology are as follows: terminal states; predicted hbo failure, most often caused by irreversible pathological changes of the basic lifesupport systems; necessity for urgent surgical and resuscitator medical provisions; presence of a shock along with labile central hemodynamics (systolic arterial pressure below 90 mm hg). It is necessary to consider such general contraindications to HBO, as claustrophobia, hypersensitivity to oxygen, pathological changes of ENT organs. Nowadays, the clinical practice has no trusty and accessible measure, allowing to characterize adequacy of HBO treatment. Nevertheless, if conducting sessions constantly each time the question should be answered: which patients can benefit most from HBO and how efficient is this method? Proposed forecasting of HBO efficiency is based on the ability of functionally active microvessels in an eyeball conjunctiva to respond by improvement of microcirculation to HBO
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sessions. Physicians isolate three possible responses of microcirculation system to a medical hyperoxygenation: improvement of the functional indicators, lack of the expressed changes and their decline. It was noted that after the first HBO sessions patients showed positive dynamics of microcirculation, followed by the improvement of basic clinical functional indicators after several HBO sections, and, as a whole, clinical effect HBO was regarded as positive. If the conjunctival biomicroscopy showed no improvement of microcirculation in response to HBO first session, the subsequent sessions yielded inappreciable effect. Same patients exhibited paradoxal responses from the standpoint of clinical and functional indicators. These casualties comprised class of casualties with contraindications to HBO. Mainly this group was compounded by patients with plural and combined wounds with massive hemorrhages and a severe, resistant shock; casualties with a purulent peritonitis in state of the basic life-support systems decompensation, but more often in an terminal stage of pathological process in an abdominal cavity; patients in a catabolic sepsis stage. To estimate microvessels of a bulbar conjunctiva visually, the device was designed on the base of optical microscope MBS-2. To estimate efficiency of HBO at medical evacuation stages it is necessary to use complex approach, including study clinical, instrumental and laboratory indicators (Fig. 9.19)

Fig. 9.19. Estimating HBO efficiency in combat damages treatment Clinical indicators are separated into subjective and objective criteria of HBO use efficiency. Before starting HBO course the following subjective indicators should be evaluates, as: state of health, sleep, appetite, pain intensity in the damaged region. The following objective indicators
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are of value: frequency of heartbeat, frequency of respiratory motions, the state of a wound, intensity and character of intestinal peristalsis, dynamics of a neurological symptomatology. Of instrumental indicators the greatest practical value is represented by those, reflecting state of the cardiovascular system arterial pressure, CVP and other indicators. Most important laboratory criteria are the indicators of acid-base balance and gas composition of blood. Other interesting laboratory tests are the levels of lactate and pyruvate of blood serum and state of lipids peroxidation. For a bacterioscopic estimate of wound surface state, physicians frequently use smears with coloring by Kopylov. In a clinical practice it is necessary to adhere to the following rule. If HBO course of appropriate duration resulted in improvement of 3-4 chosen clinical, instrumental or laboratory indicators, available at the current stage of medical evacuation, application of a medical hyperbaric oxygenation course is considered effective. Priority should be given to the clinical indicators, defining course and outcome of pathological process. Their steady normalization warrants discontinuing HBO sessions. Hyperbaric oxygenation in medical establishments can be performed using aerial and oxygen hyperbaric chambers: line-decompression chamber (PDK-2), large recompression chamber (BRK), small recompression chamber (RKM), mobile recompression stations (PRS), singleoccupancy HBO chambers "Oka-" and "Irtysh-". For HBO sessions, air chambers (PDK, BRK, RKM, PRS) are equipped with additional oxygen tubing and oxygen devices. HBO chamber "Irtysh-" deserves special attention in view of combat damages treatment at the stage of evacuation. This chamber is standard for any field military hospital (Fig. 9.20). This chamber is portable and mobile and allows to conduct HBO sessions in the standard deployment place and if placed on the transport vehicle. Deployment time is 3-5 mines. For the peak pressure 1kgs/m2 (0.1 MPa) the oxygen capacity allows to run the chamber for 90 minutes. Chamber is installed according to Supervisory technical material 42-2-1-84, branch methodical directions (OHM) 42-21-26-88 and 42-21-27-88 USSR MoH. Authors used hyperbaric oxygenation to treat 63 casualties with mine-explosive avulsions and fractures of distal segments of extremities. This method was considered as an important component in the complex treatment of mine-explosive wounds. It has to be noted that satisfactory effects of treatment to patients with MW during HBO were achieved only taking into account features of the mine wound pathogenesis. In initial stages, responsible for clinical experience accumulation, HBO was used in the system of complex treatment without taking into
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account degree of homeostasis indicators correction, stages of a wound process and character of concomitant damages. Effects were unsatisfactory as the quantity of contagious complications and terms of hospitalization did not decrease. Gradually, the authors designed proven system for complex MW treatment, which allowed improving effects of treatment. This system will be described below.

Fig. 9.20. Single-occupied oxygen HBO chamber Irtysh-MT As casualties entered the stage of qualified or specialized surgical aid, upon reception the anesthesia was rendered, container novocaine blocks were performed, blood-substituting solutions were introduced. Blood transfusions were performed when indicated. After delivering casualties from the state of shock and stabilization of the central hemodynamics and breathing basic indicators, the surgeries were performed most often amputation of the defective extremity with respect to changes in explosive wound tissues. Surgery was followed by the postoperative corrective symptomatic and local treatment. The blood-substituting solutions were chosen to improve rheologic properties of blood and microcirculation in tissues. The preference was given to intravenous drop introduction of 1.0-1.5 l rheopolyglucin or Haemodesum. Infusion-transfusion therapy continued through a surgery. 6-10 hours after the end of surgery, HBO was initiated, consisting usually of 4-5 sessions of medical hyperoxygenation (PO2 0.180.20 MPa, exposure 40-60 mines daily). During 3-4 days of postoperative period intravenous introduction of reopolyglucinum or Haemodesum continued in combination with intramuscular injections of Heparin (5 thousand units 2 times a day). Combined of HBO with drugs refining microcirculation in injured tissues, has pathogenetic substantiation. Mechanism of HBO positive activity in combination with these specified drugs is as follows application of drugs amplifies HBO effects, refines an oxygenation of the injured
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tissues, liquidates oxygenous backlog, which raises number of functioning capillaries and improves microcirculation. Ultimately, congenial conditions are created for restitution of the injured tissues vitality, their resistance to wound a microflora raises. Therefore, peculiarity of this MT casualties treatment consists in pathogenetically proven sequence of drugs application and HBO. The following clinical observation is a good illustration. Patient 3. (case history 3247), 25 years old, wounded by anti-personnel mine blast 12.03.85. Paramedic aid morphine injection, aseptic bandage and transport immobilization. From CMH MOD RA airlifted 18 hours after wound. Upon receipt: the general state severe, pulse 98/min, feeble modulation, rhythmical. AP 90/60 mm hg col. Diagnosis: mine-explosive wound, avulsion of a dextral inferior extremity at the level of a medial third of shin, crushed soft tissues of a lefthand shin, plural nonperforating wounds to the soft tissues of other segments of the inferior extremities and trunks. Shock of II-IIIrd degree. Complex of antishock provisions included infusion of 2l rheopolyglucin. Wound revision showed spreading necrosis of tissues proximally to place of shin avulsion. Amputation of a dextral inferior extremity is executed at the boundary of the inferior and medial third of femur. 6 hours after the completion in addition to intensive corrective therapy by Heparin intramuscularly 5 KU / 2 times a day the trial session of HBO (PO2 0.12 MPA, exposure 30 mins) is conducted. In the subsequent five days of a postoperative period HBO sessions (PO2 0.2 MPA exposure 60 mins) were conducted, time of compression and decompression was 15 mines. Barochamber "Irtysh-" was used. State of the casualty improved after the second day: the temperature curve has normalized, appetite appeared, and pains in the region of an operational wound have decreased. According to a conjunctival biomicroscopy, indicators of systemic microcirculation were considerably improved. Within the first 3-4 days inflammatory reaction decreased to moderate, grains started to form and attributes of necrotic suppurative changes disappeared. Of significant interest is comparative analysis of the morphological studies of granularly and muscular tissues, sampled from wounds of amputated stumps in casualties treated and untreated by HBO. 65 tissues samples were biopsied within two weeks after amputation. It turned out that application of HBO objectively promoted collagen formation in the fibroblasts of granulation tissue. Its transformation into fibrillary connecting tissue was more uniform. It accelerated epithelialization and final healing of wounds. Medical sessions of a hyperbaric oxygenation correct functional disorders of the basic lifesupport systems of the organism, inherent to acute period of wound sickness.
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Electrocardiographic examination confirms this fact. Relative analysis of dynamic ECG monitoring in 11 casualties with MW in the extremities, treated by HBO (81 ECG records), 21 patients, untreated in a postoperative period (49 records), testifies to the fact. Use of HBO promotes prompt normalization of ECG parameters: after 4-5 sessions at 5-7th day after wound heartbeat essentially decreased, and indicators Q-T, S-P returned to normal values, metabolic disorders reversed. If by the end of 3rd week after wound (17-21 day) only 10 % wounded, who received HBO, did not return to normal heart activity. At the same time number of heart disorders in the untreated group reached 80 % of cases. 11 casualties with mine-explosive avulsions of the inferior extremities avulsions, treated by HBO, were subjected during first 14 days after a trauma to mathematical analysis of heart pace using method of variational pulsometry [Bayevskij R.M. et. al., 1984]. It was noted that first day after a trauma is characterized by the sympathicotonic variation with a mean of their mode () 0.52 0.01. dispersion (d) 0.160.033 and amplitude (A) 98.47.56. In the subsequent days these indicators did not change essentially, at the same time dispersion range essentially increased: 0.28 0.031 5-7 days after ( <0.05) and 0.240.027 10-14 days after ( <0.05). Congenial course of a posttraumatic period in the examined casualties suggests that such character of heart pace change is rational and testifies to normalization of homeostasis indicators. It is noted that first sessions of HBO during the complex treatment of MW casualties led to more expressed changes of heart pace: duration of heart cycle and its amplitude increased (height of variation curves decreased and their shift to the right was noticed =0.670.5. =80.712.0. X=0.260.041s). These positive changes had stable character and essentially did not vary after termination of HBO course. Durability of HBO medical effect is confirmed by reliability of differences in quantities for variation curves in main group (treated with HBO) and control group 10-14 days after a trauma ( = 0.720.036 s, 0.56 0.055 s, <0.05). HBO sessions for patients with MW was accompanied by distinct reductions of mannitol positive and mantis negative of skin microorganisms, essential decrease of colibacillus colonies on tongue mucosa (Table. 9.6). These data testify to a boost of the casualty immune response by HBO [Sargsian V.P., 1988]. Majority of patients showed correlation of the positive dynamics with the clinical indicators of the wound process course. The state of a wound for main group of casualties allowed in 65 % of cases (41 observation) to cover an amputation stump by using most preferable in region primary delayed or early secondary sutures 5-10 days after amputation or a surgical treatment (Table 9.7).
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Table 2.6. Bacterial dynamics for skin and tongue mucosa for the casualties with mine-explosive wounds to lower extremities, treated by HBO (X m) Tongue mucosa Study period Before HBO (1-2 days after wound), n=19 After 2-3 HBO sessions (3-4 days after wound), n=12 Completed HBO (6-7 days after wound), n=12 Endo medium 166 18+5 42 Korostele v medium 29 11 83 17 20 12 61 7 84 12 5 Skin (Korostelev medium) Neck Left Right 44 16 38 10 65 13 81 17 32 12 21 6 60 10 57 11 14 4 10 4 10 8 83 Trunk 24 11 106 20 10 5 59 17 44 17 6 Forehead 19 9 87 15 11 5 42 10 82 21 11

Note: Numerator number of mannitol-positive colonies, denominator mannitol-negative colonies. E.coli is studied endo. At the same time control casualties with same damages (182 observations) left without HBO treatment, the state of amputation stump allowed to take advantage of the primary delayed or early secondary sutures only in 18 % cases (33 observations). Differences are statistically reliable (X2 = 49.. <0.002). Cases of severe purulent and gas-making infection contamination for these casualties were absent (as our studied show, frequency of gas-producing wound infection in army of Republic Afghanistan averaged about 2 %). Table 9.7 Cover of amputation stumps in the main group and MW control group Main group (treated by Control group Wound cover HBO) # % # % Primary delayed or early secondary sutures 41 65.1 30 17.2 Secondary surgical treatment/reamputation 22 34.9 144 82.8 Total 63 100.0 174 100.0 To estimate efficiency of HBO for casualties with MW we took advantage of widespread indicator of duration of hospitalization (Table. 9.8). Table 9.8 Treatment terms of MW patients for different options of postoperative treatment Treatment scheme Main treatment scheme (control group) 1 + HBO 1 + HBO + microcirculation improvement provisions Treatment terms 33.6 4.3 30.1 1.8 22.8 3.1 Number of wounded 10 10 12 P 1.2 > 0.05 1.3 < 0.05 2.3 < 0.05

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Thus, the offered plan of complex treatment involving HBO promotes reduction of hospitalization terms. At the same time, using HBO by itself cannot be accepted as effective. Performed studies of the central and microcirculatory hemodynamics, metabolism, acid-base balance and a gas composition of a blood confirm clinical data concerning efficiency HBO in casualties with MW. The most effective indicator is changes of microcirculation, evaluated according to the plan developed by us. In the majority of casualties, during first 3-4 days after wound, HBO sessions did not improve microcirculation. By 5-7th day after wound the casualties, treated with HBO as a part of complex postoperative treatment, had considerably better indicators of microcirculation in comparison with control group (Table. 9.9), and this trend was maintained and after terminating HBO. Table 9.9 Dynamics of microcirculation indicators in basic group of casualties treated with HBO and in control group MW (X ) Day when Days after wound Microcirculation the wound indicators 1-2 3-4 5-7 9-10 inflicted OKI (N = 3.75 7.49 0.31 6.31 0.21 6.28 0.30 4.12 0.19 4.57 0.23 0.26) 6.14 0.23 6.71 0.22 5.89 0.17 6.36 0.24 VK (N = 6.51 0.23) 5.13 0.29 5.19 0.30 5.24 0.24 6.21 0.19 6.36 0.24 5.27 0.23 5.40 0.27 5.31 0.20 5.44 0.27 OKG (N = 2.07 8.31 0.44 5.01 0.42 4.61 0.90 5.55 1.32 5.03 0.42 0.60) 4.24 0.12 4.49 0.86 6.23 0.78 6.39 0.54 RKG (N = 1.72 9.35 0.66 5.89 0.80 4.33 0.67 6.11 1.37 5.06 0.48 0.53) 6.12 0.16 4.69 0.54 7.89 0.73 7.62 0.50 Note: Numerator main group, denominator control group Changes in system of microcirculation are determined by state of the central hemodynamics and, in turn, have significant impact on the state of a blood flow in the main vessels [Chernuh A., 1975; Horizons And., 1976]. Complex treatment of MW involving HBO was accompanied by the expressed elevation of SBV (strike blood volume) after the third ( <0.01) and fifth HBO sessions ( <0.01). In addition to that, minute blood volume (MBV) showed trend to elevation as well after. After the first session SBV increased and after 3rd and 5th session the changes were becoming statistically reliable ( <0.01 and <0.05 accordingly). Thus, HBO for casualties with MW eliminates or reduces hypodynamia of a myocardium.
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Generalization of clinical experience in treatment of mine-explosive wounds has allowed discovering indications for HBO usage within complex therapy of this specific combat trauma. These indicators, aside from characteristic for cardiorespiratory, microcirculatory and metabolic disorders, are: - extensive wounds with damages to skin and underlying tissues of trunk and extremities (more than 5 % of a body surface) with threatened purulent-septic complications; - presence of factors, capable to complicate course of a wound process (amputations through obviously defective tissues, the long-term compression of tissues by hemostatic tourniquet, late medical aid, strong contamination of wounds, et. al.). Contraindications for application HBO in this class of casualties is a state of shock with the labile hemodynamics, unstopped bleedings, life-threatening states which can be eliminated only by urgent surgical and resuscitatory provisions. Unconditional contraindications are agonal state and an individual hypersensitivity to the oxygen, if discovered during trial session of HBO. Thus, presented data testify that pathogenetically proved treatment plan of mine-explosive avulsions and fractures of extremities distal fragments should include HBO as a method to correct functional and trophic disorders. HBO method should be used along with surgical provisions, coordinated with specific features of explosive wound pathogenesis. Application of HBO method allows to considerably improve effects of treatment. Wound fever. The indication to use HBO in treatment of contagious complications of gunshot and explosive wounds is the profound effects of hyperbaric oxygen on the reparative wound processes. Another reason is the changes of biological properties of microorganisms under hyperoxia conditions. The surgical intervention directed on sanation of a suppurative focus and its active drainage should by a prerequisite to HBO. Using HBO in casualties with local purulent infectious contamination usually compounds 5-6 sessions at P02 0.15-0.20 MPA for 50-60 mines, one session per day. As a result of the first 2-3 sessions, casualties predominantly manifested reduction of tissues edema, elevation of wound discharge. It was followed by the wound graining, filling major share of wound and wound surface. The degree of toxic-absorption fever simultaneously decreased. In 85 % casualties with purulent complications of bullet wounds, HBO application was accompanied by a distinct positive effect. During sepsis HBO is considered to be important element of intensive complex corrective therapy having a multy-directional effect. According to understanding on mechanisms of medical effects of HBO, during sepsis its effects are manifested by improvement of a purulent wound
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state infection contamination focus (under condition of surgical provisions adequacy), trend to normalization of the functional indicators of the basic organism systems, action on microflora. HBO it is not indicated during catabolic phase of a traumatosepsis when changes in organism have largely irreversible character. It is necessary to aspire to earliest inclusion of HBO in system of sepsis complex treatment. It is possible to regard clinical pattern of a disease, not waiting for the laboratory studies data. HBO sessions during sepsis should consist of 10-12 sessions with PO2 0.18-0.20 MPA with an exposure of 60 mines daily. Gas-making wound fever. This term designates severe contagious complications of a wound process with various etiologies, involving formation of gas and edema in the damaged tissues. It is assumed now that anaerobic gas infection contamination and a gas gangrene are different varieties of a gas-making wound fever caused by clostridia. Presence of clinical attributes of a gas-making infection and proved suspicions of its possible development are unconditional indications to using HBO as a part of complex treatment (1st group of indications). Clinical pattern in the majority of observations did not allow to isolate gas gangrene pathogens. Therefore in cases when wound complication proceeds with the expressed intoxication, formation of gas and edema, it makes sense to initiate full cycle of treatment, not waiting effects of bacteriological studies. Surgical treatment has priority. Wide incisions of a skin, subcutaneous fiber and fascias allow to open and drain purulent flows, remove necrotic tissues and create conditions for aeration of wound surfaces. In a postoperative period, the leading part is played by the infusiontransfusion therapy combined with artificial diuresis. The procedure of HBO is defined by a series of factors: a stage and the shape of contagious process, character of previous treatment, presence of complications. In typical cases (Table. 9.10) the following plan is recommended.

Table 9.10 HBO regimes for anaerobic infection Treatment days 1 day 2nd day 3rd day 4-6th day
st

Number of sessions 3-4 2-3 1-2 1

Session duration, min 120 90 60 60

Pressure, MPa 0.2 0.2 0.2 0.2

Clinical experience and analysis of published data allows to formulate following principles of HBO use for prophylaxis and treatment of severe contagious complications during gunshot and explosive wounds:
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with the purpose of wound contagious complications prophylaxis, the HBO is indicated at the earliest possible terms after wound and surgeries; at the sight of the first clinical attributes of a gas-making wound fever it is necessary to start HBO, viewing it as an urgent provision; breaks between HBO sessions should be used for conducting an intensive care.

When treating wound contagious complications, HBO should be combined with infusiontransfusion, antibacterial, detox, corrective and symptomatic therapy. Preparation of the wounded patient for HBO sessions. The question on using HBO in each case is resolved by collective decision of the attending physician and HBO expert. Thus, aside from character of damage and presence of indications to application, it is necessary to consider developing medical and tactical conditions. Before initiating HBO it is necessary to familiarize wounded with an offered method of treatment and to gain its consent. In case of the impeded contact with the patient (unconsciousness) the question of HBO initiation is solved by the board of doctors. Before beginning scheduled sessions, the patient should be examined by an ENT-surgeon for passability of eustachian tubes and checking for other ENT-pathology. Minimal list of examination includes: a radiographic analysis of lungs, clinical analysis of a blood, general urine analysis, estimate of a state of hemodynamics and external respiration. Wounded patient should be instructed on the rules of behavior in a pressure chamber. Should pains in ears occur during a compression and decompression the patient is recommended to swallow and conduct Valsalva maneuver to carry out a vigorous expiration through the nose with nose and mouth closed. If necessary, sedatives should be prescribed before placing patient in the chamber. The patient can be fixed to a hand frame of the chamber by wide soft straps. If necessary the dynamic monitoring of heart activity is performed: electrodes of the electrocardiograph are attached to the extremities. The device is installed outside and connected with airtight sleeves to HBO.

9.3.5. Morphofunctional and topographic-anatomic substantiation of preserving treatment for amputations of the inferior extremities after a mine-explosive trauma
Despite prolonged evolution of amputations theory, whole tiers of the major medical-tactical questions (the choice of level and a method of extremity truncation, principles of amputation
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wound treatment and technique of treating of stump tissues) still demand comprehensive solution. Especially it concerns mine-explosive wounds and damages to extremities. Low cost of mine manufacturing and simplicity of their installation, the relative safety for installers, high perform of explosives have led to an irreversible trend of mine-explosive trauma share growth in recent local conflicts. Tactics of mine application caused predetermined preferential damage to the lower extremities. In 27.3-54.7 % of cases avulsions of segments of the inferior extremities, often inferior third of shin and foot were noted. Severity of trauma in each case was defined, as a rule, by perform and design of ED, position of the casualty in relation to front of an explosive wave [Dedushkin V.S., Farshatov M.N., Shapovalov V.M., 1994]. Among all amputations, executed in Afghanistan, truncations of the inferior extremities at different levels comprised 87.3 %. For 84.9 % casualties the operative measure was related to mine-explosive wounds or damages to inferior extremities. Notwithstanding the experience of extremities combat damages treatment, accumulated by military surgeons, provides certain basis for development of preserving methods for amputations, the main practical approach remains truncation of segments of extremities within the limits of viable tissues but as close to the basic damage focus as possible. Definition of an optimum amputation level for this combat surgical pathology still remains unresolved question. Alongside with attempts to define level of amputation by diagnostic incisions, in view of tissues separation extents [Gritsanov A.I, et. al., 1994], perform angiography of the main vessels in the region of damage, to evaluate state of tissues by the "soft" radiographic analysis of the inferior extremity [Minnullin I.P., et. al., 1989], there are still propositions to use amputation plans, being widely criticized in publications [Kejer A.N., Rozhkov A.V., 1996; Kejer A.N., et. al., 1996]. Authors of the monograph Mine-explosion trauma [Nechayev E.E., Gritsanov A.I., Fomin N.F., Minnullin I.P., 1994] proposed to perform intracontainer tissues revision with respect to architectonics of weak spots and peculiarities of surgical anatomy of different explosive trauma, to find out the optimal amputation level. This method proved itself during combat, and is closest to a position of surgeons, belonging to International Committee of the Red Cross (ICRC). ICRC position is to introduce most organpreserving principles for surgical treatment of "mine" avulsions [Coupland R.M., 198. 199. 1993]. Nevertheless, practical directions for specific ways to execute amputation of a shin in the majority of monographs and manuals do not consider rather essential features of explosive wounds, in particular, a degree of mechanical injury to the structures of a shin when planning
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surgical provisions, and, also, relationships of the major organ neurovascular formations of n shin and regions of explosive disintegration and a contusion of tissues. Moreover, retrospective analysis of casualties treatment, executed by specialists of the St.Petersburg scientific research institute of a prosthetic repair, showed that only 17.3 % of stumps originally were suitable for a prosthetic repair, and the others demanded reamputation for the reasons of defects and sicknesses in stumps in 36.2 % and 63.8 % cases of reamputation, accordingly [Kejer A., Rozhkov A., 1996]. Complex study of mine-explosive wounds mechanogenesys, topography of fractures of shin tissues and anatomical integrity of its major neurovascular hilus and fate of the defective tissues [Lipin A., 1997] has allowed to conclude that often conducted empirical preserving surgery during avulsions extremity under certain conditions can lay the groundwork for the system of organ-preserving treatments and a medical aftertreatment. For this purpose it is important to consider topography and mechanism of fractures in shin histic structures during blast injuries, relationship of explosive disintegration levels and, most important, organ neurovascular hilus of a segment. Role and value of a vascular component in maintenance of necrobiotic and reparation processes in a traumatic shin stump should be considered as well. Studying topography of neurovascular hilus of the major organ anatomical formations of shin in 26 corpse extremities confirmed that they are predominantly situated in a proximal half of shin. Blood supply of the superficial tissues of a segment (skin, subcutaneous fatty tissue, the superficial fascia) is maintained by subcutaneous vascular trunks, so-caused axial vessels, fed immediately from the main arteries and from their muscular branches in the respective containers. Arteries, which form "axis" (usually 2-3) exit through intramuscular barriers and gaps at various shin levels. In a medial third of segment their outer diameter, as a rule, is the greatest. Principles of "vascular axes location in extremities and morphometric characteristics of underlying arteries confirm results, generated by many researchers, including studies at the Department of operative surgery Central Military Medical Academy. When studying neurovascular hilus of shin muscles to substantiate morphometric data and practical calculations of incoming vessel regions, we introduced conventional coefficient (K). This coefficient was calculated by dividing distance from knee joint space to the point of neurovascular hilus entry by the shin length. The coefficient can be positive and negative in connection with some shin muscles being proximal to the line of the knee joint space. Examination of blood supply peculiarities in muscles of a segment proved that large (> 1.0 mm)
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arterial muscular branches in anterior and lateral shin containers are localized within the limits of its proximal half (K= 0.1-0.46). The largest (> 1.2 mm) vessels are within the limits of the upper third. For muscles of a back case the coefficient is 0.035 to 0.437. Greater total amplitude points on various principles of the blood supply organization in deep and superficial muscles of a back container. Studying of blood supply features in a tibial bone revealed that the outside diameter of a feeding artery (a. nutricia os tibiae) depends on sizes of shin and on the average equal 1.2 0.2 mm. Distance from the knee joint space to place of artery entry in a tibial bone is constantly. According to an entire sampling it is 10.2 0.2 cm, which matches boundaries of the upper and medial third of segment (K = 0.316 0.01). In this connection, when possible, sawing of the tibial bone should preserve this major neurovascular bundle. These data, being of interest in other applied aspects of this problem, were used for comparison with regions of an explosive disintegration of shin tissues. With this purpose contact blasts were simulated, using embalmed inferior extremities (n = 18) and HE charges 2. 50 and 100g. Studying mutual relations of entry regions of neurovascular hilus and levels of an explosive disintegration/separation of shin tissues revealed that the basic feeding vessels of segment tissues remain intact (Fig. 9.21). Their anatomical integrity, as a rule, is not broken except for separate experiments, combined greatest HE mass, and least length of a segment. Therefore, topography and anatomy of fractures in an extremity and volumes of intact tissues are influenced by two basic factors mass of HE and individual size of a blasted extremity segment. Consequently, when developing means of extremities protection, the basic effort should be directed on liquidation (or essential reduction) of explosive effects or increasing distance (if possible) from HE charge to the foot. This issue is already discussed in publications is partially realized in development [Shapovalov V.M., 1989; Fomin N.F., Ballistic studies, dealing with different objects, were been executed in two qualitatively different groups: anatomical material and experiments with animals. Use of two varieties for simulation of mine blasts allowed to clear the difference in change of bioindicators for dead and live shins, which facilitates extrapolation of experimental data, even if anatomical size, construction and shape of human and dog shin are incompatible

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Fig. 9.21. Schematic relationships of basic neurovascular hilus for shin muscle and tibial bone to the regions of explosive tissues disintegration during the explosion of 100g HE charge (conditional coefficients) basic neurovascular hilus; explosive tissues disintegration regions total anatomic defect region As known, action of injuring factors of mines explosion on a tissue of humans and animals is [Nechayev E., et. al., 1994] separated into high-explosive (atomizing) and demolition (shockwave). The high-explosive blast action leading to full pulverization or the significant disintegration of tissues is less interested than demolition action. Latter represents the complex interaction f various injuring factors on live tissues. We have selected two most important factors: impulse excessive pressure in the segment tissues and a pulse shock accelerations of shin and entire body. Waveforms of pressure in shin tissues, acquired in our experiments with 18 inferior extremities of corpses and 4 dogs, considerably differed from the ideal diagram due to physical features of biological tissues and are characterized by lower velocity of pressure increase. They have less expressed curve of decreasing pressure and practically missing negative phase of an impulse. During experiments, we noticed two peaks at the curve, observed in experiments with both anatomical and biological material. This is most likely described by the reflected blast wave

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registration. Pulse shock accelerations (PSA) for shins and femurs for different HE yields contain 2-3 bursts of impulses with total duration from 3.8 up to 5.2 ms. PSA pattern for different objects did not vary essentially. However, of importance was the anecdotal fact of absolute peak acceleration decease for animal shin in comparison with the inferior extremities of a human, despite small linear dimensions of a segment. We explain this fact, first of all, by the higher inertia of living tissues due to original hydroeffect and, to a lesser degree, various anatomical structure of animal and human shins. Comparison of the obtained results with materials of other scientists revealed the following. First, despite various observational models, HE types, and frequently methodical approaches to modeling of mine blasts, recorded values are quite comparable with published data. Secondly, recorded level of blast wave effects on a tissue of a proximal half of segment [Parashin V.B., 1993], is obviously insufficient to start irreversible changes in tissues. Summarizing ballistic studies, it is possible to deduce that there are biophysical backgrounds for preserving significant amount of tissues in traumatic stump of a shin after its mine-explosive avulsion. X-ray angiography and thermal imaging during experiment with 15 dogs showed that during the blast of HE charges (2. 50 and 100 g) the most expressed vascular network during 1st day is positioned in the upper and medial third of shin. Peak quantity of thermal changes, according to a thermometry, falls on a medial third of segment. The angiography allowed to expand knowledge concerning state of a vascular bed of shin down avulsion line. Analysis of angiograms showed that the most significant vascular disorders in segments of a pelvic extremity for dog are observed after the wounds inflicted by 100-g C4 charge. Damages, inflicted by the blast of 50 and 25-g charges differed in quantitative parameters, with no drastic difference. Analysis of angiograms of vessels in the defective shin allowed to find basic stages of restitution of a peripheral circulation. The contrast medium, injected into a femoral artery of the injured extremity, is tracked down to avulsion level third day after wound. Formation of collaterals from the surviving arteries of all shin formations initiated later. Continuing from the experimental observations, creation of new architectonics of vascular shin stump by mobilization of all survived vascular reserve in the form of a collateral ring [Fomin N., 199. 1996] is intensively continuing during 2-3 weeks after a trauma. Thus, all tissues more distant from collateral "baffle", are exposed to necrotic decay and a rejection. The following law was found the
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smaller mass of an applied charge, the closer "baffle" is to the wound base. Comparison of thermometry, angiography and multilevel doppler imaging allowed to state that boundary of an adequate blood flow in an extremity, exposed to immediate action of explosion, is positioned at the level of the upper and medial third of shin, which defines topography of necrobiotic and regeneratory-proliferative processes in a shin stump. Despite numerous publications addressing pathomorphology of mine-explosive wounds, we did not encounter studies dealing with dynamics of tissues healing of tissues, damaged by factors of mine explosion. Evaluation of tissue preparations of the defective extremity taken at different dates showed reliable positive dynamics in course of inflammatory-regenerative processes. Total necrosis of muscular fibrils and diffuse leukocytic infiltration with predominance of polymorphonuclear leucocytes (3 days after blast) was replaced by obvious attributes of muscular tissue regeneration with magnification of myoblasts quantity and the active reorganization of muscular elements during 14th day. Basic stages of an explosive wound healing in animals finish in a month after blast by formation of a scar tissue in a distal department of a shin stump. Preparation analysis of the muscular tissue taken from animals after modeling of wound, inflicted by the blast of 25 and 50 g charges, confirmed this law. Differences consist in only shorter terms and more distal level of the basic processes course during healing of the defective tissues. Thus, the injured tissues of a segment possess the expressed ability to regeneration. Course of necrobiotic and reparation processes in tissues of shin of a dog proceeded due to formation of anastomoses between the preserved arteries of a segment. Considering last data on features of evolution and operation of a collateral circulation in gunshot and explosive wounds [Fomin N., 1996] and adapting these data to the peculiarities of this manual, it is possible to assume that traumatic stump of an shin at manifests all disorders of roundabout circulation with the subsequent objective outcomes: decompensated within the limits of a distal wound segment with evolution of irreversible changes and a necrosis of the tissues, subcompensated at a level of a medial third of shin where the restricted focal necroses are usually noticed and the great bulk of tissues survives, and, at last, compensated through an entire upper third of the segment, not excluding, however, evolution of microfocal necrosis. The latter stage provides full healing and recovery of primary circulatory disorders. Specific boundaries of allocation of the specified regions will undoubtedly depend both on the amount of primary disorders and efficiency of conducted surgical and drug treatment.
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It would be desirable to note that due to some reasons, authors did not target a problem of the detailed and profound studying features of roundabout blood flow in a traumatic stump of a shin, injured by explosion. Nevertheless, functional state questions of a collateral circulation in a stump in early and late postoperative periods, specific methods of roundabout blood activization when preparing patient for a prosthetic repair, and for treatment of stump sicknesses demand the further studying in theoretical and practical aspects. The basic results of the complex anatomic-physiological studies testify that it is possible to develop organ-preserving methods of shin amputation at mine-explosive wound. Amputating technique during mine wound is based on some the important principles. First, it is necessary to maximally maintain integument and superficial muscles of a shin proximal half, as most rational "material" for the delayed cover of an amputation stump. It is necessary to supplement these methods by more radical excision of stratums of muscles adjacent to the bone, targeted drainage of deep intermuscular and paravasal spaces, especially popliteal canal. Secondly, if sawing-off tibial bone it is necessary to maintain, whenever possible, the diaphyseal nutrient vessels having huge value in maintenance of its trophicity. Thirdly, considering the major role of a neurovascular component in maintenance of reparation processes, surgical treatment should include provisions against a traumatic edema of tissues and wound fever, normalization of microhemocirculation and collateral circulation near the wound. Thus, preserving operative technique during amputations and a surgical treatment of mine wounds of extremities should be based on estimate of relations of the major organ neurovascular formations and regions of the basic fractures and a tissues contusion, caused by explosion. It is also important to know laws of necrobiotic and reparation processes in a stump of the defective extremity. Among casualties with mine-explosive wounds to shin, arriving to on stages of medical evacuation, it is necessary to isolate group where the application of organ-preserving methods of the defective segment truncation is possible. It is necessary to include, first of all, casualties with the insulated avulsions of a shin in its inferior third at lack of the significant fractures in higher segments of an extremity. By the moment of surgery, the operation indicators of the basic vital function of an organism should be balanced. The major organ neurovascular formations of a shin providing trophicity of segment tissues and having the greatest value in pathomorphologic evolution of an explosive wound are confined to the proximal half of a shin. They include diaphyseal nutrient artery of a tibial bone, situated distally to the knee joint space by 10.8 0.2 cm.
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During contact blast of HE, with perform equivalent to standard anti-personnel mines, the degree of blast wave effects on a shin tissue in the upper third of segment does not attain level, sufficient for evolution of primary irreversible changes in tissues, unlike medial and inferior thirds of shin where quantities of pulse shock accelerations and interstitial pressure exceeds critical value. Upper bounds of an explosive disintegration and separation of tissues of a shin after typical contact mine blast are characterized by a nonuniform distribution through a segment and, in general are, localized in inferior and medial thirds. The major organ neurovascular hilus of integument and periblasts of the proximal half of shin muscles in most cases is not damaged. By amputating shin in casualties, belonging to this group, it is necessary to consider preservation of the major organ neurovascular formations of a segment. The level of an extremity in overwhelming majority of similar cases can be on a boundary of the upper and medial thirds of shin. Sawing line of the tibial bone, whenever possible, should be distally to level of diaphyseal nutrient vessels entry. Use of classical amputation should be complemented by the methods of maximal maintenance of integument and the superficial layers of muscles of a proximal segment half. At the same time, it is necessary to excise more radically the superficial layers of periosseous shin muscles and, at the same time, reliably drain deep intermuscular and paravasal spaces, especially in the region of the popliteal canal. The major constituent of complex postoperative treatment of MW should be the provisions, targeting against traumatic edema of tissues and wound fever, normalization of microcirculation and collateral circulation in the periwound area. Considering leading part of a collateral circulation in a healing of an explosive wound, to accelerate and optimize reparation processes in the postoperative and rehabilitation period, physicians should perform novocaine blockages of peripheral nerves of the defective extremity in combination with drugs, improving microcirculation.

9.4. DAMAGES TO SKULL AND COLUMN DURING EXPLOSIONS 9.4.1. Mechanisms of brain damage through an explosion
Damages to skull and brain during explosive damages are the most widespread component of the multifactor damage resulting from action of blast wave, a gas-flame jet, toxic fumes, debris of
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explosive and secondary projectiles. Various types of damages to skull and a brain during mine blasts are encountered in 83.4 % cases. Viewing explosive damages as plural combined multifactor damages, not restricted by single point of the application, and embracing entire organism, it becomes obvious that pathological changes in the central nervous system are caused not only by direct injuring action of separate injuring factors of explosion on brain or their combinations, but is also a consequence of various extra-brain traumas and wounds. Depending on predominance one or another factor explosive damages of a skull and a brain can be separated into explosive wounds when damages by projectiles prevail, and explosive damages where damages by a blast wave predominate along with gas-flame jet and their aftereffects in the form of head impact by the surrounding objects. It is possible to isolate thermal damages of a various degree and the area. According to the statistics, explosive wounds to a skull and a brain are encountered in 11.7 % of cases, explosive damages in 71.7 %, thermal damages in 0.6 % and combined damages in 5.5 % of casualties. In the general pattern of neurotrauma, the predominating part is casualties with clinical syndrome of the open craniocerebral damages and the severe closed skull trauma. Explosive effects are strongly contributed by the conditions of personnel injury. According to the analysis of casualties in Afghanistan, presented by N.D. Klochkov and coworkers, (1987), the relation of damages, inflicted at open terrain to explosive damages in the armor was 3.6:1; similar data were supplied by A.I. Gritsanov with coworkers. (1987). Prominent feature of damages at open terrain are the extensive open damages combined with plural fragmentation wounds. Predominance of the plural closed and open mechanical injuries in an explosive polytrauma combined with severe barotrauma distinguishes explosive damages in the closed circuit. According to U. Baker (1986), damaging effect of excessive pressure in an explosive blast wave inside closed circuit increases 4-5 times, similar data are given by A.I. Filatov (1982). Meanwhile all varieties of mechanical injuries to skull and brain during explosions can be reduced to three basic varieties of the craniocerebral trauma acceleration trauma (inertial trauma), the concentrated shock (impression trauma), head compression. This classification is accepted by majority of clinicians, forensic experts and pathologists. Currently there are no the direct reliable data describing mechanisms of diffusion damaging action of shock explosion accelerations on a brain. Under lack of local organic brain damages and distinct compression mechanism of brain damage, clinicians collide with a stubborn problem
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how to define of "primacy" or secondariness of brain damage, inflicted by a blast. Meanwhile, answer to this question determines complex of medical and diagnostic provisions in casualties with this combat pathology. Use of traditional classifications of brain trauma with separation of all craniocerebral damages into closed and open, if applied to explosive damages, often does not reflect pathological changes in brain.

Fig. 9.22. Conditions of explosive damage Principle of skin, bone and dura mater preservation, underlying craniocerebral traumas, not always objectively reflects pathological changes in brain at explosive damages. Combination of the local open damage in the point of injuring projectile hit with simultaneous action of shock accelerations on a brain is characteristic for explosive damages. Under these requirements, most actual concepts are local place of the injuring factor application or diffuse or translational brain damage alongside cerebral derangement, caused by indirect damage. Injuring factors of explosion in itself reflect preferentially its physical characteristics. At the same time potential injuring capabilities of HE munition are implemented into specific damaging mechanisms only through the third link in the system explosion human - conditions of an explosive damage (CED). Conditions of an explosive damage are not solid and passive element of this system. Requirements, in which there is an action of explosion on the person, are defined by human protection and the peak blast effects of ammunition. Under formally similar "content" of injuring factors of various explosives, manifestations of
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injuries can vary radically. Only final effect of specific interaction of injuring factors with specific requirements of an explosive damage defines volume and character of the damage, caused by explosion. Depending on conditions of an explosive damage, all explosive effects are partitioned into four basic groups (Figure 2.22): - damages in the nearest explosion zone in the open circuit with no immediate contact of casualty with an explosive device (1); - explosive damages at direct contact of the casualty with explosive device in the open circuit. Contact gravitational explosive damages (2); - beyond-armor explosive damages during blasts on mines or IEDs in the armored vehicles, cars, trains, et. al. (3); - explosive damages in the closed circuit in a building, mine, car, train, armor, shelters (4). According to our data, in the majority of observations explosive neurotrauma was caused by blasts in the armor and very close to explosive device (1st and 3rd variety). They constituted 65 % of all casualties. Contact mine blasts of people in the open circuit of 2nd variety are accompanied by much heavier extracranial damages, but seldom by severe traumas and wounds to skull and brain.

9.4.2. The clinico-morphological changes in brain at explosive damages

Comparing clinical signs of brain damages during explosions with pathomorphologic processes in a brain for 183 casualties, the regularities were found between expression and character of cerebral derangements and conditions of explosion. Dependence of brain morphological changes in brain upon death term was found. All casualties, who died during first 12 hrs after explosion, there were no noticeable changes in brain. Casualties, who died within 12--24 hrs, showed fast development of pathomorphologic processes, including perivasal aggregations of the erythrocytes, extended perivascular spaces filled by a fluid. Of casualties, who died 2-3 day after.73.3 % manifested macroscopic plural punctual hemorrhages in deep departments of a brain (region visual lumps, interior capsules, pons varolii, brain legs).Hemorrhages attained 2-2.5 mm in size. Casualties with heaviest damages perish during first hours. 88.9 % casualties, who died in this
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time span, showed heavy fractures of extremities at a level of the upper third of shin, the inferior third of femur, fracture of both inferior extremities segments. Rough morphological changes are detected in all these casualties in lungs and a cardiac muscle that, which testified to high force of explosive action. However, in this group of casualties pathomorphologic changes in a brain were minimal. In the casualties, older than 2-3 days morphological brain changes were peaked though extracranial damages were essentially less significant. "High" fractures of extremities were observed in 51.8 % of casualties in this time span Stated relationships in forming morphological changes in casualties brain testify to "secondary" character of these developing processes. These changes are defined by secondary cerebral derangement both due to local occlusive damages and systemic disorders of a hemodynamics, caused by shock, hemorrhage, severe contusional damages of lungs and heart, forming endotoxicoses. It is established that the damages caused by throwing of a body by explosive wave, are noted only in 0.7 % casualties. All of them had severe diffuse brain bruises with blood presence in the cerebrospinal fluid. Dead casualties exhibit extensive maculae of leptomeningeal contusions, fractures of skull base bones. Extracranial damages in these casualties were regarded as incompatible with life. Explosive perform in all these observations exceeded TNT 50 g. No throwing effect was noted in cases of unprotected personnel being blasted by ammunition of smaller power. Throwing effect translation of entire body, has the high significance in the genesis of craniocerebral damages in casualties only for shielded blasts inside armor (requirements of an explosive damage 3). Damage biomechanics, imposed by a throwing blast effect inside the armor, is exhibited through the bruises and crushes of temporal lobes with paracontusional hematomas, maculae leptomeningeal contusions in the brain base. These traumas are noted in 61.3 % casualties of mine blasts inside the armor. It is very important, that 19.4 % of casualties lacks the fact of a braking impact, and intracranial changes are caused only by action of shock-shake accelerations from an armored vehicle hull along the axis of backboned channel at the skull base. This damage mechanism is confirmed by the high specific share of casualties with skull base fractures (45.2 % from all casualties with severe craniocerebral damages under requirements of an explosive damage 3).
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The important place in the pattern of severe explosive neurotrauma is held by severe open traumas of a skull and a brain. 93.1 % severe open explosive traumas are resulted from the mine blasts in armored vehicles. The important peculiarity of massive fractures in soft tissues of a head, accompanying explosive traumas, is their combination with severe extracranial damages, bruise of lungs and heart, rough hemodynamic derangements with the expressed hypotension syndrome. Such combinations are noted in 80.6 % of casualties. Features of pathological changes in a cerebral wound should be considered in connection with extracranial damages. Phenomena of shock and the massive hemorrhage accompanied 2/3 explosive traumas and essentially influenced course of neurotrauma. Decrease of systolic arterial pressure down to 70-80 mm.hg. was registered in 74.2 % of casualties. The arterial hypotension in this condition is the important factor of bleeding stop in a craniocerebral wound. Analysis of clinico-morphological manifestations of the open explosive craniocerebral damages and effects of their treatment testifies that the treatment of these casualties requires local stopping of a bleeding from a craniocerebral wound and replacement of extensive damages to a skull and its integument. As noted above, injuring factors of explosion can not only have direct damaging impact on a brain, but also define gravity of brain suffering through mediated action. Relation of the direct and mediated damages to brain in mutual injury of explosive action has crucial importance in definition of medical treatment tactics. The major problem of the neurosurgeon during classifying of casualties is detection of personnel with direct brain damages as only this class of casualties is referred for surgical treatment. From the medevac standpoint it is expedient to isolate light brain damages. The unity of this group consists in a generality of the morphological and pathogenetic processes, taking place in brain and organism after a trauma, as well as in identical medevac profiles. During light damages to brain, pathological processes educe preferentially in its cortical departments and shells, and the vital brain lobes and vegetative centers are involved in it transiently or remain intact. Integral function of a brain during minor and moderate traumas suffers least damages. In essence minor and moderate traumas differ mainly in the quantitative sense concerning expressions of neurological symptoms. Brain Concussion lightest form of craniocerebral damages, predominated by reversible
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functional changes of a brain. Accordingly in clinical pattern general brain symptoms signs predominate over focal. The characteristic clinical attributes are transient loss of consciousness during trauma, clear consciousness at examination, traumatic amnesia, headache, nausea, vomiting, and tinnitus. Most permanent and recognizable objective sign of brain concussion is the adjusting horizontal nystagmus, encountered during mine-explosive damages in 52.4 % of cases. Brain bruises are always accompanied by the organic changes in the form of more or less significant hemorrhages or contusions of a brain or its shells. They are localized both in the trauma region, and on the opposite side in the form of a counter-concussion. Objective attributes of the brain bruises are the subarachnoid hemorrhage, skull fractures or resistant focal signs. The specific severity of brain bruises during explosive trauma has compounded 19.3 %. Severe brain damages also accompanied by the characteristic morphological and pathogenetic manifestations subcortical formations and structures of an interstitial brain are involved in pathological process. Severe damages to brain are accompanied by damages to the centers of a regulation of vegetative functions and metabolism, localized in subcortico-diencephalic regions. During such damages integral function of a brain is upset, and compensatory-adaptive activity becomes defective. The clinical pattern of severe craniocerebral damages develops from general signs and attributes of damages to subcortical formations or an interstitial brain. Focal signs are shaded in acute period of a trauma by bright general brain derangements, traumatic shock and are isolated distinctly during later periods of traumatic sickness. Main general symptom is a state of consciousness, e.g. during severe brain damages casualties exhibit the sopor or the superficial coma. Extremely severe brain damages. This kind of explosive brain damages involves primary or secondary (during dislocation of a brain) damages to structures of mesencephalon, bridge and myelencephalon, i.e. lower departments of a trunk. It is the heaviest kind of craniocerebral damages at which brain functions and the vital functions of an organism are practically entirely disabled. The heaviest brain damages are manifested mesencephalobulbar syndrome. The clinical pattern of this trauma is comprised of deep coma and signs of a damage to the brainstem lower departments a muscular adynamia, full areflexia, atony, lack of a swallowing and coughing jerk, buildup of arterial hypotension and a tachycardia, pathological character of breathing. The heaviest brain damages are seldom and majority of these casualties die at prehospital stage. They
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compound 1.4 % of all explosive head damages. Early complications of explosive wounds and head traumas have the major value as these complications threaten casualties life and demand urgent medical care at all stages of evacuation. The most typical early complications of explosive damages to a skull and brain are external bleeding, asphyxia, the convulsive syndrome and compression of the brain.

9.4.3. General principles of diagnostic and course of casualties with explosive brain damages
Multicomponent character of damages to skull and brain during explosions significantly complicates diagnostics and character of brain damage and extracranial damages. In this connection, the examination of damages should be based on a minimum number of popular clinical signs carrying maximal information, and to be conducted under the certain program. As clinical experience testifies, preliminary diagnostics of explosive damages to skull and brain should be constructed to reveal two groups of signs. The first group the signs describing gravity of a brain damage speech contacts, motoric response to pain and the pupillary test. The second group, allowing diagnosing or expelling of a brain compression an anisocoria, fixation of a head or look aside, bradycardia, local cramps. Presence of even the elementary speech contact testifies to not light brain damage, and, hence, gives an opportunity to postpone treatment of craniocerebral damages. Lack of speech contact testifies to the deep disorder of consciousness in the form of a sopor or coma and severe brain damage. The motor response to pain consists in coordinated protective motions in response to pain stimulation. Its maintenance testifies to the extrapyramidal character of severe brain damage, lack testifies of coma. Maintained pupillary test to light in the absence of motor response to pain is characteristic for the superficial coma and testifies to the diencephalic shape of a severe brain damage. Thus, lack of speech contact and the maintained pupillary test testify to a severe explosive brain damage. Such character of an explosive damage assumes: - conducting an intensive care of a brain damage simultaneously with antishock therapy; - active search for attributes of a possible compression of a brain; - prompt evacuation to a stage of specialized medical care. It is necessary to consider that the severe brain damage is not contraindication for pressing and
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urgent surgeries on other body regions; however, the delayed surgeries can be carried out under condition of adequate compensation of the vital body functions. Lack of a pupillary response to light testifies to deep coma and heaviest brain damage. Therefore, such damaged should be administered only symptomatic therapy, especially if stages of medical evacuation are overloaded. Thus, on the basis of above described signs it is possible to define medevac profile of casualties in field conditions and urgent medical tactics. Pre-hospital stage of treatment is responsible for immediate elimination of life-threatening conditions, prophylaxis of a wound fever and the fastest delivery of casualty to the hospital. The major provisions conducted here, are: a temporary stopping of external bleeding, elimination of asphyxia, anesthesia and anti-shock measures, prevention of cramps and a pernicious vomiting. The qualified medical care is provided, as a rule, by general surgeons and anesthesiologistsresuscitators. Its objectives are: final elimination of life-threatening conditions, restitution of the vital functions up to an optimum level up to the subsequent evacuation, pressing and urgent surgeries on skull and a brain, prophylaxis of contagious complications. This stage is comprised of and intensive care and surgical treatment for not only explosive damages of a skull and a brain, but entire mine-explosive damage as well. The specialized care and the subsequent treatment for casualties with explosive damages of a skull and a brain is provided in specialized hospitals, staffed general surgeons, neurosurgeon, the maxillofacial surgeon, the ophthalmologist, ENT surgeon. These hospitals are equipped by all necessary resorts for the final treatment of these casualties. Objectives of the specialized care are: normalization of the vital functions of an organism; surgical treatment of wounds of a skull and a brain; postoperative treatment; treatment of late complications of wounds and traumas; regenerative treatment; examination and an aftertreatment. Surgical provisions at the specialized care stage are prioritized as follows: - first of all surgery is performed for casualties with asphyxia (plural damages to the head) and with an external bleeding; - in the second turn casualties with a brain compression, undiscovered earlier or manifested during evacuation; - In the third turn the casualties with skull explosive perforating wounds, accompanied by severe brain damage; - in the fourth turn the casualties with skull explosive perforating wounds, accompanied
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with light brain damages; - in the fifth turn casualties with skull non-perforating wounds or with depressed fractures of skull bones with no brain compression. Damages to skull and brain, caused by action of explosives, are characterized: - a high share of combined damages, attaining in neurosurgical casualties 70-85 %; - predominance of plural wounds to head and the adjacent segments with high density of primary and secondary fragments and projectiles in a damaged zone; - wounds, inflicted by antimagnetic and X-ray contrast projectiles (debris of mine shell and pane glass, stones, fragments of buildings); - combination of the fragmentation wounds with open and closed mechanical trauma of skull and brain, combustions, destruction of skin over a head and face. In this connection, it is obvious, surgical treatment of casualties with mine-explosive wounds of a skull and a brain has a series of important distinctive features, as addressed below. Experience of leading neurosurgeons has convincingly shown that significance of primary surgical treatment terms for brain wounds was quite often overestimated. According to N. Ahutin's (1942), The time elapsed between wound and surgery plays for cranial wounds considerably smaller role than quality and duration of hospitalization. The attitude to early surgeries has found reflection in N.N. Burdenko famous words (1943): ... Under all options it is necessary to remember that hasty, blindfold, with manual examination and feverish trepanation surgeries do only harm. It is more favorable to operate later than to operate badly The question of a primary surgical treatment terms for skull and brain wounds cannot be solved using a template. Contagious complications in a craniocerebral wound are known to evolve in various terms. "Lightning" meningitises and encephalitises originate during first hours after wound. At the same time, there is large number of congenial cases for perforating gunshot wounds with no surgical treatment at all. Nevertheless, laws of wound process course in brain once again testify that 3-5 days after wound, the probability of contagious complications evolution is highest. For this reason, before this term surgeons should surgically treat a craniocerebral wound. The surgical treatment of skull and a brain wounds, undertaken in the first three day after wound is considered early. Surgical treatment undertaken 4-6 days after wounding is delayed it should be performed only if it is impossible to carry out a surgical treatment in specialized hospital in later terms. Surgical treatment of skull and brain wounds. Major element of a surgical treatment for
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craniocerebral wounds is thorough preparation of a surgery region. Any surgical treatment of a head wound independently of its depth and sizes should start with shaving and a careful cleaning of a skin. These provisions represent one of the most long-term and labor-consuming stages of pre-surgery preparation. At the same time, accuracy of their accomplishment is one of indispensable requirements for congenial wound course. Medial duration of preoperative preparation stage in presence of necessary instruments and trained personnel is 25-30 minutes. Surgical treatment of soft tissues wounds. Despite seeming simplicity of this surgery, treatment of casualties with the soft tissues wounds in the head are characterized by the significant number of complications for all military conflicts of second half XX century. During WWII only 50 % of soft tissue casualties have completed treatment in terms less than 2 months Presence of extensive damages to head integuments was typical complication of damages to skull and brain during WWII. These casualties reflected the most widespread errors of wounds surgical treatment. Unanimous condemnation of a procedure, termed cutouts of coin-sized head skin flaps in postwar publications, unfortunately failed to reduce frequency of this complication in the subsequent military conflicts. Presence of extensive granulating wounds to head and face with a denudation of bones of a calvaria and meninges was peculiar indicator of many recent military conflicts. Second significant reason, which stipulated neurosurgeons to pay the most steadfast attention to this problem, is special character of damages to the head caused by explosions. These damages, as a rule, accompanied by extensive fractures of integuments, which can not be eliminated by simple stitching of a wound. It is necessary to note that after the surgeries, treating perforating and non-perforating explosive damages to skull and a brain at the stage of the specialized medical care, damages to integument are noted in 3.1 % of casualties. Meanwhile, after the surgeries, performed at stage of the qualified care, these damages were observed in third of casualties. The most frequent errors accompanying surgical treatment of the soft tissues wounds at stage of the qualified care are: - unfairly wide excision of cutaneous wound edges; - insufficient hemostasis; - poor closing of cutaneous wound edges; - inadequate drainage. Among all Afghan conflict casualties with combat craniocerebral damages untreated damages to skin after a primary surgical treatment were observed in 6.8 % cases.
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Damages to integuments by causes can be separated into primary, caused by weapon injuring factors, and secondary, caused by surgical errors. Formation of most major skin defects is characteristic for contact explosive damages on the open terrain (conditions of explosive damage 2), and damages by armor-piercing rounds (conditions of explosive damage 4). It is characteristic that all casualties with explosive wounds to skull and a brain exhibit primary damages to the soft tissues, caused by mechanic-thermal action, and the leading part in damage to integuments belongs to mechanical injuries while thermal action is exhibited by spot combustions of II III degree. The combustions occur where the melted metal or particles of HE touch the skin. Combined mechanic and thermal damage of cutaneous defects edges essentially complicates covering naked bone sections in cerebral wound local tissues during a primary surgical treatment. Appropriate equipment is a binding requirement of successful surgical treatment of a craniocerebral wound. Important instruments include the electrical aspirator, Egorov-Freidin osteal pliers, Grebenyuk cone drill and equipment for surgical diathermy. During surgical treatment of the head soft tissues wounds it is not necessary to excise edges of a cutaneous wound, because it increases essential deficit of the soft tissues, while efficiency of this provision is low. Wounds to the head soft tissues without damage to fascia are not a subject resection of edges. Such wounds should be carefully flushed with 3% solution of hydrogen peroxide; foreign bodies should be removed by Folkman spoon; then, wounds should be covered with sterile dressing. Plural fine (punctual) wounds of the head soft tissues are handled in the same way. Special attention should be given to detailed examination of wound bottom and sides, removing hair and small foreign bodies. Thorough washing-off of all foreign bodies should be combined with coagulation of all bleeding vessels and reliable hemostasis in a wound. Wounds with sizes more than 4 cm are subject to washing drainage, carried out through PVC tube. The important element of surgery is exact adjustment of wound edges without creating any tension. An effective way to achieve this state of wound edges is "two-storied" dermo-fascial sutures by Donatti. In the explosive wounds, combined with combustions and destroyed skin around the wound, the overand sub-fascial spaces are separated using wound resection through knot-suturing through fascia or putting sutures over the skin. Sutured fascia restricts bones of a skull from the most infected superficial wound layers. The damaged sections of an integument in a postoperative period are
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treated under damp-drying up dressings and are exposed to UV radiation daily. It is necessary to note, that up to 10-12 % of wounds of the soft tissues, inflicted by the modern weaponry require the complex surgeries, directed on prevention of contagious complications in a wound, elimination of soft tissues damages to conceal of the naked sections of a calvaria. These surgeries can be performed only in the specialized neurosurgical hospital. Surgical treatment of non-perforating craniocerebral wounds. Surgical tactics, applied for treatment of modern non-perforating craniocerebral wounds is characterized by specific features, related to contradictions between seeming manifestations and character of intracranial changes. Off-wound classic cuts (according to classic access cuts to different cranium section) are used as access paths to the wound. Plural character of a wound predetermines choice of such an access which would provide an opportunity to examine a bone in the projection of plural cutaneous wounds. Regional bone erosions (incomplete fractures) require milling of an opening in damaged region with mandatory exam of an epidural space. If epidural hematoma is revealed, trepanation incision is expanded to remove a hematoma. In case of a damage of an external and interior cortical plate, craniotomy with revision of a subdural space is performed. In 66 % casualties with nonperforating craniocerebral wounds, sometimes brain crush foci are observed with paracontusion hematomas in a fracture projection. After an aspiration of the brain crush foci, incision of a dura mater is sewed by atraumatic thread 4/0. Drainage of an epidural space is performed 3-4 days after the surgery. Surgical treatment of-perforating craniocerebral wounds is the most complicated task for the neurosurgeon. These medical provisions can be comprehensively performed only at the stage of the specialized care. While planning the surgical provisions one of the key moments is to select operational access. The method applied during WWII forced dilation of the wound the channel is now discontinued. Modern surgical treatments of perforating craniocerebral wounds are characterized by numerous neurosurgical innovations use of linear access paths, application of microsurgery, wide use of redesign during primary surgical treatment. Considering plural character of the contemporary combat damages to skull and a brain, sometimes it is necessary to examine at once several sections of bone and brain from one operational access. The optimum incisions for these purposes are: - incision through biauricular lines in wounds with frontal and frontal-orbital regions; - linear incision by Cushing in wounds of temporal and parietal regions;
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- paramedian access in wounds of a back cranial fossa and occipital region. Incision line should be positioned outside wounds, and drawn only through the intact sections of a skin. Before incision the soft tissues are infiltrated by 0.25% solution of Novocaine 1 g of broad spectrum antibiotic per 250 ml solution. Skin-fascial flaps are separated from periosteum to have an opportunity to examine a bone in the projection of all wounds to the soft tissues in this region. It is not necessary to remove all fine metal foreign bodies (their number can reach 8-12) from the head soft tissues during explosive wound treatment at this stage. It is important to find out which ones caused damage to a bone and concentrate only on these splinters. At this stage it is important to remember, that 1/3 all wounds with damage of dura mater are secondary perforating. It means that projectiles initially did not penetrate dura mater, and its damage is caused by the osteal fragments, created in the region of gunshot fracture. Such osteal fragments with good reason can be considered secondary projectiles. Similar brain and brain shell damage is to the greatest degree characteristic for tangential bullet and fragmentation wounds. Character of osteal damage in the region of enter opening defines an approach to craniotomy. In case of pierced gunshot fractures, characteristic for blind perforating fragmentation wounds, the craniotrypesis can be executed through bone -plastic approach. Bullet wounds, in view of much higher kinetic energy wounding projectile, cause rough extensive fractures of a bone in the form of multifragmental fractures. These kinds of fractures require resection craniotrypesis. Size of trephine opening is defined by a region of bone fracture. It is necessary to avoid extending trepanation damages to sinuses projection regions. Wide trepanation of a dura mater is a binding stage of a radical primary surgical treatment. Incision line of a dura mater should be positioned so that the incision of a dura mater could be easily closed. The fittest approach for this purpose is "H-shaped" incision. Before the beginning of a cerebral stage, the surgery region should be restricted with sterile linen. Operational instruments should and gloves for an entire surgery team should be changed. After removal of large osteal fragments and clots from initial departments of wound channel and intrathecal areas, the brain around wound channel is cleaned by the cotton wool stripes moistened by 0.9 % saline solution. Only the region of a wound channel is left opened. Surgical treatment of wound channel is the most complex and responsible surgery stage. The main task of this surgery is full removal of all osteal fragments, clots and cerebral detritus. Removal of metal wounding projectile is a desirable element of operation, but if latter is located in brain ventricles or deep-seated departments of a brain (parastemal regions or region of
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subcortical knots) the search and removal should be abandoned. It is established that osteal fragments are 7 times more likely to cause cerebral abscesses than metal foreign bodies. Effective search and removal of osteal fragments are possible only with respect to laws of osteal fragments localization in a cerebral wound. Proven regularities have been found, concerning localization of osteal splinters in brain wounds independently of the wound channel length. The bone debris which have implanted in brain from bone gunshot fracture region are positioned into two groups. The first group of osteal fragments presented by large bone splinters with the sizes 0.5-1.5 cm is localized in clearance of wound channel, not deeper than 1.5-2 cm. They can be easily removed by a water jet, along with clots and a cerebral detritus, or lifted from sides of wound channel by a tweezers under a visual control. The second group of fine osteal fragments 0.1-0.2 cm an osteal cloud is implanted in brain marrow along the wound channel 4-4.5 cm deep. Osteal fragments do not descend deeper even in case of perforating wounds. Complete removal of the second group osteal splinters is mandatory. This objective is achieved through the tight filling of wound channel by the mixture of fibrinogen and thrombin. The mixture is comprised of two components: 1st and 2nd. Component 1 1 g human fibrinogen is dissolved in 20-25 ml of 0.9 % saline solution. Component 2 400 units of thrombin (two vials) are dissolve in 6 ml 0.9 % saline. Two squirt guns are filled with mixture components. The components are mixed using squirt guns directly in the wound channels by depressing pistons of squirt guns simultaneously. Due to mixture of components in a wound canal there is a formation of a fibrin clot forming the dense mould in wound canal. After filling wound canal with mixture and extraction of a resulting clot together with embedded it a cerebral detritus and foreign bodies, the wound channel is refilled. This approach promotes a good hemostasis and allows visual exam of a cerebral wound. The mould of fibrin thus carries out a role of an elastic soft retractor using which it is possible to audit entire wound channel. Surgical treatment approach to brain wound is as follows. The head of a suction unit is inserted 5-7 mm into the wound and used to aspirate contents of wound channel and the crush foci on the sides. An aspiration stops, when the yellow-pink bone marrow with fine bleeding vessels becomes visible. Upon completion of surgical treatment at this level, the clot is removed through the depth of 7-10 mm, subjecting next wound fragment to surgical treatment. Metal foreign bodies can be effectively removed from deep blind wound channel by using peg-magnets. The magnet is inserted in the wound inlet channel till the light click is heard, testifying to the fact
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that fragment is found and can be removed. After conducting surgical treatment of a cerebral wound, the channel is drained by a doublebarreled tube for continuous long-term wound flush. During the radical careful surgical treatment, the wounds of dura mater are sutured by atraumatic thread 4/0. Suturing of the soft tissues carry wounds is performed by fascial sutures. Washing drainage efficiency and duration are estimated by cytologic examination of washing fluid.

9.4.4. Damages to column and spinal cord during explosions

Damages to column and spinal cord during explosions are encountered in 2.5 % cases. Being usually a component of the combined explosive damages, damages to column are often accompanied by entire a set of problems of the diagnostic and medical-tactical character. Depending on the trauma mechanism it is expedient to isolate explosive wounds (2.3 %) and explosive damages (0.2 %). During explosive and mine-explosive wounds, column damages are usually combined. They are combined with a trauma to extremities in 76.5 %, abdomen in 44.5 %, chests in 34.9 %, pelvis in 12.8 %, neck in 8.7 %, head in 4 %. Clinical manifestations of explosive damages to column are defined both by the trauma to spinal cord, and accompanying changes an edema of a spinal cord, disorders of cerebrospinal fluid circulation and hemodynamics, compression of the spinal cord, hematoma, fragments of the displaced intervertebral disk and osteal splinters. According to wound channel character for the fragmentation wounds of a column, physicians isolate three groups of casualties. First paravertebral wounds at which anatomical damages to column elements, and frequently wounding projectile (debris) is missing, and the clinical pattern is caused by concussion or bruise of a spinal cord, inflicted by lateral shock of wounding projectile (26.2 % of cases). Second non-perforating wounds to column. During these wounds the projectile damages bodies and appendixes of vertebrae, while osteal sides of the spinal channel remain intact. Thus, there are usually no serious osteal damages demanding specialized treatment. Non-perforating column wounds comprise greatest number of cases up to 40.3 %. Third group perforating wounds, during which sides of the spinal channel are damaged and injuries to spinal cord by wounding projectile or osteal splinters are inflicted. This type of
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wounds is the heaviest as the dura mater is damaged, dural pouch is pierced, spinal fluid effuses in environmental tissues, natural biological barriers are broken, and the spinal cord is to some extent damaged. Perforating wounds of a column and a spinal cord are encountered in 33.5 % cases of mine-explosive wounds. The damages to spinal cord in this group of casualties were present in more than one-third of casualties (38.4 %). Thus the complete conductivity disorder was encountered in 18.8 %, partial in 19.6 % of observations. Clinically damages of a spinal cord are manifested by preferentially motoric derangements in the form of paralyses and paresises. The degree of their expression is defined by both gravity of a damage of a spinal cord and localization of a wound. Disorders of sensitivity in acute period in the form of anaesthesia or hypotension, preferentially according to conductive type, are the important clinical evidence of spinal cord wounds too. Disorder of pelvic organs functions after spine mine-explosive wounds in acute trauma period is, as a rule, manifested by delays in urination and defecation. Subsequent activity of pelvic organs was determined by character, localization and a degree of a wound, efficiency of medical provisions and the chosen urine diversion method. Spine fluid tests during mine-explosive trauma are used for examination of subarachnoid space passability during a compression of a spinal cord, caused by hematoma, osteal fragments, foreign bodies, torn ligaments or the displaced intervertebral disks. It is necessary to note that in early terms after column damage, it is very difficult to define degree of spinal cord damage. Since virtually all mine-explosive wounds of the column are accompanied by spinal cord damages, the spinal shock evolved. The spinal shock is an initial symptomcomplex of the spinal cord conductivity upset. The spinal shock essentially exceeds real volume of neurologic derangements of spinal cord damage. The spinal shock is caused by the distributed effects of wounding projectile on a spinal cord, accompanying circulatory and vascular derangements, edema. Clinical manifestations of a spinal shock include flaccid paralyses, anaesthesia and acute urinary retention irrespective of spinal cord damage level. Duration of a spinal shock is defined first of all by efficiency of treatment and can last for days or weeks. Measure of spinal shock liquidation is restitution of neurologic symptomatology up to the full conformity to a level of spinal cord damage. Expressed neurologic disorders can be caused by explosive damages even if there are no damages to osteal structures of a column. Usually it is related to hemorrhages in brain matter, epidural and subdural hematomas, and also compression of spinal cord by the section of an
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intervertebral disk prolapsing in the backboned canal. In these cases diagnostics is complicated, because the signs of spinal shock smear the pattern of damage to spinal cord. The problem of adequate treatment of column and spinal cord explosive damages first of all is reduced to urgent specialized surgical aid for this contingent of casualties. Casualties with wounds or traumas of the column, accompanied by damages to spinal cord, deserve special attention in the medical-tactic scenario. All other explosive damages to column can either be diagnosed or not up to a stage of specialized medical care. Hence, considering issues of the first medical and qualified medical care to casualties with severe mine-explosive wounds, the special attention during diagnostics should be paid to signs of spinal cord damages disorder of breathing, presence of paresises and paralyses, ischuria and wound channel localization in the region of a column. The first paramedical and medical assistance for column and a spinal cord damages, caused by explosions, except for the provisions treating other body parts, is reduced to revealing damages to column and spinal cord and the correct transportation of casualties. Damage to column is indicated by the pain in the column region, especially during motion, damage of a spinal cord is indicated by breathing disorders, paresises and paralyses of extremities. Transportation on stretchers of casualties with damages to cervical section of a column is performed with a wounded on the back with a cushion under the neck; casualties with lumbar and thoracic spine damages are evacuated positioned abdomen down. Wounds are closed with aseptic dressings, the analgetics are injected. Provisions of the first medical assistance after explosive damages to column and a spinal cord have no essential influence on the casualties fate, except for cases with an external bleeding in which case tamponade is due. Optimum path for casualties with mine-explosive wounds to column is immediate airlift to the stage of specialized care, so the surgeons have enough time to execute specialized neurosurgical and traumatology treatment within the first day elapsed from the trauma. However, by virtue of combined damages character this path is not always possible. The majority of casualties with mine-explosive wounds require life-saving provisions of the qualified surgical aid in relation to damages of other body regions, but, first of all, to intracavitary bleedings, pneumothorax, shock, heart bruises, avulsions and fractures of extremity segments. Evacuation of casualties with explosive traumas to column comes is performed over a hand frame with a board, lying on the back for damages of thoracic and lumbar spines. Damages of
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cervical column department require immobilization by the ladder splints complex rigidly affixing head to median curved position (the long longitudinal splint is situated from a forehead to a sacrum and is rigidly joined by the bandages with two traversal shorts: one fixes head at the ear levels, another fixes the long splint to a shoulder girdle). The qualified medical care. Casualties with explosive damages to column and a spinal cord are treated preferentially for damage of cavities and extremities and phenomena of traumatic shock when there are no indications for pressing and urgent surgeries. Qualified surgical aid for casualties with column damage consists in a stopping of an external bleeding and in breathing restitution, if cervical department of a column is damaged. Stopping of bleeding from a column wound can appear rather complex operation for the general surgeon, especially when vertebrae and venous plexuses of epidural space are damaged. Therefore, it should be performed by the skilled surgeon. In lack of experience with these surgeries, the bleeding stop should be restricted to a thorough tamponade of a wound with superimposition of cutaneous sutures affixing the tampon. In case of paravertebral wounds, the bleeding comes from muscular arteries of paravertebral region, less often lumbar arteries and veins. In these cases surgery is performed through an inlet opening and represents a typical primary surgical treatment of a wound with respect to topographic-anatomic features of paravertebral region. In case of perforating and non-perforating wounds of a column, the bleeding comes from vessels of the defective bodies of vertebrae and epidural space. In most cases these bleedings are intensive and their stopping demands special neurosurgical knowledge and experience. Therefore, when rendering the qualified surgical aid the following tactics is optimal: - broad layered dissection of an inlet opening and wound channel up to osteal structures; - surgical treatment with a bleed stop from muscular vessels through a surgery course; - removal of freely laying osteal debris and foreign bodies. If the source of bleeding are osteal structures of back departments of a column, it is expedient to stopping bleeding by wax; if the bleeding source are venous plexuses of peridural space, it might be expedient to try stop bleeding by hot solution or hemostatic; in cases when bleeding points are positioned deeper, its identification may be difficult in the conditions of the qualified medical care stage. The attempts to stop bleeding may be inefficient. In this case, the wound is abundantly filled with hemostatics, tamponed by large napkins and the skin above them is fixed with spanning sutures. Napkins localization in a wound should be marked up.
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When rendering qualified medical care and preparing for evacuation, casualties with damages to column are isolated into four groups: 1. Casualties without attributes of spinal cord damage and without obvious threat of its damage. They are evacuated in the second turn. 2. Casualties with attributes of a spinal cord damage or threat of its damage (non-stable fractures of spinal column). They should be evacuated first. 3. Casualties with ongoing bleeding from a wound of a column and with beginning breathing disorders (in stable general state). They require conducting pressing provisions of the qualified surgical aid in operation room or intensive care center. 4. Casualties in the terminal state or with deep disorders of breathing (periodic or superficial frequent breathing for the full phrenoplegia and unstable general state). Evacuation of casualties with mine-explosive column wounds, in particular damage to a spinal cord, should be performed as soon as possible. Optimal term is the first day if there are no cavity damages or severe shock, second day after cavity surgeries and performing anti-shock provisions. Preparation for evacuation is reduced to immobilization of cervical column department using complex of ladder splints in lack of spinal disorders; immobilization of cervical column department using special splints (CITO type) or a plaster collar if spinal cord is damaged; restitution of breathing by introduction of air duct or intubation of trachea for periodic pulmonary ventilation under the conditions of specialized air transportation equipment presence. Immobilization of thoracic and lumbar spines is performed by placement of casualties on a hand frame with a hardboard, lying on a back. Casualties should be braced to a hand frame strops in this position. The specialized medical care the casualty with explosive damages to a column is rendered according to what damage is dominant. In cases of spinal cord damages or in presence of the complex fractured dislocations of vertebrae, able to cause damage to spinal cord at any stage of transportation and treatment, the specialized care is rendered in neurosurgical hospitals. In case of stable fractures of vertebrae, paravertebral and gutter wounds of a column, the specialized care facility is defined by predominant damage. If chest and abdominal cavities or pelvis damages are dominant, a specialized treatment is rendered in hospitals, specializing on thoracoabdominal surgeries. In case fractures of long bones, pelvic bones or damages to large joints are dominating, the specialized care is rendered in trauma hospitals. Under the conditions of dominance of avulsions and fractures of extremities, extensive damages of the soft tissues, the specialized
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treatment is performed in general hospitals. When rendering a specialized medical care to casualties with explosive damages to column and spinal cord the following groups are isolated: 1. Casualties requiring specialized surgical aid in first turn: wounds and traumas, accompanied by continuing bleeding from a column wound, increasing derangements of breathing after damages to cervical department of a column. 2. Casualties requiring provisions of the specialized surgical aid in the second turn: wounds and the traumas, accompanied by compression of a spinal cord. 3. Casualties requiring specialized surgical aid in the third turn: through and blind perforating wounds, and traumas, accompanied by complete breakage of spinal cord. 4. Casualties, being subject to the regular conservative or surgical treatment: paravertebral blind and the gutter wounds, non-perforating wounds, various views of vertebrae fractures without damage to spinal cord. 5. Casualties in extremely grave condition with indications for intensive or symptomatic therapy. In general it is possible to conclude that the specialized medical care for casualties with explosive damages to a column and spinal cord is reduced to pressing, urgent and delayed surgical provisions during the first two days to save a life, prevent complications and restitution of the defective column and a spinal cord functions of, regular conservative and surgical treatment, directed on prevention and treatment of complications, restitution of column and spinal cord structure and function. Surgical treatment of gunshot wounds and explosive damages is essentially different. In view of combined character of mine-explosive wounds, they require first chest, abdomen and extremities surgeries, in second column and a spinal cord surgeries. It is desirable to conduct surgeries during single narcosis session if the state of the casualty allows, because for column surgery, casualty should be positioned on the abdomen. If the condition of a wounded after abdominal operations is severe, the intensive therapy is undertaken and only after subcompensation is achieved spine surgery is performed. Essentially, column surgeries after explosive damages, depending on character, can be isolated into four groups. The first variety primary surgical treatment of the paravertebral region wound. Such surgeries are performed for paravertebral and gutter wounds to the column, accompanied by
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intensive bleeding. Surgeries are performed by general rules dissection of a wound, removal of the defective tissues, clots, foreign bodies, osteal splinters, hemostasis and drainage of a wound. The second variety primary surgical treatment of a wound with typical or atypical laminectomy. Such surgeries carried for non-perforating wounds to the column, without damage to spinal cord. Typical primary surgical treatment of a wound in paravertebral region is supplemented by laminectomy (cutting defective acanthas and handles of vertebrae, removal of debris from the column channel, its revision and evaluation of a dura mater state without opening it). If the bullet wound is localized on midline of paravertebral region, primary surgical treatment is performed first, followed by flushing and drainage of wound channel and laminectomy through standard access. Third variety primary surgical treatment of the wound, typical laminectomy with dura mater opening. These surgeries are carried out in case of a compression of spinal cord, perforating wounds of a column and for wounds, accompanied by some degree of spinal cord damage. After a laminectomy, the surgeon should dissect a dura mater and revise contents of dural sack. If spinal cord is damaged, a surgeon should wash out the detritus and remove necrotized sections of a spinal cord. Sections of doubtful vitality after flushing should be left out, with the hope of at least partial recovery of nervous elements. Upon completion of surgery on a spinal cord, dura mater grafting with free autofascia flaps or plastic materials is performed. The fourth variety primary surgical treatment of a wound with properties of 2nd and 3rd variety and back fixation of the spinal cord. These surgeries are carried for wounds, accompanied by unstable vertebrae fractures and after extensive (more than two vertebrae) laminectomies. Effective methods of back fixation under the condition of column instability are caused by damage to frontal structures, is column fixation using handles above and below intact vertebrae with 1-2 stitches. Back fixation provides mobility for the casualty during early, most responsible and dangerous stage of traumatic sickness. Explosive damages to column can be caused by damaging action of a blast wave and throwing effects. These non-gunshot damages to column and spinal cord are often encountered in armored vehicles crews, including ships and submarines. Indications to surgical interventions for these traumas originate in presence of damages to spinal cord. Similarly to fragmentation wounds, column surgeries after explosive damages are performed after surgeries on cavities and destroyed extremities segments. Surgeons should aspire to perform all surgeries within first two days
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only in these cases they are effective with respect to restitution of function of a spinal cord. Surgical treatment of fractures of vertebrae and the fractures-dislocations, not accompanied by damage to spinal cord, is performed in later terms according to the regular schedules when the casualty state is compensated.

9.5. EXPLOSIVE DAMAGES OF THE SIGHT ORGANS

The term explosive damages of sight organ is used to characterize damages to eye at the close distance, caused by explosions during war, terrorist acts or technogenic catastrophes. During the contemporary local wars and conflicts they predominate and comprise sometimes 80-90 % of all gunshot damages to an eye. These damages are united by multifactor character: - plural primary and secondary splinters with high kinetic energy, cause severe damages of thin histic structures, with high frequency of perforating eye wounds; - explosive wave, with mechanical force inversely proportional to distance, considerably increases damage severity through the commotio action; - thermal impact of explosion flame, as a rule, aggravates effects of the previous factors. The multiplicity of the heterogeneous debris, produced by explosion of contemporary ammunition, its high kinetic energy, combined action of a blast wave and the thermal factor, entire lack of protection from the smallest fragments, not only increased frequency but also severity of sight organs damages during local wars of late XX century, if compared to that in WWII. Explosions of various ammunition types generate specific damages of sight organs which, whenever possible, should be taken into account at different stages of medical evacuation. Among eye explosive damages by character of damages, a pathogenesis, properties of intraocular foreign bodies, one could isolate the following damages: - mine-explosive; - damages resulted from shape-charge ammunition; - explosions of artillery shells and mortar mines, air bombs, rockets, hand grenades; - damages by "microexplosions" detonators, fuses, cartridges. Mine-explosive damages of the sight organ are quite often compounding greatest group of explosive damages (30-50 %) during local wars and is characterized by particular severity. These damages originate: - during blast on anti-personnel mines traumas to eyes combined with avulsions of the
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inferior extremities distal segments, the significant hemorrhage and a severe shock - explosions of "boobytraps" (under clearing probe or in hand) when along with the hardest damages to an eye, the upper extremities suffer; - explosions of anti-personnel, less often anti-tank mines in immediate proximity to the casualty. In 90 % of mine-explosive damages to eye there are damages to other regions of a body: plural wounds and avulsions of the inferior extremities, severe open and closed traumas of skull and a brain, organs of thoracic and abdominal cavities. In 2/3 cases (64 %) these casualties, according to dominant damage, are treatment outside ophthalmologic hospitals. High frequency of (65-70 %) binocular damages deserves the special attention; it 2-3 times exceeds frequency of damages to both eyes at other forms of explosive wounds. Brief characteristics of this severe explosive trauma are dramatic enough: perforated wounds are encountered more than in two thirds of cases, each third bilateral and each fifth fracture of one eye, in 4 % both eyes are destroyed. In case of perforated wounds, the wounds to cornea and corneal-sclera regions (more than 80 %), with distinctive peculiarity wrong flap-stare shape and the expressed seepage of edges predominate. The damage is usually accompanied by impregnation of tissues by soil, sand, fragments of stones, torn clothes and shoes (Fig. 9.2. see color insert). Non-perforating wounds to eyes are characterized by presence of fine plural foreign bodies in various stratums of a cornea, conjunctiva and in a sclera. Almost all mine-explosive damages to an eye are accompanied by wounds to eyelids, periorbital region and face. Extensive multiflap wounds with dissection of tissues are quite often accompanied by fractures of bones of an obverse atomy and orbit sides. Small enter openings are frequently the beginning of wound channels ending with ampulla-shaped the cavities stuffed by disperse bedrock, fine stones, clots. In several hours after wound the curtailed blood crusts together with the destroyed tissues (Fig. 9.2. see color insert) under which the inflammatory process transforms in torpid purulent, if there is no adequate surgical treatment within 7-8 hours. Damages to organs of sight caused by hits of cumulative projectiles inside armor are caused by plasma jet (heated gases) and high-velocity beyond-armor debris (equipment parts or chips). These conditions define combined (thermomechanical) character of damages. In such cases eye damages are often combined with wounds to the soft tissues of trunk and with plural burns of the body surfaces, facing plasma jet. Perforated wounds are encountered among cumulative
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ammunition eye damages with the same frequency as that, inherent to mine wounds (about 70 %). Unlike mine wounds, cumulative jet damages cause linear wounds often rather than scrap wounds. Damages of eyeballs are encountered less often (15 % less than perforated wounds), and they are always accompanied by damages to orbit tissues. Both eyes are damaged in each fourth cumulative ammunition casualty. Eye damages caused by explosions of hand grenades, rockets and mortar mines are characterized by high frequency of orbit wounds, which are frequently complicated by fractures of its osteal sides (80 %) and often combined with perforating wounds to skull and a brain (40 %). In this group perforated eye wounds attain 75 %, with high frequency of sclera wounds (up to 40 %). Binocular damages in this group of explosive damages are encountered in almost 32 % casualties. Damages to eyes, caused by "microexplosions" of fuses, cartridges and boobytraps (the explosives disguised as fountain pens, keychains, toys etc.) are in most cases accompanied by severe damages to hands and fingers (56 %). Frequency of perforated eye wounds in this group is higher than in other groups and exceeds 80 % with destruction of eyeballs compounding 5 %. It is necessary to note high frequency of damages of the left eye in comparison with right eye. It is caused by eight eye "shielding" by right hand when handling explosive objects. In a pathogenesis of perforated eye wounds, special place is taken by presence of intraocular foreign bodies. Their distribution has considerably changed since WWII: magnetic (and therefore X-ray contrast) compound now only 35 %, antimagnetic 65 %, X-ray contrast about 50 %. Majority of intraocular splinters in case of mine-explosive wounds is comprised by the fragments of stones and dust, and in 80 % the wounds were plural. Part of these fragments is fragile and soft, and can leave impregnations tracks in tissues. The mucks close to clay can be dispersed and become slushy, extensively contaminating tissues. Usually, several some later, soft tissue wounds of face and conjunctiva manifest significant purulent discharge. Magnetic intraocular foreign bodies, caused by close blast or armor or personnel on anti-personnel mines are encountered rarely. Eye wounds, caused by hits of cumulative projectiles in armor, cause the intraocular debris to be plural and heterogeneous (magnetic and antimagnetic, X-ray contrast and indistinguishable) in the same eye, frequently in the form of fine shining metal points (foil-like). Perforated eye wounds caused by explosions of ammunition, mines and hand grenades are mostly by introduction of X-ray contrast (ferruginous) debris and only in 30 % they are plural. By
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structure they are similar to intraocular WWII period foreign bodies. Intraocular foreign bodies after "microexplosions" of cartridges, detonators, fuses are frequently plural (60 % cases). Quite often eyelashes are found in an eye cavity. By considering combined damages according to a leading sign, it is necessary to note that eye wounds in 35 % cases appear a leading damage. It is natural that in 65 % cases requiring lifesaving surgeries, even severe eye wounds fade into the background. But, as soon it becomes clear that there is no danger to life for the casualties, the first place is taken by the blindness-menacing.

9.5.1. Amount of medical care at the stages of medical evacuation

The correct medical care at pre-hospital stages has crucial importance not only for maintenance of an organ of sight functions, but also for subsequent optical-reconstructive surgeries and rehabilitation. First aid consists in superimposition of mono-, or under suspicion on a severe damage, a binocular bandage, analgetic injection, peroral administering of antibiotic and preparation to evacuation to the next stage of assistance. When rendering paramedical care there is an opportunity to treat wound surfaces of eyelids, periorbital region and face with removal of the superficial foreign bodies and blood by the napkins moistened by one of antiseptics (3 % a solution of hydrogen superoxide, solution of Furacilinum, 2% solution of boric acid, 0.5-1% solution of Dioxydinum). Bandages are imposed or corrected, antibiotics are introduced parenterally. Medical care alongside with usual urgent provisions (instillation of eye drops, eye medicated films with antibiotics, parenteral introduction of antibiotics) assumes antibiotic introduction inside a lower eyelid (thus creating local depot of a drug, which amplifies prophylaxis of purulent complications). With this purpose 20-40 mg of gentamycin is usually applied. When rendering qualified surgical aid, surgeons may revisit diagnosis of an eye damages using special equipment (ophthalmo- and a biomicroscopy, X-ray diagnostics). Local antibioticotherapy (in lower eyelid, peribulbarly) and systemic antibiotic therapy (intravenously, intramuscularly) is continued. The careful cleaning of the periorbital region soft tissues, eyelids and face performed. Using osteal Folkman spoon, surgeons should carefully remove soil particles, destroyed tissues, clots. Edges of wounds incision are injected with solutions of antibiotics. In presence of the trained specialist and equipment (operative microscope,
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microsurgical tooling, atraumatic suture material 5-8/0) it is possible sew wounds on eyelids, periorbital region and in, unusual cases, enucleation of the destroyed eye under rigorous indications. The specialized care provides compliance with gravity of a damage and medicotactical circumstances. It assumes accomplishment of entire set of surgical, drug, and in the subsequent, regenerative treatment. Progress in treating damages to an eye is appreciably bound to achievements of diagnostics and microsurgery, leading to substantial improvement of surgical treatment quality, a sparing manipulation, solution of certain eye traumatology problems. Before a surgery in postoperative period multiple diagnostic techniques are used to produce optimal treatment plan verification of organ of sight functions, examination in focal and transmitted light, biomicroscopy, transillumination, studying of entoptic phenomena, ultrasonic and radiological diagnostic, computer tomography. X-ray inspections of a sight organs in casualties with combined wounds represent significant technical difficulties as standard placement with rotational displacements of the wounded cannot be executed or appear too traumatic and menace severe complications: bleeding, displacement and dropout of shells. In these cases X-rays should be taken using of special placement. Degree of eyeball dislocation (enophtalmos, hypophthalmus, exophthalmos), caused by fractures of orbit sides, can be recognized marking both eyes by Komberg-Baltin prostheses-indicators. It allows calculating more precisely sizes of an implant and its position with respect to an eyeball. Of special value for diagnostics of even small disorders of orbit bottom integrity are lateral X-ray patterns (symmetrical median edges 45-50 mm from a table both orbits) and the X-ray patterns, executed in placement on the nose somewhat modified pictures of the upper orbital fissure (slightly the nose is uplifted 5-10 degrees). These images show better tissues, displaced to the upper-jaw cavity and osteal structures of vertex of an orbit. Now ordinary techniques as ultrasonic scanning, computer tomography can not always replace local X-ray imaging, but become necessary for revealing weak X-ray contrast foreign bodies and improvement of a state of internal environments and shells (quantity of a hemophthalmia, presence of retinal and ciliary body detachment). During a surgery, of significant worth are intraoperational diagnostics methods (during preoperative period because of the general grave condition and plural-combined damages, sometimes it is not possible to realize a series of diagnostic approaches: improving X-ray
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diagnostics, ultrasound and, especially, a transillumination). Infra-red beams transillumination is extremely effective. In these requirements, even applying usual scleral light, it is possible to achieve an intensive illumination of an eyeball and shading a foreign body. Prior to the surgery, physicians perform bacteriological and bacterioscopic studies of contents of a conjunctival cavity and eyeball wound. Removed foreign body and excised tissues are subjected to examination as well. The bacterioscopy of Gram-stained smears allows to obtain estimated data on the microbial impurity (contamination) of the wound and promptly begin intraand postoperative antibiotic therapy.

9.5.2. Specialized treatment of explosive damages to an organ of sight

Multiplicity of explosive damages entails non-standard medical approaches. Therefore, we consider necessary to address principles of their specialized treatment. The greatest difficulties are related to treatment of perforated, especially through and perforating wounds of an eyeball. Essential rise in frequency of antimagnetic and plural splinters, caused by explosive damages largely complicates their diagnostic and treatment. Trauma severity is defined not only by such factors, as localization and size of wounds, but degree of damage and loss of a vitreous; amount and location of hemorrhages in eye cavities; presence, location, size and character of a foreign body, its path, presence of ricochet zones, dislocation and damage to the shells, finally leading to nebulas of optical medium, evolution of an intraocular fibrosis, severe inoperable amotio of a reticular shell, subatrophy and atrophy of an eyeball and, causing functional or anatomical loss of an eye. Thus, preservation of damaged, but functionally perspective eye appreciably depends on prevention of metabolism disorders and related redundant proliferation in the defective structures. Efficiency of diagnostics and treatment of perforated wounds is influenced mainly by their multiplicity, bilateral character (more than 20 %), presence of non-perforated damages, burdening of wounds by contusions to an eyeball, at last, high frequency of damage combination (60-80 %) to an organ of sight and other body parts, first of all head, extremities, chest and abdomen. Main principles of a surgical treatment for perforated eye wounds are: 1. Removal of a blood, foreign bodies, destroyed lens and other nonviable tissues.
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2. The reconstructive approach to treatment of damages, providing the greatest possible restitution of an strata integrity, their normal positions, the shape and the turgor of an eye, prophylaxis of pathological bracing (first of all retina and vitreous body), in some cases replacement and a prosthetic repairs. 3. Prevention of postoperative complications, first of all a wound fever, excessive inflammatory response in reply to alteration of tissues, deep circulatory derangements, redundant proliferation and fibrosis, causing functional destruction and an atrophy of an eyeball. Small perforating wound of a cornea (up to 3-5 mm) with well adapted edges, lack of filtering (leak of intraocular fluid) or with an inappreciable filtering, remaining anterior chamber and not accompanied a damage of a lens can avoid exposure to surgical treatment. It will be enough to administer bacteriological (bacterioscopic) examination, introduce broad spectrum antibiotics (including drops of the extended activity, injections under a conjunctiva or peribulbarly). If soft contact lens is available, it is necessary to impose it, preliminary having saturated it (for 2-4 hrs) with antibiotics (for example 0.4% solutions of gentamycin). Impose a binocular bandage; appoint a confinement to bed up to the filtration stop. In the subsequent 4-5 days, physicians continue active prophylaxis of an intraocular purulent infection contamination until the latter is 100% reliably cured. In the absence of damage to structures of an anterior chamber, but in presence of large corneal-limbal wounds with attributes of filtering and welding of ocular coats, sealing of a wound is required. The first suture is imposed on the limb, subsequent sutures are imposed with a pitch of 1-2 mm. Eye capsules from one and other sides of a wound are sutured 1 mm from edges, capturing 2/3-3/4 depths of cornea or sclera. In case of infiltrated edges of a corneal wound, it is possible to impose sutures on a distance, i.e. puncture is performed 1.5 mm from wound edge. For corneal suture, physicians should use atraumatic spatula-like needles with single-filament (synthetic) threads 10/0.Wounds of a sclera are sutured by the threads 7-8-9/0. When treating corneal wound it is necessary to superimpose continuous suture with a puncture from a wound (1st stitch) and retracing to the beginning of a suture outgoing puncture from a wound. This approach allows hiding a knot in the wound. The suture looks like two series of the parallel or crossed stitches. If the continuous suture provides insufficiently sealing, it should be reinforced with nodal stitches. Star-shaped stitches can be reinforced using purse-string stitches (Fig. 9.25), pulling together all corners (modified suture by V.V. Motorniy). Frequently, separate noose sutures (supramid, proflux or nylon 9/0) are necessary for reliable closure and holding of the wound surfaces.
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Fig. 9.25. Purse-string suture administration diagram If the wound transgresses limb region and threatens formation of anterior synechias in wound projection, basal iridectomy is administered. After sutural sealing of the corneal (corneal-scleral) wound, the anterior chamber and eye turgor are recovered by the air or isotonic saline solution through an additional limb notch. In case of mydriasis or iris extensive damages (colobomas), there is a danger that gas will go beyond iris, causing iris adhesion to back surface of a cornea, formation of anterior synechias and ocular hypertension. In case of unreliable wound sealing, air or an isotonic saline solution should be injected through an additional limb notch. Only after restitution of an anterior chamber or introduction of viscoelastic material, it is necessary to carry to reposition iris. Surgeons should use paracentesis for this purpose to avoid damages to an endothelium. At presence of wound with a lens damage (disorder of capsule integrity and threat of a lens mass bloating causing ocular hypertension), the extraction of a cataract is performed. In most cases it is more convenient technically to impose sutures on corneal wound, than to execute lensectomy or remove cataract through limbal (corneoscleral) incision. This approach should be taken if the lens is dense, corresponding to 40+ age. Physicians should aspire to preserve back capsule, and in presence of indications (preserved back capsule of a lens, lack of damages to a back piece of an eyeball, intraocular foreign body, the least evidence of a purulent inflammation or suspicion of it) and available instrumentation, it is possible to execute simultaneous implantation of intraocular lens (IOL). A lens is selected guiding by optical parameters of the intact eye. If the wound has wrong shape and is in an optical region, it is necessary to refrain from implantation, as contact correction can be more effective in this situation. In cases of damage to both anterior and posterior lens capsules, displacement of vitreous body in anterior chamber and wound, surgeons should conduct surgery with respect to location and size of a wound. In presence of a small corneal wound and lack of age-sclerotized kernel in a lens, it
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expedient to follow sealing by the gradual removal of lens masses, capsule elements, blood and fibrin from a vitreous body through the access in the flat part of ciliary bodies in two quadrants 3.5-4 mm from the limb. This procedure is performed by inserting a vitreotom probe (an ultrasonic pipe) and a needle with the delivery of fluid. If a vitreotom is present, it is necessary to restrict (better avoid) manipulations on a back department of an eyeball by ultrasonic eye fragmentor (e.g., UZH-F-05) because of a possible serious damage to cornea and retina. If the transparence of a cornea is insufficient, which is characteristic in explosive wounds for plural, complicated contusion wounds, application of intraocular light guide essential raises illumination intensity and contrast range of vision. In some cases, visualization of internal structures can be refined by reduction of illumination intensity over a surgery region (duty light) or shutting down surgery microscope light. Edema of corneal epithelium is an indication for removal. Choice of quadrants for introduction of instruments is made with respect to region of optimal monitoring of the surgical instruments through a pupil, easy access to manipulation region (foreign body location, hemorrhage, abscess of a vitreous). Application of a contact scattering corneal lens allows detecting regions of the eye-grounds structural trauma, aggregation of a blood, an exudates or a foreign body. During vitrectomy through the transciliary, actually basic, access to the defective ophthalmic structures it is possible to tap and remove most of fine splinters (less than 0.5-0.7 mm in diameter) and corpuscles of the contaminations, hiding in a blood and fibrin, in case of MWT, "slushy" fragments of bedrock, which impregnate sections of a vitreous and the destroyed lens. Larger foreign bodies are removed using magnet or a tweezers. Mobilization of a foreign body is performed under a microscope (a Sato-kind knife, a syringe needle, a microhook, vitreous microscissors, etc.) with the following capture using magnet or tweezers. Extraction should be performed using two instruments. When removing a splinter, as a rule, it is not necessary to remove completely blood or exudate clot, as the fall of a splinter on the retina and its subsequent lift-capture can lead to the additional trauma of retina. Mobilization of densely fixed debris (or encircled by the formed capsule) should be performed using two instruments, one, to sustaining a debris from displacement, and second for piercing capsule or voiding tissues. Having obtained access to the mobilized debris and removed it, it is necessary to complete excision of pathologically changed vitreous body. When doing mobilizations and entrapments (access to foreign body) of the debris, localized in equatorial and more peripheral region, it is expedient to
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use external pressure on the sides of an eyeball a using muscle hook or a glass rod. Experience assistant can be in charge of this complicated surgery part. Surgery is completed by conducting cerclage tape or episcleral sealing, which should be carried only if it is not possible to remove completely vitreous structures and there is an aggregation of the blood in a foreign body region. Episcleral sealing is expedient for surgeries, in particular, in the region of a target wound at through wounds. Perforating wounds are rather rare (2-4 % of perforated wounds) even for gunshot or explosive damages. Approach in these cases is defined by size of an exit wound (which can be evaluated by the size of wounding projectile) and its localization in relation to a back pole. Provided there are convincing data about extraocular localizations of debris, its small size (1-3 mm in a diameter), far postequatorial localization (at an optic nerve) and eye tonus is close to norm, suturing of a wound can be avoided. In other cases it is more preferable to perform revision of an exit wound zone, impose sutures on wounds of a fibrous capsule, to remove foreign body, whenever possible, execute extrascleral local impression. Provided there is no retinal detachment and it is possible to clean blood, fibrin, exudate from the cavity of an eyeball (especially in the region of wound or ricochet regions) and to eliminate basis for overtensioning these regions, surgeons should refrain from extrascleral sealing of the respective departments of an eyeball. In this case, it is feasible to perform either laser coagulation of damaged regions (clear or forming) of reticular shell or preventive oral-equatorial retinopeksia [Trojanovskij R., et. al., 198. 199. 1994]. It makes no sense to impose cerclage for prophylaxis without vitreum sanation during the expressed hemophthalmia or in cases of already evolved detachment of a retina. Clinical experience shows that the "sandglass" generated in these cases impede detachment of the posterior hyaloid membrane, create serious difficulties for the subsequent vitrectomy and do not interfere with a buildup of vitreoretinal proliferation. When character of a corneal wound does not allow to use the monitoring through a pupil, and access through a wound is overly traumatic for an eye, after suturing a corneal wound it is necessary to apply cataractal discission and remove a destroyed lens, perform reconstruction of an anterior chamber, execute vitrectomy, and, if there is a foreign body, to remove it (after mobilization) using magnet or by tweezers. This surgery is conducted using procedure of "the open palate with translimbal access. This variety of access is especially justified in presence of large foreign bodies inside of an eye. In some cases, it is convenient to carry out by it dilating wound holes, especially, if it adjoins a limb or, in particular, in case of contusional rupture of a
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sclera. Any manipulation on an eye with an extensive wound and a trend to the coat collapse should follow superimposition of a scleral ring. Without a scleral ring it is almost impossible to search for a foreign body, remove pathological structures, seal a without infringing vitreous and an iris. In presence of a gaping wound to an eyeball it is expedient to pull together its edges by 1-3 adapting sutures, then impose fixing sutures and scleral a ring. After that, the edges of a wound are separated by sutures; the removal of a destroyed lens, clots, and foreign body (with a mandatory visual control of its location) is performed. In a number of situations to preserve endothelium when dilating a wound it is necessary to unbend it using spatula a "rolling" procedure [Trojanovskij R., 1988] (Fig. 9.26). This procedure is followed by recovery of shells integrity and, at last, the wound is sealed. Special attention should be paid to prevention of pathological bracing of an eye iris and vitreous to a cornea. Light pulling of a scleral ring and edges of a wound promote a retraction of contents, intromission of a bubble in an eye cavity, which helps to strip a wound from the displaced vitreous and prevents its infringement.

Fig. 9.26. Screw-in approach for removal of large intraocular foreign body Vitreofagal technique allows using more widely the access through a corneal wound of small sizes (3-4 mm) and makes a surgery considerably less traumatic. In cases of suturing of the eye iris it is necessary to avoid involvement of a vitreous body in fibril knots. However, sanation of eye cavities should be completed by transciliary access using closed vitrectomy. Wounds to a cornea with the significant crush of tissues, disorder of integrity of the central departments of cornea should be handled using of a keratoplasty preferentially as through and layered -through transplantation. For these purposes, it is more preferable to use the material fresh or preserved in the moist room. Tectonic medical or layered transplantation is carried using
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any material. Binocular perforated wounds with fracture of one eye can be treated using autokeratoplasty by flap of the destroyed eye cornea. Eye fracture accompanies contemporary explosive gunshot trauma in comparison 1.5-2 times more often and in 4-5 times exceeds frequency of fractures to eyeballs in peacetime. At present the concept of eye "fracture" has evolved as well. By fracture, surgeons usually consider severe damage, causing complete lack of visual functions and, despite opportunities of the contemporary reconstructive surgery (kerato- and scleroplasty, vitreoretinal provisions) there is no chance to preserve an eye, even for cosmetic purposes. At the same time preservation of inner shells inside fibrous capsule (especially vascular) threatens with torpid uveitis and ultimately sympathetic ophthalmia. This diagnosis is made in cases of wounds, extending to a back pole of the eyeball and causing formation of extensive corneoscleral flaps, full avulsions of an iris, fracture of a lens, formation of total hematoma inside of an eye and imbibition of vitreous remains, shreds of reticular and vascular shells. If resulted from explosive wounds, these damages can be characterized as traumatic evisceration [Owen-Smith, 1981]. Correctly executed evisceration (performed within 3 day after fracture to an eyeball) allows avoiding evolution of such a terrible complication as sympathetic ophthalmia. At the same time, it leads to shaping of volumetric (12-14 mm diameter) and mobile stump. There is no retraction of extraocular muscles to vertex of an orbit, defects of tissues do not increase (eye fractures in half of cases are accompanied by severe damages to an orbit contents and fractures to its sides). Wounds to an orbit and medial region of the face, caused by explosive damages have extreme severity quite often there are some enter openings, massiveness of tissues fracture (down to layering and detachment of periosteum), expressed impurity of wounds (an impregnation of tissues by bedrock, cloth shreds). They are quite often accompanied by transorbital craniocerebral wounds and various brain damages (20 %), opening of paranasal sinuses (50 %), combined wounds to maxillofacial region, bones of facial skeleton. Microsurgical approach to revision of orbit wounds allows to size up character of tissues damage of tissues improve surgery plan. Special value is given to careful removal of clots, foreign bodies, the insulated osteal fragments. Therefore, when dealing with extensive wounds and their massive contamination it is expedient to apply a jet of a solution from a rubber tank and a surgical bleed. Acute osteal edges are cut; large fragments of orbit bones, still attached to periosteum are reconstructed and fixed (sutures, titanium wire, plates). If the wound surfaces are heavily contaminated by bedrock, sand, the latter are cut or economically (0.5-1.0 mm) excised by the
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blade (microscissors). Narrow wound channels are handled from an inlet opening through the end of wound the channel where, as a rule, projectile and accompanying fragments of bones are located. To open the edges of a wound in depth it is rather convenient to use cerebral spatulas with illumination and nasal mirrors. Manipulations should be rather cautious if wound channels are directed towards neurocranium towards upper side of an orbit and its top-internal angle. Probing of wound channels in these directions to prevent the damage of the dura mater and brain is strictly prohibited. Orbital-cranial wounds are handled together with the neurosurgeon, using transcranial access from an orbit. The sequence of operative provisions is defined by a leading damage, or medical tactics reasons. Interventions in paranasal sinuses with the purpose of their sanation are conducted, as a rule, with participation of an ENT-expert or the maxillofacial surgeon. During a surgical treatment of wounds to an orbit, surgeons should use elements of primary plasty in local tissues: in particular, suturing of orbital fascia and eyelids ligaments to an attachment place, the defective tissues are sutured layer-by-layer, eyelids are recovered. If there is deficit of tissues, guiding sutures are applied along relief incisions of nearby tissues, the advanced flap technique. Major defects of osteal sides of an orbit (more than 3x5 mm) require primary plasty with wide fascia of a femur, periosteum of skull bones. During avulsions of eyelids with a damage of lacrimal passages, interior corner is shaped followed by reposition of eyelids during lacing of the lacrimal canals. This provision is performed using flexible guide. The guide simplifies lacing of eyelids and provides reliable bracing. Sparing approach to the treatment of combined wounds involving eyelids and periorbita demands special attention. It is necessary to avoid cut-off or excision of tissues. The pursuit for freshening of wound edges creates deficit of tissues, which is especially dangerous at a damage to upper eyelid in connection with hazard of the postoperative complications, caused by decrease of protective functions, and damage to lower eyelid because of the subsequent reconstructive provisions complexity. In cases of a massive damage and extensive contamination of orbit wounds it is necessary to drain them by perforated silicon or PVC tubes (diameter about 3 mm) with the subsequent permanent or periodic flushing (depending on character of a wound process) using solutions of
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antibiotics or antiseptics. Non-perforating wounds to an eyeball during explosive damages are characterized by presence of plural foreign bodies in various stratums of a cornea and a sclera. Removal of foreign bodies should be performed by a razor blade or a thin syringe needle, including those with crooked end for clearing sides of the wound channel in stratums of a cornea. As a rule, the debris shaped from a blade of mild steel, has an inappreciable curve a spiral at the end that appears useful when removing foreign bodies, and if the latter are fractured for clearing contaminated regions. Also, irrigation and jet washout of splinters by an isotonic saline solution with antibiotics (gentamycin of 0.04-0.08 mg/ml) or antiseptics Dioxydin 0.5-1 % (Fig. 9.2. see color insert) is recommended. In of the delaminated flaps it is necessary to strip them, avoiding additional seepage and fix them using several corneal sutures. In these cases the distance between sutures can be 2-3 mm. In any case even after the full removal of foreign bodies it is necessary to perform subconjuctival administration of antibiotics within 2-3 days for prophylaxis and treatment of a posttraumatic keratitis. Massive subconjuctival hemorrhages (hyposphagma) "screen" punctual perforated wounds of a sclera (even at the stage of the specialized care they are missed in 1-2 % of perforated wounds). In these cases .it is expedient to execute careful revision of a sclera after limbal conjunctivectomy. Often enough (4.8 % up to 37 % according to different authors) perforated wounds to eyeballs become complicated purulent processes uveitis, endophthalmitis, purulent keratitis. Rate of an inflammation spread depends on the level of rendered care at pre-hospital stages, terms of entering stage of the specialized care and volume of a primary surgical treatment. So, endophthalmitis, caused by delay of evacuation on 2-3 days, in two thirds of cases evolve even before entering a stage of the specialized ophthalmologic care. Analysis endophthalmitis evolution has shown that the primary surgical treatment conducted later than 12 hrs, raises chance of this terrible complication 10-fold. Presence of intraocular foreign bodies increases frequency of evolution of purulent uveitis almost 3-fold. Considering increasing resistance of a microflora to traditional antibiotics it is necessary to use, whenever possible, locally 2-3 antibiotics (synergist) and second-line drugs. In addition, local treatment should be conducted intensively enough injections under a conjunctiva and peribulbarly 2-3 times a day, instillation 5-10 mins. Concentrations and doses of the most spread antibiotics for various paths of introduction are given in Table. 9.10.
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Alongside with IV introduction, the antibiotics should be introduced inside general carotid artery, including catheterization of the external carotid artery 1-2 times a day. Such path of introduction is most expedient for combined wounds to an eye, skull and maxillofacial region. Intravitreal introduction of antibiotics though traumatic, assists in breaking off build-up of purulent process. Process (Table. 9.11) subsided after 1-2 injections of drug combination.

Table 9.10 Dosages and concentration of drugs for endophthalmitis Drug Local Under conjunctiva (mg) 100 25 10-40 100 100 50-100 100 0.75 5-10 Single-dose (mg) 5 1 0.2 2 0.5 0.5-2.0 0.4 0.005-0.010 0.025-0.05 Dosage (concentration) of antibiotic Intravitreal In the solution for vitreoectomy g/ml 20 8 20 10

Ampicillin Vancomycin Gentamicin Methicillin Oxofloxacin Cephasolin Cephatoxin Amphotericin B Miconasol

Table 9.11 Drug dosages, injected intraocular for endophthalmitis Antibiotic combination Bacterial Gentamicin + Cephasolin Gentamicin + Vancomycin Tobramycin + Cephasolin Amikacin + Vancomycin Antifungal Amphotericin Miconasol

Dosage

0.1-0.2 mg / 0.1 ml 2.25 mg / 0.1 ml 0.1-0.2 mg / 0.1 ml 1.0 mg / 0.1 ml 0.1-0.2 mg /0.1 ml 2.25 mg / 0.1 ml 0.4 mg/ 0.1 ml 1 mg / 0.1 ml 0.005-0.010 mg / 0.1 ml 0.025-0.050 mg / 0.1 ml

In the subsequent it is necessary to continue antibiotic therapy within 7-8 days using traditional methods under the conjunctiva, peribulbarly, instillationally in order to prevent relapse of purulent process. Even the successful termination of a back purulent uveitis does not prevent subsequent (frequent in the near future) vitrectomy in connection with the expressed opacity of
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the vitreous body and a build-up of vitreoretinal proliferation. Provided there is no effect progressing decrease of functions, amplification of a pain syndrome, magnification of purulent exudate in the vitreous (a build-up of a local or diffuse endophthalmitis) it is necessary to execute vitreoectomy during 6 hrs (urgently), adding an antibiotic in the infusion solution, strictly adhering to concentration (see Table. 9.1. 9.11) to avoid neurotoxic action on a retina. Should the treatment fail, evisceration and enucleation is due. Of special importance is readiness of ophthalmologic service for immediate keratoplasty in case of pseudomonad (pyocyanic) damage of the cornea even after non-perforating damages. In most cases keratoplasty is a single mean to salvage an eye from destruction. In lack of a transplant another option of vascularizing operation is possible after careful removal of necrotized sections, the cornea is treated by antiseptic, the conjunctiva, sheared along a limb is tensioned using string-purse, which is imposed temporary (for 7-10 days). The conjunctival cavity is flushed by antiseptics 0.5-1% solution of Dioxydinum and Iodine, lower eyelid is injected with antibiotic effective against the microflora (according to bacterial survey data). Urgent replacement of a cornea is necessary after the subtotal vitreoectomy in case of a ring-abscess. In the end of an operation (a surgical treatment, reoperation, plan operation), as a rule, physicians should inlet broad spectrum antibiotic under a conjunctiva and a corticosteroid, for example, Dexamethasonum. Local application of antibiotics prolongs continues, at least, for 4-5 days. Antibiotic therapy is corrected on the basis of data of bacteriological examination. When treating suspicious or infected wounds, in particular, during late treatment it is expediently to add isotonic saline solution, injected inside an eye with antibiotic, for example, Gentamicin of 0.04 mg per 1 ml of saline isotonic solution. Having completed operation on an eyeball, it is necessary to perform a careful cleaning of the soft tissues the face and eyelids. Acute osteal Folkman spoon is used to carefully remove oil particles, destroyed tissues, clots. Wounds are occluded by guiding sutures, cavities and drain pouches, edges of wounds are infiltrated by solutions of broad spectrum antibiotics. At the plural wounds, accompanied by thermal combustions of I II degree it is expedient to apply dampdrying bandages, first with 2 % a solution of boric acid (with replacement after 2-3 hrs), then half-alcohol soaked bandages. In a postoperative period it is expedient to apply various drugs, depending on individual course of a wound process: analgetics, corticosteroids, ferment drugs, vitamins, stimulators and
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adaptogens. Surgical aftertreatment of the contemporary damages to an eye is the complex multilateral problem whose solution begins at the battlefield and during a primary surgical treatment. Volume and prospects of rehabilitation treatment depend on quality of the care, rendered immediately after wound. In case of using specialized care provisions only during primary surgical treatment recurring surgical interventions are required in almost 60 % cases. They are more extensive, less predictable for vision and functions of the auxiliary organs. These casualties have doubtful restitution of vision prospects during 3-5 days because of a pitching difficult to treat and, quite often, purulent uveitis. Already after 1.5-2 weeks, due to build-up of massive vitreoretinal proliferations and retina detachment contributes to the negative prognosis. Radical treatment of wounds to an orbit with various views of primary plasty allows to lower frequency of purulent complications and recurring surgeries three-fold (from 30 % to 11 % and from 42 % up to 13 %) with the significant improvement of functions and cosmetics. Total amount of early provisions is not always possible to execute even in the requirements of ideal setup. For example, insufficiently reliable monitoring of manipulations inside an eye (including use of intraocular illumination) because of optical media transparence disorders (edema, cornea folds, a hyphema at the translucent lens, repeating hemorrhages in a vitreous), should be essential contraindication for dilating or continuation of a surgery. In such cases it is better to resort to recurring delayed (2-3 weeks after) surgeries in view of the additional data, describing mutual relation of intraocular structures and received after preexam. Sealing with partial vitrectomy, cerclage, retinopexy will go as the first stage. Vitrectomy and correction of anti shearing provisions receptions can be required as the second stage 2-4 weeks later. Nowadays there is a trend to reduce usage of diascleral extraction of intraocular foreign bodies. It is related, first of all, to inflicting additional wound (actually through wound) with formation of a new region of pathological bracing shells and infringement of a vitreous in cicatrix, formation of locus for fibrous tissue ingrowing, which is dangerous. Besides, in most cases removal of an intraocular foreign body alone is insufficient, because the removal of clots and abnormal structures of the vitreous is required. Diascleral access for extraction of foreign bodies should be restricted to intraocular splinters, densely fixed in shells and localized mainly in equatorial a region, especially if sufficient skill and equipment for transvitreal extraction are missing. Extraction of splinters of such localization can be done without an excessive tension to muscles, rotational displacements of an eyeball and without loss of a vitreous. Loss of a vitreous with
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formation of pathological bracing region is prognostically extremely unfavorable. In some cases, when the ophthalmologic branch cannot cope with the problem, it is necessary to timely move casualty in specialized eye center, especially in cases of unremoved foreign bodies, at presence of a hemophthalmia and extensive hemorrhages. Casualty should be moved promptly, not forgetting, that optimum terms of rendering assistance are short (preferable during 10-14 days after wound). If primary interference is not radical enough, there is indication for recurring surgery (usually between 2-3 weeks and 1.5-2 months after wound). The main threat is a dislocation or the beginning of dislocation of shells, accompanying by functional degradation (a decline of photoperception, hypotension). Plan of intervention usually includes vitrectomy and cerclage with sealing or circular sealing. Depending on character of damages, entire amount of surgeries can demand mobilization of all technical branch capabilities and modern methods of anaesthesia. In such cases treatment should be delayed, and performed after detailed post-exam of casualty. Postponing operation, it is necessary to apply standards of local and general prophylaxis for contagious wound complications. Surgeries should be planed and carried out, taking into account readiness of a team and available equipment. Being forced to act the stage, the ophthalmic surgeon should perform operation qualitatively to expel the retreatment. It will allow to maintain an eye and in the subsequent to undertake reconstructive surgery. Treatment, especially instant and exhaustive, is an ideal outcome, but undertaken without sufficient skills and equipment it threatens with inflicting additional trauma. The microsurgery using contemporary instruments and technique (first of all vitrectomy) has allowed to lower twice frequency of blindness after gunshot perforated wounds to an eye, and increase restitution of vision twice, in almost 40 % cases to 0.1. Nowadays, there are indicators for improvement of these indicators. Considering combined and multifactor character of explosive damages, it is necessary to recognize the versatile medical hospitals, equipped by the contemporary equipment, as the best places for treatment. These hospitals are staffed with the trained specialists, resuscitators and anesthesiologists. This center can provide effective treatment of explosive damages to an organ of sight in any branch.

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9.6. EXPLOSIVE DAMAGES OF MAXILLOFACIAL REGION

Explosive damages of the maxillofacial region, as well as other segments and regions of the body, are divided into explosive wounds (mine wounds) (MW) and explosive damages (mine damages) (MD). MW are caused by direct action of primary and secondary projectiles, an explosive wave and gas jets during explosions of various ammunition mines, shape charges, grenades and fuses. MW of maxillofacial region can be gunshot, plural, fragmentation, more often blind, than through. Wounds are divided into perforating and tangential, mainly light degree of gravity (less often than a medial degree of gravity and in single instances severe). These wounds, as a rule, combining with heavier damages of organs and tissues of the adjacent anatomical head regions (organs of sight, ENT, brain), extremities etc. MD represent traumas caused by blasts of armored vehicles on mines, IEDs when the casualty is inside or on the vehicle. Heavier traumas are known to be caused for personnel inside the armor, i.e. in closed space. For this reason, personnel in combat circumstances prefer to travel on, instead of inside armored vehicles. MD to maxillofacial can be referred to gunshot damages the closed and open damages to facial skeleton bones and the face soft tissues, neck are caused by the blast effects (less often secondary wounding projectiles). MD are clinically manifested by contusion wounds, bruises, hematomas of the soft tissues, dental fractures, fractures of alveolar appendixes and jaws. MD are usually combined with severe traumas to skull, column, internals, and open and closed fractures to bones of extremities. Each of the specified traumas of maxillofacial region is not severe by itself, but their combination with damages to other organs and tissues, is manifested by a syndrome of cross burdening. During armor blasts on anti-tank mines or the IEDs, MD can combine with thermal face burns of various depths, which causes combined damages of maxillofacial region. Distant damages of internals are not characteristic for MD in this region, but it is necessary to remember them, as their presence considerably complicates a state of casualties. Distant damages originate far from a place of immediate action of explosion factors and are characterized by severe damages to internals with corresponding functional disorders. Quite often MD are accompanied by barotrauma and contusion of ENT organs, but more often wound of organs of sight and a various brain concussions. Explosive wounds to maxillofacial region are characterized by variety of clinical processes. Most
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often they represent gunshot plural fine-comminuted nonperforating wounds of the soft tissues without penetration into an oral cavity, nose and adnexal sinuses. Contaminated plural superficial fine skin wounds on various regions of the face, a nose, eyelids, jaws and auricles, are found during medical examination. The wounds size varies from 1 to 5 mm and as deep as subcutaneous cellulose. Wounds contain fine, irregular debris of explosives, soil particles and others secondary wounding projectiles, spots coated by crusts (Fig. 9.28 color insert). Such wounds are classified as light (less often medium degree of gravity); they are not accompanied by dangerous complications and functional disorders. They self-heal, as a rule, by secondary tension or under a crust with satisfactory cosmetic effect. Seldom enough, usually during close explosions of mines and grenades, the severe wounds, described by extensive damages to the soft tissues of the face with fractures of face skeleton bones of, and sometimes with a separation of facial tissues (jaws, chin, etc.) can be observed. Such wounds are accompanied by face disfigurement and disorder of vital functions (breathing, swallowing, a mastication, speech), as well as evolution of dangerous complications (asphyxia, shock and bleeding). Wounds and traumas of maxillofacial region have the defined features, first, the social, aesthetic and communicative value of the face representing a person and expressing its individuality, and, secondly, anatomic-physiological features (mimic and masseters, dentals, close locating of a brain, the upper respiratory paths, ENT organs and an organ of sight). These features demand organizational-medical provisions already from first stages of rendering medical care and define specificity of medical-social rehabilitation for maxillofacial casualties. Casualties with heavier wounds of maxillofacial region require specialized surgical treatment, directed on restitution of the broken anatomical structures and the important functions facial elements. Its basic method is the primary surgical treatment of wounds. This treatment should be completely and accurately executed in the earliest terms possible, which ensures congenial course of a wound process and prophylaxis of inflammatory complications. A binding requirement is conducting of the primary cutaneous plasty to eliminate damages of the soft tissues and face disfiguration. This helps recover aesthetic and mental status of the casualty. Jaws fractures caused by explosive damages, usually have the linear character of damage. However, the temporary disability of patients with such fractures on the average compounds 3055 days, which confirms urgency of their specialized treatment providing restitution of continuum and the anatomical shape of the defective bone, a normal bite and a high-grade mastication. It is achieved by repositioning and immobilization of jaw fragments under
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requirements of adequate anesthesia, drug and fortifying treatment, physiotherapy and physiotherapy exercises. The important places are also given to special feeding and oral cavity care. The major indicator of wounds severity is visual appearance of wounds, allowing to see whether only the soft tissues are damaged or it simultaneously combines with damage to facial bones. Among many factors defining a degree of cosmetic and functional disorders at maxillofacial wounds, the great value is taken by presence or lack of damages to tissues. The true damages to the soft tissues more than 3 cm are rarely seen at explosive facial wounds and preferentially are observed during wounds with a damage of jaws. Explosive wounds, penetrating into an oral cavity, nose and its adnexal sinuses compound only small share. However, wounds penetrating into an oral cavity quite often cause anatomical and functional disorders as a result of damage to the soft tissues of oral cavity bottom, tongue, a soft palate and pharynx. Additional contamination of wound with microflora, saliva and discharge of the oral cavity, nose and its adnexal sinuses leads to less congenial course in perforating wounds if compared to non-perforating ones. In local military conflicts, explosive damages to maxillofacial region are combined with damages to extremities in more than 70 %, eyes in 64 %, ENT organs in 51 %, chests and abdomen in 18 % and a brain in 34 %. According to damage severities, casualties should be treated in traumatology, ophthalmologic, ENT and other branches, but with binding participation and under observation of the maxillofacial surgeon or the dental surgeon. Organization of a medical care, treatment and rehabilitation of casualties is greatly influenced by isolation of casualties by wound severity, taking into account estimate of the general state, character and degree of damage to organs and tissues of maxillofacial region. Surgeons should consider type of wounding projectile, character of face damage, damage to organs and tissues (solitary, plural or combined wound), the direction of wound channel (through, blind or a gutter wound), presence of damages to soft or osteal tissues, and also whether this wound is perforating or non-perforating into oral cavity, nose and its adnexal sinuses. During medical classification of casualties with explosive damages of maxillofacial region they should be divided into three classes. 1. Severe casualties, including: - insulated wounds to soft and osteal tissues of maxillofacial region with defect of the tissues, perforating into an oral cavity, nose and adnexal sinuses, with a damage to the
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temporomandibular joint, sialadens, stem and branches of an external carotid artery and a facial nerve; - insulated plural wounds of maxillofacial region with defects of eyelids, nose, auricles and jaws; - avulsions of the face elements (a nose, jaws, auricles and a chin); - gunshot extensive wounds to soft and osteal tissues of the maxillofacial region, combining with damage to organs and tissues of other anatomical regions. 2. Casualties of a medium severity with: - insulated plural blind comminuted wounds of maxillofacial region without defect to osteal and soft tissues, perforating or non-perforating into an oral cavity, a nose and adnexal sinuses; - insulated perforating wounds of eyelids, wings of a nose, jaws and auricles without defect of tissues; - combined wounds to the soft tissues of face and neck without defects to tissues and damages to bones of facial skeleton, sialadens, temporomandibular joint, a trunk and branches of an external carotid artery and a facial nerve; - gunshot fractures of bones of facial skeleton without bone defects; - regional and buttonhole fractures of a mandible without disruption of continuum; - the insulated wounds of an alveolar appendix and dentals within the limits of two and more functional groups of teeth; - non-gunshot fractures of jaws with fragments displacement; - non-gunshot fractures of jaws complicated by suppurative processes; - purulent hematomas of maxillofacial region. 3. Light Degree Casualties with: - insulated or combined, plural or solitary wounds to maxillofacial region within the limits of subcutaneous cellulose without defects of the soft tissues and a damage of temporomandibular joint, greater sialadens, large branches of an external carotid artery and a facial nerve, wounds, which do not perforate into an oral cavity, a nose and adnexal sinuses; - non-perforating wounds of eyelids, a nose, auricles and jaws without defect of tissues; - insulated wounds to alveolar appendix within the limits of one functional group of teeth; - non-gunshot fractures of jaws without displacement of fragments; - non- gunshot fractures of an alveolar appendix, teeth;
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- extensive bruises of tissues and hematomas in the face region. The following features should be stressed among peculiarities of maxillofacial explosive damages: The disfiguration immediate or remote aftereffect of severe wound to a face, which is based on the anatomic- morphological and functional disorders. Disfiguration leads to decrease or loss of combat and work capabilities and causes alienation. The medical personnel should know this peculiarity and consider it during treatment of maxillofacial casualties, supporting casualties hope for congenial outcome of treatment. This is achieved through sensitive and impartial attitude of the medical personnel to casualty, their mercy; keeping to standards medical ethics; reading of the popular literature, promoting achievements of the contemporary regenerative maxillofacial surgery. Contradiction between wound outlook and gravity is frequently observed in maxillofacial casualties with severe and a medial degree damages. It consists in misfit of casualty outlook, caused by presence of an extensive and low-purity wound, an edema and a hematoma of the adjacent regions of the face evolving at one hour after wound, displacement of wound edges and musculocutaneous flaps due to mimic muscles. These features often make deceptive impression about hopelessness of the casualty, and at a loss of consciousness about its death. Actually, very often, degree of gravity contradicts with a state of hopelessness, and, moreover, casualty death. This information should be furnished to the medical personnel. Presence of teeth the peculiarity, essentially influencing pathogenesis, diagnostics and treatment of explosive wounds in maxillofacial regions, especially, fractures of jaws. First, teeth, being secondary wounding projectiles, damage organs and tissues, causing crimped wound channels and additional wound channels with various directions. It considerably impedes diagnostic of wound and increments a severity. It increases amount of a primary surgical treatment. Secondly, if teeth are infected (a gangrenous pulpitis, a periodontitis) they can cause inflammatory complications (a suppuration of hematomas, phlegmons fibrous spaces, the suppuration of an osteal wound and gunshot osteomyelites of jaws) and stomatologic diseases (acute odontogenous osteomyelites, et. al.). However, presence of teeth positively affects diagnostic of jaw fractures (basic sign of fracture bite disorder) and their treatment (bracing of fragments by means of teeth splints). The proximity of the vital organs (brain, upper respiratory paths, an ENT organs and an organ of sight) frequently leads to combined wounds of maxillofacial region. This issues increments their
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gravity and they can be accompanied by complications and failures. Asphyxia is the most frequent complication. At all stages of rendering a medical care, before entering a hospital, the medical personnel should be directed on well-timed diagnostics of an asphyxia and carry out provisions against it. Maxillofacial surgeon in a hospital together with other specialists (neurosurgeon, an ENT-doctor, the ophthalmologist) should classify wounded in maxillofacial region, perform diagnostics of asphyxia and the operative treatment directed on its elimination. Increased reparative regeneration of the face tissues is a peculiarity, underlying main principles of a primary surgical treatment. Owing to the raised blood supply and innervation, presence of foci for potential histogenesis, wounds and flaps of a skin, seeming nonviable at a visual inspection, maintain adequate feed, and should be subject to economical excising and use for primary cutaneous plasty. Elements of organs (jaws, a nose, eyelids, auricles, et. al.) with feeding legs should be cut off only in cases of the full crush and lack of blood supply. Diagnostics of explosive damages to maxillofacial region is performed according to: - anamnesis; - studying the medical documentation; - exam of the casualty and studying of a wound (input and target holes, a direction of wound channel); - palpation of wound region; - probing (bulbous-end probe or ophthalmic), punctures using a syringe needle; - x-ray inspection (binding even at wounds only integuments), including fistulography and sialography. In some cases for topical diagnostic in case of deeply embedded foreign bodies, as a rule debris, in parapharyngeal, infratemporal or pterygomandibular regions and retrognathic fossa, surgeons apply X-ray imaging with several syringe needles, left after examination in tissues through to a primary surgical treatment. First aid includes a stopping of a bleeding with aseptic bandage; provisions against asphyxia (aspiration, dislocation), freeing oral cavity from clots and foreign bodies; positioning unconscious casualties face downwards position or the lateral stabilized standing and introduction of anesthetizing resorts from the individual first-aid set or a complete set of the doctor's assistant. Stopping of small external bleedings from wounds of the face is done by compressing bandage, which should be strong in view of possible long-term transportation. However the latter should not be imposed after fractures of mandible within the limits of a
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dentition as it can cause additional displacement of fragments and threat of asphyxia. Application of an aseptic bandage prevents secondary microbial contamination of a wound and in the certain degree affixes fragments of jaws. Primary goal of first medical aid is provisions against bleeding, asphyxia and a shock. A bleeding is shut down by compressing bandage or a hard tamponade of a wound, sometimes a ligation of the vessel. An asphyxia is eliminated by cleaning of an oral cavity, respiratory analeptics and in rare cases a tracheostomy. One of the effective methods of against dislocation asphyxia in unconscious casualties is the suturing and bracing of a tongue by the silk ligature, led by a needle along medial line in the vertical direction or through the depth of tongue in the transverse direction, leaving distance of 1.5-2 cm from the end of a tongue. Ligatured tongue can be fixed to a cheek. Antishock therapy includes introduction of anesthetizing drugs and plasma substitutes. During fractures of jaws, the fragments are temporary attached using standard transport bandage, but more often an immobilization is performed using ordinary bandage from gauze pad or several layers of grid bandage. Maxillofacial casualty is administered IM antibiotics and tetanus anatoxin (3000 Units). The casualties are hydrated using water or tea. After rendering assistance to casualties, they are without a delay evacuated to stage of the qualified or specialized medical care. Qualified medical aid includes three groups of provisions: - emergency surgeries and other provisions under vital indications. Failure to perform these provisions (elimination of asphyxia, final stopping of bleeding, provisions against shock and hemorrhage) threatens life of the maxillofacial casualty in several hours; - provisions, whose untimely accomplishment can lead to severe complications (a primary surgical treatment of wounds with an extensively crushed soft tissues; cleaning of wounds strongly polluted by soil etc); - surgical provisions, delayed if necessary on the background of antibiotic activity (cleaning of wounds to the soft tissues, application of plate sutures at scrappy wounds, immobilization of jaws fragments by means of a standard transport bandage and intermaxillary ligaturing of teeth). Qualified medical aid to maxillofacial casualties is rendered, as a rule, by the dental surgeon. Assistance should be provided by the general surgeon. Treatment of wounds to the soft tissues of the face includes elimination of the originated early functional and cosmetic disorders,
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prevention of complications. It consists of wounds and surrounding integuments cleaning, treating them with antiseptic solutions with the subsequent aseptic dressing or treatment with of 1 % diamond green solution. Antibiotics should be administered in the soft tissues around damage; wound should be drained and closed with aseptic bandage. Foreign bodies (splinters) located superficially, in integuments, are removed. If they have small size, placed shallow in the soft tissues and do not cause functional and cosmetic disorders, they should not be removed. All casualties are administered tetanus anatoxin IM and antibacterial therapy is conducted. During hospitalization, the oral cavity should be cleaned and disinfected. Rendering of the qualified medical care to maxillofacial casualty with the facial bones damage (severe and medial degree of gravity) provides: resuscitatory provisions and intensive care, directed on elimination of a hemorrhage, shock and maintenance of the vital functions; accomplishment of minimally necessary surgical intervention under vital indications (provisions against bleeding and asphyxia). In the further, provisions are continued for elimination of disorders to homeostasis and prophylaxis of contagious complications. Besides, surgeons carry out feeding and preparation of casualties for evacuation. The asphyxia for which elimination the urgent tracheostomy is required, is observed only in single instances at extensive damages of the face. When the critical casualties enter hospital stage, surgeons evaluate their general state, presence and an expression of shock, asphyxia, volume and character of damages, group accessories of a blood and a rhesus the factor and, as a rule, start to conduct infusional therapy, and if needed resuscitatory provisions. After X-ray exam the casualties enter operational or clean dressing room, where surgical interventions are carried under vital indications (provisions against bleeding and asphyxia), cleaning of wounds and supply of hemorrhage with overflowing of blood substitutes or fresh-citrate blood under rigorous indications. After the operative provisions, depending on the general state, the casualty enters surgical or antishock department where provisions on stabilization of a homeostasis and prophylaxis of contagious complications are conducted. Dehydration of maxillofacial casualty, in distinction from other wounds is aggravated by some additional factors: difficulties of eating and drinking in a natural way, hypersalivation, constant saliva dripping due to ruptured oral cavity, increased evaporation of water through the respiratory paths due to upset nasal breathing. Casualties with the damage to facial skeleton bones are subject to, whenever possible, the
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separation of osteal and external wounds from an oral cavity by suturing of the mucosa or attachment of an iodoform tampon. An immobilization of mandible fractures by means of a standard transport bandage or teeth ligation. Fractures of the upper jaw require transport immobilization by using standard transport or individual chin (sling) bandage, made of plaster bandages. An external wound, as a rule, are not sutured, but rather are administered by the tampons, moistened by hypertonic and antiseptic solutions with the subsequent aseptic bandage. Maxillofacial casualties with severe and a medial degree of gravity demand the constant monitoring of their state, special care and feeding. At the first opportunity, they are switched to the enteral feeding, using a stomach probe. Nutrition for these casualties consists of fluid homogenous nutrition, fruit and vegetable juices, butter, raw eggs, the condensed milk and sugar. Each wounded is supplied with a water bottle. Casualties are evacuated to the stage of specialized care by air transport in lying position and are accompanied by the medical personnel. Preparation of casualties for evacuation consists in removal of rubber rings with teeth splints and application of standard transport bandage or chin sling bandage, hydration, administration of 1-2 Aeron pills. The question of transportability is solved on individual basis, with respect to general state of casualty and stability of hemodynamics and breathing. The residence time of maxillofacial casualties at stage of the qualified medical care before evacuation is usually 4-6 days The specialized medical aid is rendered in medical establishment with dental surgery department. Following provisions are carried out in the dental surgery branch: - urgent medical aid under vital indications to maxillofacial casualties, forwarded to the hospital from the places of surgeries or accidents, and also to maxillofacial casualties with the conditions, caused by transportation; - primary surgical treatment of wounds to osteal and soft tissues of maxillofacial region; - treatment of jaw fractures by means dental splints, orthopedic and special devices and various types of osteosynthesis; - plastic surgeries; - dietary and drug treatment; - prophylaxis and treatment of postwound complications; - dentures; - sanation of oral cavity for casualties and hospital inpatients; - advisories for other hospital branches;
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- practical help to dental surgeons of other hospitals in questions on organization and rendering of the stomatologic aid to maxillofacial casualties. It is established, 23.3 % to 53 % maxillofacial casualties with combat gunshot damages require a specialized medical care. They compound 1.4-3.4 % casualties, delivered to hospitals. Any large scale campaign causes this number to rise up to 3.8 %. Pattern of the combat wounds, depending on wounding projectiles and character of damage, can vary during military campaign. When use of grenades, mine ammunition and rockets peaks, it causes fragmentation wounds rise from 56 % up to 84 % and explosive wounds rise from 8.7 % up to 18 %. Gunshot wounds of the soft tissues to maxillofacial region predominate over wounds, involving damage of facial skeleton bones and compound 52-78.3 %. Gunshot wounds to face with a damage of jaws are observed in 21.7 % to 48 %. Aside with insulated and combined maxillofacial wounds at this stage it is necessary, to point out wounds, which in 8.16-14.7 % combine with heavier damages to ENT organs, eye, neck, skull and extremities. Casualties with such wounds are treated in other branches of hospital, according to the predominating damage, but with immediate participation of the maxillofacial surgeon or the dental surgeon (Fig. 9.2. see color insert). Maxillofacial surgeon in a reception conducts the medical classification. First of all casualties are selected from a stream of casualties with bandages on head and a neck. Among them, physicians select casualties with insulated, combined and concomitant wounds of maxillofacial region. Last two categories of wounds are classified jointly with an ENT-expert, ophthalmologist, neurosurgeon, traumatologist, and other specialists. According to the dominating wound, casualty is referred to the respective branch of hospital. Maxillofacial casualties with insulated and combined wounds depending on a degree of damage are separated into 3 groups. 1st group critically wounded patients, requiring pressing surgical provisions under vital indications (phenomena of the asphyxia, a continuing bleeding, severe shock). These critically wounded patients are immediately referred to surgery. Pressing surgical provisions and primary surgical treatment are performed under endotracheal narcosis. 2nd group the critically wounded patients requiring urgent surgeries, but only after preoperative preparation: stopping acute hemorrhage and anti-shock provisions in the in anesthesiology and resuscitation branch. 3rd group maxillofacial casualties with medial and light degree of gravity wounds. These
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casualties after sanitization are referred to dental surgery branch. After the third-degree surgeries they do not require observation of the anesthesiologist and they remain in dental hospital as inpatients. Postoperative treatment of maxillofacial casualties includes: dressings of wounds, drug and dietary treatment, a special care, physiotherapeutic and orthopedic treatment. Dressings of debrided wounds in the maxillofacial region for the first three day are applied by the surgeon with required aspiration of wound discharge and flushing by antiseptic solutions through the PVC pipe, installed during primary surgical treatment. Treatment and prevention of inflammatory complications should be performed using intraarterial infusion of drugs (antibiotics, anticoagulants, antihypoxants and antiaggregants) through catheter into the superficial temporal artery. Drug treatment in each case includes antimicrobial drugs for prophylaxis of purulent complications. Administered antibiotics include Penicillin group Ampicillin, Ampiox and Carbenicillin, groups of cephalosporins Kefzol, Cefamezin, Lincomicin and Gentamycin sulphate in standard dosage. Besides, all casualties are administered vitamins (Undevitum, Hexavitum or Decamevit, Aerovit) and symptomatic drugs (Benadryl, Calcium drugs, analgetics). Analysis of medical provisions in local conflicts shows, that stomatologic branch performs 56 % surgeries under emergency indications, and surgical activity compounds close to 70 %. Principal type of surgeries are: a primary surgical treatment of wounds to the soft and osteal tissues in combination with radical maxillary sinusotomy, a reposition and an immobilization of jaws fragments, osteosynthesis of jaws, exodontia, alveolectomy, primary and early plasty of damages to the soft tissues and a mandible, elimination of salivary fistulas and lancing of purulent hematomas. Percent of the complex surgeries oscillates from 17.5 % to 31 %. Stomatologic branch may employ methods of maxillofacial gunshot wounds and their aftereffects treatment, which are developed and proved by clinical-functional and histological studies of G.I. Prohvatilov in 198. including: - plasty of gunshot damages of the face soft tissues during a primary surgical treatment is performed by means of local plasty and flaps on feeding legs; - primary plasty of mandible damages by auto-rib technique; - elimination of gunshot extensive through damages of a palate by microvascular autografting of a musculocutaneous flap with insert of the broadest back muscle; - elimination of gunshot through damages of a cartilaginous nasal department, cheek and jaws
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using the combined plasty (cellulocutaneous flap from a cheek and fasciocutaneous flap from forehead over the latent vascular leg). Postoperative complications in maxillofacial casualties can be observed in 1.7-4.6 % cases. Major part of complications is comprised by suppuration of wounds after the untimely primary surgical treatment, poor and incomplete previous stages of treatment. Some critically wounded patients in a postoperative period can develop pneumonias caused by character of gunshot wounds, features of wounds of maxillofacial region and conforming functional disorders. The lethality in maxillofacial casualties makes up 0.9-1.8 %. The reasons for lethal outcomes are extensive and plural wounds of maxillofacial region with massive fracture of jaws, damage to neurovascular tract in neck combined with extensive damages to extremities or a bruise of brain, acute hemorrhage (up to 3 l) and a shock of IIIrd degree. Explosive damages to maxillofacial region are accompanied by damage of the masticatory apparatus, tissues of mouth regions, pharynx and the upper respiratory paths, causing disorders of food intake. Degree of these disorders depends on character, localization and gravity of anatomical damages. Therefore nutrition of maxillofacial casualties is based on special diets. First maxillary diet (probe) is mechanically sparing, contains multiply dishes, plenty of vitamin C (up to 180 mg/day) and does not differ by taste from general food. It is administered to critically wounded patients with MW, having acute disorders of mastication and a swallowing, and to casualties with MD. Fractures of jaws in MD casualties are treated with orthodontic (curved or standard) splints with intergnathic traction by rubber clamps. Second maxillary diet is the transition to the general table and is appointed the casualty with medial and light degrees of damage, who has derangements in nibbling and chewing of firm food. Rational feeding of critically wounded patients in maxillofacial region is provided by adhering to following requirements. The nutrition is supplied to oral cavity fractionally, 6-10 ml from an feeding device (a funnel, a major squirt gun) through a rubber tube with diameter 10-13 mm and length 25-30 cm. Consistency of food should be fluid-like (like fluid sour cream), that provides easier and less painful swallowing. Temperature of food should be 40-50. Wounds to the bottom of an oral cavity, root of tongue, palatal handles, and soft palate, when the swallowing is deranged and food transit through the pharynx is impossible, casualties are fed by nasal probe.
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Special care for casualties with explosive damages of maxillofacial region, with upset selfcleaning of an oral cavity is broken, is very important. Many specialists on the basis of WWII experience equalize it with surgical treatment of wounds. Special care includes mechanical cleaning and irrigations of an oral cavity, aimed on removal of clots, slime, wound discharge, and food leftovers. Flushing with warm solution of manganese crystals (pink) or Furacilinum (1:5000) under pressure not only effectively cleans an oral cavity but also renders bacteriostatic action on a microflora. For casualties with orthodontic splints and intergnathic extension, irrigation with antiseptic solutions prevents inflammatory complications and provides oral cavity hygiene. Antiseptic mouth cleaning is conducted 8 times a day (before and after meals, before a sleep and after a sleep), changing a solution of antiseptic each 5 days Experience in treating maxillofacial casualties during confrontations testifies to efficiency of physiotherapeutic treatment of wounds and traumas, their complications and aftereffects. Physiotherapeutic treatment is needed by more than 50 % casualties with gunshot and about 27 % with mechanical injuries to the soft facial tissues. Complex use of UV radiation of a fresh wound for prophylaxis of suppuration, UHF-therapy for rapid purification of wounds, and sun wave lamp for a faster removal of crust and epithelialization is recommended. At a regeneration stage, the effective provisions are paraffin therapy and UV irradiation of wound and integuments. An effective measure for accelerated purification of wounds is diadynamotherapy and fluctuorization. If the infiltration is formed in the region of cicatrix, physicians should prescribe darsonvalization and diadynamotherapy, electrophoresis with potassium iodide and ultrasoundphoresis with hydrocortisone and physiotherapeutic exercises. After forming of cicatrix it is necessary to appoint an electrophoresis with Lydazum and medical massage. In case of gunshot fractures to jaws, physiotherapeutic treatment will consist in consecutive or simultaneous application of several methods, as well as medical gymnastics for mimic and masticatory muscles. Rigor contractions of a mandible require use of mechanotherapeutic devices for development motions (Swinging spoons by A.A. Limberg, the wooden apparatus by G.S. Yadrova, Kovner expander, Darcissac apparatus). Last stage of a medical aftertreatment of casualties in maxillofacial region requires use of dentoprosthetic rehabilitation, which provides restitution of masticatory function and elimination of the cosmetic disorders, related to loss of teeth. Of general number of casualties with gunshot wounds and other mechanical injuries to the soft facial tissues, about 20 % require
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dentoprosthetic rehabilitation. The important peculiarity of casualties with damaged teeth and alveolar appendixes is extremely high demands of dentoprosthetic rehabilitation. More than 80 % patients with gunshot and about 85 % with the closed and open mechanical face injuries require orthopedic treatment. Thus, gunshot wounds are more often accompanied by losses of more teeth, than usual mechanical injuries. Elimination of damages to dentitions requires use of detachable and fixed dentoprosthetic rehabilitation using various dentures. So, judging from experience of local confrontations, bridge-like prostheses are made for 40.8 % maxillofacial casualties; particulate detachable prostheses for both jaws at 22.4 %; upper jaw at 12.2 %, mandible 12.2 %; solitary dentures at 10.2 % of casualties and the complex demountable prostheses over the upper jaw in 2.2 % of casualties . Elimination of the cicatricial deformity requires the grafting with pedicle flaps from the remote regions, a pedicle graft and microvascular autografting of tissues. These methods ensure transplantation of great volumes of dermaplastic material, allowing to eliminate extensive and perforating face damages, including those interconnected with an oral cavity, a nose and adnexal sinuses, and also the extensive cicatricial deformity with satisfactory effects (Fig. 9.3. see color insert). Bone plasty of a mandible is mainly performed by free auto-rib graft in all depth (VIII-IX ribs). Treatment of inflammatory complications (gunshot osteomyelitis of jaws, abscesses and phlegmons) should be complex and include operative measures (sequestrectomy, lancing of abscesses and phlegmons), active methods of purulent treatment wounds and antibacterial therapy. Drainage of purulent wounds is performed using single, double and double-barreled PVC tubes through which vacuum drainage by Redon is conducted and the active antibacterial bathing of the wound (wound dialysis). Good clinical effects are gained during treatment of purulent wounds by ultrasonic sound (device UZUM-1) and helium-neon laser (LG 75), which intensively strips wound surface, reducing microbial dissemination, promote phonophoresis of medicines and even sterilizes wound a surface [Balin V.N., 1988]. The hyperbaric oxygenation also gives good effect, especially in presence of non-clostridial wound fever. Prompt purification of purulent wounds requires local application of immobilized proteolytic enzymes and absorbers. Other aftereffects of the explosive damages, although rarely observable, include extensive
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damages of a firm palate, anchylose of temporomandibular joint, a rigor contraction of a mandible, a paralysis of mimic muscles and salivary fistulas. To conceal damages of a firm palate, patients should use tissues of a bucket-handle graft by A.G. Lapchinsky (1947) or V.I. Zausayeva (1959). It is possible to apply a musculocutaneous flap with insert of the broadest back muscle by G.I. Prohvatilov (1990). Treatment of the temporomandibular joint anchylose is based on the following principles: high osteotomy, removal of osteal agglomerations, and maintenance of jaw altitude and reliable disjunction of the osteotomied osteal fragments. Patients with the anchylose of this joint in a postoperative period 6-8 days rest should be appointed medical gymnastics, promoting active motions of a mandible. Rigor contractions of a mandible are also subject to surgical treatment, whose character is defined by localization and abundance of the cicatricial or osteal changes restricting jaw motions. Cicatrix of the soft tissues and mucosa of an oral cavity are excised and the defect is substituted by the converging triangular pedicle flaps, the bony union interfering with motions of the mandible. If necessary, the osteotomy of the coronoid process of mandible or zygoma and maxillary tuberosity is performed. Paralysis of mimic muscles originates after damage to a trunk and branches of a facial nerve, which is observed quite often in wounds of parotid regions. Important role for these wounds belongs to a primary surgical treatment, which provides not only exhaustive treatment of the gland parenchyma, the suturing of fascias and the necrectomy of nonviable soft tissues, as well as primary plasty of a facial nerve. Presence of an operative microscope or a binocular magnifier, microsurgical instruments and a suture material allows performing neurography of facial nerve extremities. If defect is found, surgeons can execute neuroplasty using a free autograft from gastrocnemius nerve. These provisions prevent irreversible cosmetic and functional damages, observable as resistant paralyses of mimic muscles. They also allow avoiding myoplasty and static suspension of the paralyzed face elements. Experience of microsurgeries on a facial nerve testifies that restitution of trunk and branch conductance takes 4-6 months after neurography and 8-10 months after a neuroplasty. Complex of rehabilitation provisions should also include: easy massage and exercises of mimic muscles, thermal procedures (paraffin, IR irradiation), electrophoresis with vitamins B. B1. neostigmine methylsulfate and ultrasoundphoresis with cortisone. Resistant sialosyrinxes occur in 0.7 % of cases from all gunshot and explosive wounds of
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maxillofacial region. They occur after wounds to the excretory duct of the parotid gland. Sialosyrinxes are treated by provisions, which can be separated into two groups: 1) creation of new channel-tap for saliva into the oral cavity and restitution of the excretory duct peripheral element. These provisions have no anatomic justification, because they do not recover the duct in full; 2) restitution of the duct using conductors, which is very complex and traumatic. Microsurgical operations are also possible, leading to complete restoration of continuum and functioning of the parotid (submandibular) gland excretory duct [Prohvatilov G.I., 1994].

9.7. EXPLOSIVE DAMAGES OF ACOUSTICAL AND VESTIBULAR SYSTEM

Up to 75 % of mine-explosive traumas are accompanied by certain derangement of acoustical and vestibular system. ENT casualties comprised up to 33 % of contusion casualties during the local conflicts of the last decades. Symptoms of an acoustic barotraumas (pierced tympanic membranes, traumatic purulent otitis) were found in 6 % of contusion casualties. MT of acoustical system in overwhelming majority of cases is accompanied by damages without rupture of tympanic membrane (82 %) and its edema (at 55.4 %). These traumas were distributed according to degree of bradyacuasia: I degree 44.3 %; II degree - 18.0 %; III degree 37.7 %. Recently, trauma to ENT organs is met in 4-4.5 % of casualties during modern local wars in the general frame of combat damages. The damage to ENT organs after mine-explosive wounds in 14.6 % cases is combined with brain injury, in 33.6 % injury to an eye and in 21.8 % jaw injuries. Experience of conflicts testifies of difficulties in diagnostic of acoustical system damages on the background of severe mine-explosive traumas, especially in early terms after a trauma. In this connection, damages of acoustical system are not diagnosed (51 %) or diagnosed late (26.5 %) which leads to delayed therapy. Delayed therapy reduces medical care efficiency and promotes nonreversible pathological processes in peripheral and central structures of acoustical system, other departments of a brain, evolution of neurosensory bradyacuasia and disabilities. Comparison of clinical data proved that the majority (65 %) casualties with leading syndromes, represented by: explosive trauma of a brain, acoustical and vestibular system is related to blasts inside armor. Although contact blasts in the open circuit are accompanied by much heavier extracranial damages, they entail severe traumas to a skull, brain and ENT organs only on rare
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occasions. In case of explosive damages inside armor, both ears are often damaged by an acoustic pressure. Explosions in the closed contour (tank or APC) damages both ears in 62 %, in 31 % one ear, facing explosion (during explosions inside unstable buildings) and in 7 % of cases, there is no damage to acoustic system at all. In case of frontal explosion in the open circuit, damages to acoustical system happen in 83 % cases uniformly from both sides, irrespective of explosive yield. For lateral direction the degree of an explosive damage is 2 times heavier, when the ear faces explosion. Rupture of a tympanic membrane of the contralateral side is observed in 2 % of cases. During clinical exam of casualties with mine-explosive traumas, concomitant damages to acoustical and vestibular systems were diagnosed: 35.8 % in traumatologic departments, in 26.4 % in neurosurgical branches only 21.3 % in surgical branches. Majority (73.4 %) of casualties manifested various degree of damages to tympanic membranes: superficial damages (54 %), ruptures (preferentially in the inferior quadrants) and edema (18 %), disruption of the chain of auditory ossicles (3.6 %). External acoustical pass quite often included foreign bodies (sand, soil), blood clots and crusts. It is important to underline, up to 82 % traumas in the pattern of mine traumas, are comprised by light brain injuries, capable of disrupting hearing functions and vestibular system, persisting (recurring) through lengthy periods. Objective measure of these damages diagnostics and outcome prediction are very complicated. They require early ENT-inspection and lengthy observations of casualties with mine-explosive traumas, which is important for expertprognostical estimates of severity and possible outcome for traumas of brain, acoustical and vestibular systems. Modern understanding of explosion implies physical process, accompanied by release of high energy in the restricted volume during short period, with localization in time and space, and generation of an audible pressure wave. Mechanism of injuring activity of an air blast wave is comprehensively addressed in the previous chapters. Damage to an organism and brain during explosive trauma is defined by combination of factors: - activity of an explosive wave (namely explosive trauma); - sharp oscillations of atmospheric pressure (barotrauma); - action of an acoustic wave (acutrauma);
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- acceleration and throwing of casualty (accelerotrauma); - impacts by impinging objects (mechanotrauma); - fat embolism of brain vessels after fractures to long bones (often observed after mineexplosive traumas); - hypoxia of a cerebral tissue after hemorrhage, shock, disorder of microcirculation; - psychoemotional aftereffects of explosion (psychotrauma); secondary changes, related to reflex, vascular, hypoxic disorders caused by a bruise and percussion of internals.

9.7.1. Basic mechanisms of neurologic, acoustical and vestibular disorders, caused by explosive traumas
Physical properties of various body parts are extremely nonuniform. The blast wave in a greater inflict stronger damages on the hollow organs containing air or fluids (in first place lungs, then organs of a gastrointestinal section, brain structures, including medial and interior ear, vestibular system etc.). Compressed air wave action is accompanied by acute compression of thorax and abdominal cavity with sharp increase of internal pressure. Dynamic pressure of an explosive wave during very short periods changes position of casualty body parts. Gravitation blast mechanism acute, sharp displacement of extremities toward trunk is combined with the "nod" of a head, known as whiplash trauma to cervical departments of spinal cord and myelencephalon. Aside from direct injuring action to the main neck vessels, displacement of body parts (coercion of legs and heads to a trunk) rapid pressure rise in spinal fluid channels. Simultaneously, elastic stress waves, induced by an explosive blast wave, propagate toward axis of the spine channel. These waves transmit impact accelerations to the fluid column in the spinal channel. Plurality of the considered mechanisms, responsible for spinal fluid pressure changes, initiates dynamic fluid impact with the implosive effect, which initiates hemorrhages to the brain shells and tissues, medial and interior ear, and damages to receptors of acoustical and vestibular systems. Impact accelerations, propagating to skull base in the area of craniospinal junction. Combination of local damages to cerebral vessels and systemic disorders of hemodynamics, caused by primary trauma to heart and lungs, can later cause distorted cardiorespiratory functions, connected with
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myelencephalon activity. Direct primary brain damage causes neurologic, acoustical and vestibular derangement immediately after traumas. These disorders peak 2-3 day after explosion. By this time discirculatory derangements induce biochemical mechanisms of brain damage with increasing of processes of a proteolysis, endotoxemia, disorders of immune system etc. In this case, derangements are triggered by upset of vasomotor, respiratory and other centers due to primary brain trunk damage. Degree of disorders is, first of all, manifested by derangement of consciousness and vital functions. Acoustic barotrauma, as a rule, is manifested by damage to tympanic membrane, medial and interior ear, the nervous conductors of an acoustic analyzer, vestibulo-vegetative, somatic and sensory disorders. Main place in this process belongs to the interconnected disorders of circulation and a metabolism. Percussion of a maze and circulatory disorders disrupt production and composition of labyrinth fluid and impede its reflux, which in aggregate, leads to an edema of a maze and aggravates metabolic disorders in cellular elements of a webbed maze and in nerve endings. Increase of a hypoxia determines tracking degenerative-dystrophic changes in all building elements of vascular stripe (capillaries, myelinic shells, epithelial cells), with impairment of trophism and innervation of Cortis organ receptor cells, peripheral appendixes of bipolar nervous cells of a spiral ganglion, edema and destruction of sound-conducting structures of myelencephalon, brain cortex and subcortical formations. Blast action causes swelling of mitochondrias in the cytoplasm in hair cells of the vestibular department of the labyrinth. They also become translucent; karyoplasm of karyons becomes moderately rarefied. Size of nerve endings increases in most cases. Nerve endings include the translucent mitochondria. Basal departments of some hairpin cells and myelinic preganglionic nerve fibrils manifest amplified process of calcium infiltration. Stagnation of blood in maze acoustical department vessels is noted. There are reactive changes of myelinized axons, fitting to capillaries. Observable damages of mitochondrias and disorders of energy supply to endotheliocytes of interior ear vessels lead to disorder of protein synthesis and respiratory system of a cell; boost of lipids peroxidation, etc., which explains resistant bradyacuasia after mine traumas. Bradyacuasia is also aggravated also by disorder of normal myelin pattern in axons of a vascular stripe. Observable destructive and reactive changes of all building blocks of a vascular stripe are, undoubtedly, accompanied by disorders of biochemical and biophysical processes in Cortis
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organ cells, which finally leads to upset of its receptor function. This can explain perennial progression perceptual bradyacuasia, as observable in clinical practice after mine traumas. Performed studies allowed to isolate three groups of the bradyacuasia of the explosive genesis: - conductive or mixed bradyacuasia, caused by mechanical (barotraumatic) damage of soundconducting structures of a medial and interior ear; - acute labyrinth neurosensory bradyacuasia, accompanied by irreversible pathological changes in specific neuroepithelium (acute acutrauma); - neurosensory central bradyacuasia or deafness, related to functionally reversible changes (air contusion). Acute period of brain explosive trauma is often accompanied by various dysfunctions of vegetative nervous system, syncopal states, and sympathoadrenal hypertonus: arterial hypertension, tachycardia, chill-like hyperkinesis, raised anxiety. Explosive traumas of easy and medial degree of gravity are accompanied multiple otoneurologic, neurophthalmologic and therapeutic derangements. During acute period of an explosive trauma there are pathological vestibular-vascular responses of a brain and peripheral vessels, being one of the triggers of discirculatory disorders. Thus, it is necessary to underline, that nonreversible vestibular disorders and pathological vestibularvascular responses can originate independently on gravity of MT. In a residual period of brain trauma vestibular responses are frequently torpid. Responses are frequently asymmetric, due to hyperreflexia of the injured side. Vestibular derangements in casualties are manifested as spontaneous nystagmus, giddiness, loss of coordination, tachycardia, hyperhidrosis etc. Clinical data testify that virtually all types of acubarotrauma, caused by explosions are accompanied by various degree damages to brain structures, receptors of Cortis organs, soundconducting and sound-receiving paths of acoustical system. This stipulates early ENT diagnostics, including careful collection of anamnesis at the first stage, external examination and otoscopy. In the future it is necessary to estimate acoustical function using whispering and spoken conversations, fork-tone studies, acoustical threshold audiometry, and, finally, to draw an acoustical certificate. Classification criterion of casualties with acubarotrauma (with no heavier damages) is the degree of hearing degradation. Usually, primary estimate of acoustical function can performed in early terms after trauma (1-5 days) after performing resuscitatory provisions. Signs of ear damage include a different degree of deafness and a giddiness, which can be
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combined with signs of a damage to other pneumatic organs by blast wave larynxes (petechias, hematomas, bleeding), lungs (lacerations, bleeding, hemopneumothorax, emphysema), intestine (lacerations, bleeding). Audiologic exam of casualties with MT of acoustical system separates several types of audiograms [Glaznikov L.A, et. al., 1996]: 1st type audiograms with horizontal variety of audiometric curves with the bone-aerial interval in the region of the basic colloquial frequencies on the average up to 25 dB. These audiograms suggest barotrauma of a middle ear with disorder of a tympanic membrane. 2nd type audiograms with steep audiometric curves. They are distinguished by the expressed boosting of hearing thresholds as on osteal and aerial conductance on high frequencies with preferential amplification at the frequency of 4000 Hz, proving acutraumatic mechanism of damage. In a region of low and average frequencies, thresholds of acoustical audition similar to normal are essential. Hearing thresholds according to aerial conductance can be raised (15-30 dB), which testifies to the mixed character of bradyacuasia. Conductive component of bradyacuasia is caused by the barotrauma to middle ear, diagnosed clinically. 3-rd view audiograms with horizontal variety of audiometric curves and increased hearing thresholds with respect to osteal and aerial conductance in, over the entire frequency band, up to 50 dB. This is clinically indicative of the barotrauma of the middle ear. In this case, characteristic is presence of tonal -speech dissociation along with satisfactory perception of tones, speech becomes barely audible. Hence, audiogram type allows to find indirectly a place and quantity of the disorders, depending on force of explosion and character of tracking changes in the cochlea. The restricted perception of one or two highest octaves is consequence of direct damage to the main curl of cochlea by ultrasonic or a blast wave. More diffuse damage, encompassing other regions of perception, probably, can be related to hemorrhages in the cochlea and biochemical disorders in a labyrinth fluid. Latter, apparently, cause disorders of a sound conductivity, observed sometimes even under lack of changes in the middle ear. In clinical studies it was established that the casualties, who experienced solely acutrauma, exhibit moderate decrease of all immunoglobulins (IgM, IgG, IgA) in the first day after the trauma with subsequent inappreciable increase of their quantity towards 9th day. IgG level rises to a greater degree. In further, these casualties show no complications. Only inappreciable decline of hearing is possible. Heavier MT leads to reliable decrease of immunoglobulins content in the
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first day after trauma. Expressed decrease of humoral immunity indicators is observed after acutrauma, combined with severe somatic explosive damages. By 9th day casualties exhibit substantial growth of IgG, IgM and IgA levels, which is related to the multifunctional activation of B-lymphocytes during this period. Relative analysis of indicators of the leukocytic formula, leukocytic coefficient of the intoxication (LCI), immunoglobulins of blood serum in dynamics of a posttraumatic period in the casualties after acutrauma of different gravity, confirms that response of immune system and blood circulation system is determined by gravity of a trauma. "Pure" acutrauma (even for severe shapes) is accompanied by minor alterations of leucocytes and lymphocytes in a blood. Thus the lymphopenia bears transitional character, caused evidently, by migration of cells in a tissue, instead of their possible destruction. Certain leukocyte equation deviation to the left on a background of lymphocytes level doubtful decrease provides incidental increase of LCI. In casualties with combined mechanical trauma, the lymphopenia, a deviation of leukocyte equation to the left and high exponent of LCI is noted. The degree of these shifts manifestation correlates with gravity of a trauma. One of the basic signs of vestibular disorders is giddiness of the directional rotatory character (circular rotation). Complaints on the poor acceptability to transportation, palpitation, general weakness, cold sweat, nausea (sometimes a vomiting) are noted. Wabbling during walking is noted. The giddiness is quite often accompanied by signs of wandering nerve pathology (nausea, vomiting). Studies of vestibular reflexes are applied for revealing pathological changes in the vestibular apparatus. Spontaneous and stimulated nystagmus is diagnosed through special tests and optokinetic assay are used. These casualties after rotatory stimulation exhibit higher (in comparison with normal) duration, amplitude, frequency slow phase rate (SPR) of the nystagmus. Long-term vestibular illusion of the counterrotation is observed and the expressed asymmetry of vestibular responses in healthy and damaged ear with predominance of the responses, caused by stimulation from the side damaged ear. Disorder of response is noted: boosting of indicators of nystagmatic, sensory and vegetative response, dissociated vestibular responses (moderate hyperreflexia of nystagmus, combined with hyperreflexia of sensory and vestibular-vegetative responses). Presence of dissociation between duration of a nystagmus and sensory response reflects changes in the central departments of the vestibular apparatus.
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Fig. 7.2. Foot destruction by antipersonnel mine

Fig. 7.4. Shin avulsion and multiple damages to soft tissues of contralateral limb after antipersonnel mine explosion

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Fig. 7.7. Distant heart damage at the mine-explosive trauma. Subepicardial hemorrhage

Fig. 9.23. Multiple perforating corneoscleral wound of an eyeball with massive contaminations

Fig. 9.24. "Shell crust" from coagulated blood and soil after close mine explosion
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Fig. 9.27. Removal of multiple foreign bodies from cornea by injection needle with simultaneous wash with antibiotics

upon entry

B -7 days after surgery Fig. 9.28. Mine-explosive wound of maxillofacial region with plural fine comminuted wounds to the soft facial tissues, an auricle, combined with fracture of an eyeball and fractures of shin bones
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Fig. 9.29. Mine-explosive plural fragmentation wound of maxillofacial region with fracture of the left upper jaw and perforating into the maxillary sinus, combined with perforating wound of the left eyeball

upon entry extensive perforating defects of eyelids and lower lip Fig. 9.30. Remote consequences of mine damages to dentofacial region (A and B)

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B result of combined plasty (local tissues, Filatov stem and scrotum flap Fig. 9.30. Remote consequences of mine damages to dentofacial region (A and B)

Fig. 9.34. Damage to abdomen and lower body after demolition on engineering munition (A)

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Fig. 9.34. Damage to abdomen and lower body after demolition on an engineering munition (B)

Fig. 9.38.Buyalski-McQuarter drainage at the combined bladder wound

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Fig. 9.39. Mine-explosive wound of a back department of a urethra. Urinary flows in the lefthand inguinal region and an interior surface of the left-hand femur. Epicystotomy. Drainage by Buyalski-McWorter

Fig. 9.40. Mine-explosive combined wound of a dextral half of scrotum with a crush of a testicle

9.7.2. General principles of medical aid to casualties with explosive damages

In treatment of casualties with explosive damages it is possible to isolate three basic stages: - arresting of menacing states and treatment of damages, which pose greatest immediate danger to life;

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- treatment of local cranial, extracranial and ENT damages, prophylaxis of complications - regenerative treatment, medical and social rehabilitation of casualties. Medical aid to a casualty at the first stage targets saving salvage of life and the greatest possible preservation of integrity of the defective organs and tissues. Primary goals at this stage are defined by preservation of the vital body functions, a temporary stopping of an external bleeding, closing wounds with aseptic bandages, immobilization of extremities with using standard and improvised means, injection of anesthetizing and sedative drugs and prompt evacuation to specialized medical establishments. All casualties are injected with tetanus anatoxin and antibiotics in combination with Sulfadiazine (head traumas) and Metronidasol (abdominal traumas). It is necessary to note, that the attempt to escalate the infusion-transfusion therapy, raising the hazard of severe complications and evolution of cardiopulmonary failure against the background of a heart and lungs bruise, is a dangerous error of antishock provisions. When transporting casualties, decrease of lethality and hazard of a pain shock can be achieved through controlled drug sedation: 1) Midazolam (2.5 mg rated 1 mg/ 30 s, recurring 1 mg, total dosage no more than 5 mg; acutely weak casualties an initial dosage 1.0-1.5 mg, recurring dosage 0.5-1.0 mg, total dose 3.5 mg); 2) Fentanyl (1 g/kg of mass; for acutely weak casualties 0.5 g/kg; recurringly 0.5 g/kg after 30-40 min). Narcotic analgetics should be used only under individual indications. Usually they are used with introduction of midazolam: first IV injection (25 % of calculated monotherapy dose), then midazolam is cautiously introduced in 5 min (25 % of calculated monotherapy dose). Can be used along with other psychoneurocorrective drugs: nortriptilin and desipramine; fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil); buspirone. During the first-aid treatment, physician applies an aseptic bandage. If vomiting or nasal bleeding, especially in casualties with broken consciousness, originate, it is necessary to prevent contents of an oral cavity getting in respiratory paths. Casualty is positioned on the side for evacuation and subsequent transportation. Narcotic analgetics are not recommended. In general, complex of provisions at prehospital stage, i.e. at the place of wound and in transit, provides elimination of the life-threatening states, prophylaxis of a wound fever and fastest delivery of the casualty in medical establishment. At the stage of the first medical assistance, physicians correct a bandage, perform IM injection of antibiotics and antitetanus serum. At this stage temporary stopping of a continuing external
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bleeding is performed, asphyxia is eliminated, antishock provisions and anesthesia are conducted, cramps and a vomiting eliminated. The stopping of a bleeding is achieved by application of hard compressing bandage over a wound, application of napkins over the brain wound of the napkins moistened by 3% solution of hydrogen peroxide. It is necessary to consider that when treating neurosurgical contingent of casualties, physicians should avoid narcotic drug analgetics as they are capable of reinforcing respiratory derangement. Method of choice for this group contained novocaine blockages, whose administration should begin with a stage of the first medical aid. The qualified medical care is performed in medical establishments, often by general surgeons and anesthesiologists-resuscitators. They accomplish final elimination of life-threatening conditions, recover vital functions up to a level, optimum for the subsequent evacuation, carry out pressing and urgent surgeries, conduct prophylaxis of infectious complications. Specialized care and the subsequent treatment of explosive damages to ENT organs is performed in specialized hospitals, staffed with general surgeons, neurosurgeons, maxillofacial surgeon, ophthalmologist, ENT surgeon and equipped by all necessary resorts for final treatment of these casualties. Maintenance of adequate energy and mineral balance is the primary goal of infusion-transfusion therapy after severe traumas to brain and ENT organs, as the acute phase of trauma is accompanied by significant energy loss. Dehydration therapy leads to essential losses of potassium. Since there is no enteral feeding during several days, energy capacity of infusional resorts in this period should comprise no less than 3-3.5 kcal. Infusional therapy during this period involves highly-concentrated (up to 30 %) liquid glucose with addition of 33 % alcohol (up to 300 ml/day) and fat emulsions (up to 500 ml/day). Starting from the third day it is necessary to begin probe enteral feeding using high-calorie nutrient mixtures. Correction of mineral balance during acute period of a trauma is monitored through the restitution of potassium deficit, which is well compensated using Laborit's mixture. It includes 400 ml of 10% liquid glucose doped by 10 IU of insulin and 5 % of a potassium chloride solution so that casualties are administered no less than 3-4g potassium a day. One of the main reasons of diagnostic mistakes when finding character of a wound is insufficient anesthesia during surgical treatment of mine-explosive wounds. Optimal surgeries are performed under general anesthesia for severe explosive traumas to heads and ENT organs. Special attention should be paid to detailed exam of wound bottom and sides of a wound, as they can be polluted by soil, clay or stones. Accurate washing off of all foreign bodies, clots and
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careful hemostasis by coagulation of bleeding vessels is the key stage of surgical treatment of soft tissues wounds. When rendering medical care to the casualties with mine-explosive damages, of special significance is the question on stages and volume of the surgical provisions, when severe damages to head, chests, abdomen and the extremities, caused by explosion, quite often overshadowing solution of especially ENT problems, putting priority to the immediate stabilization of the vital organism functions. Efficiency of a perceptual bradyacuasia treatment is defined by reversibility of changes in the Cortis neuroreceptor organ and pathways. According to I.B. Soldatov (1978), one day after the trauma, decay of axial cylinders causes and myelin in the nervous conductors begins. Starting from 3-5th day and up to 4-5 weeks after trauma, reactive inflammatory changes in Schwann cells builds up and the trophicity of nerve fibrils is becoming upset. Development of drug therapy resorts for treating damages to structures of acoustical system is based on preferential application of the vasodilators, selectively acting on brain vessels trental, cavinton, doxium, apoplectal, instenon, etc. Their use improves utilization of oxygen, rise threshold of an tolerance to hypoxia for cerebral cells, recovers the content of CAMP, serotonin and ATP, aerobic and anaerobic cell breathing, decreases aggregation of standard blood elements, boosts brain and ear blood flow. Positive results are obtained using method of a hyperbaric oxygenation for treatment of respiratory, circulatory, hemic and other shapes of the hypoxia, which is important for treatment of traumatic neurosensory bradyacusia. If the posttraumatic edema of brain and ear tissues develops, medical provisions include prime application of diuretics: hypertonic saline solutions of carbamide and mannitum, glycerine. Use of steroid hormones is directed on removing excess of sodium from the injured tissues of a brain. During acute period of acubarotrauma (without damage), physicians should apply sodium pentobarbital and sodium hydroxybutyrate, reducing redundant response of lipid peroxidation and increased oxygen metabolism. At the battlefield first and paramedic aid is rendered by sanitary instructors and doctor assistants. First medical aid to a casualty with damages to ENT organs is rendered by general surgeons. In separate medical units, qualified medical aid to ENT-casualties and contusions is rendered by general surgeons and therapists. Paramedics and doctors assistants are equipped by sterile bandages, analgetics, antibiotics,
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antiemetics and cardiacs, tweezers, hemostatic clamps, respiratory tubes. First and paramedical aid includes: - asphyxia clearing an oral cavity and a nose of foreign bodies (soil, sand, shreds of clothing); if dyspnea is caused by tongue-swallowing introduction of air duct in an oral cavity or tongue bracing by a pin; - bleeding manual pressing of the main vessel with the subsequent application of compressing bandage; - signs of shock warm drinks, injections of anesthetizing resorts. Urgent medical assistance for ENT casualties includes: - asphyxia due to wound and bruise of pharynx and larynx - typical upper dilatational-crosssection tracheotomy; - bleeding from nose and adnexal sinuses application of sling bandage after forward loop tamponade of a nasal cavity using long gauze tampons (by V.I. Voyachek); if bleeding continues through mouth backward tamponade; - bleeding from an ear aseptic narrow gauze plug and application of bandages; - bleeding from neck wounds tamponade of a wound, regular or compressing bandage application over bleeding vessels, strong bleeding from pharynx or larynx demands preliminary tracheostomy to prevent blood leakage into trachea. According to calculations, urgent aid under vital indications is required by about 20 % ENTcasualties, 30 % casualties with bruises of ENT organs and 10 % of casualties with ENT contusion. In most cases the urgent aid consists in a bleeding stop by tamponade (anterior or posterior) of a nose and external acoustical path. Perforating neck wound with dyspnea elements require immediate insertion of tracheostomy tube through the wound opening in larynx or trachea or execution of typical (atypical) tracheotomy. Casualties with ENT contusions in grave condition are injected heart activity boosters, respiratory analeptics, drugs lowering intracranial pressure. Psychomotor exaltation can be capped by IM injection of: Aminazine (2.5 % 2-3 ml), Benadryl (2 % 2-3 ml) and Magnesium Zinc Sulfate (25 % 5-8 ml). All ENT casualties are administered antitetanus serum and high dosage of antibiotics. Qualified surgical aid is rendered only under pressing indications after: - asphyxias breathing is recovered by typical is dilatational cross-sectional tracheotomy; - strong nasal bleeding - except for nasal tamponade, application of bandage over carotid
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artery is possible in case of emergency; - bleeding from an ear requires putting of a tampon over external acoustical path; - persistent bleeding from pharynx and larynx application of bandages over vessels only in emergency cases along (lingual, external soporific, sheathe of carotid) artery; further evacuation of ENT casualties is allowed after reliable stopping of bleeding and a replenishment of a hemorrhage; - shock requires complex antishock treatment. The ENT-casualties are evacuated to the multifield hospital. Casualties are transported mainly in sitting position. Reclining position is reserved for casualties with severe neck traumas after a tracheotomy with damage to interior ear (with derangement of equilibrium, giddiness and vomiting attacks). Walking ENT wounded, who are recovering at this stage, require application of a primary suture only after primary surgical treatment. The specialized surgical aid for ENT casualties is rendered in army-level hospitals. Specialized treatment of casualties with mechanical injuries to ENT organs is conducted in ENTbranches of multifield hospitals, according to character of damages and priorities, established during medical classification. Diagnostics extensively involves X-rays and other special research methods. Casualties of the first group require following surgical procedures in the framework of first aid measures: - asphyxia inferior is dilatational-cross-section tracheotomy; - bleeding from an ear dissection of the mastoid, opening of the sigmoid sinus and introduction of the long narrow gauze tampon between the osteal side of the sinus sulcus and dura mater to close sinus clearance; if there are small ruptures of the sinus wall, the ruptures are sealed by small plugs; - bleeding from a nose and failure of nasal tamponade bandage applied over the external carotid artery; - bleeding from maxillary or frontal sini dissection, a tamponade of a sinus with plug removal through the anastomosis with a nasal cavity; - neck wounds - if secondary bleeding evolves, surgeon performs surgical treatment with wide dissection a wound and a application of bandages over bleeding vessels; - traumatic shock - complex antishock treatment.
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For casualties of the second group surgical provisions include: - extensive wounds of ear and nose with damage to bones - economical surgical treatment with removal of fine osteal fragments, wound flushing with pulsing jet of antiseptic solution (by means of a rubber bulb or special device), application of guiding sutures and installation of drains, made of glove rubber; - wound of adnexal sinuses - anastomosis with a nasal cavity; - large damages to mastoid - plasty of a postoperative cavity by flaps of nodding and temporal muscles on a feeding neurovascular pedicle; - neck wounds - wide dissection of wounds with ample flushing and drainage; - damaged pharynx and esophagus - after treating a wound application of protective tamponade of a mediastinum below a wound level. Injection of high doses of antibiotics and introduction of a gastric tube for feeding; - wounds and severe bruises to larynx with fractured cartilages and sublingual bone laryngotracheofissure with economical surgical treatment of the defective departments of larynx, early laryngoplasty and bracing of mucous grafts by the plug, air bomb or laryngeal prosthesis. Gastric tube is used to feed casualty; - obturations of large vessels - cross-clamping vessel by the soft clamps on both sides an obturated spot, opening of the vessel clearance, clot removal, flushing vessels by solutions of anticoagulants, introduction of the bypass; - traumatic neck phlegmons - wide dissection by incisions in parallel to nodding muscle with careful drainage of a wound; for purulent sinusitis the sinuses are pierced with application of anastomosis; - mastoiditis typical and atypical mastoid and radical surgeries. For casualties of the third group surgical provisions include at: - extensive wounds to the soft tissues economical surgical treatment; - casualties, tracheostomized at the previous stages of evacuation check out if decannulation is feasible; - nose deformation instrumental and minimal reposition of an external nose with its bracing in median standing and a tamponade of nasal paths; - paralysis of obverse muscles due to damage of facial nerve, fracture of temporal bone pierce channel of a facial nerve and, if necessary, suturing a nerve; - greater cosmetic damages treatment of wounds and preparation of casualties for the
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subsequent surgeries with evacuation in rear hospitals; - presence of foreign bodies of ENT organs removal of foreign bodies, if indicated. Casualties in the state of agony are administered symptomatic treatment. Primary surgical treatment for wounds of nose and ear is conducted often with application of primary sutures, during wounds to neck, as a rule, the primary suture is not applied. Occluded combat ENTtrauma (ENT bruises) require surgical procedures for 25 % casualties, including mainly primary surgical treatment, reposition of osteal fragments and suturation; occasionally dissection of paranasal sinuses and removal of free osteal fragments. During ENT-surgical treatment is indicated only for purulent complication, caused by barotraumas of a middle ear (mastoiditis). In cases of combined ENT-traumas when there is no cross burdening, medical evacuation characteristics of ENT damage are similar to those of similar isolated trauma. Damages of ENT organs, complicated by combustions are related to heavier clinical course and less congenial outcomes. Terms of treatment for these casualties increase. Surgical treatment of wounds. Not every gunshot wound to ENT organs is a subject to surgical treatment. If the wound does not bleed, the skin around entry and exit openings does not change, there is no expressed edema and hematoma and no deformation of wound region, it will suffice to administer alcohol, benzene, or 3-5% alcohol solution of iodine and apply usual bandage around wound holes. This standing is confirmed by practice of field surgery, and refers to wounds of an ear, nose and non-perforating wounds to neck. The primary surgical treatment includes dissection, excision and concealment of a wound. Dissection. It is necessary to remember, first of all, that small incisions in case of long crimped wound channel lead to dangers of contagious complication, exceeding those after large incisions. This standing of wartime surgery requires essential correction with reference to treatment of ENT-wounds. In the region of nose and ear there are no the significant arrays of the soft tissues and wound is usually insignificant. Blood supply to region of a nose and ear is well-expressed. Due to this fact tissues are less prone to inflammation. However, this region is of great cosmetic importance. Therefore for wounds to nose and ear dissection is either avoided or minimized and incisions should be done parallelly and along natural folds. In case of perforating neck wounds, good results of surgical treatment can be achieved through the correct estimate of muscle damage degree. Dissection of skin and fascia is conducted so it is possible to examine well all the complex wound pockets. Dissection is usually conducted in
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parallel to nodding muscle. If wounds are plural, but shallow and are close to each other, single incision is made. If wounds are deep and at the significant distance each wound is handled separately. Dissection of the fascia and aponeurosis with additional side incisions in the inferior and upper angles of a wound not only provides an opportunity to examine defective tissues, but also ensures decompression of muscles, promoting prompt elimination of an edema and normalization of microcirculation in the defective tissues. Excision. After dissection, a bathing of the wound and removal of tissues flaps, clots, freely laying foreign bodies, surgeon examines a wound and defines boundary of the defective tissues. Whenever possible, to minimize cosmetic defects it is necessary to avoid excisions of the skin possessing high antibacterial resistance. Removal is performed for obviously nonviable sections of skin and subcutaneous tissues. Vitality of the muscular tissue is defines according to color, consistency, ability to bleed and contractility. Dark, soft, non-contracting muscles, not bleeding during dissection, are removed until there is vellications of muscular fibers and punctate bleeding. Insufficient removal of dead tissues in the subsequent leads to purulent complications, demanding recurring surgeries. Experience shows that under any condition it is necessary to carry out a surgical treatment in earliest terms. Secondary surgical treatment is carried out in with respect to clinical data on the wound, complicated by the evolution of a wound fever. Wound channel is opened, followed by removal of necrotized tissues, wound detritus and pus. Conditions are created for good drainage of a wound. In the event of primary (early or delayed) surgical treatment being insufficient, secondary surgical treatment is performed when indicated. Objectives of this treatment are similar to that of primary. The issues of wound concealment after treatment are central problem of regional medical surgery. Application of primary suture immediately after primary surgical treatment promotes evolution of infectious complications; therefore its application is restricted in field surgery. This provision is applied immediately for wounds to nose and soft tissues of an ear, and under the rigorous indications considered above. Considering neck wounds, as a rule, surgeons use primary or early secondary suture. Delayed primary suture is applied 4-6 days after a surgical treatment. During 815th day secondary early suture is applied on the granulating wound. 15-25 days after the connective tissue matures in the region of a wound, tissues get sluggish, elasticity and convergence of wound edges without additional incisions or plastic flaps becomes impossible. Indications for secondary sutures application are the wounds, which did not heal in regular terms
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due to large sizes, histic defect or delayed regeneration. Early secondary suture is applied in presence of fresh grains only. Basic contraindications for secondary suture are acute purulent inflammation in the wound and severe general state of the casualty, remaining foreign bodies, osteomyelitis, eczematous damage to skin around the wound, impossibility to pull together edges of a wound due to significant tension of tissues or excision of the cicatrixes related to large vessels or nerves. After the secondary suture, physician should apply bandage for protection of a wound against a secondary infection. Moderately expressed attributes of the inflammation are not a reason to decline the delayed suture. The suture is counterindicated in case of ample purulent discharge, expressed edema of tissues, significant seepage of wound edges, lymphangitis and lymphadenitis. When applying late secondary suture, the wound edges are freshened and, if necessary, excised. Deep wound should be drained. The drainage in the form of a tube from the perforated plastic or rubber should be inserted into a wound through a separate skin puncture. Thus, wounds to the soft tissues of a nose and an ear are closed by primary suture; the delayed and secondary sutures are exceptions. In neck wounds, refusal from a primary suture is the major standing of the surgical aid! The primary delayed suture is applied over wound without attributes of a purulent inflammation before distinct grains are formed, usually 4-7th day. Application of the delayed suture in neck wounds allows achieving safe healing of wounds in 90-100 % of cases. Secondary early suture is used for casualties with granulating wounds, lacking clinical attributes of a contagious inflammation. Granulation tissue is not excised, edges of a wound are not mobilized, optimal term of surgery is 8-15th d day. Granulation tissue and cicatrixes are excised, edges of a wound mobilized, terms of surgery are 20-30th day. It is considered that prophylaxis of wound fever for open damages foresees earlier application of a protective bandage, well-timed and exhaustive surgical treatment, early and systematic application of various germicides and the provisions promoting normalization of immunodefence. Primary bandage should defend a wound from unfavorable exterior actions, first of all, from microorganisms. Besides, it should possess sufficient gauze effect, i.e. actively imbibe wound discharge and, by doing that, separate substrate for multiplication of microorganisms. Contemporary dressing material possesses also anesthetizing and antimicrobial activity and does not adhere to a wound. With this purpose, surgeons usually employ metallized fabrics and textile material, doped by fluorides and pyridines, promoting congenial healing of
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wounds. Anaesthesia. One of the contemporary anesthesiology objectives in prophylaxis of a shock is removal of pathological input from the defective organs and tissues. The conduction of anaesthesia refers to number of highly effective provisions. When rendering a specialized ENTsurgical aid for wounds of maxillary sini, nose, ethmoidal labyrinth, and combined damages of an orbit and the upper jaw, anaesthesia through the infraorbital fissure can successfully be used. Anaesthesia is executed by sequence of manipulations. After treating skin, lower-external orbit corner is pricked by the needle perpendicularly to its inferior wall. When the extremity of a needle rests against a bone, needle is translated in a horizontal standing, in sagittal position and somewhat inside. Needle is advanced along the inferior side of an orbit so that contact with a bone is felt continuously. Injection of 5-7 ml 2% solution of Novocain is administered at depth of 40-45 mm. The anaesthesia comes in at 3-6th minute. Consequently, the pain syndrome is terminated, which allows conduct probing of a wound, X-ray and laboratory studies. If anesthesiologists at the given stage cannot participation in surgery, the primary ENT-surgical treatment can be executed and by the discussed anesthesia technique. For nonreversible decrease of pathological pain input from the maxillary sini and cells of the ethmoidal labyrinth, especially for combined damages of an orbit, surgeons additionally conduct blockage of the first and second branches of the trifacial (blockage of the latter is performed through lower-eye fissure). ENT surgeon, carrying out the anaesthesia, should overcome psychological fear to inflict an eye trauma. If there is a wound to an eye and maxillary sinus, this fear is even less proven. The main issue here is maintenance of permanent contact of needle and bone. Under combined explosive damages to various departments of a head, a brain and a body the anesthesiology provisions on ENT-indications are administered within the limits of the general resuscitation. At the stage of the qualified medical aid, physicians apply general IV anaesthesia using Ketamine, much less often various combinations of barbiturates, sodium hydroxybutyrate, Seduxen, Fentanyl. Anesthesia with Ketamine used for surgical treatments of the soft tissues with stopping of an external bleeding, thoracentesis in perforating wounds of a chest, bracing of osteal fragments for the closed fractures, primary surgical treatment of an osteal wound without bracing fragments, etc. Nitrous oxide is a substance of choice for a narcosis use nitrous oxide. It administered together with oxygen in proportion 2:1 or 1:1 through the gauge unit of Phase 5 device. Pulmonary
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ventilation is performed in the mode of moderate hyperventilation. Under low air temperature in the operational room, narcosis mixture is preheated in "Phase 5 device. Presence of secondary ventilation regime largely promotes more congenial subsequent translation of the casualty after anaesthesia to self-maintained breathing. Maintenance of anaesthesia is performed by IV introduction of Fentanyl, Seduxen (sodium hydroxybutyrate) and Droperidol. Droperidol is used fractional 2.5-5 mg, as a rule, under condition of a stable hemodynamics. Muscular relaxation is achieved by using depolarizing (ditilin 201.5 51.4 mg) and nondepolarizing (arduan 4.6 1.0 mg) miorelaxants. General IV anaesthesia with pulmonary ventilation is carried similar to the combined anaesthesia. Difference is that instead nitrous oxide, physicians use small doses of Ketamine (50100 mg), sodium of a hydroxybutyrate (2-4), Hexenal or Thiopental sodium (70-150 mg). Clinical experience showed that to optimize course of postoperative period and minimize the role of the hypoxia in the pathogenesis of the traumatic sickness for critically wounded patients it is expediently to use pulmonary ventilation (from 2 hrs up to 1 days under shock of II IIIrd degree). Extubation is performed only after precise accomplishment of Gail tetrad tests by patients. Even after a safe exit from the general narcosis, the extubation surgery patients should be observed in intensive care unit for not less than 12 hrs. Second echelon of a specialized medical care stage (peripheral, main and the central military hospitals) the anesthesiology care has preferentially plan character. Approaches are the same, as in a peace time. At the stages of the qualified and specialized care, the casualty use also the contemporary drugs for the inhalation and non-inhalation anaesthesia, having smaller number of side effects and more controlled activity (isofluran, remifentanil, sufentanil, midazolam, mivacron, tracrium), and also their antagonists (anexat). Antibiotic therapy. Combat wounds are always polluted by the microorganisms, penetrating from an external environment or from an organism of the casualty. One of the reasons of casualties death at the initial stage of treatment is the contagious complications of wounds, originating on the average in 12 %. Experience of treatment of traumas and wounds during local wars of last decades has defined indications for using antibiotics during the first hours after combat wound. Standards of prophylaxis with use of antibiotics are especially useful at the long-term evacuation of casualties, but always are secondary in relation to surgical prophylaxis of contagious complications
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(excision of a wound, removal of foreign bodies and necrotic tissues, bracing of fractures, et. al.). Doubtless indications to an antibiotic therapy of a wound fever at combat damages exist in presence of foreign bodies and the open cavities, severe and perforating wounds, open fractures, extensive damages to tissues, a delay of surgical treatment. Dynamic monitoring of sensitivity is necessary to optimization course of a wound process and prophylaxis of purulent complications of wound microorganisms to antibiotics. If it is impossible to conduct diagnostics, surgeons should use of antibiotics of last generation. Nowadays, of highest efficiency for prophylaxis are clavulanate acid in a combination with amoxicillin; cephalosporins II (cefoxin) and IIIrd generations (cephotetan). Cephalosporins can be appointed in a combination to one of is long-term acting drugs of nitroimidazole group (ornidazol, etc.), Penicillin G and M. In some cases intravenous introduction of drugs is possible if indicated: Penicillin G (4 million IU/ 6hrs), gentamycin (120 mg / 6 hrs), Metronidazole (500 mg / 8 hrs) and prophylaxis of the tetanus (antitetanic serum, gammaglobulin, et. al.). As casualty state is improving, number of antibiotics injected for treatment of a wound fever, is reduced towards less toxic and less expensive. If the pathogen is not established and casualty state is improving, antibiotics should be terminated. If after 3-5 days of a complex antibiotic therapy, there is no response and pathogen is not established, fungal contamination is quite possible. In case of progressing aggravation of symptoms of the casualty, treated with antibiotics, it is necessary to refine infection focus and pathogen. Principles of an antibiotic therapy during traumatosepsis in hospital and in combat requirements are the same, as in a peace time. Of crucial importance is the surgical treatment and lancing of the infection foci in a wound, drainage of abscess, cleaning and open treatment of a wound, removal of foreign bodies, replacement of blood loss, treatment of a shock, inflammation and edema in a wound, suturing delayed for several days. Effective concentration of an antibiotic in tissues should be sustained from the moment of wound to, at least, completion of a primary wound surgical treatment in a hospital. In combat circumstances, single-dose introduction of broad-spectrum antibiotic is preferred (e.g. Ceftriaxone). In this case the adverse effects and chance to develop bacterial resistance are much less probable. Damages to a nose and adnexal sinuses are frequently encountered among wounds, inflicted by debris of explosives, is more often and are accompanied by multiple signs: rhinalgia, headache, a nasal bleeding, swallowing blood through the nasopharynx and thereof hematemesis,
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nasonnement of speech, difficulty of nasal breathing. Bruise, avulsions of a skin, defects and fractures to osteal skeleton are considered to be light damage of an external nose. The latter cause deformation of an external nose: lateral dislocation or retraction of a wall with a crepitation of osteal fragments under palpation. During the anterior rhinoscopy physicians usually detect foreign bodies, damages of a nose septum or its hematoma, which is accompanied by abscesses in 100 % of cases. Traumas of a bridge and cartilages, and also structures of an interior nose refer to heavier wounds of a nose. In cases of nonperforating wounds, the foreign body is getting stuck in one of nasal paths, often with perforation of a diaphragm. For nasal-orbital wounds there is a fracture of all anatomical structure of a nose simultaneously to sides of orbits and paranasal sinuses. The damage of a maxillary sinus, considering its topographical anatomy, seldom happens insulated, and more often combines with the damage to a nose, orbit, and masticatory system. The sinus can be damaged after bruises with fracture of the upper jaw, which sometimes opens path between sinus and oral cavity. Maxillary sinus is penetrated with osteal splinters and foreign bodies. More often, wounding object penetrates through infraorbital, zygomatic region of the same side or through other sinus and a nasal cavity. Attributes of damage to maxillary sinuses are the above-described symptoms, characteristic for wounds of a nose. Adding up is pain, irradiating in region of the upper teeth, edema of infraorbital region, sometimes watering after direct or indirect damage to lacrimal passages. Fractures of the upper side of a sinus always causes changes in orbit contusion of an eye, displacement of an eyeball, hematoma, difficulty of an eyeball motion. The ethmoidal labyrinth during mine-explosive is often (92 %) damaged from an orbit of the same or opposite side. In the latter case both ethmoidal labyrinth and both eyes are damaged. Since osteal sides of the ethmoidal labyrinth are thin and labyrinth has many chambers, it produces small osteal fragments. Close neighborhood of back cells of the ethmoidal labyrinth with an optic nerve may cause damage of the latter. Frontal sinuses are often damaged from both sides. Peculiarity of wounds to frontal sinuses is possible damage to the anterior cranial fossa. Wounds inflicted by large debris, cause significant fractures to the anterior frontal sinus. If the frontal sinuses are large, the interior surface of a sinus is exposed through the entry wound, sometimes even the frontal lobe of a brain. All casualties with damages to even single anterior side of a frontal sinus should be examined by the neurosurgeon as, on our data, in 76 % cases, the bruise of a brain is simultaneously observed.
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Such casualty from an otorhinolaryngological class transfers to neurosurgical and requires appropriate aid. Diagnostic to damages of a nose and adnexal sinuses is based first on external research techniques (examination, palpation, probing), endoscopies (anterior and posterior rhinoscopy), examination of both respiratory and olfactory function of a nose and the X-ray inspection. Latter should be always conducted in two projections: antero-posterior (nasomental) and strictly profile projection. It is necessary to note that other antero-posterior projection (nasofrontal) is not appropriate for recognition of damages in nasal-orbital region as thus frontal sinuses and orbits are badly visible on X-ray images. Additional projection is necessary for detection of deeply embedded (a cuneiform sinus) foreign bodies. If there is damage to nose, surgeons conduct reposition of the displaced osteal fragments of a facial skeleton and adnexal sinuses, a primary surgical treatment of nasal wounds, removing crushed and contaminated sections of the free osteal fragments and foreign bodies. Maintaining vitality tissues should be treated with utmost care. If in late terms the wound abscess develops, the adnexal sinuses are pierced carefully removing all pathological contents. Surgery is completed by forming wide anastomosis with a nasal cavity. An external wound is sutured tightly. Insulated gunshot wounds to paranasal sinuses compound 17 % from number of all wounds of sinuses. The other wounds comprise: orbits 42 %, the upper jaw 37 %, head cavities 18 %, other organs and body segments 3 %. Primary surgical treatment of the insulated gunshot wounds to paranasal sinuses consists in accomplishment of typical surgeries removal of crushed tissues, osteal splinters, foreign bodies and imposition of an anastomosis with a nasal cavity. Use of the active washing drainage had no advantages in comparison with treatment without drainage. For wounds of frontal sinuses, when fractures are minimal, as exception, surgeons revise through an inlet opening with the installation of pin drainage. Thus there should be the full confidence in preservation of a cerebral sinus side. All casualties with damages to frontal sinus should be examined by a neurosurgeon for possible percussion and bruise of a brain. To liquidate pathological input from a maxillary sinus and cells of the ethmoidal labyrinth it is expedient, especially during combined damages of an orbit, to block first and second branches of the trifacial by local anaesthesia, e.g. through infraorbital fissure. Combined wounds to sinuses and orbit or damages to walls require isolation of sinuses from
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contents of an orbit by lyophilized dura mater or a femoral fascia. Sinuses are drained in a nasal cavity. All casualties with nasal sinuses wounds, accompanied by damage to brain matter are operated by the neurosurgeon with participation of the ENT surgeon. Surgical tactics consists in insulation of a cerebral wound by its deaf closing. After handling tissues of a brain, surgeon closes damage to a dura mater by aponeurosis or a section of a wide femur fascia of a femur. Wound is closed tightly. For obliteration of the damaged frontal sinus, physician should remove mucosa and a cerebral side, coagulate lead-out duct of a sinus. If there is simultaneous damage and a maxillary sinus, the latter is opened with the subsequent active drainage. Nasopharynx. Its wounds in most cases are combined with a nasal damages, sinuses, pterygopalatine fossa, base of skull, retro-and parapharyngeal space, large vessels and nerves. In such cases leading signs are damages to the vital organs. General signs of nasopharynx wound include frequent loss of consciousness, state of a shock, headache, a nasal bleeding with blood spill in a nose and pharynx, whence it is expectorated. During simultaneous damage of the upper vertebrae, acute morbidity with restriction of motions or complete nonmotility of the soft palate is noted. Owing to that, the swallowing and speech (hit of food masses in a nose, a nasonnement) are noted. Damage to lateral sides of a nasopharynx can be accompanied by the reactive phenomena in the middle ear with derangement of acoustical functions. Torn tissues, subcutaneous hematomas and clots sometimes completely occlude nasopharynx and shut down nasal breathing. Wounds to nasopharynx have especially severe course during damage to parapharyngeal space, where the large vessels and nerves are located (internal carotid artery and jugular, glossopharyngeal and vagus nerves). These damages cause life-threatening bleeding and dysphagia. Consecutive infection can lead to the development of the deep cervical phlegmon, anterior mediastinitis, and sepsis. Wounds of a nasopharynx back side quite often combine with a trauma of the basic bone body and an arc of an atlas. In these cases, head motions become acutely restricted and morbid, the head loading causes a acute pain in a place of trauma. The damage of the upper cervical vertebrae can become complicated osteomyelitis or spinal and cerebral meningitis. Wounds to the back side of the nasopharynx can enable the infection to go down on retropharyngeal space downwards, causing posterior mediastinitis with a severe septicopyemia. The damage to the next regions (maxillotemporal joint, masticatory muscles,
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contents of an orbit) is quite often accompanied by a derangement of mastication and vision. Diagnostics is based on data of examination, probing and X-ray analysis. In case of wounds to nasopharynx the casualty often shows occipital headaches and head oxycinesia. During endoscopy (postnasal rhinoscopy) quite often it is not possible to examine the nasopharynx; therefore the soft palate is stretched by a thin rubber tube according to A.J. Galebskiy from one or both sides. Objective approach to diagnostics of wounds of a nasopharynx is the X-ray analysis in two crossly perpendicular planes with the subsequent correction of X-ray images by K.L. Hilov, giving representation on gauges and character of damages to sides of a nasopharynx, presence and localizations of a foreign body. X-ray analysis is performed with the metal points, inserted through the nasal cavity and oropharynx. Oropharynx. Wounds are frequently combined with damages to face skeleton, tongue, cervical vertebrae. In early terms the important and frequent sign of the wound to the oropharynx is the life-threatening bleeding, caused by proximity to large veins and their branches, belonging to systems of an external and interior carotid artery. Under simultaneous damage of cervical vertebrae lateral departments, the bleeding from a backbone artery can start. Greater hemorrhages in a tissue of parapharyngeal space are quite often noted. The bleeding can be external and intrapharyngeal. The latter is associated with pneumorrhagia and threatens blood aspiration. Impeded swallowing, sometimes dyspnea, refer to early symptoms of the oropharynx wound, as well as acute pain in the wound region. In the remote period, the inflammatory phenomena in sides of pharynx, peripharyngeal space and in the region of cervical vertebrae can evolve. Aspiration pneumonia, oropharyngeal abscess and meningitis are some of extreme complications. Through a cervical vascular bundle, the infectious contamination can spread to a anterior mediastinum and cause a purulent mediastinitis. Diagnostics is based on the examination, probing and palpation, and also on X-ray inspection. Laryngopharynx. The distance between the hypopharyngeus and the larynx with the aperture to the esophagus is insignificant; therefore, a wound to the inferior department of the pharynx in this place is very often combined with the certain damage to next departments (epiglottis, arytenoid cartilages, esophagus). Non-perforating wounds can cause the debris to damage all stratums of pharynx, vessels and nerves, without breaking mucosa integrity. However, submucous layer can manifest expressed edema, hemorrhage, causing upset of swallowing or breathing.
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Perforating wounds are accompanied by more expressed functional disorders. The diagnosis erect on the basis of effects of external and endoscopic studies. Diagnosis is performed according to the results of external and endoscopic examination. Wound to the inferior departments of the pharynx and cervical department of the esophagus is characterized by the severe general state caused by an external and intrapharyngeal bleeding, dysphagia, difficulty of breathing, subcutaneous emphysema in cervical region, morbidity of neck motions, difficulty of a swallowing and choking. Sometimes the spit or fluid nutrition can exit from a wound. The damage to cervical sympathetic and wandering nerves causes accordingly the Horner syndrome and hoarseness with choking. Contamination of tissues surrounding a wound causes an inflammation spread through tissues of the entire neck and frequently to the mediastinum (cervical phlegmons, mediastinitis, sepsis), due to lack of anatomical barriers between a mediastinum and cervical peripharyngeal space. The diagnosis of wound erect on the basis of effects of external and endoscopic examination (pharyngoscopy and mirror-image hypopharyngoscopy), and also ascertaining of the functional derangement. The X-ray inspection is low-informative, except for definition of foreign bodies. Wounds to a neck often damage larynx and a trachea. Depending on, whether the larynx or trachea communicate with an external wound or surrounding media, surgeons discriminate the open and closed damages. Occluded damages of the larynx or trachea originate more often during bruises. Aftereffects of wounds and the functional forecast are in direct dependence on, whether wound of a larynx is perforating or not, insulated or combined. Perforated wounds cause the most significant fractures of tissues and are accompanied by the expressed reactive phenomena. The basic signs of these wounds disorder of breathing, change of a voice, pain, a subcutaneous emphysema, a pneumorrhagia, subcutaneous hematomas, disorder of swallowing (at the damage of the epiglottis and arytenoid-epiglottic cartilages). The diagnosis is drawn on the basis of: external examination; palpation of a neck; probing; laryngoscopy (indirect, less often direct); X-ray inspection, including introduction of contrast mediums. Acute stenosis of upper respiratory tracts is particularly life-threatening due to the retraction of tongue, mechanical concealment of respiratory paths by a blood clot or foreign body, compression of the larynx or trachea by a hematoma, emphysema or other reasons. In this situation the degree of disorder of breathing and body response to an oxygen starvation should be
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promptly evaluated. By rapidity of respiratory derangements, they discriminate: - instant stenosis (asphyxia) owing to a spastic stricture of voice crimps, occlusions of a larynx or trachea by a foreign body; - acute stenosis (build-up of stenosis within hours and days) - chronic stenosis (build-up of symptoms within weeks or months). The rapidity of stenosis development defines the severity of pathologic reactions to a large extend, as the asphyxia deprives of the compensatory mechanism activation. The most difficult in the clinical and prognostic sense are, as a rule, neck damages. The basic treatment criterion for such casualties is the degree of damage of the neck organs. If the wound of large vessels (carotid artery, jugular vein) is present, a vascular surgeon should be the leading expert. Casualties with wounds to neck in the region of an angle of a mandible, a root of tongue, oropharynx and a sublingual bone o it is expedient to treat them in maxillofacial surgery hospital. Casualties with damage to neck in the inferior departments (jugular notch, thyroid gland, esophagus, sternoclavicular joints) require care of a thoracal surgeons often. ENT hospital treats casualties with damages to cartilaginous atomy of a larynx (perforating and non-perforating wounds). According to our data, they compound 30 % from all casualties in a neck, 20 % at wounds of pharynx and 16 % at wounds of a trachea. The basic surgeries for wounds of the larynx and trachea include the tracheotomy and laryngofissure. The laryngofissure makes interior surface of a larynx accessible. It is necessary for conducting an early laryngoplasty. The latter is very important during the prophylaxis of the larynx cicatrical stenosis, causing total disability. They can be eliminated only through lasting multistage surgeries. During the laryngectomy (laryngofissure) the thyroid-hypoglossal diaphragm is dissected. This procedure structures enough easy approach to the region of the larynx and laryngopharynx aperture. Dissection of a thyroid cartilage on a medial line gives good access to an interior surface of a larynx. Foreign bodies, flaps of nonviable tissues, cartilages are removed. Plastic shaping of larynx mucosa is performed using local mucosa or mucosa, taken from region of a laryngopharynx. Surgery is completed by introduction rubber balloon or endoprosthesis. During postoperative period, physician monitors formation of an interior corduroy from a mucosa of a larynx. In case of rubber balloon application the wound remains unclosed. During the second
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stage, the laryngostome is closed. When using endoprosthesis, it is possible to close laryngofissure simultaneously with surgical treatment of a larynx and trachea wound. Prosthesis is removed endolaryngeally 3-4 weeks later. Application of corticosteroids in early terms after surgery promotes restriction of the excessive reactive phenomena and congenial engraftment of mucous grafts without a swelling submucous layer and formation of rough cicatrixes. Casualties with larynx wound require rest, silence, anesthetizing drugs and spasmolytics treatment (atropine, etc.), a due care of the oral cavity is necessary as well. However, in any case, these casualties should be treated by all mentioned above specialists as the insulated damages of separate anatomical neck organs of an explosive genesis are seldom to meet. Casualties with combined wounds of the next organs throat, larynxes, tracheas, an esophagus, spinal column are encountered more often. Substantive provisions of neck wounds treatment include: - sparing treatment of surrounding tissues at a primary surgical treatment; - occlusive suturing of tissues is contraindicated (can lead to suppuration over course of wound channel or abscesses and phlegmons of a neck); - necessity of drainage wound the channel on all extent, removing closed spaces and foreign bodies; - in case of greater fractures of the larynx and trachea skeleton an early laryngofissure with the subsequent modeling of their clearances (cannula by N.A. Pautov with ointment plugs by Mikulich); - rigorous substantiation of indications to a tracheostomy, being the additional injuring factor and quite often causing serious complications. During tracheostomy more sparing and cosmetically justified is traversal (2 cm distally from the jugular notch) dissection of neck skin and fascia with the subsequent dilatational blunt opening of muscles and the soft tissues. One of most complex chapters in otorhinolaryngology is still diagnostics and removal of foreign bodies at nonperforating wounds, especially at their localization in hard-to-reach departments of ENT organs. Difficulties of foreign bodies diagnostics include: - localizing foreign body in relation to the vital formations, whose damages can be accompanied by severe aftereffects; - selection of the most adequate and safely operative approach to remove a foreign body, allowing to inflict the least operative trauma and to avoid serious complications.
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The ENT surgeons approach to foreign bodies can be viewed basing on four wound types (by V.I. Voyachek): - foreign body is hard-to-reach, but its presence is rather safe; - foreign body is hard-to-reach, and its presence is rather dangerous; - foreign body is accessible and its presence rather safe; - foreign body is accessible, but its presence is rather dangerous. In first combination operation on removal of a foreign body can be postponed till late terms and is performed under favorable conditions (in the absence of casualties traffic or in rear hospitals when a casualty is sufficiently compensated). In the second combination it is indicated to remove the foreign bodies, not procrastinating with surgery, but with greater precautions and involving qualified specialist in the specialized hospital. At the third combination the surgery is indicated conditionally. And, at last, in the fourth case removal of a foreign body is rather safe and is indicated at the specialized aid stage. In addition to classical methods of removal of foreign bodies it is necessary to note feasibility of the nonstandard approach to extraction. In particular, provided there are head and neck wounds, physicians estimate the track of a wound channel, depth of a foreign body and danger degree of its extraction. Practice prompts that in some cases it is safer to approach a foreign body through a contralateral incision. For example, wounding debris which entered through a neck with backforward direction at a level of a mastoid behind nodding muscle is hard to reach. Besides, its extraction can damage facial nerve or other nervous neck trunk (wandering or sympathetic). Removal of a body can be carried out easily through parapharyngeal cellular tissue (here its depth is 2-3 cm). K.L. Hilov recommends removal of foreign bodies in the case of nonperforating gunshot wounds of a nose by orthoscopic methods. Long nasal cuspidate mirrors of various sizes are inserted through the entry opening of a wound channel, depending on how deep a foreign body is. Wound channel on all extent becomes well visible and then it is feasible to find foreign body using a probe and remove it with nasal tongs. Wound location of the cervical esophagus is approached depending on the access along the interior border of the left sternocleidomastoid muscle. A surgeon should open all leakages and pouches, bare the esophagus, economically excise its destroyed edges and apply isolated one-row sutures. If it is impossible to put sutures on esophagus, wound opening is fixed to a skin by the solitary sutures. Surrounding tissues are thoroughly drained. In presence of suppurative focuses,
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physicians perform wide cervical mediastinotomy with dissection of both anterior and posterior mediastinums and their flow-washing drainage by N.N. Kanshyn. In the clinical pattern of stenoses of the upper respiratory tracks, physicians discriminate four stages (by Undrits V.F.): 1. Stage of compensation is characterized by deeper and less frequent respiratory excursions, elimination of a respiratory pause. 2. Stage of incomplete compensation (subcompensation) auxiliary muscles participate in breathing, during inhaling supraclavicular and Mohrenheim's fossas are retracted; breathing is accompanied by noise (stridor), the cyanosis of lip mucous membrane arises. 3. Stage of a decompensation acutely expressed stridor, respiratory muscles are maximally contracted, the restless behavior, the expressed cyanosis of mucosa and integument, cold sweat. 4. Stage of asphyxia is characterized by consciousness loss, heart activity decline, dilating of pupils, consensual urination and defecation. Thus, the considered issues underline, that bullet, fragmentation and mine-explosive wounds of an ENT organs have the specific features, distinguishing them from damages of other organs and systems. The accumulated experience allows to giver a series of recommendations raising efficiency and quality of treatment of these casualties. Since the moment of wound, it is necessary to sustain passability of respiratory passes. During external bleeding, physician should put compressive dressing or tampon a wound. In case of separation of a nose or auricle, they should be preserved until specialized medical care is rendered. Nose bleeding is stopped by standard first aid measures. Usually, physicians conduct anterior or posterior tamponade by V.I. Voyachek and Bellok followed by superimposition of sling bandage. To prevent an infection, plug in a nasal cavity is maintained without change for no more than 2 days. During bleeding from the inferior department of pharynx, a larynx or a trachea, especially with attributes of passability disorder of respiratory paths, the tracheostomy is indicated. A bleeding from acoustical pass is shut down using tight tamponade. At stage of the qualified medical care of similar casualties general surgeons more often treat: casualties with a continuing bleeding are operated only in presence of obvious threat of asphyxia. Stopping of bleeding, as a rule, is supplemented with revision of a wound, a ligation of the defective vessels or their dressing by standard (classical) procedures. The damage of a sigmoid sinus requires the antromastoidotomy with the sinus baring and introduction of tampons
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according to Whiting: a narrow wick drain saturated with antibiotics or iodoform is placed between the bone and the sinus side. The plug should remain for 10 days. Temporal muscle can be used for this purpose. Surgical interventions for nose wounds, adnexal sinuses, throat, esophagus, an ear are performed at this stage exclusively under pressing indications. At the stage ofa specialized medical aid all casualties upon entering are separated in three basic groups: - casualties with the continuing or recommenced bleeding or disorder of breathing (first in line for surgery under pressing indications); - casualties with wounds to a neck, medial and interior ear, but without life-threatening signs (surgery after cavitary surgeries and amputations); - casualties with damages to an external ear, nose, adnexal sinuses (last in line, after stabilization of the vital organism functions). Simultaneous surgeries are carried out by the mixed surgical teams including ENT surgeon, eye surgeon, the neurosurgeon and the maxillofacial surgeon. Ear damages. At the wounds of chondromembranous region of an external ear the primary goals are maintenance and reconstruction of an external auditory canal, where a PVC tube is inserted. In cases of wounds to osteal region of external acoustical pass, surgeon should remove osteal splinters, foreign bodies with the subsequent coetaneous plasty free or a flap. Parotid wound either sewed or further treatment is conducted through external acoustical pass. The wound can be left without sutures with a packless tampon. In deep ear wounds, provisions include mastoidectomy and radical ear surgery. Provided there are microsurgery instruments and operative microscope, simultaneously with a primary surgical treatment of a noninfected ear wound surgeons should conduct primary reconstructive surgeries on a middle ear, like ossyculo/tympano/myringoplasty. Restitution of vestibular-vegetative system functions in casualties with a mine-explosive trauma. Considering significant decrease of the vestibular system excitation thresholds and vulnerability of MT (mine-explosive trauma) casualties, their evacuation by any kind of transportation represents serious problem. In practice, evacuation of casualties with head mine-explosive traumas requires administration of drugs with the adaptive stress-protector, cerebral protector, nootropic and antidepressant activity:
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1) formula AEP includes Aeronum (1-2 pills), Etimizol (1 pill 0.1g) and Pyracetam (pills or capsules, 0.6-0.8 g dose); 2) formula AET includes Aeronum and Etimizol in the above doses, and Gammalon (23 pills 0.25g); 3) formula BAP includes Bemitil (2 pills 0.25 g), Aeronum and Pyracetam in the above doses. If the independent administration of pills is impossible, the drugs are administered through the enteral probe (Aeronum, Pyracetam, Gammalon, Bemitil) or IM injection (Etimizol 1 % , 36 ml single dose). After reception of AEP, AEG or BAP for 12 hrs before evacuation, duration of protective adaptive activity is 68 hrs, presenting window of opportunity for recurring administration. Additionally, at all stages of evacuation, all casualties are administered immunomodulator drugs (T-activin, Thiamine or Tymogen) in the usual therapeutic doses. Introduction of either formula promotes optimization of brain functions during the transportation and evacuation in the majority of casualties with MT of brain, damage to acoustical and vestibular system. Pathogenesis of acute posttraumatic bradyacusia defines sequence of treatment: elimination of edema and regulation of humeral, trophic and vascular mechanisms. Thus, it allows optimizing metabolic processes in the defective structures of the sound-perceiving apparatus, raising a resistance of a brain and acoustical system to hypoxia and tissue acidosis, elimination activity aggravating pathogenesis of exo- and endotoxins that finally promotes preservation of highest number of neurons and cells of Corti organ in their interconnection. Complex of the basic special therapeutic provisions, optimizing metabolic processes and vitality of acoustical system cells, includes: Restitution of a circulation in the cochlea and in central departments of acoustical system; Restitution of functions of diaphragms at vascular side and a hemato-labyrinth barrier; Liquidation of all hypoxia forms; Optimization of metabolism in the brain and acoustical system. The following pharmacological resorts are used during acute MT period for the pathogenetic and symptomatic therapy: Correcting intensity of the metabolic responses to distress and oxygen brain demand, in particular, tracking damages of cellular membranes; speeding up their restitution (stressprotectors, including lipid peroxidation adjusters, antioxidants, antyhypoxants, stimulators of proteosynthesis, rapid adaptogens etc.);
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 Controlling microcirculation and the vascular disorders, restricting range and quantity of intracellular and intercellular edema (various vasoactive drugs); Improving energy balance and metabolic processes in the brain (energy drugs, vitamin complexes, nootropic drugs). In known plans of treatment of casualties during early MT, first-line drugs correct and recover vital indicators a cerebral blood stream, an intracranial pressure and brain metabolism. This promotes other functions restitution, reduces manifestations of the tissues hypoxia and syndrome of cross burdening, boosts reparative processes and optimizes homeostasis and adaptive processes. In particular, during acute acoustical system MT, physicians administer unloading dropper once a day for 3 days: Prednisolon-hemisuccinate (60 mg), Furosemide (40 mg), vitamin B1 (3 % 1 ml), ascorbic acid (5 % 5 ml), glucose (5 % 250 ml). Each infusion is completed by IV injection of Panangin solution(10 ml). In hospital conditions, this therapy is complemented for 8 days by HBO for 45 min under 2.1 atmospheres pressure. When pressure peaks and during decompression, patients inhale pure moistened oxygen. The plasmapheresis is performed (2-3 operations with interval 3-4 days) over venal-venous circuit with removal of 3040 % plasma on the background of high (300-400 Units/kg) heparinization and replacement of removed plasma by solutions with expressed rheologic and antiaggregant activity. Plasmapheresis is also highly effective during late explosive trauma (2-3 days, even a week). In case of early admission of casualties with the rupture of tympanic membranes, their primary plasty is performed under a microscope and includes closing edges of tympanic membranes above hemostatic tube, inserted into a tympanic cavity through perforation. These casualties, in addition to unloading droppers, HBO, plasmapheresis and other methods of treatment, are administered local therapy (vasohypertonic drops and ointment, anemization of the eustachian tube orifice, physical therapy), which accelerates epithelization, cicatrization of perforations and decrease of the inflammatory phenomena in middle ear. Resistant dry perforation of a tympanic membrane in further (3 months and more) is completed by myringoplasty. Increase of the treatment productivity for MT acoustical system casualties is promoted by their medical classification. According to the severity of acoustical system damage, 5 groups are considered. 1st group casualties requiring early regenerative operations (myringoplasty, tympanoplasty,
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etc.). The approach provides earliest restitution of audition and prevention of purulent, necrotic or adhesive processes in the middle ear. 2nd group casualties without rupture of tympanic membranes with decreased audition and perception of whisper up to 4 1 min are referred to the walking wounded branch under observation of the general surgeon. They can return to ranks in 1015 days 3rd group casualties with decreased perception of whisper to 2 + 1 min, with rupture of tympanic membrane and the inappreciably expressed vestibular disorder (spontaneous nystagmus of the first degree, low-amplitude and horizontal) are referred to the ENT branch staffed with the ENT surgeon. After treatment (up to 60 days) they can return to ranks. 4th group casualties with severe combined damages require hospitalization according to the leading pathology. The acoustical system barotrauma is treated by the ENT experts through the interhospital consultations inside the multifunction hospital. 5th group of casualties is referred to neurosurgical hospital (within the system of uniform hospital infrastructure), if there is suspicion of ear fluid leak with a concomitant bruise of brain and spontaneous nystagmus of IInd and IIIrd degrees. 20-30 days after general condition stabilization, casualties are moved to hospital of IInd echelon or in rear hospital, belonging to the Ministry of Health. During first 5 days after a severe trauma of the acoustical system all casualties once a day are administered IV unloading dropper. Infusional procedures are completed by IV injection of 10 ml Panangin. Under psychoneurological indications, physicians can administer Seduxen 0.5 % 2 ml IM once a day; magnesium Zinc sulfate of 25 % 10 ml IM daily (6 days); Tavegil (Diazolin) 0.001 g on 1 PO 2 times a day; Dibazol 0.02 g 1 PO 2 times a day. If treatment in clinic begins 10-15 more days after trauma, Seduxen and antihistamine drugs are replaced by Complamin (nicotinic acid) 15 % 2 ml IM daily; subcutaneous injections of Galantamin (Strychnine) 0.1 % 1 ml daily 10-15 injections; Cerebrolysin 1 ml IM, 2030 injections. In presence of the audible noise, physicians should administer metatympanic novocaine blockages; sedatives and tranquilizers (Sonapax on 0.025 g 23 times a day, 34 weeks; Trioxazin on 0.3-0.6 g 2-3 times a day); sessions of HBO (8 sessions). If the above therapeutic treatment fails, and also for persons with severe disorders of neurodynamics (according to EEG), especially in an acoustical region, disorder to intracranial hemodynamics or inadequacy of such response (estimated by REG and dynamics of microcirculation in a bulbar department of a conjunctiva in reply to a ultrasonic loading) rather
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high efficiency is achieved by plasmapheresis (up to 3 per course). Etiopathogenetic substantiation of plasmapheresis during explosive brain trauma are avalanching pathological changes in sound-perceiving department of the acoustical system, uncorrectable by the drug therapy, increasing disorders of microcirculation, hypoxia, increase of blood viscosity, decline of its rheologic properties, accumulation of antigens, activation of enzymes and biologically active materials, toxic material of cytolysis etc. Plasmapheresis helps eliminate negative aftereffects of an explosive trauma and is indicated for the hearing disorders of perceptual type with decrease of whisper perception less than 1m in one or both ears, increase of audiologic thresholds at the colloquial frequencies (1-3 kHz) above 20 dB and at high frequencies above 40 dB. Efficiency of acubarotrauma treatment is judged by the expression of hearing disorders, noise level in the ears, adequacy of speech perception, and thresholds of an audiometric curve, vestibular-vegetative resistance and the dynamics of biochemical indicators restitution. Peak efficiency of plasmapheresis is observed in the first two-three days after acubarotrauma. The method is most expedient at the stage of the specialized and qualified surgical aid, using mobile units as enhancement medical teams.

9.8. PECULIARITIES OF SURGICAL TACTICS AND TREATMENT OF CHEST AND ABDOMINAL EXPLOSIVE DAMAGES.
Since N.I.Pirogov time, severe damages to chest and an abdomen, caused by air blast wave of closely flying projectile are known. Subsequent wars provided more illustrations, but only after WWII the opportunity opened for scientific study and subsequent explanation of this phenomenon. Alternating, according to laws of ballistics, rarefication and compression waves cause conforming oscillations of the live tissues. Depending on morphofunctional and anatomical features of an organ, it causes changes ranging from inappreciable functional disorders of preclinical level up to avulsions of internals and their fracture. In previous chapters, the authors addressed this question to some extent. In the given chapter we shall describe in details explosive damages to chest and abdomen. Classification of explosive damages to chest and abdomen is based on the basic positions according to which, they are divided into two groups with indirect or contact wound mechanism. According to this, one should separate closed damages to chest and abdomen and

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open damages or wounds.

9.8.1. Chest explosive trauma

During peacetime and wartime, the chest damages refer to a class of severe traumas. During WWII, depending on a nature of combat operations and terms of medical care, incidence of damages to chest ranged from 5 to 12 % of total number of casualties, with general lethality about 13 %. During modern local wars specific share of chest traumas increased, which is related to earlier delivery of casualties to medical hospitals and capabilities of modern medicine. Rise in number of closed thoracic traumas in local conflicts is related to growing use of explosion munitions [Bisenkov L.M., 1993. Nechaev E.A. et.al., 1994]. Of special importance is increment in number of the combined chest explosive damages. They, as a rule, are characterized by major severity and, quite often, render major influence on course of traumatic sickness. Experience of war in Afghanistan points out that various types of chest damages were noted after an explosive trauma in more than half of casualties. Major share (49.3 %) was comprised by the closed chest damages, which is essentially different from the industrial and road accidents. Penetrating wounds to chest occurred in 9.3 % cases, nonpenetrating wounds, often plural, in 27 %. Combined character of thoracic traumas considerably complicates state of casualties. The clinical pattern of combined trauma manifested respiratory and cardiovascular disorders, whose expression was defined by the quantity and degree of damage severity. Often enough, explosive damages were combined with damages to chest, extremities and skulls, and the craniocerebral traumas were mostly light. Abdominal damages were noted much less often, but the forecast in these cases was notably worse. During active campaign in Chechen republic during 1994-1996 damages to chest were observed in 20.4 % of all explosive damages [Lashenov G.V., 1999]. Significant number of casualties, delivered in the severe and extremely severe conditions deserves special attention. These high numbers are possible to explain, at least partially, by peculiarities of medical-evacuation system, when frequently there were no intermediate stages of medical aid between battlefield and stage of qualified medical care. Accordingly, casualties with severe damages were forwarded directly to the hospitals. Indicators of lethality matched the situation as well during WWII 21 % of all dead casualties were those with penetrating wounds to the chest, during Chechen campaign this indicator comprised 7.7 %. Classification of the chest explosive damages can be presented as follows (Fig. 9.31) .According
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to experience of operations in the Chechen Republic, chest wounds comprise 76.4 % of an explosive traumas to chest, 23.5 % of them being nonpenetrating fragmentation wounds.

Fig. 9.31. Classification of explosive chest trauma Character of damages to thoracic tissues varies and depends on the ammunition, distances to the blast and wound conditions. It can be represented by the spot wounds and extensive fractures of tissues with damage to the bones and parietal pleura. Essential contamination of such wounds by the soil and shredded clothes is usually observed, which considerably raises hazard of purulent complications. Nonpenetrating wounds cause damages to ribs, blades, chest bones and clavicles. The gravity of casualties state in this group is usually defined not by the thoracic wound, but rather by damages to internals of chest or organs of other anatomical regions, caused by the combined traumas. Major factors defining character and severity of an explosive chest trauma, damages of thoracic internals and skeleton are disorders of external respiration and hemorrhage, which is finally accompanied by the onset of pulmonary-heart failure and hypoxia. Fig. 9.32 shows hypoxia pathogenesis diagram during explosive chest trauma.

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Fig. 9.32. Pathogenesis of a hypoxia after the explosive chest trauma Diagnostic of damages and wounds to chest is quite often impeded because of the severe state of casualties and rapidly varying clinical pattern, caused by a buildup of pathological changes. The chest damages have a series of general diagnostic attributes [Bisenkov L.A., 1995]: pain of various intensity at the side of the trauma, increasing in strength during aspiration, cough, change of a body position, frequently with acute restriction of respiratory motions, especially after skeleton damage; dyspnea, impeded breathing and a pain, strengthening during motions and forcing a casualty to accept the enforced position; changes to hemodynamics of varying severity; pneumorrhagia of various intensity and duration; emphysema in tissues of a thoracic side, a mediastinum and adjacent regions; displacement of mediastinum opposite to the wound spot. Majority of these clinical attributes is noted in the overwhelming majority of casualties (pain, dyspnea), while others are met much less often (emphysema, pneumorrhagia). Usual methods of clinical examination including survey, palpation, percussion, auscultation, studying of character and localization of wounds, in most cases allow identifying the damage and taking appropriate medical provisions. The clinical data serve to substantiate the selected type and sequence of
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diagnostic provisions. Important place among them, especially for diagnostics of hemo -and a pneumothorax, ongoing intrapleural bleeding or hemopericardium, is taken by the medicaldiagnostic puncture. The degree of an anemia and attributes of ongoing intrapleural bleeding can be determined by studying the peripheral blood indicators (general analysis, hemoglobin, hematocritical number). For all chest damages it is necessary to consider mandatory radiological survey. Ultrasound imaging is another prospective complementary method. By using echo pulses it is obviously possible to find depth of a pleura, contents of pleural cavity, mobility and airiness of a lung, find radiotransparent foreign bodies. The diagnostics of intrathoracic damages is sometimes performed by using thoracoscopy, bronchoscopy and esophagoscopy. It is necessary to consider that the symptomatology of closed chest trauma depends on severity of thoracic wall damage, degree of hemopneumothorax, prevalence of damages to lung, heart, bronchi and other organs. Improvement of treatment effects for casualties with explosion chest damages in many respects depends on the rational organization of medical care at all stages. Provisions, conducted at the spot of incident, during transportation, and, further, in hospital should be pathogenetically proven and targeting fastest arrest of functional disorders and stopping shock state of a casualty. Pre-hospital stage of treatment includes, as a rule, first, paramedic and first medical aid levels. At the spot of an incident it is necessary to stop the injuring factors action, as circumstances allow, the casualty should be moved to the other place, preferably on a hand frame in half-sitting position. Wound of a thoracic side should be closed with occlusive bandage. This requirement is mandatory. As it neither possible, nor required to conduct differential diagnostic at the spot and define indications for the sealing bandage, it is expedient to apply this bandage for all casualties with the thoracic wall wounds. In cases of asphyxia, oral cavity is cleaned by finger, protected by a napkin. The blood, slime and foreign bodies are removed, if necessary artificial breathing is performed using S-shaped air duct. Analgetics and cardiotonics are injected SC or IM. Indicator of the good organization of the medical aid at the pre-hospital stage, provided there is prepared nurse or the general practitioner available, is capabilities for infusional therapy (IV infusions 1.01.5 l of the saline isotonic solution, polyglucinum or other antishock resorts). When rendering the first medical aid, the earlier bandages should be corrected, if necessary, tetanic anatoxin should be injected, broad spectrum antibiotics should be applied. Pain syndrome and normalization of the vital functions is achieved using various novocaine blockages
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intercostal, juxtaspinal or vagosympathetic. If there is an extensive explosive wound of a thoracic side, the wound edge can be infiltrated with Novocaine solution and antibiotics. Under conditions of proceeding external bleeding, the general surgeon sutures bleeding vessel in a wound or stops bleeding by application of the hemostatic clamp. The clamp remains in the wound until the following stage. If the pressure pneumothorax evolves, pleural cavity should be punctured by thick Dufo needle in second intercostals region along median-clavicle line, with bracing of valve to skin. The valve is usually made of cut finger of rubber surgeons glove. If there are attributes of acute hemorrhage and drop of an arterial pressure, transfusions of the whole donor blood or its elements are expedient under vital indications. Casualties with explosively-related chest damages require mandatory immediate evacuation to the stage of the qualified surgical aid. The general diagram of surgical treatment of chest explosive damages includes following items: adequate drainage of a pleural cavity; replenishment a hemorrhage; restitution and maintenance of passability of respiratory paths; elimination of a pain syndrome; stopping of an intrathoracic bleeding, sealing and stabilization of a thoracic side; antimicrobial and symptomatic therapy; antihypoxia therapy. At a stage of the qualified surgical aid casualties with chest damages are classified. Following groups are isolated: 1. Casualties with severe chest damages requiring pressing surgical aid under vital indications (proceeding external or interior bleeding, open pneumothorax with explosive damages to thoracic wall tissues). 2. Casualties in a state of shock IIIIIrd degree, not requiring pressing surgical aid. Urgent operations are expedient after completion of the antishock provisions. 3. Casualties of average severity and walking wounded. Upon rendering appropriate aid they are moved to intensive care or general units. 4. Casualties with extremely severe damages to chest requiring, in most cases, only conservative symptomatic therapy. It is necessary to note that experience of surgical operations in the requirements of local conflicts, natural or technogenic disasters, testifies that in condition of adequate medical resources, the latter group (conditionally termed agonizing) should not be isolated. If the available resources
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are sufficient, medical provisions should be administered to all who requires, irrespective of their condition severity. Afghan war experience showed that about 30 % casualties, counted as agonized because of the objective indicators, were saved by well-timed and high-grade medical provisions (which generally is possible only during local conflicts). Our clinical experience testifies that each group with chest damages shows the prominent features, exhaustively addressed in the thoracic surgery manuals [Wagner E.A., 1981; Kolesov A.P., Bisenkov L.N., 1986; Bisenkov L.N., 1995]. When discussing general principles, it is necessary to address indications to thoracotomies during chest explosive damages. Physicians discriminate pressing, urgent and delayed operations. Pressing thoracotomies are indicated for: 1. Resuscitatory provisions (cardiac arrest, fast buildup of valve pneumothorax, a profuse intrapleural bleeding). 2. Wounds of heart and large vessels. Urgent thoracotomies should be carried out within the first day after wound. They are indicated for: proceeding intrapleural bleeding, confirmed by blood removal from pleural drainage at rate >300 ml/hr; resistant valved pneumothorax; open pneumothorax with a massive damage to lungs; damages of an esophagus; proved suspicion of wounds to chest and aorta. Delayed thoracotomies are carried after 3-5 days and even later. Indications: curtailed hemothorax; persistently relapsing pneumothorax with a collapse of a lung; large (more than 1 cm diameter) foreign bodies in lungs and pleura; relapsing cardiac tamponade. All operative measures on chest organs are completed by the mandatory flushing of a pleural cavity. For this purpose, physicians should use minimum 3-5l of antiseptic solution. Resection of sharp rib fragments, novocaine blockage of intercostal nerves, drainage of a pleural cavity with subsequent resection of thoracotomic wounds. Surgical treatment of input and exit wound chest openings should be completed. Usually, after the thoracic surgeries, chest casualties are considered incapable for motor transportation during 7-8 days, airlift during 23 days. The
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postoperative treatment targets recovery of circulating plasma volume, maintenance of cardiac activity and lung ventilation, prevention and treatment of complications. The therapy includes high dosage of antibiotics, analgesics, cardiac glycosides, broncholytics, antihistamine drugs, infusional resorts and antihypoxia resorts. Latter includes hyperbaric oxygenation (HBO). Experience of chest combat trauma treatment using HBO allows to single out the following mechanisms of hyperbaric oxygen action: elimination or reduction of hypoxia caused by functional disorders cardiovascular and respiratory systems; restitution of the oxygenous blood capacity, lowered by the acute hemorrhage; Boost of oxygen diffusion efficiency and, accordingly, increase of its partial pressure in the injured tissues of the damaged region. Gunshot and explosive chest wounds are characterized by the high risk of purulent complications, largely defining the trauma outcome. When deciding on using HBO for chest casualties it is expedient to consider and evaluate the following pathogenetic factors of complications: degree of manifestation of pulmonary-cardiac failure; character and depth of microcirculatory hemodynamics disorder; extents of a damage to the tissues in the wound region; degree of the injured tissues infectious contamination; the character of concomitant damages and an expression of respective functional disorders. Following groups of purulent complications risk factors (Fig. 9.33) can be isolated: local features of wound, flaws of medical aid and factors related with combined trauma character. Thus, pathogenetically and tactically, HBO use for treatment of the wounds to chest is warranted by the risk factors related with the contagious complications. According to our data, adding HBO to the treatment led to clinical improvements in 71 % observations. Incidence of a pleural empyema was decreased by 8.4 %. When administering HBO to chest wound casualties it is necessary to follow the rule do not apply HBO in presence of pressing surgical interventions stopping of bleeding, pending resection of open pneumothorax, drainage of the pleural cavity, liquidation of valved and pressure n pneumothorax. Clinical experience proves that the chest wounds warrant 3-5 HBO sessions at 0.150.18 MPA with an exposure of 40-50 min, one session daily. For extensive damages to tissues in casualties with open pneumothorax, massive hemorrhage and combined
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traumas, the medical effect is attained using longer HBO courses (810 sessions at 0.18-0.20 MPA with an exposure of 60 min, 23 days two sessions daily, subsequent period one session daily).

Fig. 9.33. Risk factors of purulent complications after gunshot and explosive chest wounds

9.8.2. Explosive abdominal trauma

Damages to abdomen, inflicted by injuring factors of explosion are extremely severe. Blast wave effects on an organism both at the land or water, body concussion with the surfaces or hard objects, cause mostly damages of intra-abdominal and extraperitoneal organs, usually bearing the combined character. Contact wound mechanism can possibly cause penetrating and nonpenetrating fragmentation abdominal wounds and explosive wounds with major defects of the abdominal wall tissues, possibly combined with eventration of an intestine. Necessity to isolate casualties with explosive damages to abdomen goes back to WWII. This category included only

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closed abdominal traumas caused by blast effects. However, wartime literature only briefly addresses this issues in journal papers and small generalizing chapter in XXII volume of Experience of the Soviet medicine during Great Domestic war 1941 1945. During the last decades, domestic literature was enriched by the series of monographs, addressing diagnostics and treatment of insulated and combined abdominal damages. However, only experience of surgeries in military conflict zones, detailed differential studies of the explosive damages allowed revealing variety of abdominal damages, caused by explosions. It has been noted that the closed abdominal trauma is caused by the propellant, displacing blast wave effects or by the direct shock wave effects. According to Afghanistan war data; these casualties manifest damage to organs of an abdominal cavity in 3.6% cases. Abdominal damages after contact blasts on standard anti-personnel mines are rarely clinically diagnosed. Among variety of internals pathology, encountered by the military surgeons during operations, bruises are the most frequent [Klochkov N.D. et.al., 1992]. Autopsy of casualties during last decade local conflicts and those, who died in the hospitals, showed bruises of a colon in 6.4-7.4 %, small intestine 5.6-6.7 %, pancreas 3.5-4.4 %, stomach 3.3-4.8 %, paranephritis 1.2-2.3 % [Rogatchyov M.V., Timofeev I.V., 1991]. Bruises of these organs are encountered in casualties with explosive damages and less often in casualties with explosive wounds. Their ruptures are noted in 3.2 % casualties, which is 2.5 times above the given indicator for the closed mechanical traumas during the peacetime. This fact is explained by the blast wave being the basic etiological factor of internals damage, while peacetime traumas are caused by body concussions against blunt objects and ground [Klochkov N.D. et. al. 1992]. Closed abdominal traumas inflicted by the contact mine blasts on land are related with high incidence of liver and spleen traumas (17 %). Diagnostics of the liver damages is considerably impeded, especially in persons with polytrauma in the shock state or unconscious due to the severe neurotrauma [Tynjankin N., et. al., 1987]. Using experience of clinical observations during war in Afghanistan and comparing with data of autopsies, it is possible to conclude that the casualties on battlefield manifest bruise of liver 1/6 cases. Those who perished in medical hospitals manifest them in 5.8 % (survivors in 3.8 % cases). The ruptures of liver are discovered in 8 % casualties [Klochkov N.D., et.al, 1992]. The bruise of a spleen was detected, as a rule, after casualties autopsy on the battlefield and in the hospitals. In 1.2 % of cases the combination of spleen bruise and bruise or rupture of liver,
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kidneys, intestine [Rogatchyov M.V, Timofeev I.V., 1991; Klochkov N.D. et. al. 1992] was noted. Prevention of the interior bleeding at the stage of qualified medical aid was achieved by executing laparocentesis, laparoscopy and laparotomy [Tynjankin N.A., et. al., 1987]. Insulated bruises of hollow organs of an abdominal cavity, inflicted by the contact mine blasts show clinical pattern, similar to acute abdominal and intestinal disorders [Nechaev E.A., et. al., 1994; Harman J. W., 1983]. Unlike bruises of parenchymatous organs, bruises of hollow abdominal organs, caused by blasts of anti-personnel mines are encountered more often than ruptures. Bruises of hollow organs usually combine with ruptures of parenchymatous abdominal organs [Tynjankin N.A., 1987; Klochkov, N.D., 1992]. Diagnostic of bruises to stomach and intestine for combined damages is possible during life-time using diagnostic EGD, laparoscopy or laparotomy. Bruise of pancreas is detected approximately in 3.5 % casualties of contact blasts of anti-personnel mines. For all casualties the pancreas bruise is combined with ruptures and bruises of other abdominal organs [Bisenkov L., 1993; Nechaev E., et. al., 1994]. Certain casualties of contact mine blasts have attributes of acute renal failure (AReF) decrease of a diuresis, increase of creatinine, carbamide and filtrate nitrogen in a blood) during 2-3 days after a trauma. However, there is not a single case of its evolution being related to bruise of kidneys. Above-stated fact was explained by the prolonged hypotension owing to shock, hemorrhage, cardiac arrest and drop of filtration pressure in kidneys, myoglobinuria on the background of massively crushed muscular tissues [Storozhenko A.A., 1993; Harman J. W., 1983]. In the pattern of internal damages, caused by the contact mine blasting on land, damages of adrenal glands are detected in no more than 0.7 % casualties and are manifested by the expressed focal or total hemorrhages, preferentially in the cortical layer. Clinical attributes of the acute adrenal failure are diagnosed during lifetime in no more than 1/3 cases [Klochkov N.D. et. al., 1992; Bisenkov L., 1993]. Thus, greater share of casualties with explosive damages manifest damages to the abdominal organs. Primary action of the blast wave causes usually damage to the respiratory organs, at second parenchymatous organs. Basic pathomorphologic attribute of the internal bruises are disorders of the organ cellular structures integrity and hemorrhage. The more the area and volume of damage, the higher is a degree of functional disorder. According to the data of I.D.Kosachev and P.G. Alisov (1994), during Afghanistan campaign, abdominal MTs were observed in 11.1 % casualties, and mine-explosive wounds comprised 6.7 %, mine-explosive damages 4.4 % of casualties with abdominal damages. During the Chechen campaign 1994-1996. MT of abdomen comprised 20 %, and a pelvis 9.4 % of explosive traumas
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[Lashenov, 1999]. MT of abdomen in 78 % cases was penetrating, thus the majority of wounds was accompanied by the damage of several organs (96 %). Hollow organs (51 %) were damaged more often; wounds of parenchymatous organs comprised 41 %, wounds of large vessels 7.5 %. Nonpenetrating wounds comprised 22 %. Those were gutter wounds of the soft tissues, or nonpenetrating wounds of the anterior abdominal wall, inflicted by the fragments with low kinetic energy. Mine-explosive traumas to abdomen only in 3 % cases were insulated, 36.4 % casualties had plural wound, and in 60.6 % it was accompanied by damage to other body regions.

Fig. 9.35. Classification of an explosive abdominal trauma During explosive wounds to abdomen, two groups with different mechanisms are singled out. First, rather small, includes abdominal wounds caused by the immediate injuring factors of explosion. As a rule, such wounds combine with damages and avulsions of the lower extremities segments, plural wounds of rumps and perineum. This is an extremely severe wound, as it is

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simultaneously caused by the blast wave, gas-flame jets and fragments. Combined action of these factors often causes extensive wounds with damage to the abdominal wall tissues and possible eventration of an intestine (Fig. 9.34 see color insert), damages of urethra, genitals and a rectum. The second group is made of the abdominal wounds, received by casualties at the distance of several meters from an explosion center. The leading injuring factor in these cases is ammunition fragments or secondary wounding projectiles. Classification of explosive trauma is illustrated on Figure 9.35. Objective consequence of the explosive abdominal trauma is the posttraumatic peritonitis. It is triggered by alteration of tissues during trauma with the subsequent trophic disorders of the intestinal wall tissue, its transmittivity for the pathogenic microorganisms and the subsequent contamination of abdominal cavity with microflora. The contamination originates, naturally, for wounds or abdominal damages with wounds to intestine and disorders of its integrity. Depending on the type and character of damages, these disorders can have character of various degree adaptive changes. In the extremely severe cases, the syndrome of multiorgan failure can develop (Fig. 9.36). As proven by the clinical experience, the greatest difficulties in diagnostics of the abdominal explosive trauma are noted for combined traumas. It is caused by the presence of cross burdening syndrome. In such cases, careful dynamic survey of the casualty is due, accompanied by the estimate of combined damages to clarify the degree of their influence on the course of traumatic sickness. However, majority of casualties show dominant clinical patterns, more or less appropriate for damages to the abdominal cavity organs. These signs usually point to the bleeding in the peritoneal cavity, caused by the damaged liver, spleen, pancreas and mesentery or testify to peritoneal irritation by the contents of perforated gastrointestinal section. Severe conditions of most casualties with explosive damages and abdominal wounds demand full diagnostic routine in parallel with a complex of antishock provisions. Opportunities of the instrumental diagnostics of wounds and abdominal damages have recently notably improved. This is mainly due to the new procedures of scanning (computer tomography, ultrasound examination), improvement of the instrumental (peritoneal lavage with procedures of sparing catheter, puncture of lateral channels of abdomen, laparoscopy) and laboratory methods. However, diagnostics of the abdominal organs damages at stages of medical evacuation is still based on clinical approach to the collection of anamnesis, data of the functional and laboratory examinations.

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Fig. 9.36. General schematics for explosive damage or wound to abdomen X-ray inspection can give the valuable information for explosive abdominal traumas. Left-side damages to ribs can suggest spleen trauma. The detection of gas in retroperitoneal space can be a radiological attribute of rupture of a duodenum. The free gas found in an abdominal cavity testifies to damage of a hollow organ. Disappearance of a major lumbar muscle on the images speaks about presence of the blood in retroperitoneal space. Dilated shade of kidneys or spleen specifies subcapsular hematomas of these organs or bleeding. X-ray analysis with contrasting bladder, kidneys or duodenum can provide valuable information on damage of these organs. However, according to collective statistics of different authors, diagnostics worth of the discovered changes does not exceed 3540 % probability. Well-known and practically verified principle fate of the casualty with abdominal trauma is defined by time of delivery to stage of the surgical aid remains valid, however, according to the modern representations, correctly organized pre-hospital treatment is very important. This treatment includes first, paramedic and medical aid. First of all, a casualty should be removed
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from the spot of incident to a safe place, thus terminating action of disturbing factors. First aid after wounds include application of aseptic bandages, introduction of anesthetizing narcotics by the disposable syringes and prompt evacuation of the casualty to next stage of medical evacuation, preventing intake of food and fluids. At the stage of paramedic aid, infusional therapy (IV drops of Polyglucinum, sodium chloride 0.9 %, etc.) should be started. In case of the extensive explosive abdominal wounds with damaged tissues of the anterior abdominal wall and eventration of intestine, the intestines, which went through the front wall of peritoneum are affixed by bulky gauze circle (bagel). Paramedics should not try to reinsert the intestinal loops in abdominal cavity. This simple provision can be complemented by blockage of mesentery or protruding intestinal loop by 025-0.50 % solution of Novocaine and concealment of intestinal loops by the dressing or towel, moistened by an isotonic saline solution. In case of a proceeding bleeding from an abdominal wall wound, nurse can carry out hemostasis by applying clamps over bleeding vessels. Hemostatic clamps can be left in a wound up to next following stage. These activities can be, if necessary, executed at the stage of first medical aid. In case of anemia and unstable hemodynamics, these provisions are supplemented with transfusions of donor blood or its components in cases of interior bleeding. All measures are taken to ensure fastest evacuation of casualty using sparing means of transportation to the stage of qualified surgical aid. Depending on urgency and priorities of complex antishock provisions and operative measures at stage of the qualified surgical aid, physicians conduct medical classification and single out following groups of casualties with an explosive abdominal trauma: casualties with attributes of ongoing interior or external bleeding immediately direct them to surgery ward for an emergency laparotomy and surgical treatment with simultaneous antishock provisions; casualties in a state of shock IIIIIrd degree, but without attributes of bleeding should be directed to the antishock unit for the antishock treatment and necessary diagnostic provisions. If operative measures are needed, they should be executed after 23 hrs of the intensive antishock therapy, directed on the stabilization of vital functions; casualties with nonpenetrating wounds of a abdomen, bruises of an abdominal wall or an internals, and also casualties with penetrating wounds of the abdomen, forwarded to the stage 1 (or more) day later in general satisfactory state, are directed to general ward. Diagnostics and medical provisions are performed on as-needed basis in the last turn; agonizing casualties are directed to hospital chambers for symptomatic conservative therapy.
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If the hospital is not overburdened, agonizing casualties should be treated similar to those, belonging to the first or second group. Depending on indications, they are directed to surgery or antishock units for the entire complex of necessary medical provisions. In general, algorithm of diagnostic and surgical tactics at abdominal damages is presented on Fig. 9.37 [by Metelev E.V., 2000]. Operative intervention for damage of a abdomen consists of following stages: laparotomy (as a rule, median); draining and revision of an abdominal cavity; stopping of bleeding; liquidation of a peritonitis source (suturing, resection of the hollow organ defective section); provisions completing surgery: final revision and sanation of an abdominal cavity, rational drainage, novocaine blockage of a root of small intestine mesentery, decompression of an intestine, surgical treatment of abdominal wall wounds. Detailed description of these provisions is presented in the respective monographs and manuals.

Fig. 9.37. Diagnostics and surgical treatment of abdominal damages

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Reactive stage of peritonitis, is more often encountered during insulated damages of parenchymatous organs, stomach, small intestine, in early (up to 12 hrs) terms. This condition has favorable course and outcome, provided the adequate treatment is rendered. When conducting intensive postoperative therapy for these casualties it is expedient to follow the plan presented in Table. 9.12. Indications to HBO usage during treatment of casualties with a reactive stage of peritonitis are relative. Table 9.12 Intensive therapy during reactive peritonitis, caused by trauma Provisions Surgery Post-surgery days 1 2 3 4 5 Surgery Adequate anaesthesia and analgesia Peritoneal lavage Intramesenteric introduction of drugs Decompression of an intestine Epidural blockade Prophylaxis of a pneumonia HBO Rational antibiotic therapy Infusional therapy Parenteral feeding Drug stimulation of an intestine Inhibitors of proteases Heparin + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + +

+ + + + + + +

Toxic stage of peritonitis usually is encountered during combined damages of an abdominal cavity internals, is frequent at damages of a colon, admission of casualties in late terms from the moment of trauma. Abdominal wounds with a toxic stage of peritonitis are characterized by the greater lethality and frequent complications. Intensive postoperative treatment plan for these wounds is presented in Table. 9.13. Results of clinical-laboratory studies testify to the lack of medical effect of HBO during the terminal stage of peritonitis that is caused by preferentially irreversible changes in organs and tissues. In this connection, it is necessary to consider terminal stage of peritonitis as contraindication to HBO being a part of complex treatment of gunshot and explosive abdominal trauma. Purpose of HBO during the treatment of the gunshot diffuse peritonitis pursues the following objective:

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 elimination or reduction of hypoxia creating conditions for normalizing functions of the vital organs and systems of an organism; Restitution of injured tissues vitality outside wound channel of a bullet wound improvement of tissues regeneration in the region of an intestinal seam; creating conditions for normalization of gastrointestinal section motoric-evacuator functions; restitution and maintenance of vitality of intestinal walls; boost of a nonspecific immune response; bacterioscopic and bactericidal effects on pathogens and increase of antibiotic therapy efficiency. Table 9.13 Intensive therapy of toxic trauma-induced peritonitis Provisions Surgery Day of the postoperative period 1 day 2 day 6 hrs Surgery Adequate anaesthesia and analgesia Peritoneal lavage Intramesenteric drug introduction Decompression of an intestine Epidural blockade Prophylaxis of a pneumonia HBO Rational antibiotic therapy Infusional therapy Parenteral feeding Drug stimulation of an intestine Inhibitors of proteases Intraarterial infusions Anabolic hormones Autoblood infusions Hemosorption Lymposorbtion Laparotomy (dressings) + + + + + + + + + + + + + + + + 12 hrs 24 hrs 12 hrs 24 hrs + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

3 4 5 6 7

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9.9. EXPLOSIVE DAMAGES OF UROGENITAL ORGANS

Damages to organs of genitourinary system in the modern conflicts comprise 2.54 % of the total wounds [Shpilenia E.S., 2000. Heidarpour et al., 1999. Tucak A. et al., 1995]. Frequency of damages to the organs of genitourinary system among casualties, who died on battlefield, is considerably higher and attains 23.5 % [Petrov S.B., 1999]. Considerable proportion of combat damages to the organs of genitourinary system is caused by the bullet wounds (38.2 %). During the Afghanistan war, enemy widely used mines and explosives, which determined high incidence of wounds to genitourinary system (21.8 %). During the Chechen campaign mine and explosive wounds of genitourinary organs were encountered less often (16.3 %), but the number of fragmentation wounds increased (45.5 %) due to wide application of mortars, grenade launchers and hand grenades [Shpilenia E.S., 2000]. During the modern confrontations, increase of closed traumas number to organs of the genitourinary system amounts to one third of all damages. Modern battlefields are now saturated by the complex military equipment and means of transportation. The closed traumas happen during the transport accidents, blasting and overturning of armored vehicles and automobiles, during maintenance of other military equipment and regular construction work. 82.4 % of wounds and traumas of genitourinary system, inflicted in armed conflict regions, are combined. And if combined damages comprise hardly more than half (55.7 %) closed damage cases , practically all gunshot and explosive wounds (92.1 %) are combined. Organs of genitourinary system as leading localization of combined damages, are damaged in 36.5 % cases. Remaining cases are dominated by damages to other organs and anatomical regions, but often enough the abdominal cavity organs 34.6 % [Shpilenia E.S., , 2000]. Severity of these casualties defines plurality of the inflicted damages and peculiarities of staged treatments for these casualties because of necessity in most cases to conduct urgent surgical interventions. Damages to kidneys and ureters. Besides classification attributes, general for any organs damages, damage to kidneys are classified as [Shevtsov I.P., 1972]: at the damage side (right, left, bilateral); localization (body of kidney, upper pole of kidney, lower pole of kidney, pedicle); by the form of a damage: a) closed ( bruise, a rupture without damage of calyx and pelvis, rupture with a damage of a
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calyx and pelvis, crushed kidney, damage to vascular leg, separation of kidney from a vascular leg); b) open (a bruise, a gutter wound, through and blind wounds without damage of the pelvis and calyxes, through and blind wounds with a damage to pelvis and calyxes, crush of kidney, wound of vascular pedicle). Modern battlefield is dominated by the combat bullet wounds to kidneys (56.0); fragmentation wounds are encountered in 32.0 % cases, mine-explosive wounds in 12.0 % casualties. All gunshot wounds of kidneys have one common feature massive fractures and, as a consequence, high level of the combined damages (88.0 %). Damages of two, three and more vital organs are diagnosed for many casualties with kidney wounds, and in most cases, they represented leading wounds. Most frequently, wounds of kidneys are concomitant with wounds of abdominal cavity organs (84.0 %). Kidneys wounds are outstanding in the regard of damages to abdominal cavity organs and subsequent complications. The basic attributes, allowing suspecting wound of a kidney, are localization of an entry opening for nonperforating wounds and direction of wound canal for through wounds in regions of chest, abdomen, pelvis and hematuria [Lopatkin N.A., 1998]. Other significant attributes of wound of kidneys are practically absent. At the stage of qualified surgical aid diagnostic of wounds to kidneys should be performed based on an estimate of clinical attributes immediately during an operation. At the stage of the specialized surgical aid, if possible at the qualified aid stage, physicians should perform radiological and ultrasonic examinations. Perfect diagnostic provision is an infusional urography (one picture at 10th minute after introduction of X-ray contrast material), provided the peak arterial pressure is above 90 mm.Hg. Obtained data allow estimating presence of the foreign bodies, character of wound, functional state of the defective and opposite kidney. Ultrasound is also an effective method for diagnostics of damaged and contralateral kidneys. Rendering medical aid begins with antishock provisions. If these provisions fail in the short term and condition state continues to deteriorate, the urgent operative measures with continuing of antishock therapy at the operating table is indicated. Surgical treatment is indicated for wounds of kidneys. In rare cases of the proved insulated damages to kidneys typical skew lumbar access can be used. For combined damages of organs of an abdominal cavity, kidney revision is necessary by means of a median laparotomy. Intraoperation estimate of the defective kidney is possible only after revision of vascular leg(pedicle) region and application of tourniquet or the
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soft clamp with temporary (up to 10 min) arrest of a blood flow. At the stage of qualified surgical aid, physicians should avoid organ-preservation operations on a kidney and those, increasing time and hazards of the subsequent complications during evacuation. Organ-preserving operations are essentially influenced by presence combined wounds, severity of a casualty state, flow of casualties, and equipment of branch and surgeon qualifications. Indications to mandatory nephrectomy at stage of the qualified surgical aid are crushed renal parenchyma, deep ruptures or separations of a kidney pole, plural ruptures and wounds to kidney body penetrating in pelvis and reaching entries, damages to the main vessels of kidney. Indications to organ-preserving operations at the stage of the qualified surgical aid are solitary fissures and superficial ruptures of a kidney body, without penetration into pyelocaliceal system, damage of the single kidney or damage of one kidney in presence of patholological changes in the second one, and also bilateral damages. In cases of massive renal hemorrhages, in presence of intact second kidney, its preservation is inexpedient due to a threat of recurring bleeding during evacuation. Indications to organ-preserving operations at the stage of specialized surgical aid can be expanded. If the general casualty state allows, it is expedient to perform regenerative operations at ruptures or separations a kidney pole, including those affecting pyelocaliceal system, plural ruptures and wounds to kidney body, nonpenetrating into pelvis. During suture or resections of the defective kidney, of all the proposed methods, the most suitable for military requirements is that of M.N.Enfendzhiev (suturing kidney by double catgut ligature with tying on the placed slices of a fatty tissue). In all cases of organ-preserving operations, reliable drainage of the renal bed should be provided. If there are wounds to cavitary system of a kidney, urine should be diverted by using nephro- or pyelostoma. Use of interior stents for pelvis drainage is unacceptable during wartime because it is impossible to monitor for possible renal hemorrhage during evacuation. In the modern local conflicts, in comparison with the previous wars, the trend to rising number of the closed damages to kidneys is observed. Mechanism remains the same in peace and wartime. Closed damages are caused by direct or indirect forces Shocks, quick jolts refer in lumbar region or abdomen, body compression between rigid surfaces. Mediated forces, concussions of a body during falls and other traumas lead to indirect damages to kidneys. Behavior of troops and population during armed conflicts not only increases probability of damages from traditional factors, but also create backgrounds for traumas, unusual for a peacetime. During wartime, the direct damages to kidneys are caused by falls over lumbar region (28.6 %), shocks and
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mechanical compressions after overturning and blasting of armored vehicles (14.2 %) or in destroyed buildings. Modern means of personnel protection produce background for closed damages to kidneys as well, during beyond-armor blasts of armor and armored vest being hit by bullets or fragments (local contusion trauma). Unlike gunshot wounds to kidneys, characterized by the high incidence of combined damages, closed damages to kidneys more often (60 %) manifest the insulated traumas. For combined traumas, the simultaneous damages are inflicted on kidney organs of abdominal cavity, more often liver (33 %) and spleen (50 %). But, unlike gunshot wounds, combat-induced combined closed traumas are a leading damage in half of cases. Closed damages to kidneys are characterized by the triad of clinical signs: hematuria, pain and tumescence in lumbar region. Hematuria with clots should call for especial vigilance. After severe trauma the shock is possible. As a rule, 23 hrs after a trauma hematoma or urohematoma in lumbar region can be discovered. Decision on tactics of patient treatment is based on its stabilization or, on the contrary, a buildup. Of no less value are the general attributes of ongoing interior bleeding: frequent filamentary pulse, drop of arterial pressure, drop of hematocrit and hemoglobin. If there is closed trauma of the lumbar region, accompanied by macrohematuria, the infusional urography is indicated. Damage to kidney, as shown by urograms, corresponds to reduced accumulation of drugs in kidney, various degree of extravastion, damage of filling, amputation or strain of calyxes, change of external kidney contours. Especially precise pattern of kidney parenchyma damage and presence of pararenal hematoma can be generated by ultrasonic examination [Shaplygin L.V., 1999]. Treatment during closed traumas to kidneys should have preferentially conservative character. It should include confinement to bed, administration of hemostatic resorts (introduction of plasma, Calcium chloride, Dicynon), antibiotics and observation of general conditions, hematuria and hemodynamic indicators. Basic indications to the urgent operative treatment during closed damages of kidneys are the buildup of interior bleeding, increase of pararenal hematoma, intensive long-term hematuria leading to a decline of the general state, and combination of damages to kidney and traumas of other internals. In such cases operation begins with a median laparotomy and revision of abdominal cavity organs. This access is justified since it allows to single out and apply tourniquet over renal vessels of the defective kidney and stop bleeding immediately after baring an abdominal cavity (before dissection of Gerotas fascia). After that, surgeon revises a kidney and,
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if possible, applies sutures over rupture of renal parenchyma, thus saving kidney. When performing regenerative operations on a kidney, only dissolving suture material should be used. Restitution of the defective kidney is facilitated by its placement in special vycril net, and application of local hemostatics (oxidized supercellulose, a gelatinous sponge-gel, microcollagenic materials) during suturation of kidney wound [Veliev E., 1993]. Operation is completed by nephrostomy and drainage of pararenal space. Antibiotics are administered. Nephrostome is maintained during two and more weeks, and then, after X-ray confirmation of the kidney wound healing and satisfactory ureter passability, it should be boosted for 23 days, followed by its removal. Damages to ureters are separated by side (right, left side, bilateral), localization (damage of the upper, average and inferior third) and by form: on open (bruise, gutter wound without damage of all stratums, a gutter wound with a damage of all stratums, rupture, dressing during operation) and closed (bruise, incomplete rupture of a wall, the full rupture of a wall, break). Wounds of ureters in wars of first half XX century are seldom encountered. With increment of destructive firearms power, ureters started to be involved in the damaged regions. Thus, damage to ureters during the modern combat attains 3.3 % in the general structure of genitourinary system wounds. During a peace time, damages to ureter are seldom. Both, during peacetime and combat operationsm, surgeons encounter open damages of ureters more often now. Closed damages of ureter during combat and peacetime are seldom and accompany severe combined polytraumas with a kidney crush or separation. In peacetime practice, surgeons should encounter damages of ureters during various surgical, gynecologic or urological operations. In the modern local conflicts, basic share of wounds to ureter is comprised of bullet wounds. Anatomical features of ureters location (close encirclement by other organs) cause in all cases combined character of their wounds with damage of no less than two vital organs, which inevitably burdens course of a wound process and impedes well-timed diagnostics. The first hours after wound to ureter proceed asymptomatically; therefore it is necessary to be especially vigilant when revising entry openings in a projection of retroperitoneal space. Detection of damage to ureter during operation is promoted by IV introduction of indigokarmyne solution and revision of retroperitoneal space from the wound side. In case of well-timed detection of ureter wound, resection of the defective section is performed in skewed direction, and then seamed by thin (0000) dissolving thread (at a diastase no more than 3-4 cm) with keeping frame tube (interior stent) for 10-14 days. If it is impossible to conduct regenerative
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operation, surgeons should adjust reflux of urine from kidney (pyelo-, a nephrostomy or an ureterostomy) for the subsequent regenerative operation in specialized hospital. The ureterocutaneostomy is undesirable because of complex surgery, required for subsequent restitution of ureter passability. In most cases, the diagnosis of ureter damage stated when the urinary overflows develop, which usually happens 412 days after wound. If they are pierced, urine starts to flow from the wounds. In these cases early regenerative operations are ineffective. Similar to cases with extensive damages, it is necessary to execute pyelo -or a nephrostomy for urine diversion and creating conditions for subsequent restitution of a ureter in urological hospital. Bladder damages. It is important to discriminate intra- and extraperitoneal damages to bladder. By localization surgeons discriminate damages to forward, lateral, back, bottom, neck, a vesical delta circuit. By the form of damages: Occluded: bruise, incomplete rupture, full rupture; Open: bruise, wounds: full and incomplete, gutter, through, blind. Damages of the bladder always took a significant place in wartime statistics, and their exclusive severity explains steadfast attention of surgeons. Treatment of casualties with damages to bladder till now poses a challenge to the military surgery: in the modern wars the lethality of this wound attains 25.0 %, and in peacetime 14.0 % of all casualties in this class [Shpilenia E.S., 2000]. Among gunshot damages to genitourinary system, bladder wounds during the modern wars comprise 16.6 % of, predominately plural, fragmentation wounds (78.6 %). Increased yield of the firearms caused higher incidence of through wounds (64.3 %) and the number of (42.8 %) mixed (extra-and intraperitoneal) bladder wounds. In conflict regions the number of closed bladder traumas has essentially increased, reaching 1/3 of all bladder damages [Dubrovsky A., 1999]. Bladder position in relation to the pelvic bones and organs of an abdominal cavity creates background for high incidence of combined wounds. Pelvic bones, organs of an abdominal cavity and the inferior extremities are usually simultaneously damaged. Frequency and extents of combined wounds of bladder with damage to many anatomical structures and organs cause severe condition in the casualties. Frequency of shock state attains 92.9 % for wounds and 66.7 % for closed bladder damages. Condition of casualties with damaged bladder is related not only to the destruction, caused by a projectile, but also to leak of the urine into abdominal cavity and environment leading to terrible complications if evacuation is delayed. Ruptures of bladder walls
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cause urine to leak in the fibrous environment or an abdominal cavity. An imbuing of pelvic fat with urine and its absorption causes intoxication that leads to impairment of local and general organism resistance. Granulation bank is not formed; urinary leaks are promptly spread, contaminating greater areas. As a rule, joining infection contamination leads to meltdown of fascial walls, alkaline decomposition, and deposition of salts causing incrustation of infiltrated and necrotized tissues, urinary phlegmons of pelvic and retroperitoneal pelvic fat. Vessels of a pelvis are getting involved in the process, causing periphlebitis, phlebitisis and thrombophlebitis. The separation of thrombi quite often leads to embolism of branches of a pulmonary artery causing infarcts of a lung and infarct-pneumonias [Shevtsov I.P., 1972]. Necrotic and inflammatory processes of bladder wound region spread to entire bladder causing purulent-necrotic cystitis and pyelonephritis, pustular pyelonephritis, abscesses and anthraxes of kidney. If the bladder rupture combines with fracture of pelvic bones and their contamination by urine, necrotic process starts, followed by an osteomyelitis. Intraperitoneal damages of the bladder in a combination with leaks into abdominal cavity are combined with peritonitis and severe intoxication. Therefore, both intra and extraperitoneal damage to bladder rapidly cause severe, life-threatening complications. Most patients, deprived of timely surgical aid, perish from a peritonitis and urosepsis. Gunshot wounds cause this pathological process to be more severe due to extensive damages to bones and soft tissues, as a rule, due to combined damages to bladder and rectum or other intestinal departments, rapid spread of infection, including anaerobic gangrene. Severity of the casualties general condition demands prompt and, at the same time, extremely accurate estimate of the urinary system condition. General symptoms, caused by penetrating wound to abdomen, dominate over a clinical pattern of combined damages. Locations of entry wound openings, cute ischuria, hematuria, damage imbuing by urine testify to damages of bladder. Combined wounds cause difficulties in differentiation of extra -and intraperitoneal damages on the basis of data of clinical patterns alone. Final judgment on character of the bladder damage is possible on the basis of additional examinations. Simplest and most accessible instrumental method of diagnostics at stages of medical evacuation is catheterization of bladder. During catheterization, damage to bladder is indicated by: lack or inappreciable quantity of urine in the bladder for casualty who did not urinate long time; excessive quantity of urine, exceeding normal organ volume;
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 mismatch of fluid intake (introducing 300 ml of saline isotonic solution) and a fluid output in catheter (Zeldovich positive sign). Most informative picture is provided by radiological techniques. Survey of X-ray patterns of abdomen and pelvis can show fractures of bones, foreign bodies, and presence of the free fluid or gas in an abdominal cavity. After a catheterization and emptying a bladder, surgeons should perform cystography, allowing revealing disorders of bladder integrity, differential diagnostics between intra and extraperitoneal rupture, detect urinary flows. For this purpose, bladder is filled with 300-350 ml of 15 % of a X-ray contrast solution followed by radiographic analysis in direct and lateral projections. Bladder is then emptied and after flushing by Furacilinum or other antiseptic fluid solution, and after that, so-called pelvic region the flushed picture is taken, allowing to detect flows after extraperitoneal damage of a bladder. Direct radiological attribute of bladder damage is a presence of contrast medium beyond bladder limits, indirect strain and bias of bladder up or aside. In case of intraperitoneal rupture contrast shades and strips in an abdominal cavity are found among inflated loops of an intestine. Extraperitoneal rupture reveals blurred shadows beyond the displaced bladder contour. Gunshot wounds of a bladder require urgent operative measures. Main principles of surgical treatment for wounds with the open bladder damages consist in the following: dissection of wound canal for maintenance of good reflux of wound contents, urine, blood, pus; excising obviously nonviable tissues, removal of foreign bodies and free osteal fragments; lower-median access to bladder, irrespective of wound location; mandatory revision of a cavity of a bladder and removal of projectiles; suturing of intraperitoneal wound by catgut in two rows with remaining PVC tube for introduction of antibiotics; accessible wound in the bladder is sutured by a catgut (dissolving suture material); wound in the region of bottom and neck of bladder is sutured from mucosal side, drainages installed at the place of suture; bladder is drained by application of cystostoma (sealed suturing of bladder is prohibited); drainage of pelvic fat, considering its infection from the moment of wound, greater incidence of combined and massive damages in all casualties, using procedures by Kupriyanov-McWarter (Fig. 9.38. see color insert). Mechanisms of the closed traumas being similar, their causes differ in peacetime and during combat. Peacetime surgeons encounter mostly casualties of road accidents or falls from altitude.
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The same causes happen during wartime, but such traumas are caused by bodies compression by armored vehicles (heavy armor) during training exercises, mine blasts or building collapsse. Causes of trauma in peacetime and wartime presume strong mechanical action on pelvic region, leading to severe combined traumas. More often, trauma of bladder is combined with fractures of pelvic bones with damage to sciatic (66.6 %), pubic (75 %) bones and a sacroiliac joint (25 %). In addition to fractures of pelvic bones, extraperitoneal damages of a bladder are combined with damages of urethra (25 %). Predominant are combinations of closed traumas to bladder and abdomen, inflicted during military conflicts, ruptures and bruises of a parietal peritoneum, mesentery of small intestine or the organ itself. The basic signs of closed bladder damages are pain in the bottom of abdomen and suprapubic region, ischuria, hematuria, frequent void urination calls. Tympanitis above a pubis is noted in the patients along with free fluid in lateral canals of a abdomen, hanging front rectal wall, found during the rectal examination. For extraperitoneal damages physicians note: lack of bladder boundaries, a blunt sound above a pubis without precisely shaped boundary, building up infiltrate in ileal fields, swelling of spermatic cords, pastosity above prostate gland during rectal examination. However these signs are not necessarily met simultaneously. They can originate in series and be the shaded attributes of the general character, related to shock, hemorrhage, signs of peritoneum irritation etc. During diagnostics, the major attention should be given to clarification of the mechanism of trauma, degree of bladder fill. Tracks of a trauma on a body, grazes in the region of abdomen, disorders of urination, hematuria, acute morbidity in suprapubic region, tension of forward abdominal wall, fluid aggregation in the lateral canals of abdomen suggests damages of bladder. Presence of attributes of pelvic bones fracture reinforces this suspicion. Revision of damage character demands mandatory cystography. Casualties with the full closed damages of the bladder require surgical treatment. The purpose of operation is restitution of bladder wall integrity, urine diversion and drainage, if necessary, draining urinary leaks. Urethra Damages. Urethral damages are divided into: - Closed (occluded) and open, insulated and combined; - By localization damages of a forward urethra (trailing, scrotal, perineal department of spongiform region) and a back urethra (a webbed and prostate region);
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- By the form of a damage: open bruises, gutter and nonperforating wounds without damage to all stratums of urethra wall; gutter, blind and through wounds with damages of all stratums of urethra wall, urethra rupture and crush; closed bruises, incomplete ruptures or surface tears, full ruptures, crush. Damages to urethra of gunshot and explosive origin comprise 10-14 % of wounds to organs of genitourinary system. 17.8 % casualties in Afghanistan and 37.5 % in the Chechen Republic manifested wounds of a urethra, caused by projectile fragments. 28.5 % casualties in Afghanistan and in 12.5 % in Chechen Republic the urethra was damaged by mine blasts and explosions [Shpilenia E.S., 2000]. In a peace time gunshot wounds to urethra is seldom encountered in surgical practice. Significant destructive force of modern projectiles in combination with anatomical location of the urethra practically excludes insulated damages. Most often urethral wounds are combined with gunshot fractures of pelvic bones, preferentially sciatic and pubic. Damage, inflicted by factors of explosion or mine blasts causes a high level of combination with wounds to inferior extremities (75 %), scrotums and its organs and penis (50 %). Condition of casualties, entering stages of the qualified or specialized aid is defined by the character of inflicted combined damages and localization of wound of urethra. Wounds of a back urethra are accompanied by the significant fractures of environmental tissues and organs, urinary leaks proximally genitourinary diaphragm and severe course. Mine-explosive wounds of urethra differ by extreme severity since they capture organs of an abdominal cavity, extremities, buttocks, a perineum and pelvic bones, causing the extensive fractures, accompanied by shock and significant hemorrhage [Marerovic T.O. et al., 1997]. Wounds of a urethra are accompanied enough by the expressed symptomatology: morbid void urination, acute ischuria (hyperinflated bladder) and urethral hemorrhage, tumescence in perineum, urination from a rectum in case of combined wounds. Nevertheless, recognition of gunshot and explosive wounds of a urethra sometimes is related to certain complexities, especially considering that bullet wounds (76 % cases) cause entry and exit points being remote from urethra. Difficult to diagnose clinical pattern is related to combined damages of bladder and a urethra, encountered in 38 % casualties. Despite recent negative attitude it justifies diagnostic catheterization use. Impossibility of catheterization confirms disorders of urethra integrity. Analysis of treatment of urethra damages together with catheterization, performed at stages of qualified and specialized surgical aid, is yet to discover any related complications [Shpilenia
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E.S., 2000]. This is related to cautious application of catheters, made of modern synthetic materials, diligent care and early introduction of antibacterial drugs. Successful catheterization of bladder facilitates the subsequent treatment. Metal catheters should not be used for this procedure. Suspicion of damage to urethra can evolve after X-ray inspection of pelvis, from the character of bone fractures and a location of projectile fragments. Nevertheless, complete information on localization and character of damage to urethra can be produced only by urethrography. For this purpose it is recommended to inject 1520 ml 20.0 % X-ray contrast solution under small pressure in the urethra. Examination should be conducted in direct and skewed projections, though it is not always possible because of fractures to pelvic bones. In case of bruises and incomplete breaks of urethral walls and successful installation of a catheter, it is possible to conduct conservative provisions. Gunshot wounds to urethra are seldom of easy or average degree of severity, when one can avoid operation. If it is impossible to conduct surgical intervention at the stage of qualified aid, it is necessary to diverse urine by using trocar cystostomies or installation of suprapubic capillars. Treatment, alongside with antishock provisions, begins with diversion of urine through high cystotomy, dissection of wound canal to maintain removal of wound contents, urine, blood, pus; removal of foreign bodies and nonviable tissues. During operation it is necessary to attempt Foley urethra catheterization, using method of colliding bougies [Gorjachev I.A., 1996]. Metallic bougie is inserted from the side of external urethra opening, while another bougie is introduced from the bladder side. When they are joined, the bougie, inserted from urethra, is advanced to a bladder, not losing contact with the second bougie, which is gradually removed. After that, end of bougie is covered by rubber tube and Foley catheter is installed. Operation comes to an end by application of a suprapubic vesical fistula and drainage of pelvis through wound at the forward wall of abdomen and perineum by Kupriyanov or Buyalsky-McWarter. Catheter is left in urethra for 3-4 weeks. Ureteric catheter should be inserted daily between catheter and urethra at the depth of 10-12 cm, used to flush urethra with antibiotics (Fig. 9.39. see color insert). Outcome of gunshot wounds of a urethra are, as a rule, strictures, frequently also obliterations demanding complex reconstructive interfering, directed on restitution of independent urination, however they can be conducted only in specialized hospitals. During modern confrontations, damages of genitourinary system are represented by the increased number of the closed urethral damages, comprising 38.4 % of all damages to urethra. In
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peacetime surgical practice, closed damages of urethra predominate (91.6 %) above open wounds. In armed conflict regions, predominant causes of closed damages to urethra are road accidents (85.7 %), however unlike peacetime, traumas are caused by compression of body with heavy armor (28.5 %), armored vehicles blasts (14.2 %) or overturning (21.4 %). Strong mechanical impact causes all closed damages of urethra to have combined character. However, if during wartime simultaneous damages of urethra and pelvic bones and extremities, during peacetime remote organs are often damaged. Extensive fractures involving damages to two, three and more organs cause the significant severity of these casualties. During local conflicts, state of casualties is aggravated by long terms of delivery to stages of the surgical aid, and 73.7 % casualties with the closed damages to urethra being in state of shock, preferentially IInd degree (42.8 %). The most typical signs of the closed urethral damages are: dull ache in the region of a perineum and scrotums; acute pain on a course of a urethra, especially at a desire to urination; blood discharge from a urethra in the form of clots or crusts around of external opening of urethra; ischuria, frequent barren desires to an urination; enlarged bladder, as defined visually or percutory; urinary infiltration of tissues, manifested by pastosity of perineum skin, interior hip surface, scrotums and overhanging front rectal wall with its pastose consistency during rectal examination. Specified signs allow suspecting damage to urethra, but they do not prove damage fact. Diagnostics of damage is combined with rendering assistance for ischuria in bladder and consists in cautious nonviolent catheterization of bladder by soft rubber catheter. If latter is successful, it proves easy or average degree of severity of urethral damages. Catheter should be left in bladder for 78 days. Failed attempt of soft catheter introduction in bladder does not warrant introduction of metal catheter. Most reliable data about state of urethra are produced by the ascending urethrography. Treatment of urethra damages of easy and average degree of severity is, as a rule, conservative. If the damage is not accompanied by an acute ischuria, the patient is prescribed rest, cold pack over perineum, spasmolytics, dehydrating drugs, antibiotics. In case of an ischuria urinary canal is entered by thin rubber catheter for 78 days. In impossibility of catheterization, the bladder is
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emptied by capillary puncture 3-4 times a day or patient undergoes capillary (troacar) cystostomy for 810 days before reduction of an edema at the site of injury and restitutions of urination. In case of full rupture (break) of urethra the operative measure is indicated. Surgical tactics does not differ from those for open wounds with mandatory urine diversion and drainage. The primary urethra suture can be imposed during first hours after trauma in the specialized urology department by the surgeon familiar with primary suturing of urethra [Gluharev A., et. al., 1999]. External genital damages Wide application of anti-personnel mines led to increasing number of external genital wounds, posing a serious problem to the field surgery. In the modern combat, wounds of scrotum comprise 1922 % and wounds to penis 11-27 % of damages to genitourinary system. Number of closed damages to scrotum has increased as well: in Afghanistan closed traumas number increased to 16.6 %, and in the Chechen Republic up to 52.9 % of all damages to scrotum. Unlike other combat traumas to organs of genitourinary system all damages to penis are open. Closed traumas of penis, characteristic for sexual extremes, are rarely met during combat. Damages to scrotum and its organs are divided into open and closed. They can be also insulated and combined. By the damaged side they are divided into on right, left side and bilateral, and by damages type: a) closed: bruise and the superficial hematoma of a scrotum, bruise of a testicle; surface tear of tunica albuginea without dropout of parenchyma; rupture of tunica albuginea with dropout of a parenchyma; crush of testicle; bruise and rupture of spermatic cord and epididymis; dislocation of testicle; b) open: gutter, blind, through wound of a scrotum without damage of its organs; gutter, blind, through wound of a scrotum with damage of organs; bruise of testicle, appendage, spermatic cord; rupture of these organs; crush of a testicle; separation of testicle from the cord. The most severe are gunshot wounds to scrotum, leading almost always to damage of scrotum, appendages segments of the spermatic cord. Insulated gunshot wounds of scrotum are encountered extremely seldom. The general state of casualties, as a rule, is severe. Diagnostic of wounds to the scrotum is usually easy. Entry wounds in 80 % are located on a skin of the scrotum or in immediate proximity. Edges of bullet wounds, due to high elasticity of the scrotum skin expand and curl, which, being accompanied by a bleeding. These features give garbling impression on the real character of a wound. Presence of well developed vascular network and areola fat tissue cause also interior bleeding leading to extensive hematomas.
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Hematomas of scrotum can reach significant (up to 800 ml) size. Palpation in these cases does not allow locating damages of testicle or appendage. Exterior of wound and its depth do not reflect true character of fractures. During Vietnam War surgeons noticed that modern projectiles can cause severe damages combined with superficial gutter wounds to scrotum [Salvatierra O. et al., 1969]. This observation was confirmed during the modern military conflicts. External examination allows locating wound of a scrotum, but the final judgment on the depth and character of damage is only possible after additional examinations (Fig. 9.40. see color insert). Symptomatology of scrotum wounds is defined by combined character of wounds and damage of its organs. Gutter wounds to skin of scrotum limit the set of symptoms, preventing general and local responses. Wounds of testicles are accompanied by intensive pain in region of damage. Quite often, external examination reveals dropout of testicle in a wound of scrotum, including insignificant gutter wounds, due to skin contractions. Survey and radiographic analysis of the pelvic region allows locating fragments of projectile in the projection of scrotum and surgically removing them. Untouched fragments of a projectile in the scrotum can lead to subsequent suppuration of wounds and fistulas, not healing for lengthy periods of time. The ultrasound is an optimal resort for diagnostics of scrotum wounds, allowing locating damage of a testicle at preoperative stage. The diagnostics of wounds to scrotum requires special attention due to possible damages of nearby genitourinary organs the urethrography can locate the contrast medium leaks in a scrotum. Despite using modern research methods in the clinical practice, reliable determination of wound character for scrotum and its organs at the early stages of the surgical aid, is still possible only using primary surgical treatment. Treatment of the open damages includes anesthesia (introduction of analgetics, novocaine blockage with antibiotics according to Lorin-Epstein), primary surgical treatment. The operative provision consists in excision of crushed and necrotized tissues, removal of foreign bodies, final stopping of bleeding and application of rare sutures with drainages. Dropout of intact testicle after a surgical treatment requires its placement in scrotum, wound is drained and rare sutures are applied. If there was no crush of a testicle suturing is performed by white rare catgut (vicryl) threads. If the testicle pole is crushed, its resection is performed within the limits of able-bodied tissues with application of rare sutures. Vaginal shell is resection is not recommended. It is also necessary to perform surgery according to Bergman or Vinkelman, leaving the drainage open. Quite often, despite the intact testicles there is a separation of skin of scrotum from its root. In this surgeon should not be in a hurry to
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translocate testicles under a femoral skin, as sometimes mentioned. The cutting muscles, which lift testicles, push them up. In such cases, it is sufficient to cover testicles with oil napkin soaked with antibiotics. 23 weeks later testicles turn out to be inside regenerated scrotum. The closed damages of scrotum are caused by the impacts, drop and compression. Ample blood supply leads to hemorrhages and formation of the superficial hematomas. In case of simultaneous damage to organs of scrotum there are the deep hematomas, divided into extra- and intravaginal. Extravaginal hematomas, as a rule, are caused by damages to spermatic cord or testicle covers and have no precise boundaries. Their main difference is possibility to palpate a testicle, frequently painless, because it does not suffer. Intravaginal hematomas are formed due to an aggregation of a blood and clots between parietal and visceral leaves of a vaginal sheath of a testicle. Usually they are precisely encircled, morbid and strained. Unlike hydrocele, they are not transparent; testicle in this half of scrotum is not possible to palpate. These hematomas are formed by damage to testicle or appendage. Unlike damage to scrotum, the damage to testicle is accompanied by the strongest pain, a vomiting and sometimes shock. Sometimes, blunt traumas cause the displacement of testicle to perineum, groin, suprapubic region such type of a damage is named as dislocation of testicle and is simple to diagnose. Treatment of closed damages to scrotum is preferentially conservative. Casualties are prescribed relaxation, rest, cold applications, and analgesics. In presence of data on testicle damage (deep intravaginal hematoma, expressed pain syndrome, vomiting) similar to dislocation of the testicle, it is indicated that surgery is required, but in most cases it can be delayed up to a stage of the specialized surgical aid. During operation, depending on the detected changes, deep and superficial hematomas are emptied, only nonviable testicular tissues are removed, testicular sheath is sutured using catgut. Indication to the testicle removal is its crush or separation of the testicle from spermatic cord. In case of dislocation, the testicle is moved to scrotum and affixed to the bottom of a scrotum. Damages to a penis are divided: by localization: bridle of a prepuce, prepuce, balanus, body of the penis, root of the penis; By the damage form: closed: bruise, fracture, dislocation, compression (infringement) by foreign body; open: rupture of the prepuce bridle; gutter wounds without damage and with damage of tunica albuginea, cavernous bodies, urethras; scalping of penis; a separation (traumatic amputation) of
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penis. Diagnostics of gunshot penis wounds are based on the data of anamnesis, survey, palpation and X-ray inspection. Character of gunshot penis is revised after stopping a bleeding and revision of the wound (locating entry and exit openings, direction of wound canal, presence of foreign bodies). More often, casualties enter stages of surgical aid with the shaped hematomas and without bleeding. The intensive bleeding is combined with damages to cavernous bodies in 12 % casualties. Quite often, penis wounds with damaged urethra disrupt urination to the extents of acute ischuria. In these cases penis wounds are accompanied by urethremorrhagia. Urination disorders can be related to the urethral compression by hematoma and increasing edema of tissues. When treating penis wound, it is mandatory to remove foreign bodies, capable to cause inflammatory complications, strain of the penis and a pain during erection. For this purpose radiological survey is indicated for casualties. When rendering the surgical aid, simultaneously with the provisions directed on stopping of bleeding and anti-shock provisions, combined penis wounds require from the general surgeon highly sparing wound treatment. Superficial gutter wounds with inappreciable damage to tissues should be treated by application of a compressing bandage only. Healing of similar wounds happens in short terms and, as a rule, without complications. More extensive wounds to penis skin should be sutured after economically excising the defective edges of a wound. In most cases edges of a cutaneous wound should be reduced without a tension. Extensive scalping wounds of the penis demand sparing primary surgical treatment with respect to the damaged area and possibility of the subsequent plasty. Extensive damage to a skin of penis body requires damage recovery using leaves of a prepuce. If there is damage of cavernous bodies, surgical manipulations should be sparing and conducted only after necrosis region is formed. Tunica albuginea and cavernous bodies are sutured by catgut (vicryl) seams. Penis tissues excision is conducted only in case of the obvious frailty of penis tissues. Seams should be applied for suturing cavernous bodies and tunica albuginea in a transverse direction towards penis axis to avoid compressing cavernous bodies or entrapment of arterial vessels. If the penis avulsion happens and even a small cutaneous section or tunica albuginea is preserved, it is necessary to perform tissues suturing. In case of complete traumatic amputation of a penis, after the stump heals, phalloplasty is indicated. Phalloplasty can be executed in specialized hospital.

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9.10. EXPLOSIVE DAMAGES of FEMALE GENITALS

Explosive traumas of the female genitals are encountered during technogenic disasters and acts of terrorism in 20-40 % of women casualties. In armies of some countries with is the significant share of women personnel, this pathology is also happening during combat; blasting of the noncombatants on anti-personnel mines in the regions of military conflicts are frequent also. Physicians isolate wounds and closed damages of external and interior regenerative organs. Traumas of the external genitalia (pubis, vulvar lips, clitoris) result from direct action of explosion on tissues. Explosive trauma is predominated by the wounds (up to 80 %) with ample external bleeding, resulted from good blood supply of the given anatomical region. It is necessary to note that severity of such condition state is seldom caused only by the given damages; the wound of genitals can be inappreciable, however accompanied by distant damages to other vital organs. In 2025 % cases there are closed damages, causing greater hematomas inclined to extend on pelvic fat, subcutaneously-fatty hip tissue and abdomen; in 10-15 % cases suppuration is observed. Wounds of the internal genitals during the mine-explosive traumas are encountered in 5-23% cases and by character of damage refer to distant ones. Insulated damages of a uterus, uterine tubes and ovaries can be observed during fragmentation wounds; however their protection by the adjacent anatomical structures (a pelvic ring, muscular and fatty files of a perineum) causes this pathology to be rare. It is necessary to consider, however, that if woman is pregnant, has ovarian cyst, hydrosalpinx or other fluid-flow formations in appendages, the explosion, can provoke rupture of the organ with subsequent evolution of a massive interior bleeding [Harrison S. D. et al., 1995]. Combination of traumas to the interior and external genitals is observed in 22 % of women with the wounds of this region [Tsvelev Yu.V., 1996]. Many casualties with wounds to interior genitals manifest damages to 2-3 adjacent organs , and for nonpregnant women, they are becoming leading damages and, thus, define further surgical tactics. Most often, traumas of interior genitals are combined with wounds to the organs of abdominal cavity (up to 76 %), which defined severity of damaged conditions in 54.2 % [Swartz D., Harwood-Nuss A., 1998]. Features of the female genitals explosive trauma are: insulated wounds of genitals during the explosive trauma are met in 0.2-1.5 % cases. Overwhelming majority of cases (up to 99 %), the trauma of genitals is combined with traumas
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of extremities, pelvis, damage to an intestine, bladder [Coppola P., Coppola M., 2000]; tactics of casualties treatment depends on pregnancy; thus pregnancy is the factor acutely worsening forecast; trauma is often accompanied by ample external bleeding that demands pressing surgical aid; explosive trauma in women can cause intraperitoneal bladder rupture, causing internal bleeding, damage to fluid-flow appendages, hysterorrhesis in late gestation; cause of external bleeding in nonpregnant women are wounds to external genitals, whereas during pregnancy the external bleeding in 70 % cases is accompanied by bleeding from uteral cavity of the uterus, which is rather difficult to diagnose; untimely or inaccurate surgical intervention leads to specific pathology: infertility, genital fistulas etc. These complications will later demand complex reconstructively-plasty surgeries. Classification of an explosive trauma of female genitals organs: 1. in nonpregnant women; pregnancy within 23 weeks; pregnancy for more 23 weeks; accompanied by the intranatal destruction of embryo. 2. insulated combined (with damages to extremities, organs of an abdominal cavity, pelvis, other regions); 3. external genitals organs; internal genitals; both. 4. closed; open. 5. caused by the fragments and secondary projectiles (fragments of pelvic ring bones, etc.) damages caused by the blast wave. Diagnosis is stated the basis of examination, with respect to type and character of damages. External examination and survey with mirrors clarify character of damages, localization of wounds, hematomas, burns, presence of bleeding from cavity of uterus, etc. Palpation and bimanual examination clarify size of hematomas, presence of colporrheses, attributes of damage to interior genitals, presence of pregnancy. Damage to forward and back walls of vagina require catheterization of a bladder and rectal examination, which allows to exclude perforation vesicovaginal and rectovaginal barriers, and wound of urethra.
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Vulvar hematoma with small size and without trend to enlargement is subject to conservative treatment. Operative treatment is indicated for buildup of hematomas, attributes of their suppuration, presence of crushed tissues, and suspicion on damages to large vessel of perineum. Treatment consists in sanation, careful hemostasis and drainage of a cavity. Application of coaptation sutures is admissible. If a wound or hematoma is localized in the region of clitoris, suturation is expedient after introduction of metal catheter in bladder to prevent a damage to urethra. Vaginal wound primary surgical treatment includes sanation and application of primary seams. With additional hemostatic purpose, surgeons carry out tamponade of vagina (for 56 hrs and it there is no uterine bleeding). Inappreciable superficial wounds to perineum and wound of vulva can be sutured tightly after treating by antiseptics and economical excision of the destroyed edges. Special attention is necessary for wounds of the anterior vaginal wall. This condition witnesses high probability of urethral damages. These wounds also can be caused by fracture of haunch bones, accompanied by extensive pelvic hematomas, major hemorrhages and a high lethality of 40-50 % [Niemi T. A., Norton L. W., 1985; Coppola., Coppola M., 2000]. Such fractures of a pelvis refer to to the class II by risk of damage to adjacent organs of urogenital systems (Malgaigne pelvic fracture, pubic bones fracture). The certain complexity in treatment is represented by traumas, caused by blunt compression of the urethra and periurethral tissues to the pubic symphysis. Such damages are related to explosive trauma in 46 % cases and require bladder catheterization with the subsequent hard tamponade of a vagina (only after full survey and exclusion of pregnancy and other damages). This approach prevents extensive periurethral hematomas, accompanied by the compression of urethra, an ischuria and the subsequent evolution of cicatrical strictures [Shwartz D., Harwood-Nuss A., 1998]. Combined wounds to organs of perineum with damages to rectal sphincter require primary surgical treatment of wound with economic excision of sphincter, infiltration of walls by antibiotics, application of unnatural anus on a sigmoid intestine. After completing manipulations on an intestine, vagina and perineum are recovered. The laparotomy is indicated in presence of interior bleeding attributes, or penetrating character of wound, confirmed by data of laparoscopy. It is necessary to consider that wounds to lateral vaginal vault can penetrate into a parametrium and be accompanied by wounds to uterine and ileal vessels. Hence, such damages require laparoscopy for verification of the diagnosis (increasing hematoma of a parametrium) with the
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subsequent hysterectomy. Explosion trauma during pregnancy. Principal cause of intranatal death of an embryo is mothers death. If the pregnant woman is in shock state, the embryo perishes in any gestation period in 83 % cases [Henderson S.O., Mallon W., 1998] and the best treatment of a fetal embryo after trauma is adequate therapy of mother. At the same time, one of principal causes of injured pregnant woman death is a bleeding related to abortion [Lavery J. P., Staten-McCormick M., 1995]. The most frequent cause of intranatal traumatic death after high-yield explosions is the hysterorrhesis and placental detachment, as observable in 40-50 % casualties with an intranatal lethality up to 100 % [Agnoli F. L., Deutchman M. E., 1993]. If there is no high-power direct injuring factor, incidence of traumatic abortion comprises 30-88 %. Even the minimal trauma with inappreciable mechanical effect on the pregnant woman is accompanied by stressor effects, leading to intranatal death or abortion in 20-30 % cases [Hill D. A., Lense J. J., 1996]. Adequate diagnostics and medical tactics for trauma in pregnant women adheres to following classification (on Henderson S.O., 1998) Group 1. Women with the trauma, unaware of their pregnancy. Pregnancy leads to significant physiological changes in organism, possibly preventing impartial assessment of state severity and a therapy choice. Exception of pregnancy by testing for chorionic Gonadotropin allows avoiding serious complications related with misdiagnosis of gestation abortion. Group 2. Pregnancy within 23 weeks. Therapy should be directed, first of all, on stabilization of mothers state, as during these terms the embryo is nonviable. Group 3. More than 23 weeks terms. In these situations the aid should include mother and embryo. Thus, spontaneous traumatic abortion at these terms, in 70 % cases demands laparotomy and cesarean cross-section. This operation can be required for preservation of embryo life. In all cases, participation of specialized neonatal reanimation teams is necessary. Group 4. Pregnant women in extremely severe conditions. Disproportional blood circulation of mother on a placental blood stream reinforces severity of the traumatic shock. This class of casualties after stabilization of a state require cesarean cross-section with a hysterectomy. It is necessary to consider that the embryo in a womb is a hindering factor and poses danger during resuscitatory provisions. Misbirth most typical attributes are abdominal pains and external bleeding. Frequently, pain syndrome does not allow differentiating abortion from an interior bleeding, caused by the rupture
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of internals, hence in these cases laparocentesis or a laparoscopy is indicated. Premature placental detachment attributes are abdominal pain, tension and morbidity of a uterus, as found during palpation, rising anemia owing to formation of a retroplacental hematoma, bloody excretions from urogenitary paths. Evolution of the acute disseminated intravascular coagulation syndrome [by Tsvelev J., 1996] is quite often. The basic attributes of hysterorrhesis are the abdominal pain, acute morbidity at palpation of uterus, building up attributes of acute hemorrhage and fetal destruction of a embryo. Intensive external bleeding demands curettage of uteral cavity (gestation till 20-23 weeks), sometimes a laparotomy with cesarean cross-section or hysterectomy. The indication for an emergency laparotomy during explosive trauma in pregnant women are an external bleeding after 23 weeks gestation, hysterorrheses, premature placental detachment, shock state. In all cases cavity of the uterus should be emptied (cesarean cross-section); subsequent hysterectomy is indicated in case major bleeding and extensive damages to uterus. Penetrating wounds for hemodynamically stable casualties demand laparoscopy at the first stage to estimate internals damages. Explosive trauma in girls has a number of features: distance between the external and interior genitals is less than that in adult women, hence, wounds to perineum represent greater danger, increasing probability of penetrating wounds and interior bleeding; pelvic diaphragm is closer to integuments, hence, even inappreciable superficial wound can cause damages of a pudental nerve and vessels of an urogenital diaphragm with evolution of massive bleeding; rectovaginal barrier is thin, and even inappreciable wound of a vulvar tube can be accompanied by rectal wounds; for children, the bladder is intraperitoneal organ, thereof intra-abdominal bladder rupture is observed much more frequent than in grown women. Tactics of treating women and girls with mine-explosive traumas is identical. In all cases, physicians, should tend to execute adequate surgical interventions, at the same time, trying to preserve reproductive function.

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9.11. THERMAL DAMAGES CAUSED BY EXPLOSIONS 9.11.1. Peculiarities of pathogenesis and clinical picture
Last decades are characterized by the increasing number of disasters and fires related to industrial and road accidents, acts of terrorism, explosions of natural gas. These disasters of a peacetime are characterized by massive human losses, instant nature and severity of inflicted damages. These disasters produce as many thermal damage casualties as the active combat operations. In an explosion epicenter, area is formed where casualties are simultaneously affected by the following injuring factors: explosive blast wave, secondary wounding projectiles (glass splinters, fragments of constructions, constructions, flame, thermal radiation, high temperature of surrounding medium, toxic burning products (smoke, carbonic monoxide, cyanides etc.). In addition to that, sudden explosion appears to be strong demoralizing factor. Activity of injuring factors depends on the type of explosion (explosive, leakage of natural gas or explosive materials) and degrees of casualties protection. Damaging factors affect a human body simultaneously. Therefore, this kind of trauma simultaneously causes: deep burns of integuments; closed traumas and wounds; compressions of various body sections; barotraumas of lungs and ears; thermal-chemical damage of respiratory paths; poisoning with carbon monoxide; general overheating; eye damages and psychiatric disorders. These damages are termed combined. In addition to that, thermal damages include multifactor damages (skin burns, damage to respiratory paths by flame products, carbon monoxide poisoning, overheating of an organism) or insulated damages , when casualties are subjected to single injuring factor (insulated skin burns, inhalation damages of respiratory paths etc.). Skin burns caused by flames, burning clothes or thermal radiation. More often (up to 5080 %) of open body sections are burnt: face, neck, upper extremities. For example, flame temperature can reach 20003000 during coal mine explosions. However, exposure usually comprises
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close to 0.1s. Therefore, skin does not have time to get heated in depth. This, as a rule, results in superficial (IIIIII degrees) burns of a face, neck and hands. Sometimes, even regions covered by clothes are suffering from burns. It is a direct result of gas combustion underneath the clothes. During the railway disaster in Bashkiria in 1989 powerful fuel-air-like explosion caused forest fire, encompassing 6 hectares area, and ignition of railway cars. Majority of casualties were burnt by burning clothes and flames of burning railway cars. Of 469 casualties treated in medical hospitals of Ufa, 177 (37.7 %) casualties had less than 20 % skin destroyed, 158 (33.7 %) patients lost 40 % of skin surface, and other 134 (28.6 %) more than 50 %. According to R.J.Gershtenkern and coworkers. (1985), N.M.Vodyanov and coworkers. (1990), coal mines gas and dust explosions cause combined thermal-mechanical or multifactor damages in 50% casualties. In such cases it is necessary to expect high incidence of burn shock. According to Z. Ja.Murtazina (1995), during railway crash in Bashkiria (1989) burn shock was diagnosed more in 77 % of casualties, with majority of cases being severe and extreme shock. Diagnostic of area and depth of burns. Diagnostics of III degree burns is rather simple. Their telltale signs are skin sections with hyperemia and moderate edema with blisters, filled by yellowish liquid. If the blister cover is split, the wound bottom shows a growing layer of epidermis. Sections of hyperemia turn pale if being pressed, which specifies preserved microcirculation in skin. Capillary response to pressing finger is clearly seen. Pain sensory response is preserved, which can be verified by needle prick. Early differential diagnostics of IIIa and IIIb degree burns is much more complicated. Damaged sections with whitish-grey color and pastose consistency are characteristic for burns of IIIa degree. The burn region is manifested by the dry, yellowish, sometimes dark-brown or black skin in case of IIIb degree burns. Epidermis easily peels from the burnt section. Reliable attribute of the burn depth is transparency of clogged subcutaneous veins under the necrotic scab. Capillary response is absent. Needle prick shows no response to the pain. Hair can be easily and painlessly removed from the deep burns. Objective burn assessment is impossible without estimating the damage area. For this purpose, surgeons use rules of nines and palm, whose area is equal about to 1 % of body surface. The rule of nines is based on the fact that area of various anatomical regions are multiplies of nine: head and neck 9 %, anterior and posterior trunk surfaces on 18 %, the upper extremity 9 %, lower extremity 18 %, and only the perineal and genital skin area comprises 1 % of body
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surface. Burn shock diagnostics. The burn shock accompanies almost all casualties with deep (IIIbIV degrees) burns of more than 10 % body surface or superficial (IIIII degrees) burns of more than 30 % body surface. It is also noticed in patients with the combined thermo-mechanical and multifactorial damages and smaller burn areas. By severity of clinical manifestation, three degrees of burn shock are isolated: light, severe and extremely severe burn shock. Light burn shock (I degree) takes place if the area of deep burn is less than 20 % of body surface. Integuments are pale. Casualties manifest cold fit and light thirst. Consciousness is clear. A pulse within 100 beats/min, AP is labile. Short-term hourly diuresis (30 ml) drop is noted on the background of normal daily quantity of urine. Shock does not last longer than 2436 hrs. Welltimed treatment terminates shock for all casualties. Severe burn shock (II degree) takes place if deep burns area is 21-40 % of a body surface. Complaints to strong cold fit, thirst, pains in wounds are noted. Exaltation and motorial disturbance during first hours are replaced by retardation. Consciousness is maintained. Unaffected skin is pale, dry, cold. A tachycardia up to 120-130 /min, AP lowered. Decrease of hourly diuresis during first 912 hrs down to 400600 ml daily. In some cases the macrohemoglobinuria is discovered. Nausea and multiply vomiting is noted. Blood analysis shows hemoconcentration (Hb to 185190 g/l), with expressed metabolic acidosis. Body temperature is normal or lowered. Duration of shock is 48-72 hrs. Well-timed and adequate treatment allows terminating shock in majority of casualties. Extremely severe burn shock (III degree) happens if area of the deep burn is over 40 % of body surface. It is characterized by severe disorder of all organs and systems. Casualties manifest strong thirst, cold fit, multiply vomiting (vomit is colored as coffee ground). Right after traumas transient exaltation, soon replaced by the deep retardation. Skin is pale, soil-colored and cold. Pulse 140-150/min, AP lowered to 80-90 mm.Hg. Dyspnea is present. The expressed oliguria is replaced by anuria. Urine color is from dark red to almost black, with pungent smell of ashes. Blood contents manifest azotemia (up to 40-50 mmol /L), decompensated metabolic acidosis, expressed hemoconcentration (Hb up to 190 g/l), leukocytosis (up to 20-25 * 109/L), hypoproteinemia, hyperpotassemia. Lethality in severe burn shock state reaches 80 %. Duration of shock for survivors is 6072 hrs.
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Despite clear symptomatology of a burn shock, its diagnostics (especially shock of I and II degree) is complex. There is no clinical attribute, observed in all casualties; on the contrary, sometimes shock symptoms are noted in the burn casualties, who do not actually manifest the shock itself. Exception is the area of burn (especially deep), allowing reliably diagnose burn shock. Final diagnostics of a shock degree is performed through dynamic observation over the casualty during 12-24 hrs. However, timely and sufficient infusional therapy demands early diagnostics of shock degree. Therefore, basic attributes are a total area of burn, area of deep damage, combination with mechanical injuries, and damage to respiratory paths by combustion products. Multifactor damages, including latter, are frequently accompanied by the disorders of consciousness during 23 hrs to day after trauma. These patients frequently die, being still unconscious. Usually, it is caused monoxide carbon poisoning, increases lethality by factor of 23. Multifactor damages frequently go along with arterial hypotension and acutely expressed disorder of gas metabolism. Thermal-inhalation damages of respiratory organs. Flames, hot air and combustion products during explosions often damage respiratory organs. Surgeons discriminate burns of upper respiratory paths, spread from a jaw mucosa and forward nasal paths up to a larynx and thermochemical damages of respiratory paths inflicted by explosion products (often carbon and nitrogen compounds). The latter propagate through an entire respiratory path and caused by lengthy stay of casualty at smoke-filled premises or fire site. Both forms of damage, depending on condition of trauma, can be encountered separately, however, as a rule, they combine. Aspiration of hot air or steam causes expressed edema of glottis and subglottic region with possible mechanical asphyxia during the very first hours after trauma. Thermochemical damages to respiratory paths are distinguished by toxic activity of fly ash particles, depositing on the mucosa of trachea and bronchi and causing necrosis of epithelial cells. Experience of Thermal Damage Clinic of the Army medical college, generalized by I.F.Shpakov and coworkers (1999) suggests that diagnostics by the fiber-optic bronchoscopy should be carried out during first 6 hrs after trauma, when it is obviously possible to clear fly ash from mucosa. At the later terms, fly ash impregnate mucosa and removal can cause an additional traumas to walls of trachea and bronchi. Severity of the thermal inhalation damages to the respiratory paths depends on duration of casualty staying in the smoke-filled premises and on the composition of inhaled smoke (burning paint and varnish coats, man-made finishing agents produce most toxic fumes). Diagnostics of
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damages to respiratory organs is based on the trauma conditions and clinical survey of patients. Thermal inhalation damages to respiratory organs are often combined with burns of the face, head, neck and anterior thoracic wall. CO poisoning (or poisoning by other toxic fumes) casualties can be unconscious when delivered to medical hospitals. Survey can reveal hoarse voice, cough (dry or with black excretions), difficulty breathing, a hyperemia and smoking of mucosa of mouth and a nasopharynx, loss of nasal hair. Mucosal examination in mouth, pharynx and the glottis should be performed using laryngoscope. The estimate of damage severity for mucosa of trachea and bronchi is possible only using of a fiber-optic bronchoscope. Depending on endoscopic pattern, light, medium and severe damages to lungs are isolated. Easy degree of inhalation damage is manifested by moderate hyperemia and edema of mucosa, small (up to 1 cm2) the speckled aggregations of black and inappreciable quantity of mucous secret in the form of tension threads and hairlines. Damages of medium degree are characterized by the expressed hyperemia and an edema of trachea and the bronchi mucosa, plural speckled aggregations of fly with of 3-4 cm2 area, hypersecretion of slime. Removal of fly ash pale makes visible sections of mucosa with petechial hemorrhages. Severe inhalation damages exhibit total coating with fly ash, obstruction of subsegmental bronchi and a small amount of a secret with an impurity of fly ash, pale dry mucosa with plural petechial hemorrhages. Physicians of thermal damages clinic, namely I.F.Shlakov (1997), discovered that adding usual bronchoscopy with endotracheobronchal 0.25 % aqueous solution of methylene blue (chromatographic bronchoscopy) can essentially increase accuracy, due to coloring of fibrin lines and cytoplasma of epithelium defective cells. Three stages of respiratory paths damage should be distinguished: Ist stage lasting for 624 hrs. Initially leading mechanism is generalized bronchospasm. Edema of tracheobronchial tree soon evolves. Disorder of bronchi passability leads to the significant decline in lung ventilation. Burns of larynx with disorders of passability, in early terms shows attributes of mechanical asphyxia. IInd stage (2436 hrs from the moment of trauma) can be manifested by lungs edema, caused by disorders of circulation in a small circle and bronchospasm. Thus, during inspiration alveolar pressure, leading to discharge of fluid in alveoli and to damage of pulmonary surfactant considerably decreases. Plural foci of microatelectases and the emphysema are formed in lungs, leading to further ventilatory disorders ventilation.
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III stage (starting 2-3rd days after trauma) is characterized by inflammatory changes (purulent tracheobronchitis, pneumonias). Oppression of cough reflex, restriction of respiratory excursions and disorder of abstersive function of a ciliary epithelium cause disorders of drainage bronchial function, accumulations in of slime and an inflammatory exudate, sometimes leading to complete obturations of bronchi. The atelectasis cause evolution of the pneumonia. Damages to respiratory paths causes pneumonia (including destructive) in 70-90 % patients, evolving disorders of gas exchange cause death of 20 % patients within first 23 days after a trauma. The damage of respiratory organs is accompanied by the substantial increase of a vascular transmittivity and plasma loss, which is more expressed than during insulated burns of skin. Hemoconcentration is acutely expressed, blood viscosity considerably rises. Often enough, inhaling toxic burn products causes suffering of cardiac muscle. Disorders of kidney functions are more expressed, causing frequent evolution of olygoanuria or anuria. Carbon monoxide poisoning. Light poisoning casualties are conscious, observable clinical pattern (headache, sonitus, dyspnea, nausea, vomiting) is combined with burn shock symptoms. Therefore reliable attribute of light carbon monoxide poisoning is carboxyhemoglobin (1030 %) in blood. Medium degree poisoning shows same symptoms, although enhanced, especially muscular weakness and an adynamia. Intact skin is of rose-reddish color. Concentration of the carboxyhemoglobin in blood attains 3040 %. Severe poisoning is characterized by evolution of coma (lasting for days). Pupils are dilated, do not respond to light. Tonic-clonic cramps are periodically noted. Spontaneous urination and defecation are possible. Breathing is superficial. Pulse rate is high, feeble modulation, arterial pressure is low, carboxyhemoglobin attains 40-50 % and more. If coma lasts for more than two days, the forecast is usually unfavorable. Lethal outcomes are caused most often by damage to a respiratory center.

9.11.2. Principles of first medical aid

Organization of medical care for the casualties of explosions in many respects is defined by the location of incident: big city, small settlement, greater or smaller remoteness from settlements, features of medical conditions and requirements of medical provisions. First aid. Peacetime disasters are usually sudden, and, hence, are associated with the panic,
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despair and at the same time, heroism. This condition can exert influence on medical aid provisions. Crashes or derailments, especially those happening at the distance from cities, require first aid rendering through self and mutual help, or by casual people with no medical training. Under such requirements it is possible to extinguish fires, extract casualties from the accident site if it does not threaten their life. Under such circumstances, delay with paramedic and first medical aid can be as high as several hours. For example, during the gas explosion in Bashkiria, evacuation to medical hospitals of Ufa took 10 hrs after disaster. 50 % casualties [Nechaev E., Farshatov M., 1994] were delivered to hospitals during first 10 hrs. One should expect mismatch between available resources and required medical aid amount. The experience testifies that delay in rendering antishock therapy increments lethality 10% with each passing hour. Therefore infusional therapy should be started immediately after accident and continue during evacuation. Indications for infusional therapy are: burn shock of any degree, attributes of increasing intoxication, disorder of hemodynamics and breathing of other genesis. Infusional therapy should include blood substitutes with hemodynamic and disintoxication activity (saline isotonic solution, ringer-lactate solution, trisol, mafusol, 5 % liquid glucose). Transfusion volume should provide stabilization for basic indicators of the hemodynamics (pulse, arterial pressure). Depending on shock severity at the initial stage of treatment (at pre-hospital stage) it is necessary to infuse 2-3 l of these solutions. Effective anesthesia in the conditions of assumed lengthy transportation is provided with extended action analgetics (prolonged Morphine) and neuroleptics (Droperidol, Haloperidol). If there is the damage to respiratory organs, measures should be taken for reduction of larynx mucosal edema by applying corticosteroids (60120 mg Prednisolone or 125250 mg Hydrocortisone IV/IM) to eliminate spastic stricture of bronchi. In the extreme cases of rising edema in subglottis spaces with acute disorders of respiratory paths passability, it is necessary to perform tracheal intubation. It is not recommended to apply bandages over the burnt surfaces at the accident spot, especially if there is massive amount of casualties with extensive burns. This approach can lead to unjustified losses of time and is frequently impractical due to the deficit of dressing materials. Exception should be made for casualties with combined damages, accompanied by external bleeding and, fractures. Classification. Examples of large disasters show that the first aid, rendered after fuel-air
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explosions, is characterized by lack of the medical classification of massive sanitary losses. This issue is known to cause serious shortcomings in antishock infusion therapy for casualties with the burn-trauma shock. When performing classification at the spot of accident, first of all, physicians should isolate casualties, requiring medical aid under pressing indications: inhalation damages of respiratory paths (impeded breathing, attributes of a bronchospasm, threat of asphyxia); poisoning with carbon monoxide (adynamia, confusion or loss of consciousness); states of severe burn (or burn-trauma) shock with the expressed attributes of hemodynamics disorders; proceeding external bleeding. Evacuation of these casualties without the urgent reanimation aid is dangerous to their life. After short preparations, these casualties should be evacuated as soon as possible, preferably using air transportation. First of all, specialists should evacuate all casualties with heavy burns (being in state of shock). Antishock therapy should be initiated, whenever possible, as soon as practical. It is also appropriate to form separate group for casualties with traumas incompatible with life (deep burns over 40 % body surfaces, combined with inhalation damages, other severe traumatic damages). 33% casualties after explosion in Bashkiria died within one hour after trauma. This group of casualties should be administered anesthetizing and sedative drugs, water and warm conditions. Evacuation of such casualties should be delayed until all curable casualties are evacuated. At the same time, as proved by experience of recent local conflicts, all casualties should be provided adequate medical aid under conditions of sufficient available resources. Evacuation. In the conditions of big city, severe casualties should be evacuated from the spot of incident using ambulances. Casualties with light traumas could be transported using regular vehicles. Evacuation of casualties by regular transport is also possible, if the ride duration is less than 1 hrs. During explosion in Bashkiria, accident spot was 6 km from the nearest city (Asha). Casualties were forwarded there using regular cars, intact railway branch (16 km) and even by foot. 33% casualties were evacuated to Ufa (about 70 km) using helicopters (not including casualties who died on the spot). Transportation of burn casualties on greater distances is performed under protection of adequate infusion-transfusion and medicamental therapy. This approach provides delivery to specialized
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medical hospitals in shortest terms and does not burden subsequent course of burn disease. Airlift of burn casualties can be successful even in the conditions of mass trauma. It is inexpedient to evacuate severe burns casualties using other means of transportation. Organization and main principles of the specialized aid. Effective rendering of medical aid depends on effective classification of casualties with burns. Partitioning in the following groups is justified: 1) light burns with superficial, preferentially burns IIIIIa degree, not exceeding 10 % of body surface; 2) casualties with burns of average degree including: casualties with extensive (more than 10 % of a body surface) burns IIIIIa degree; casualties with deep burns IIIbIV degree, but with limited (<10 % of body surface); 3) severe burns casualties with deep (IIIbIV degree) burns, occupying > 10 % of body surface; 4) casualties with extreme degree burns of more than 40 % body surface. Additional inhalation damages, barotrauma, mechanical injuries aggravate severity of trauma and worsen the forecast. If there is mass flow of casualties, those belonging to the first group can be sent directly to general or trauma hospitals, thus relaxing burden on the specialized burn centers. Burns of III degree over the area up to 5 % body surface can be treated on the outpatient basis. Casualties of the second and third groups demand specialized treatment. All severe burn casualties will manifest, at least, burn shock condition. If there is a mass flow of casualties, it makes sense to concentrate on treatment of casualties with the light shock, classifying them as casualties with reversible shock. The extremely severe burn shock (burn of more than 40 % body surface) is extremely unfavorable in the prognostic sense. Despite use of all modern infusional resorts and drugs, lethal outcome happens either during shock, or 7-10 days after an exit cessation of shock. In case of mass flow, the antishock therapy will be far from perfect and unfavorable outcome is rather probable. These casualties should be classified as those with irreversible burn shock. Under the proposition of thermal damages clinic employees, belonging to Military Medical Academy (S.F.Malakhov and coworkers, 1986), this simplified (dual) classification can employ plan of universal approach to infusional therapy for burn casualties in state of reversible shock. The plan provides infusion of glucose-saline solutions during first 12 hours (close to 4 l), in
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second 12 hrs they are complemented by the synthetic colloid blood substitutes. Starting from the second day blood preparations (plasma, albumin, protein) are introduced in the infusional therapy plan. Termination of a light burn shock (deep burns of < 10-20 % body surface) can be performed through so-called peroral antishock therapy. The therapy consists in administering 2-4l/day of alkali-saline solution in equal portions. This antishock therapy is administered in case of mass casualties flow and acute deficit of infusional solutions. Various treatment plans are implemented for high-grade antishock therapy in burn centers and branches a. The rough estimate for the first day can be of 34 ml fluids per 1 kg of body weight and 1 % of the burn area. For first 12 hrs 2/3 of this quantity is infused. During second 12 hrs, the fluids composition is complemented by the albuminous compositions. By the second day the volume of infused fluids is reduced by 1/3. Ratio of crystalloid and colloid infusional agents for the shock therapy should comprise 3:12:1. If shock attributes still persist, another 1/3 of initial quantity is administered. When conducting antishock therapy, the calculations are corrected with respect to indicators of hemodynamics, hourly diuresis, and gas metabolism indicators. Experience of thermal damages clinical treatment, generalized by A.G. Klimov and I.F.Shpakov (1999), showed that thermal -inhalation trauma of a medium severity requires additional microtracheostomy for conducting jet high-frequency lung ventilation. Besides, indications for high-frequency lung ventilation: damage to respiratory paths by burn products of light degree + burn to upper respiratory paths; damage to respiratory paths by burn products of light degree + deep burns of > 20 % body surface. Average duration of the high-frequency lung ventilation is 5 days as long as there are no attributes of the respiratory failure or pneumonia. In case of severe and extreme thermal-inhalation trauma there are indications for tracheal intubation, used as a measure for prophylaxis of asphyxia. The latter can be related to the expressed bronchospasm and an edema of subglottic space. The question of independent breathing through an endotracheal tube or artificial ventilation is resolved on the basis of hypoxemia and hypercapnia clinical signs, data on the gas composition of blood (decrease O2 < 70 mm.hg during inhalation of 100 % oxygen during 10 min; increase of paCO2 > 60 mm.Hg) In addition to that, artificial ventilation criteria are: damage to respiratory paths by burn products of severe and extreme degree without clinical
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and laboratory attributes; damage to respiratory paths by burn products of average severity + the deep burns of 20-40 % body surface without clinical and laboratory attributes of acute respiratory failure; damage to respiratory paths by burn products of an easy degree + the deep burns of > 40 % body surface without attributes of acute respiratory failure; burn of the upper respiratory paths + the deep burns of > 20 % body surface. Use of thermoplastic tubes and diligent care, plan of reintubation within 36 days provide the long-term artificial lung ventilation through an endotracheal tube and sufficient opportunities for sanation of tracheobroncal tree. Average duration of artificial lungs ventilation comprises 1012 days In extreme cases, liquidation of acute respiratory failure, caused by edema of subglottic, may require tracheostomy. Casualties with a thermal-inhalation trauma require 50% increase of infusion-transfusion therapy amount. Due to essential delay of antishock therapy, burn shock and early post-shock period is known for disorders of metabolic processes, first of all albuminous exchange with evolution of the expressed hypoproteinemia. For the same reason, the course of burn disease is severe, with expressed purulently-resorbtive fever, early psychoses, persistent disorders of homeostasis, early development of pneumonias, frequent generalization of an infection contamination. Psychoemotional disorders lead to long-term hypertension. After terminating shock state in patients, i.e. 35 days after a trauma, the most severe but transportable patients should be distributed over large and well-equipped burn centers. It will allow to improve quality of treatment, avoid outbreaks of intrahospital infections and simplify certain organizational issues. According to specialists of the Nizhniy Novgorod burn center: V.V.Azolov et. al. (199), it serves no purpose to concentration all burn casualties in one-two nearby large medical hospitals and should be considered only as temporary and involuntary measure. Concentration of many burn casualties, especially severe, in one hospital leads to overload, impossibility of adequate antishock therapy, acute shortage of specialists, lack of continuity in rendering aid. Experience of Vishnevskis Institute of Surgery physicians: A.V. Vishnevsky, B.G.Borisov (1986) promoted approach of continuing infusional therapy during airlift, equal to that in a hospital. Combined thermal-mechanical damages , caused by large FAE explosions, are characterize by severe course and more adverse outcome, than those caused in industrial or other
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peacetime settings. According to generalized data by A.V. Yemelyanov (1995), explosion-related combined thermalmechanical damages comprise about 25 % of hospitalized casualties, and not less than 65 % among killed at the explosion epicenter. The state of a burn-traumatic shock is observed in 60 % casualties. Average lethality for the combined thermal-mechanical damages can reach 2530 %, and for severe and extreme combined thermal-mechanical trauma it can reach 50 and 100 % accordingly. Causes of lethal outcomes are: burn -traumatic shock, pneumonia, a sepsis. Only half of the casualties are later returning to ranks. Patients with multiple fractures, fracture-dislocations, craniocerebral traumas, poisoning by burn products, trauma of internals and burns manifest severe combined shock, an entire treatment poses significant difficulties, especially in presence of the severe and extreme combined trauma. During shock period, fractures and dislocations are repositioned under narcosis, skeletal extensions are applied, open fractures are closed, fragments are immobilized, interior bleeding is stopped, closed pneumothorax is opened. Circular compressing scabs are dissected by necrectomy incisions, extremities are raised. Multidisciplinary traumatology team treats of severe casualties until they manage to stop degradation of clinical pattern of posttraumatic signs and syndromes. After terminating the shock conditions, the casualty should be moved to the specialized burn branch, provided the burns are the leading damage. Casualties are, as a rule, moved by the end of 56 days from the moment of admission. According to the experience of Vishnevsky Institute of Surgery specialists: R.A.Gundorova et al (1986), eye burns are the most severe damages of this organ, often leading to blindness. During the initial 6-96 hrs after a trauma, first and urgent aid are the main medical provisions. These provisions include instillation of antiseptics, antioxidants, protease inhibitors, vitamins every 1520 min for the first 2-3 hrs and hourly during subsequent 12 hrs, including night. Dehydrational therapy (concentrated solutions of glucose, Urotropin IV, Diacarb, Hypothiazid PO) is administered in the conjunction with antibiotics, sulfanilamide and desensitizing drugs. Subsequent treatment demands participation of an ophthalmologist, responsible for the prophylaxis of cornea perforation and the secondary glaucoma.

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Chapter X
MENTAL DISORDERS AT EXPLOSIVE DAMAGES
10.1. GENERAL PROVISIONS
The first scientific data on the mental disorder clinical patterns, accompanying combat surgical pathology, refer to the US Civil War and German-Austrian war of XVIII century. In particular, there is a well-known term Dupuytrens delirium (named by Parisian surgeon G. Dupuytren), designating mental disorders after wounds. At the same time, diagnostics and correction of the negative mental aftereffects, caused by the combat damages and accompanying stressors, is one of the least studied issues of military medicine. Sufficiently to say that there are no dedicated studies, addressing mental disorders caused by the mine-explosive traumas. Many researchers or doctors, not practicing psychiatry, underrate mental disorders accompanying physical traumas. These disorders are often masked by the behavioral disorders or substance abuse. At the same time, mental disorders are the important components of the traumatic sickness. Quality and terms of wounds healing to no small degree depend also on the psychological factors. According to the modern concepts, mental disorders caused by the mine-explosion damages, can be conditionally isolated into the following basic groups: mental disorder at the craniocerebral traumas, caused by the mine-explosive damages; mental disorder caused by the extracerebral mine-explosive wounds; mental disorders caused by the burn traumas; surdomutism (barotraumas related disorder, as an element of the mine-explosive pathology); psychogenic mental disorders (disorders caused by the psychotraumatic action of mineexplosive damages).

10.2. MENTAL DISORDERS DURING CRANIOCEREBRAL TRAUMA

Prevalence. The craniocerebral trauma (CCT) prevails among all the exogenic-organic diseases. Closed craniocerebral traumas comprise > 90 % of brain injuries and 30-50 % of all traumatic damages. According to WHO statistics, their annual rise of incidence averages at 2 %. Main
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share of casualties are the persons of active age (20-50 years) approximately 22 % of them have recurring CCT [Babichenko E., 1993]. During the modern confrontations, the number of open and combined traumas in this region, sometimes caused by the blast traumas, increases rapidly [Nechaev E.A. et.al. 1994; Gaydar B.V., et.al, 1998]. Explosive damages frequently cause combined (with burns) CCTs. In general, the incidence of explosive CCTs directly depends on the intensity of combat operations [Snezhnevsky A.V., 1947] and is the highest when antipersonnel and anti-tank mines are used during modern confrontations [Gritsanov A.I., 1987; Miakotnih V.S., 1994; Gaydar B.V. et.al, 1998]. The prevalence of mental disorders, caused by CCT, is defined by the character of traumas (closed, open, combined, etc.) and also trauma conditions (premorbidal background, peacetime or wartime traumas etc) . Thereof, during the wartime (WWII) mental disorder after CCTs comprised about 70 %, while during the peacetime only 2040%. Snedkov E.V. et al. (1996) consider that the most expressed and polymorphic psychopathologic pattern is observed after mine-explosive wounds and traumas (mainly after the brain explosive contusion 57.3 % and extremity wounds 50.7 %), manifesting as a combination of obsessive-anxiety (68 %) and depressive (59 %) disorders. Mental disorders of the explosion CCT late periods are less studied, since many authors are still confident in stable neutralization of the T remote aftereffects during the wartime. At the same time, recent studies show that the persons who suffered explosive CCT, at the age of 5055 manifest expressed and frequent generalized disorders of cerebral circulation and concomitant mental disorders [Lytkin V.M. et.al., 1999; Yemelyanov A.V., 2000; Pomnikov C.V., 2000]. Etiology and pathogenesis. Common issue for various concepts and theories of the brain mental disorders is the primary mechanical injury to cerebral tissue, causing all the subsequent (including mental) manifestations. However, other generalizing factor is overemphasizing leading pathogenetic links, which gave birth to the conforming theories of suffering: molecular concussion, brain fluid jolt, hydraulic, reflex-vascular, asynaptic, neurodynamic, metabolic, neuroendocrinal, hystotoxic, physicochemical, neuropeptid, autoimmune, etc. [Petit, 1774; Duret, 1878; Ricker, 1919; Henschen, 1927; Smirnov L.I., 1949; Zograbjan S.G., 1965; Detlav I.E., 1984; Romodanov A.P., et.al.., 1986; Potapov A.A., 1989 et. al]. Recently, a number of scientists tends to study mechanisms of the mental disorder evolution during craniocerebral trauma not from the pathogenetic, but rather from the sanagenetic (adaptive) positions [Volozhin A.I., Subbotin Yu.K., 1987; Bekhtereva N.P., 1988; Blumberg,
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1988; Hilko V.A. et.al., 1990; Hlunovskij A.N., 1991]. In the majority of studies [Shustin N.A., 1959; Zambrzhitskij I.A., 1972; Tishchenko I.A., 1973; Birjuchkov Ju.V., 1987; Sovetov A.N., 1988] the special attention is given to the reticular formation, influencing, on one hand, tonus of CNS and, first of all, brain cortexes (reticularcortical system). The latter defines state of wakefulness, active attention, degree of orientation (tonus of consciousness), the level of metabolic processes, vegetative, visceral and neuroendocrinal functions (reticular-hypotalamic system), correlating with the human affective sphere. Reticular-cortical-subcortical-spinal disorders are, in turn, aggravated by the discirculatory, metabolic and neurohumeral shifts influencing evolution of hypoxia, edema, brain swelling, hemorrhages etc. Cross-burdening of these pathogenesis links defines severity and diversity of the psychopathologic manifestations [Ivanov M.M., 1974; Odinak M.M., 1995; Litvintsev S.V.,et. al. 1998]. Essential contribution to revealing mechanisms of the psychopathologic processes evolution during the brain traumas was made by the studies of morphological changes during certain mental disorders [Flor-Henry, 1983; Sarkisov D.S. et.al., 1990.], studying lateralization of the mental functions [Springer S., Deitch G., 1983; Bragina N.N., Dobrohotova T.A, 1977. 1988. etc.], use of stereotaxy neurosurgical methods in the diagnostics and treatment of mental diseases [Smirnov V.M., 1976; Hassler, 1982; Kandel E.I., 1981; Anichkov A.D., 1986; Mindus, 1988; Shustin V.A., Korzenev A.V., 1996. et.al.] In connection with prevalence and the complex relationship of pathogenic and sanagenic factors and determining course of the traumatic process, the most widespread are polyetiological theories of CCT pathogenesis. Extreme severity of the mental disorders, accompanying explosive CCTs can be explained by its plural and combined character, causing not only massive hemorrhages but also disorders of the vital organs and systems first of all, CNS. Use of the modern powerful explosives literally expanded explosive CCT concept to that of explosive organism trauma with the presence of multiorgan damages [Gritsanov A.I. et. al. 1987. Malakhov Yu.M, Kolomiec G.D., 1987; Odinak M.M. et.al. 1996]. E.g. M.M.Odinak and coworkers (1996) specify that 96 % of the combat combined brain damages are caused by the injuring factors of explosion. It is not accidental that the modern understanding of brain etiopathogenesis of brain explosive damages is considered through the prism of entire body etiopathogenesis during the explosive trauma [Verhovskij A.I., 1996; Bryusov P.G., Hrupkin V.I., 1996; Savenkov V.P., 1996; Emelyanov A.V., 2000]. Clinical pattern. Psychopathologic processes accompanying CCT are rather polymorphic and are
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defined, mostly by the traumatic damage character, concomitant pathology, possible complications, stage of traumatic sickness and a premorbidal background. Craniocerebral traumas can be divided into closed and open. Additionally, the practice of military psychiatry separately considers traumas, inflicted by the air blast wave, and combined traumas. Three degrees of CCT (light, average, severe) are joined by the four periods of evolution: initial (hyper acute), acute (secondary), late (reconvalescence) and remote (residual) aftereffects. Such division is of rather conventional character, but, nevertheless, is convenient in the practical sense. Initial (hyper acute) period , immediately after injury, 9095 % cases manifest consciousness loss of various depth (beginning with easy torpor to a coma) and duration (from several minutes to 1 week), whose expression is proportional to the CCT gravity. In case of extremely severe CCT, after termination of a coma, patients manifest apallic syndrome and akinetic mutism. The former is different from the coma by the open eyes (lucid coma) phenomena with impossibility to fix a sight on the environment. In case of akinetic mutism, the patients manifest persistent akinesia and lack of speech, nevertheless they are still capable to fix a sight on an objects. Both syndromes are the varieties of coma and, as a rule, are prognostically unfavorable. The acute (secondary) period continues from several days up to 1 month and begins with termination of consciousness lockout. Judgment of ongoing events is impeded; various mnestic disorders are noted (Korsakovsky syndrome, acute confabulation) on the background of developing cerebrasthenic processes, instability of mood, hyperesthesia and hyperpathia (hypersensibility to psychogenic agents). Alongside with mental, patients exhibit neurologic, vegeto-vascular and vestibular disorders. Occurrence of epileptiform attacks is possible together with the evolution of acute psychoses. During the period of reconvalescence (up to 1 year) gradual (full or partial) restitution of the upset functions takes place. Remote aftereffects of CCT (over 1 year) are manifested by the psychoorganic syndrome, described by the raised emaciation and small productivity of all mental processes, lack of comprehension, degradation of memory and intelligence, incontinence of affections. Formation of pathological qualities (asthenic, hypochondria, litigious paranoia, hysteria, epileptiform) is possible. Late traumatic psychoses include affective (manic, depressive), epileptiform, delirious and schizophrenia syndromes. The focal neurologic symptomatology and diencephalic crises may be observed as well. In view of the expressed clinical polymorphism, systematics of mental disorders of traumatic
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genesis is extremely complicated. At the same time, it can be divided into the three groups of disorders: 1. Non- psychotic mental disorders of the traumatic genesis (psychasthenia, neurosis-and psychopathic disorders). 2. Traumatic psychoses (acute, subacute, chronic). 3. Defective-organic states (traumatic encephalopathy, traumatic dementia and epileptiform syndrome). Among non-psychotic mental disorders of traumatic genesis, the special place is held by psychasthenia, being the axial (through) syndrome during CCT. Its difference from the typical asthenic disorder (an asthenic triad) is a resistant character, high degree of dependence on the course of traumatic process and influence of additional exogenous factors (including meteorological factors) and the predominance of general-brain, somato-vegetative and vestibular disorders (headache, giddiness, gastrointestinal dyskinesia, oscillations of the arterial pressure, hyperhydrosis etc.) . Separate intellectually-mnestic disorders can be observed within the framework of cerebrasthenic manifestations. Two basic varieties of psychasthenia are usually diagnosed: hyposthenic (adynamic) and hypersthenic (with predominance of irritability and emaciation). The former is characteristic for craniocerebral trauma acute period, while the latter is characteristic for the late period. Neurosis and psychopathic (traumatic encephalopathy) disorders of traumatic genesis evolve on the background of psychasthenia, as a rule, in the late periods. The more expressed are psychasthenic phenomena, the more expressed are those of neurosis-and psychopathic disorders and vice versa. Progressive or regressive character of neurosis and psychopathic disorders course, in addition to the trauma character and severity, depends on the patients age, additional psychogenic and exogenous factors and premorbidal personal features. Similar disorders manifest predominance of the affective disorders (hysteroforming, dysphoric) on the torpid background of mental activity and moderate degradation of intellectual-mnestic activity. Expression of the emotional responses, as a rule, is inadequate to their causes. Traumatic encephalopathy (unlike psychasthenia) is manifested by the presence of focal neurologic symptomatology. By character of the affective response, hysterical and explosive varieties of the traumatic encephalopathy are isolated. Traumatic psychoses can evolve at the various stages of the traumatic process (more often during first hours), after any craniocerebral trauma (often after an open trauma). Exogenous
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factors play greater role in the evolution of the less severe CCT, and, accordingly, pathoplasty of the traumatic psychoses. Their division into acute, subacute and chronic is rather conventional and defined by the length of traumatic process. Clinical pattern of acute and subacute traumatic psychoses, as a rule, is exhausted by the states of obscured consciousnesses (stupefaction) with the subsequent transgression (depending on the trauma severity) to asthenic or psychoorganic syndrome. At the same time, syndromes of stupefaction can be noted even after the acute period of CCT (after decline of somatic state, exacerbation of traumatic process, additional exogenous factors). Different mnestic disorders are frequently noted upon termination of stupefaction (syndrome of Korsakovski, acute confabulation). More remote stages can be accompanied by the affective and affective-delirious psychoses. Twilight state of consciousness is a widespread psychosis with acute narrowing of conscience region, presence of illusions, hallucinations, psychosensory disorders, sketchy delirious ideas, paroxysmal affective and psychomotor exaltations. Complicated character of CCT (increase of intracranial hematoma etc.) causes progress of the twilight state to the extent of amentia or sopor (coma). As the conscience is recovered, memory disorders are noted along with the deep asthenia. Twilight stupefactions are possible in the form of ambulatory automatism with the regularized actions. There are also states with the slightest change of consciousness (so-called oriented twilight ). Twilight states can last for hours or days. Delirium evolves, as a rule, on the background of consciousness restitution, especially in the conditions of additional exogenous actions, and also in persons with the concomitant somatic burdening. Pattern of the delirious disorders gets mixed in these case and is sometimes atypical. Analyzing conditions of origination and involution of the delirious disorders, shapes of manifestation (relation of various components of a delirious syndrome), contents of experiences and comparisons to features of personal response to the originating psychopathologic disorders, allows to determine preferential genesis of the delirious syndrome and, accordingly, prescribe more selective therapy. E.g. evolution of the delirious disorders during CCT is facilitated by presence of chronic alcoholization or excessively active cholinotropic therapies. Delirium tremens (DT) is noted in habitual alcoholics and is discovered on the background of the expressed withdrawal (36 days after a trauma), preferentially in the evening; has no rigorous dependence on cholinotropic therapy. DT is of kaleidoscopic, dynamical, scene-like character with sensually bright, thematically colored visual and acoustical hallucinatory feelings, as a rule, of frightening
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character, causing corresponding mimic and motoric-defensive responses. At the same time, delirious disorders of an anticholinergic genesis are known for their origination and disappearance in various terms after surgery (trauma), dependence on administration and canceling of cholinotropic therapies; predominance of visual hallucinations of monothematic consecutive developmental character, frequently with oneiric inserts. Plot of feelings is preferentially of the professional, household, family or situational-related character and is not accompanied by the expressed mimic or motoric-defensive processes. It is important to underline that isolating a delirious syndrome, it is possible to speak only about a preferential genesis of delirious disorders, fathoming that in each specific case on its formation is influenced by the complex of factors, where traumatic damage can be the mainstay, or the trigger i.e. facilitating evolution and pathoplastically changing course of the other delirious syndromes (alcoholic and anticholinergic varieties). The traumatic delirium is characterized by high dependence of psychopathologic manifestations on the course of traumatic sickness, tendency to relapses (after short bright gaps), predominance of visual, plural illusory-hallucinatory processes, dominance of anxiety affects, fear, psychomotoric exaltation, spotted topical shaping of the psychopathologic disorders, conformity of personality response to the contents of the hallucinatory-delirious feelings (as a rule with the professionally-household plot), their inexpressive and promptly exhausting character. Duration is from 12 days to one week. Korsakovs psychosis manifests upon termination of the broken consciousness state (sopor-coma, delirious-amentive or twilight). Condition is predominated by the fixating, retrograde (to lesser degree antiretrograde) amnesia, false memories and confabulations. The content of confabulations is usually related to the pre-traumatic situation. During the first days Korsakovs syndrome often combines with the altered consciousnesses. The state of so-called knockdown dominates during the daylight hours when disorders of memory and consciousness are accompanied by the elevated mood and uninhibited behavior. As a whole, fits can vary from apathy and complacency up to exaltation and dysphoria. Duration ranges from weeks to months. Affective psychoses are more often characterized by the depression, frequently with a dysphoric tone. Patients are affectively strained, refuse procedures, nutrition, manifest trend to aggressions, self-inflicted damages and escapes. Less often, fits are of hypomaniac or maniac character with motoric exaltation or, on the contrary, flabbiness and retardation (the solidified mania). On the background of affective disorders, patient can exhibit confabulations, episodes of stupefaction,
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deceitful perceptions. Delirious psychoses proceed with syndromes of acute sensual delirium with illusory perception, verbal hallucinations, derealization and a depersonalization. Fits of anxiety, alarm, agitation, behavioral disorders (impulsiveness, tendency to aggressive activities) are typical. Transient episodes of stupefaction can periodically evolve. Duration is between days and weeks. Defective-organic states (traumatic dementia, epileptiform disorder) are noted, as a rule, in the remote period of a craniocerebral trauma. Thus, the traumatic aphrenia can also result from traumatic psychoses. The traumatic dementia is encountered rather seldom (in 35 % cases) and is characterized by the dysmnesic disorders, decrease of an intellectual ability (frequently with a disinhibition of affections), restriction of interests area, flabbiness, spontaneity and faintheartedness. It is usually accompanied by the distinct focal neurologic symptomatology. Physicians usually separate euphoric (damage to basal departments of frontal lobes) and apathetic (damage to convex departments of frontal lobes) varieties of traumatic dementia. Traumatic epileptiform disorder are characterized by clinical polymorphism and can be accompanied by both convulsive and convulsiveless paroxysms (sometimes combined) on the background of psychasthenia or encephalopathy. They are frequently accompanied by dysphoric fit, matching (at the remote stages) changes of personality. Paroxysmal disorders of traumatic genesis (including convulsive) can be provoked by various psychogenic actions, acquiring hysteroformic character that impedes their differentiation from naturally hysterical ones.

10.2.1. Closed CCT (closed brain trauma)

Closed brain trauma (CBT) denotes mechanical injuries of the brain, meninxes and vessels and also skull bones and soft tissues with the mandatory integrity of dura mater. Intracranial cavity and its contents remain closed to an external environment and do suffer immediate effects. Clinically, physicians isolate three basic types of CBT: concussion (commotio), bruise (contusion), compression (compression), and three degrees of severity: light, average, severe. Light CBT is more typical for concussion, while average and severe for bruise and brain compression. Brain concussion is characterized by the diffuse damage and, in most cases, is restricted by the general brain disorders and syndromes of consciousness lockout , whose expression is defined
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by the severity of concussion. Concussion of an easy degree, after transient loss of consciousness (seconds-minutes), in most cases, is characterized by cerebrastenic disorders, with typical mnestic disorders (retro- and congrade amnesia), phenomena of hyperesthesia and emotional lability, light general brain disorders (nausea, vomiting, giddiness, headaches), neurologic and vegetative disorders. The prevalence of manifested complaints grows inversely to then expression of asthenia. The restitution of consciousness period (to 7-10 days) exhibits episodes of psychomotor exaltation. Concussion of average severity degree is manifested by the long-term loss of consciousness (minutes-hours) preferentially in the form of torpor or sopor, replaced by the somnolence, psychomotor retardation and adynamia. However after 12 days, the episodes of psychomotor exaltation and euphoria with reduced criticism of his own condition and behavior are possible. During restitution of consciousness, the clinical course is dominated by the psychasthenia, hyperesthesia and hyperpathia, retro-, antiretrograde and a fixing amnesia, various neurologic disorders (dilated pupils, horizontal nystagmus, weakness of convergence, anizoreflexy, pathological reflexes etc.). Severe concussion causes deep soporific-comatose (days-weeks) state. Restitution after this state manifests the attributes of a psychoorganic syndrome. This syndrome can be accompanied by the epileptiform attacks and psychomotor exaltation. Faster and expressed character (in comparison with medium degree of concussion) is characteristics for the general brain and neurologic symptomatology and meningeal symptoms. Brain bruise is characterized by the brain matter damage, to the extent of a cerebral tissue crush. Mechanical action frequently falls on the small brain surface (mechanism of a countershock). A bruise is always accompanied by the brain concussion. Initial stage is manifested by the total disorder of consciousness in the form of a sopor or coma (days-weeks) with gradual transition into obnubilation. Restitution of consciousness causes attributes of a psychoorganic syndrome. Occurrence of psychosensory disorders is possible. Typical neurologic disorders, characteristic for the severe degree concussion, are combined with the focal symptomatology. Various epileptiform manifestations are frequent. Neurovegetative syndrome (as an indicator of damage to vital functions of organism) is characteristic. Neurovegetative syndrome is characterized by disorders of breathing (acceleration to 40-60 /min, difficulty, superficial breathing, hoarseness, change of pace to Cheyne-Stokes), cardiovascular activity (acceleration, thready pulse, arrhythmia, drop of arterial pressure), thermoregulation (a
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hyperthermia 39-40C without contagious complications), water, electrolytic, albuminous, fatty and carbohydrate exchanges. Symptoms caused by the brain concussion, vanish in the first days after the trauma, and, depending on a bruise, accumulate starting 2-3rd day to the end of the second week and only then start to regress. Swallowing disorders can arise with fluid being trapped in respiratory paths, which on the background of others stem disorders and build-up of neurovegetative syndrome can be regarded as threatening (in the prognostic sense) state demanding emergency medical provisions. Brain compression is caused by the hematoma , in turn, caused by the bleeding from the defective vessels of menynxes, venous sinuses and brain matter. It evolves after percussions and bruises of the brain, fractures of the skull bones and testifies to the severity of craniocerebral trauma. Alongside with hematomas (epidural, subdural, subarachnoidal, intracerebral), evolution of an acute edema and brain bloating is possible. The initial symptomatology is caused by the brain concussion or bruise. Consciousness is disturbed (sopor, coma). Consciousness restitution is accompanied by the appearance of a bright gap, which is again followed by the retardation and torpor, to the extent of sopor and coma (due to increasing brain compression by hematoma). Bewilderment, anxiety, sense of cold fit , yawning can precede the state of torpor. Compression, as well as brain bruise, is characterized by the neurovegetative syndrome. Features of clinical compression pattern are related to hematoma localization. Thus, depending on damage specifics, the psychopathologic symptomatology can have different specific features. Epidural hematomas caused signs compression usually 630 hrs (less often 56 days) after a rupture of the vessel (as a rule, middle meninx artery). Criterion of the casualty state dynamics is the degree of consciousness inhibition. There are no menyngeal signs and blood in brain fluid. Major neurologic signs, accompanying the epidural hematomas are: pupil dilation (factor of 3 4) at the damaged side, paresis, paralyses at the side opposite to damage and disorders of sensitivity by hemitype. In case of distinct clinical manifestations of a hematoma buildup, the spinal puncture (in view of brain dislocation danger) is counter indicated. Subdural hematomas are caused mainly by a venous bleeding and evolve slower than the epidural ones. Attributes of a brain compression are manifested 1-3 days after or by the end of the first week. The bright gap is more extended. Epileptiform attacks or psychomotor exaltation can be observed. Brain fluid is bloody for fast compression and xanthochromatic for slow compression. Local signs are expressed less distinctly, than for epidural hematomas. Dilation of
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pupil from the damaged side is seen less frequently. Subarachnoidal hematomas usually happen quickly after a trauma. Acute period is characterized by psychomotor exaltation. Bright gap is short. During this period, the patients exhibit expressed cerebrastenic disorders (strong headaches, giddiness, nausea, vomiting, photophobia, itchy eyes, difficulty of eye motions etc.) The neurovegetative phenomena (syndrome) holds for 12 weeks, then regresses.

10.2.2. Open T (open brain trauma)

Open CCT due to an opportunity of contagious complications attachment, differ by the greater severity and diversification of mental disorders. Thereof, character of early mental disorders is determined by the trauma severity, performed regenerative treatment (operation) and expression of intracranial contagious complications. During later terms by damages features, premorbid personality conditions, presence of concomitant diseases. During acute period majority of patients exhibit states of lockout (coma, sopor, torpor) or obscurations (twilight disorder, delirium, amentia), but the evolution of other traumatic psychoses is also possible. As the consciousness is being recovered, episodes of psychomotor exaltation alternating with motoric retardation are noted together with the phenomena of the deep asthenia. Epileptiform (preferentially convulsive) disorder can evolve. Alongside with the psychopathologic, physicians note general-brain, meningeal (after hemorrhages) and a focal neurologic symptomatology (paresises, paralyses, anisoreflexia, pathological reflexes, aphasias, disorders of a craniocerebral innervation). If combined with intracranial infection, it usually causes evolution of a purulent meningitis, meningocephalitis, brain abscesses, which in addition aggravates state of patients, causing matching psychopathologic and neurologic (meningeal, focal) symptomatology. Even more complex character of CCT course is noted for combined varieties. In such cases clinical manifestations are defined not only by features of a trauma, but also concomitant traumatic damage (for combined CCT), and also extent (degree) of toxic, burn and other factors (for combined trauma) influence. Cross-burdening character stipulated complex clinical patterns. However, they are mostly restricted to so-called exogenous responses (by K.Bongeffer). It is necessary to remember that at different stages of evolution of combined CCT, the role and influence of additional exogenous factors (burn, toxic etc.) on the course of traumatic process
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and, accordingly. Clinical processes can vary essentially. For example, an additional burn trauma can cause septicotoxemia. At the stage of restitution, the character of mental disorders is mainly defined by localization of brain damage. Left hemisphere damages are characterized by the right hemiplegia, disorder of speech functions, states of bewilderment and tendency to depressive responses. In turn, right hemisphere by left side hemiplegia, disorder of orientation (preferentially in space and a time), disability to learn associates (prosopagnosia), recognize drawings, psychosensory disorder (autometamorphopsia) and tendency to euphoria. Of greatest topical sensitivity within psychopathologic processes are disorders of perception, whose psychopathologic pattern largely depends on the damage lateralization. Since the traumatic damages, with rare exception, have diffuse character, the issue position is of, not only theoretical, but also essential practical value. So, in particular, damage of right hemisphere causes olfactory and gustatory hallucinations, visual and nonverbal acoustical delusions. Latter the smeared (illegible) character, are deprived of existential definiteness, projected in a dark visual region (they are seen in outer space, but with interior eye ). Damage of the left hemisphere causes predominately verbal acoustical hallucinations, while visual ones are assigned specific space and temporary orientation, extraprojection [Adrianov O.S., 1986; Bragina N.N., Dobrohotova T.A., 1988. et al.]. Damage of occipital brain lobes causes metamorphopsia, photopsia, disorder of body scheme, phenomena of depersonalisation and visual agnosia. Disorder of a body scheme with the sense of separated extremities, change of their shape, size, et. al., is characteristic also for the damage of parietal shares. Damage of a parietal lobe mainly causes neurologic disorders apraxia, disorder counting and writing, insulated alexia and agnosia of cutaneous and deep sensitivity. Damage of temporal lobes, as a rule, causes various acoustical, gustatory and olfactory illusoryhallucinatory disorders (dextral temporal region), psychosensorial disorders, sensory (Vernike center) and total (left temporal region) aphasias, acoustical agnosia, amusia, acalculia. The damages to mediobasal brain departments (limbic complex), cause patients to manifest mnestic and affective (alarm, depression, fear, melancholy) disorders. Finally, clinical processes of the frontal lobe damages are most diversiform and can be expressed through apraxias, agraphia, apathic-abulic and pseduroparalysis syndrome, and also by a number of other disorders depending on the damages topics.
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In general, practice testifies to predominance of the so-called frontal psychics in casualties with the open craniocerebral trauma. Specifics of this psychics is defined by decrease of intelligence and memory, torpid thinking, emotional-will disorders (euphoria, apathy, moria etc), usually accompanied by the disinhibition or distortion of attractions, extinction of energy potential, narrowed circle of habitual interests. Thus, it is necessary to note that the frontal symptomatology can not only have naturally traumatic, but also the mediated genesis, in particular, due to the reactive brain edema (during brain damages in the region of a back cranial fossa). In this case, it differs by the transient and polymorphic character, predominance over the manifestations of general brain disorders with distinct dependence on dynamics and level of intracranial pressure. Since individual features of the frontal syndrome are defined by the features and expressions of affective processes, isolation of the following varieties can be helpful: apathetic, depressive, asthenic, dysphoric and euphoric. Apathic variety is characterized by the acute psychomotor retardation, aspontaneous behavior, apathy to the surroundings, conducted treatment, health conditions, fate of relatives and friends. Depressive variety of a frontal syndrome is accompanied by the psychomotor retardation and decrease of drives on the background of the suppressed mood, negative attitude to the present and pessimistic predictions for the future, manifold senesto-hypochondriac disorders. The asthenic variety of a syndrome differs by emotional lability, lack of dominant moods, predominance of the raised emaciation, hyperesthesia, irritable weakness, phenomena of explosiveness, affective excitability, irritability, originating, as a rule, without appreciable motivation. These phenomena define clinical originality of the dysphoric frontal syndrome with predominating melancholicspiteful (naturally dysphoric) or peevishly-grumbling (dysthymic) fits. Finally, euphoric variety manifests elevated mood with carelessness, complacency, acute decrease of criticism, inadequate behavior, tendency to worn-out jokes, silliness (moria). Featured varieties of a frontal syndrome in addition have the certain topical conditionality. Hence, deep traumas are characterized by the dysphoric and euphoric, convectial left hemisphere damages apathetic and asthenic and righthemisphere damages euphoric and asthenic syndromes. If joined by infection complications, alongside with the disorders typical for craniocerebral trauma, patients naturally exhibit the contagious psychoses: transient psychoses, as a rule, depleted syndromes of the extinguished or shaded consciousnesses (torpor, sopor, coma, delirium, amentia, twilight stupefaction, oneiroid);
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 persistent psychoses proceeding without disorder of consciousness (so-called transient syndromes: hallucinosis, hallucinatory paranoid syndrome, catatonoformic, maniac state, apathetic stupor, confabulation); permanent mental disorders with attributes of organic brain damage (varieties of psychoorganic syndrome, aphrenia). Therefore, cornucopia of psychopathologic manifestations for the open CCT, along with the traumatic effects, is determined by a number of additional factors course of treatment, infectious and somatic complications, premorbid background, traumatic sickness etc. During the acute period, especially for CCT, mental disorders have non-specific character, being manifested by preferentially syndromes of the disturbed consciousness in later terms. However, those accompanying convexal traumas, have more specific, topical and individual psychopathologic profile. Finally, during the stages of the remote aftereffects, mental disorders again gradually lose individually-topic originality, having more and more nonspecific character.

10.3. MENTAL DISORDERS DURING EXTRACEREBRAL EXPLOSION DAMAGES

Mental disorders during extracerebral damages are referred to the group of somatogenic mental disorders. On the other hand, it is obvious that the combat surgical trauma is inevitably accompanied by the mental trauma. Consequently, clinical pattern is dominated by the somatogenic disorders, combined with psychogenic ones, i.e. caused by the psychotraumatic factors. At last, essential influence on clinical form of the psychopathologic manifestations is caused by the premorbidal personal features, and also accompanying mental and somatic diseases. The most accepted in military psychiatry is the systematics of mental disorders by the stage (period) of wound sicknesses. Thus, disorders of acute, subacute periods and stages of the remote aftereffects (reconvalescence) are isolated. It is important to underline, however, necessity to account for mental status immediately before a trauma, as its features can essentially affect not only clinics and course of the subsequent disorders but also be a cause of the traumatic damages (inadequate behavioral responses, carelessness etc. due to extreme overstrain, asthenias, psychogenic disorder resulting from combat circumstances). Depending on expression of the somatogenic, psychogenic and personality disorders, features of
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their mutual pathoplastic and pathogenetic influence, they can cross over to psychoses (psychotic level of a pathology), borderline disorders neurotic level) or be restricted to the phenomena of psychological stress responses (premorbidal changes of a mental state). As a whole, the easier is a mine-explosive trauma (or as state of casualties improves after severe damages), the greater value is acquired by psychogenic and personal peculiarities of the mental pathology. Mental disorders during the acute period are caused by response of an organism to severe mechanical injury, massive hemorrhage, and related infectious intoxication caused by acutely expressed inflammatory changes. The most typical for severe mine-explosive traumas are syndromes of consciousness lockout in the form of a coma, sopor or torpor. In the latter case, despite severe course of the pathological process, patients quite often manifest indifference to the conditions, complaints on general weakness, become unsociable, show no imitative. Partial disorientation in surroundings, passive, flaccid behavior with the subsequent amnesia through an entire period is noted. Sometimes the state of oscillating consciousnesses evolves when the clear consciousness is unexpectedly transiently substituted by a sleep-like state. On this background, acute somatopsychoses can evolve which are mainly characterized by the stupefaction syndromes (delirium, amentia, twilight stupefactions, oneiric states). Traumatic deliriums exhibit disorientation in space and a time (with preservation of orientation in own personality), garbled recognition of surrounding persons, unaccountable fear and alarm, motoric exaltation, bright visual illusions and hallucinations. Besides, manifold psychosensory disorder and tactile hallucinations can be found. After a termination of the delirious condition, whose duration usually ranges from several days to a week, residual delirium and transient Korsakovski syndrome, transgressing to asthenia, is quite often observed. Evolution of amentia, as a rule, testifies to severe, long-term (exhausting) course of wound sickness. Consciousness is deeply baffled, to the extent of not only allopsychic (in time, place, situation), but also autopsychic (natural person) orientations. The intellect and speech are incoherent, hallucinations and delirious feeling are sketchy, motoric exaltation inappreciable due to deep emaciation. Fits of misunderstanding of surrounding events, bewilderment are characteristic. Clinical patterns of amentia, alongside with the basic manifestations, can exhibit motoric-will disorders reminding catatonic stupor or exaltation (catatonic amentia ). Duration of amentia state ranges from one to several weeks. Upon exit from this state, psychoorganic syndrome or the long-term expressed asthenia are noted. Less severe course of the traumatic sickness is not associated with the amentia, but rather
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amentia-like state or the state of asthenic confusion which is defined by the combination of bewilderment, expressed emaciation and inconsistency of intellect, small depth and undulate character of stupefaction. Oneiric states are characterized by predominating dream-like experiences of fantastic (less often ordinary) character. Patients actively participate in scene-like fantastic patterns as spectators or casualties, experiencing fits of fear, alarm, and horror. Dreamlike phenomena combine with illusions, hallucinations, psychosensory disorders. Exaltation with bewilderment and fussiness can evolve. These states usually last from several days to 1 week. Typical outcome is asthenia with transient disorders of memory. Twilight stupefactions seldom reach level of the deep, expressed stupefaction with the subsequent amnesia and are usually restricted to paroxysmal mood disorders combining with disorders of intellect, sensory synthesis and derealization disorders. In addition to that, twilight states can proceed as the paroxismal disorders of consciousness in the form of convulsive epileptiform attacks (usually partial). Various durations and expressions of convulsive attacks and their motoric component are possible, hyperkinesia (along with tonic-clonic cramps) are possible. Disturbed consciousness states, related to the mine-explosive pathology, are usually atypical. They are frequently manifested by the syndrome incompleteness, wavy course, prompt transitions from one syndrome to another, original combinations (alloys), mixed states (delirious-amentia, delirious-oneroid etc.). Less severe wounds in the acute period cause the the additional lockout syndromes: stupefactions, affective, neurotic and neurosis-like states, transient hallucinatory-delusional states. The same disorders dominate during subacute period of congenially proceeding severe explosive damages. Most frequent affective disorders are the dysthymic disorders and, in particular, various degrees of depressions, manifested by degradation of mood, alarm, fear. Rarely physicians can encounter hyperthymic disorders in the form of complacency, euphorias. Euphorias can be accompanied by reduced criticism and underestimated condition severity, causing inadequate behavior. Comprehension of a wound event is always accompanied by the respective response from a casualty. These responses are often psychological. However, restriction of vital activity caused by an explosive damage, possible dangerous aftereffects or their perception, quite often lead to the evolution of psychogenic changes exceeding a level of psychological responses and leading to clinically contoured neurotic syndromes. Detailed description of the neurotic and psychological disorders is addressed in the section Psychogenic mental disorders. Here, it is
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pertinent to underline that the similar clinical development processes (decrease or instability of mood, sleeplessness, visceral-vegetative disorder, disorders of sleep) can originate not only as the developing process of psychogenia, but also as a consequence of immediate traumatic sickness (neurosis-like states). In case of persistent, exhausting character of the damage subacute period, some casualties exhibit so-called Vick's transient syndromes in the form of hallucinatory-paranoid and depressiveparanoid symptom-complexes. Course of psychoses in these cases can be the borderline between acute and persistent. Pathogenesis of subacute psychoses is dominated by the infectious-toxic factor, hypoxia, anemia, expressed electrolytic unbalance, dystrophic changes and the disorders of organism response. Finally, the stage of remote aftereffects often manifests asthenic disorders ( through for easy damages and observed at all stages of traumatic sickness). Severe and extremely severe damages cause the psychoorganic syndrome phenomena. Features of somatogenic asthenias, unlike psychogenic asthenic states, are: dependence of their origination and dynamics on somatic state and various exterior physiogenic factors (in lack of exact connection with mental traumas); lack or poor content of the intellectual component; expression of a syndrome vegetative component in the form of persistent (frequently paroxysmal); vasal-vegetative disorders; relative monotony, monotony of signs; frequent organic coloring of manifestations (disorders of memory, raised emaciation, crudeness of emotions, predominance of asthenic-disthymic mood background, diffuse neurologic symptomatology). Characteristic for the given period is a combination of somathogenic and psychogenic (physical mutilation-related psychotrauma) and asthenic disorders. Depending on the traumatic damage, personality of the patient, and character of the developing situation (prospects), the gamut of psychogenic processes can be rather broad from transient neurotic responses to the fixed neurotic states and even reactive psychoses or psychopathic disorders. Often casualties exhibit astheno-depressive and depression-explosive states with the sensations of uncertainty, being unlucky, sense of survival guilt in front of fellow soldiers, obsessive memoirs about past events, irritability and desire to take revenge on the enemy. As a whole, actualization of
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psychogenic experiences more expressed in favorable surgical pathology cases (in the case of congenial course or for recovering casualties). Early postwound stages are related with the undifferentiated (thymopathic) states, preferentially with the phenomena of generalized anxiety, fear and insomnia. During later course they become more and more contoured, specific, and individually-oriented. On occasion, as a rule, after severe damages, formation of psychoorganic syndrome (acute decrease of intelligence and the memory, expressed emotional instability) is possible. The syndrome can be manifested in various ways: asthenic, explosive, euphoric, apathetic. Asthenic variety manifests resistant asthenic disorders on the background of general for psychoorganic syndrome disorders elevated physical and mental emaciation, phenomena of irritable weakness, hyperesthesia, affective lability, easy dismnestic disorders. Explosive variety is characterized by the predominance of affective excitability, irritability, explosiveness combined with dysmnestic disorders and decrease of adaptive opportunities. Quite often there are also impairments of resolution delays, loss of self-control, increase and disinhibition of drives. Euphoric variety is defined by the elevated mood with toned complacency, euphoria, stupidity, acute decrease of criticism, disinhibition of drives. Some patients manifest explosions of irritability, replaced by feebleness, tearfulness. Ability to work is considerably lowered. Apathic variety is characterized by the acutely narrowed area of interests, apathy to surrounding events, aspontaneous behavior and expressed dysmnesias.

10.4. MENTAL DISORDERS ACCOMPANYING A BURN TRAUMA

Clinical pattern of mental disorders after a burn trauma to great extent exhibits dependence on the area, depth of a burn, general state of an organism, presence of concomitant diseases and also on the stage (period) of trauma course. The first period (burn shock). After receiving superficial (less than 25 %) or deep (less than 10 %) burn of a body surface, distinct mental disorders are noted in the majority of casualties. Only separate persons can manifest moderately expressed motoric and speech exaltation during first 512 hrs. Extensive thermal damages cause mild physchomotoric exaltation (erectile shock) during 2-4 hrs after an explosive trauma. Orientation in a time and space is maintained, patients remain accessible for contact, ask for medical aid. As the shock gets deeper, exaltation is
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replaced by general retardation, most casualties lay blindly, answer questions after pauses, tersely, with low voice, not interested in anything. Formal attributes of consciousness disorder are missing. Second period (toxemia) evolves 4872 hrs after damage and lasts for 410 days Casualties manifest acute weakness, decrease or lack of appetite, pain in the damaged sections of a body. Patients manifest persistent sleep disorders with accompanying visual hypnagogic hallucinations, sometimes in combination with acoustical and tactile ones. Third period (septicotoxemia). Duration is defined by specifics of an organism. Mental disorders are shaped on the background of the expressed astheno-adynamic. Patients, as a rule, are sleepy, inactive, fine orientation in the environment is disrupted, mood is acutely lowered. Most frequent among the psychotic disorders evolving during 3-7 days after burn, are delirium, oneiric and amentively-delirous states. Delirious syndrome lasts for 14 days and differs for burn casualties by a number of peculiarities originates on the background of general flabbiness, sleepiness, sometimes without phase of general hyperesthesia and hypnagogic feelings. Attitude of patients to psychotic experiences is quite often indifferent, with no expressed fits of fear, alarm and motoric exaltation. Oneiric disorders are dominated by themes related to the explosion character (psychotrauma) experiences. Along with naturally oneiric, spots of delirious manifestations are sometimes noted. Casualties see kaleidoscopically sensual, bright, fantastic events, which they are actively participating in, externally remaining quiet and detached. At the same time, upon seeing unpleasant visual objects, casualties can feel fear, alarm, phenomena of psychomotor exaltation. Quite often, oneiric states proceed on the background of euphoria, with decreased criticism to severity of their state and inflicted damage. Duration of this disorder ranges from several days to 3 weeks. Amentive-delirous states usually originate during fixed (exhausting) course of a burn disease and are usually accompanied by the severe somatic complications (pneumonia, sepsis etc.). Patients are not capable of productive contact, predominated by the bewilderment, trying to understand an event (or state). Casualties speak with sketchy, senseless phrases, make chaotic, within the limits of bed, discoordinated motions, want to go somewhere, oppose to medical procedures. Perception of an external world is garbled and fragmentary. Hallucinatory-delirious disorders are noted for fragmentariness, plainness, incidence and incoherence. Emotions are inadequate and versatile. An orientation is disrupted. The forecast, as a rule, is unfavorable, to the
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extent of death. Termination of an amentia state is related with intellectual decrease. Duration can reach several weeks. The fourth period (reconvalescence) happens after the full graining of wounds. Major role in the clinical pattern of mental disorders is played by various psychological feelings, asthenic, asthenoand psychopathic disorders. Patients administered with high doses of drug analgetics, can manifest withdrawal phenomena. During this period, there are expressed psychogenic disorders caused not so much by actualization of psychotrauma experiences, related with character of an explosive trauma, but rather with the cosmetic postburn defects. Highest level of these disorders takes place in women and children, in particular after face burns (even an easy degree). Insufficient attention from doctors to these casualties can lead to the tragic aftereffects (suicide).

10.5. Surdomutism
Closed CCTs, caused by the air blast wave (explosions of bombs, projectiles, mines etc.), are inflicted by its immediate (mechanical) action, which is comparable to an unexpected hit over the entire body surface and by secondary bruises of head (body) after concussions with the firm objects (if a casualty is thrown by the blast wave). Thus, naturally the blast wave can cause brain concussion or bruise with damaged functions of the audition and speech. Prevalence. Among psychoneurological sanitary losses during WWII, the neuroses (collective concept of that period) were noted in 26.6 % of cases (during the Russian-Japanese war 53.0 %, WWI 64.2 %), with conversion disorders predominating (45.2 %). Among all hysterical disorder the first place is taken by the surdomutism (38.0 %). Complete surdomutism was encountered in 80.0 % cases. During modern confrontations, on the contrary, phenomena of the particulate surdomutism (dysarthtia, mutism with depression of audition, mutism with normal audition etc.) are more frequent. It is necessary to note that representation of casualties with surdomutism and expression of clinical processes directly depends on the combat operations intensity, and level of troops experience. Etiology and pathogenesis. Acute pressure drops (barotrauma), when the pressure wave is instantaneously replaced by the rarefication wave, can inflict destructive effects on the hollow organs (lungs, stomach, intestine, average and interior ear), where the intrinsic pressure during explosion does not have enough time to equalize with external. Blast acoustic wave after explosion, being a superstrong irritant, affects not only peripheral, but also the central unit of an
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acoustic analyzer, causing state of inhibition, projecting on a speech region, functionally tightly related to the acoustical region. Genesis of conversion disorders during explosive trauma is addressed in many post-war publications. Certain foreign authors, considered hysterical alalias being a simulative response, pursuing cleanly selfish purposes. Now the given viewpoint is of only historical interest. Majority of researchers, mainly domestic, considers that surdomutism is based on the phenomena of hysterical fixation on temporary (caused by explosive trauma), functional loss of audition and speech (became deaf after an explosion, became mute from a fear). Even light bruise of a brain leads, as a rule, to selective disorders of its most dynamical region (speech) with the subsequent original dysarthtia of contusion casualties. Fixation on this dysarthtia caused mutism evolution. Severe blast traumas are mandatory related to severe concussion and bruises. This condition eliminates needs for separation of clinical syndromes, characteristic for brain blast traumas. Exception is made for the surdomutism, encountered frequently after these traumas. Clinically developing manifestations. Loss of audition and speech functions (surdomutism), when detected right after a trauma, recovery from obnubilation or termination of sopor (coma) state point on the manifestations of surdomutism. According to some authors, typical for mechanical craniocerebral traumas brain disorders (nausea, vomiting, giddiness, headache) encountered rarely during the first several days after contusion. Much more frequent are the somatic complaints (severe feelings, pressures, bloating, hum, ringing, heat inside the head, constrained chest, impeded breathing, squeezing in the region of heart, heaviness in a body, pain in muscles, etc.). This is frequently accompanied by impairment of the intestinal peristalsis, meteorism, constipations, bradycardia, moderate drop of arterial pressure [Snezhnevskij A.V., 1947; Svjadosh A.M., 1982; Litvintsev S.V., et. al., 1998]. Using preserved written speech, casualties are actively trying to obtain explanations of their sickness from physicians, find out treatment terms, ask to write everything down. The adynamia of the first days, is frequently replaced by states of elevated mood with carelessness, a disinhibition, impulsive acts. Patients exhibit expressivity of facial expressions, hazed sight, making impression of being drunk. Acrimony and emotional lability, including dysphoric responses to inappreciable motives are quite often noted. In some cases (usually among combatants) psychotrauma experiences with elements of anosognosia (underestimation of the condition) come to the foreground. For this reason, A.V.Snezhnevsky (1947) addressed combat503

related figurative mentism, described by obsessional memoirs about past experiences. This phenomena is related to visual images of traumatizing experiences appearing in front of the closed eyes (explosion flash, burning fighting vehicle, death of fellow soldier), combined with anxiety and fear. Sleep is frequently interrupted, restless with nightmares (thematically colored). This combination of conversion disorders and obsessional experiences allowed separate authors to revise traditional understanding of a surdomutism evolution [Litvintsev S.V., Snedkov E.V., Fedorov A.E., Popov E.A. 1998]. By experience of rendering assistance to casualties during local wars (Afghanistan) and armed military conflicts (North Caucasus) it is noted that the phenomena of surdomutism are quite discovered in wounded (in particular with easy wounds of extremities) owing to combined trauma character. Surdomutism, in these cases, frequently acquires severe, not always typical course. It is necessary to note that the combined trauma (whether it be an organic brain damage, combined wounds or presence of ENT diseases) always, to some extent, alters the course of surdomutism, masking (aggravating) both somatic, and psychogenically caused pathology. At the same time, well-timed removal (during psychotherapy) of psychogenic stratifications in these casualties, allows not only correlate severity of discovered disorders with the character of the inflicted wound, but also to achieve (without the significant expenses) substantial improvement of mental and somatic states. It is necessary to note that the expression of hysterical stratifications the higher, the less severe is the traumatic damage, i.e. contusional disorder. For example, surdomutism (in particular, deafness), is noted in much smaller number of casualties with rupture of tympanic membrane. Occasionally phenomena of a surdomutism (rudiments, sign substitutes ) take the form of an easy staggering, sense of obnubilation, plugged ears and are noted in case of usual traumas (fall from a fighting vehicle, wounds to the heat soft tissues, extremities etc.). However, these patients either saw (before trauma moment) manifestations of explosive trauma , or heard about them, or experienced contusional derangements according to anamnesis, which once again confirms hysterical genesis of their evolution. Despite course of surdomutism being largely defined by the trauma character, conducted therapy and series of other conditions (premorbidal background, concomitant diseases etc.) and, consequently, is not always typical, conditionally it is possible to separate three basic types: with gradual buildup of symptomatology, including occurrence of set aside form of hysterical fixation;
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 with gradual reduction of symptomatology after the phenomena of full surdomutism; with wavy course, i.e. opportunity of bright gaps between psychogenic relapses. Each of these courses can proceed on the background of the organic and somatic disorders. Asthenization of patients due to traumatic damages, lengthy somatic and contagions diseases, and even in presence of easy psychogenesis often promotes relapses of surdomutism. At the same time, M. I. Astvatsaturov, based on WWII experience, underlined that incidence of neurotic complications is inversely proportional to the trauma severity, while A.L.AbashevKonstantinovsky, confirming the given thesis, specified that severity of trauma restricts the energy necessary for hysterical symptoms. Therefore, the more brightly expressed are the hysterical manifestations, the less serious is concomitant organic disorder, severity of wound or a somatopathy. The originality of an affective background in many respects depends on casualties age. Young persons manifest mainly raised mood with insufficient criticism, sometimes moria-like silliness alongside with transitional dysphoric states. Senior persons are notable for the phenomena of depression-asthenic, depression, hypochondria (frequently persistent), being usually interrupted by dysphorias with the exaltation, transgressing to the state of irritable weakness. Phenomena of a surdomutism are usually retained during several days, their lingering character follows psychogenic mechanisms of conventional desirability, and therefore the expression and length of surdomutism are defined preferentially by the timeline and adequacy of therapeutic provisions. After restitution of hearing and speech, staggering is noticed for some time. Forecast of air blast wave traumas (provided there are adequate therapeutic provisions) is, as a rule, congenial. However, in some cases (severe bruise of a brain), temporary or permanent decrease of personality level, sometimes down to traumatic aphrenia, is possible. Differential diagnostics. Coexistence of conversion, anxiety-obsessive and organic manifestations in a clinical pattern of explosive pathology causes complexity of their differential diagnostic. Exterior expressiveness (severity) of surdomutism clinical manifestations in some cases leads to the erroneous medical-evacuation tactics forwarding of these casualties to further stages of medical aid solidifies their hysterical disorders, with the subsequent synchronization and disabilities. Finally, no less important is possible occurrence of set-aside hysterical responses during healing (on the background of additional psychotraumatic circumstances). Hysterical mutism, unlike an organic (motor) aphasia, is characterized by persistent and full
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silence, active demonstration (gestures) of mutism, lack of speech contact attempts, preservation of written speech, abundant accompanying vegetative manifestations and additional hysterical symptomatology without precise organic signs, typical origination (after an explosive trauma) and specific dynamics. Accordingly, hysterical deafness, unlike organic, is virtually always bilateral (i.e. full), without distinct vestibular disorders (vestibular responses are intact, there is no asymmetry, no phenomena of vestibular giddiness, etc). Voice is usually well modulated (patients are not trying to hear another person speech, do not look in the speakers eyes). Treatment. The largest experience in treatment of surdomutism was accumulated during WWII. Complexity of psychotherapeutic correction alone, seemingly the most pathogenetically proven method, is related the patient with surdomutism inability to hear the doctor, restricting the verbal contact. Therefore, as a rule, methods of stress-therapy or disengaging are used: electroconvulsive therapy, light ethereal or magnesium narcosis; IV introduction of 5-10 ml 33 % alcohol or 15-30 ml or 10 % solution of Calcium chloride (method of calcium shock); various topical procedures (ear blowing, vibratory massage of a larynx, dArsonvalization of ears and a larynx, pain, tactile and motoric irritation of auricles etc.); somnolent therapy and a number of other provisions. Thus, all methods of surdomutism treatment can be conditionally divided into releasing the brake and stress-therapy (certain studies off their combination). These methods are being improved by using new and more effective drugs and psychotherapeutic procedures. In whole, choice of a medical approach should be defined by the specific patient state (features and an expression of surdomutism, CCT character, presence of a concomitant pathologies etc.) and therapeutic capabilities (drug availability, trained personnel presence etc.). Three conditions should be mandatory fulfilled: simplicity of treatment (rapidity of procedure, capability of field provisions administration), time of rendering assistance (the earlier, the more effective) and its character (suddenness and harmlessness for the patient together with sufficient and prompt medical effects). According to the given principles, express-therapy can be recommended for surdomutism treatment [Savenko V.P., Shamrei V.K. y, 1995] by using diagnostic spinal puncture, which is usually indicated to virtually all explosion casualties to exclude bruise of a brain. The method is approved for treatment of casualties with mine-explosive traumas during wars in Afghanistan and North Caucasus.
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Specifics of this method consists in introduction (after extracting 34 ml spinal fluid) of 2030 cm3 air in spinal space, with the subsequent inappreciable lifting of a head which, through unexpected headache, promoted unconscious speech production. The procedure is conducted on the background of active psychotherapeutic suggestion. All patients showed restitution of speech during the session, and complete disappearance of surdomutism clinical manifestations at the 2nd day.

10.6. PSYCHOGENIC MENTAL DISORDERS

Psychological-psychiatric aftereffects of extreme situations first of all are defined by the individual significance of disaster for the specific person (psychological disaster ). These aftereffects can be delayed and lack typical clinical manifestations for a specific extreme situation, i. . objective and subjective disaster characteristics sometimes do not show the direct interrelations. In this case observant attitude to the disaster comes up much later (months and years) though severe psychic sufferings and psychosomatic disorders. The experience, accumulated by the domestic and foreign military psychiatrists using extensive material of modern local wars and confrontations, convincingly testifies that the combat surgical trauma is inevitably accompanied by the mental trauma. As noted above, changes of mental state (carelessness, illegible accomplishment of official duties etc.) resulted from chronic psychotraumas by themselves frequently cause mine-explosive damages. Isolation of psychogenic disorders from other mental diseases is performed using the triad of diagnostic criteria (triad of K.Jaspers): sickness originates after a mental trauma; content of feelings streams from character of a mental trauma and manifests clear psychological intercommunications; disease is related to an injuring situation, disappearance or disactualization is accompanied by disease termination (arrest). Depending on depth (expression) of mental disorders, the following groups of psychogenic disorders are distinguished: disorder of non- pathological (premorbidal) level: psychological stressful responses and posttraumatic stress disorders; disorders of a borderline (clinical) level: psychogenic responses and neurotic states;
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 disorders of a psychotic (clinical) level: acute and fixating reactive psychoses. Non-pathological (premorbidal) level of disorders differs by vast polymorphism of manifestations and characterizes states (response varieties), under the level of mental pathology. Similar manifestations, despite the psychological clearness and conditionality the specific situation, are extremely persistent, unlike emotional feelings natural to any person (when witnessing sufferings, corpses, destruction etc), partially critical (concerning full criticism of surrounding events and person himself), distinct distortions of subjective perception of time and space as well as subjectively unpleasant somato-vegetative disorders. Unlike pathological forms of response, psychological stressful responses do not have syndromally contoured character, distinguished by transient and rudimentary manifestations, lack of subjective illness sensation, being accompanied by rather safe behavior (dialogue), ability to search, though not always productive, correct way from a difficult situations, no expressed attributes of socially-psychological disadaptation. Essential difference from clinically contoured disorders is also the fact that manifestations of psychological stressful responses are, as a rule, leveled by change of activities (switching attention) to adequate rest and psychological relaxation. Acute and delayed forms of psychogenic disorders can be isolated: Acute psychological stressful responses evolve immediately after the life-threatening situations, differ by predominance of the bewilderment, emotional tension, sense of anxiety and fear, stereotypic forms of behavior, transient course and, at the same time, congenial forecast. Depending on predominance of motoric retardation or exaltation, physicians isolate hypo and hyperkinetic varieties of acute responses. Hypokinetic variety of acute psychological stressful responses, as a rule, is characterized by the light idea-related and motoric retardation with the moderate phenomena of alarm and some bewilderment, flabbiness, passive submission, difficulty to concentrate, obsessional ideas, which dominate over consciousness and reduce productivity of primary activity. Hyperkinetic variety manifests easy motoric and speech exaltation, tendency to active functioning, usually unproductive and lacking a purpose, constant distraction for incidental details (trying to sweep all, be everywhere in time ), elements of agitation, to the extent of hyperthymia ( combat exaltation type), insufficiently critical attitude to the behavior and lack of surrounding reality validation. Unlike acute, delayed (set aside) responses evolve after the immediate threat to life passed (in
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12 days). They are less situationally caused and physiologically mediated (more psychological and personally determined). Their pattern differs by greater polymorphism (in particular, separate specific obsessional manifestations, rudimentary ide fixe). Predominant emotional background is the state of interior, quite often causeless (general) alarm. These responses have more prolonged character and tend to relapse (in lack of appropriate, usually psychotherapeutic, aid), sometimes to the extent of somatization. They do not manifest rigid situational dependence and their evolution wears autochtonous character (outside of visible psychotraumatic condition, to a state of seclusion). Hence, psychological stressful responses did not exhibit qualitative contortion of surrounding reflection and do not manifest syndromally complete psychopathologic constructions. Mental disorders are manifested in the form of separate attributes (signs) or even signs substitutes, whose expression, however, can be rather significant, as it defines clinical directivity of psychological responses (with predominance of ideas-related, mnestic, emotional, will, motoric, motivational and other disorders). The critical attitude is maintained, though ability to adequately check and correct the emotional and behavioral responses is lowered. Duration of psychological responses usually does not exceed several hours, their relapses (spontaneous or provoked by recurring psychotrauma actions) are possible. Posttraumatic stress disorders can evolve first as primary changes of a mental state, and also be the consequence of a stress. They originate in large number of people after suffering lifethreatening situations, which brought them together. Despite the elapsed time, aftereffects of this situation can persist for a long time in the capacity of individual significant psychogenia. Physicians isolate basic criteria , generalizing posttraumatic stressful disorders and separating them from other borderline cases: fact of the stress-causing state presence during extreme event; influx of memoirs about life-threatening situations, onset of survival guilt in front of dead fellow soldiers and their relatives, excruciating dreams with dreadful events gone through. Exacerbations of these states are related with, inappreciable at first sight, psychogeny or somatogeny: tendency to shun emotional load, uncertainty due to fear of excruciating memoirs (tragedy replay), causing delayed decisions and lack of association; complex of neurasthenic disorder with predominance of acrimony, decrease of concentration (tonus of operation);
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 stigmatization of separate pathological symptoms and trend to psychopathy with episodes of antisocial behavior (substance abuse, cynicism, lack of respect for the authorities who allowed the tragedy to happen commanding officers, persons in charge of rescue operations, construction supervisors etc.). Each of the mentioned criteria is not specific only for the posttraumatic stress disorders, however joined together they comprise substantially typical clinical pattern. Diagnostic criteria of posttraumatic stress disorders, used in practical medicine, are reduced to the following categories: I. The casualty suffered an injuring situation with two following requirements: 1. The casualty witnessed or participated in the event (events), including death, serious damage or threat of a damage, also danger of a natural trauma or a trauma of other people. 2. Response of the casualty included the strong fear, feebleness, horror. II. The injuring situation is constantly relived through one (or more) following ways: 1. Repeating and obsessional distressing memories of event including images, ideas or sensations. 2. Repeating distressing reflections about a situation. 3. Sensory activities senses matching psychotraumatic event. 4. The strong psychological distress as a result of interior or exterior hints, symbolizing or resembling aspects of a traumatic situation. 5. Psychological response to the action of interior or exterior hints, symbolizing a trauma or resembling a traumatic situation. III. The permanent avoidance of irritants associated with a trauma, decrease of the general reactivity (non-existing before a trauma), which is manifested by below items (three and more): 1. Attempts to shun an idea, sense or conversation, related with the trauma; 2. Attempts to avoid activity, places or people reminding condition of the trauma; 3. An impossibility to recollect important aspects of the trauma; 4. An appreciable decrease of interest or participation in familiar activities; 5. The sensation of estrangement or dispassionateness from others; 6. Narrowing of affective range(for example, inability to feel love). 7. The sense of the truncated future (for example, lack of expectations of career successes, an opportunity to marry, have children and live the normal life). IV. Permanent signs of an overexcitement (non-existing before a trauma), presented by two or
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more items: 1. Sleep problems and frequent awakenings. 2. Irritability or fits of anger. 3. Concentration difficulties. 4. The raised concentration. 5. The raised concentration over impressions. 6. The exaggerated response to scares. V. The disorder duration (presence of signs) is greater than month. VI. Disorder caused clinically expressed distress or a professional and social disadaptation Depending on the beginning and duration of symptoms existence, shapes of posttraumatic stressful disorder are marked: Acute in presence of signs lasting for less than three months. Chronic in presence of the signs lasting three months and more. With the delayed beginning in case if six months elapsed between traumatic event and the onset of symptoms. Plurality of all the above conditions is vital for diagnostics of these states. In addition to that, the stress factor should be extreme (life-threatening). For example, obsessive-compulsive disorders (OCD) also manifest repeating notions of compulsion, but they are recognized as improper for the given person and mismatching the traumatic event. When conducting differential diagnostics it is necessary to exclude cases of simulation in hope to gain the material and moral benefits. Finally, J.A.Aleksandrovsky (1993) isolated so-called atypical posttraumatic stressor responses, , considering them in the frame of psychogenic disorders during mass disasters. These responses onset in casualties during closing, third period of life-threatening situations. They are expressed in the aggravated responses to the exterior irritants, related with the basic injuring factor, decrease of the initiative, possible resistant ideas blaming those responsible for the tragedy. Unlike typical responses atypical signs include lack of guilt sense and recurring experiences of an acute psychogenic trauma Acute stress disorders differ from posttraumatic stressor disorder by the fact that their symptomcomplex should be manifested within four weeks after a trauma action and resolved in four-week term. If the symptomatology is maintained for more than a month and matches criteria of posttraumatic disorders, the diagnosis varies from the acute stressor disorder to the posttraumatic stressor disorder.
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The psychogenic (psychogenically caused) responses transient, from several hours to two weeks, affectogenic disorders of the mental activity originating immediately after the psychotrauma in the persons with unstable psychological sphere. Standard classification of psychogenic responses does not currently exist, which speaks of low scrutiny of these disorders. The systematics of psychogenic responses, constructed on the basis of personal disadaptation depth, includes acute affective, neurotic, pathocharacterologic and somatomorphic responses. All psychogenic responses, despite their variations, have general attributes: duration of psychogenic responses from several hours to two weeks; occurrence and recurring responses can vary (from incidental to frequent; from solitary up to serial); responses manifest through exterior manifestations; degree of subjective importance as well as exterior expressiveness of psychogenic responses, peaking in young and mature patients (1740 years); while being uniform, diffuse and limited in children and old patients (the symptoms are the more limited the older/younger is the patient); once initiated, responses, as a rule, are reduced; quality of responses are defined by the persons individuality (premorbidal characteristics) and leading radicals of morbid states; quantitative performance of responses consists in the intensity of affect and depth of affective consciousness narrowing; psychogenic responses evolve on the background of mental sphere abnormalities. Acute affective responses include states of the extreme affective tension, caused by mental traumas or crisis situations. They last from several hours to several days. The need for a natural sleep serves as the boundary, defining the peak duration of an acute affective response. The fits (affects) can reach such intensity, that the person looses control over his actions and does not account for their consequences. An orientation in space is maintained, the subsequent amnesia does not happen, self-control is not lost completely. These responses evolve in the persons subjected to the long-term psychoemotional stress. Following types of acute affective responses are known: extrapunitive (aggressive), intrapunitive (autoagressive), impunitive (escape-like response), demonstrative response. Extrapunitive response is characterized by various aggressive acts, committed at the acme of negative feelings. Thus, frequently, the object of aggression are the people having no relation whatsoever to the psychotraumatic situation. Intrapunitive response is manifested by self-inflicted damages or
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suicidal attempts. Decrease of pain sensitivity threshold is noted during intrapunitive acts, therefore self-inflicted damages are noted for heavy character. Impunitive response is expressed in escape behavior from psychotraumatic situation. In the military conditions it is manifested by desertion from military unit. Escape is not planned and does not account for environmental conditions, travel route and final destination. Comprehension of severity sets in after desertion of military unit. Demonstrative response includes various shapes of the severe internal mental experiences demonstration. They are manifested as the demonstrative suicidal attempts, disease course aggravation or simulation, substance abuse. Neurotic responses are syndromally contoured mental disorders, caused by the mental traumas. They differ by the course duration (about two weeks), the emotional disorder which bares personal features, gradual increase followed by fading of the symptoms, tendency to hide causes of the condition. Neurotic responses are characteristic for the persons in the pre-neurotic stage of neurosis. Following types of neurotic responses are clinically separated: astheno-depressive, anxiety-obsessive and hysteric-neurotic. Astheno-depressive responses are manifested by the combination of asthenic and depressive disorders with the expressed somato- vegetative manifestations. Anxiety-obsessive responses are characterized by alarm with obsessional disorder and are accompanied by the behavioral activity, directed on the discharge of psychoemotional tension. Hysteric- neurotic responses are expressed by the conversion of hysterical disorders with demonstration of the morbid incompetence. Under the military conditions they are manifested by signs of certain organism functions dropout, e.g. example, mutism, amovrosis, functional paralyses and paresises etc. Pathologic temper responses are the psychogenic stereotyped behavioral abnormalities, accompanied by the repeating diversions in behavior and somato-vegetative and other neurotic disorders. These responses lead to temporary disorders of social adaptation. Their characteristic features are: tendency to generalization, i.e. they can happen in different situations and in relation to inappreciable causes; tendency to repeat the same acts in response to a different motive; exceeding certain ceiling of behavior disorders; disorder of social adaptation. They evolve in persons with accentuated character traits. Depending on a leading clinical radical, pathologic temper responses are divided into responses of labile, hysteric and affective-explosive types Somatomorphologic responses include psychogenic, subjectively perceptive somatic feelings in lack of objective data on the presence of characteristic pathology in internals and body systems. Somatomorphologic responses are based on the manifold personal disorders. These responses are
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dominated by the complaints of somatic character, decorated by the hysteric, depressive or explosive fits. Patients assert their complaints by demonstrativeness or malice (accompanied by threats if refused necessary medical provisions), depressive certainty in presence of the severe somatopathic behavior. Diagnostics and differential diagnostics of psychogenic responses is based on determination of a causal-time relationship with a mental trauma, affective constriction of the consciousness, characteristic clinical manifestations. Differential diagnostics is conducted with psychological stress responses, for which affective consciousness constriction and presence of a psychopathologic symptomatology is not characteristic. Behavioral manifestations in psychological responses are confined to the limits of habitual personal stereotypes and do not exceed allowed ceiling, characteristic for psychogenic responses. Essential value for the psychogenic responses diagnostics is the presence of premorbidal mental abnormalities. Neurasthenia. This neurosis is manifested by hypererethism and irritability combined with the fast fatigability and emaciation. The clinical pattern of neurasthenia is rather characteristic and includes general neurotic disorders, insomnia and headache along with various vegetativevisceral signs. General-neurotic disorder usually include undue fatigability, decline of basic mental functions, first of all memory and attention, acrimony and labile mood. Emotionalaffective disorders may acquire depressive color and, as the disease evolves, sometimes reach the stage of neurotic depression. Asthenic syndrome is the most typical for neurasthenia. Patients exhibit hypererethism and at the same time weakness, an emaciation and easy transitions from the hypersthenia to hyposthenia, from excessive activity to apathy. Frequent manifestations of the neurasthenia a clinical pattern include the signs of hypochondriac character, manifested in the form of astheno-hypochondriac and depressively-hypochondriac syndromes. Among clinical manifestations of neurasthenia, major place is taken by the sexual dysfunction, in men it is usually premature ejaculation and erectile dysfunction combined with lack of sexual desire. Numerous disorders of visceral functions psychogenic cardiac disorders, disorders of gastrointestinal path and breathing are characteristic. It is also necessary to consider such mandatory signs of neurasthenia as the vegetative disorders, manifested in the form of extremities cold, general and distal hyperhydrosis, lability of pulse, more often with inclination to tachycardia. Frequent signs are the uniform increase of tendon reflexes, tremor of eyelids and dactyls of the stretched arm, muscle pain, hyperesthesia of
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separate integuments sections etc. More expressed disorders in the form of vegetative crises are also noted. Hysterical neurosis (Greek hystera uterus). The diagnosis of hysteria is based on three basic criteria: clinical pattern, personality features and originality of a pathogenic conflict situation. The complex and mottled symptomatology of hysteria can be related to several groups of morbid manifestations, including mental disorders, motoric, sensory and vegetative-visceral disorders. Such mental disorders as psychogenic amnesias, twilight states, hysterical hallucinations, pseudodementia, puerilism, etc. are now less frequent during a hysteria, at the same time they are typical for situations of the acute mental overloads related to threat to life (combat). Now, however, emotional-affective disorders are encountered frequently, phobias, asthenia and hypochondriac manifestations are often noted as well. The hysterical symptomatology of the emotionally-affective character frequently acts in the form of mood decrease and fears. General features of the specified disorders, as a rule, are small depth, demonstrativeness, deliberateness of feelings and absolutely certain situational conditionality. Patients with the hysterical neurosis differ by hypersensitivity and impressionability, suggestibility and autosuggestibility, instabilities of mood. They are inclined to attract attention of associates, which is a basic trend of the hysterical person demands of recognition. Motoric disorders during hysteria include convulsive attacks, paralyses and pareses, astasia-abasia, hyperkinesias, rigor contractions, nictitating spasm, aphonia and mutism. Sensory disorders and disorders of sensitivity include hysterical blindness, deafness, olfactory loss, loss of taste and sensory disorder, including hyposthesia, hyperesthesia and paresthesia. The vegetative-somatic manifestations include disorders of cardiac activity, breathing, gastrointestinal section, vegetative and sexual disorders. Obsessive states disorder is dominated by the obsessive states: obsessive fears (phobia), obsessive thoughts, images, memories, doubts (obsessions), obsessive motions and acts (impulsia, rituals). Obsessive-phobic manifestations are encountered in various combinations, spontaneously originating in the consciousness of patients, are characterized by consciousness of their morbidity and the critical attitude. The group of obsessional fears is most presented by: the cardiophobia, thanatophobia (phobia of death), claustrophobia (phobia of the closed spaces) etc. Besides, clinical pattern of obsessional states neurosis is always exhibiting general-neurotic signs: acrimony, fatigability, difficulty of concentration, insomnia etc. These signs can reach the significant degree of intensity and act as a concomitant asthenic syndrome during the neurosis.
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Transient psychotic responses to psychotraumatic situations and related to the threat of a life, a health and a safety are referred to acute reactive psychoses. Acute reactive psychoses evolve immediately after the exclusively severe stress and are manifested by a state of a panic with acutely expressed fear fits with affectively constricted consciousness. Patients refuse to accept the environmental situation, lose the conscious control of their behavior. The expressed vegetosomatic responses in the form of a tachycardia, increased arterial pressure, a sweating, thirst are noted. After the psychosis termination, full or partial amnesia is noted. Among acute reactive psychoses physicians discriminate between affectogenic stupor and fugiform response. The affectogenic stupor is met in 40 % cases of acute reactive psychoses. The clinical pattern evolves promptly and is comprised of the affectively constricted consciousnesses, acute speechmotoric retardation with immobility and loss of speech (mutism). Sight is directed to the certain spot, no blinking is noted. Patients stay in the posture, experienced during the catastrophic event. Similar behavioral responses are noted in some primitive animals under the name of imaginary death. The stupor can be replaced by transient periods of motoric exaltation. Duration of psychosis is from 2-3 hrs to several days. Upon termination of a psychotic state the asthenic disorders are observed for about two weeks. Fugiform response is characterized by the affective constriction of consciousness caused by the strongest fear and panic with chaotic speech-motoric exaltation. Thus, the real circumstances are not considered, the behavior of patients is defined by senseless escapism, the verbal response is absent. The exaltation can be maintained for about a day and transgresses into 23 weeks long asthenia. Persistent reactive psychoses term the psychotic states caused by the chronic mental trauma, related with the necessity to be in psychologically complex situation, demanding the significant mental tension. The situation is actively being worked on in the consciousness and takes the predominant value. Under the combat conditions persistent course is sometimes taken by psychoses evolving after a acute mental trauma, happened on the background of chronic psychotraumatization in the battlefield conditions. Persistent reactive psychoses comprise majority of all reactive psychoses. They can last for 45 months In case of the prolonged psychosis, attachment of atypical symptoms it is possible, initiating evolution of reactive endogene process. Persistent reactive psychoses are divided into situational depression, psychogenic twilight stupefaction, pseudodementia and reactive paranoid. A situational depression is the most spread (2535 % reactive psychoses). Duration of situational
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depressions ranges from 20-30 days up to 4-5 months. Clinical pattern of depression is manifested by the lowered mood (oligothymia), inhibited intellectual and motor activity, decrease of the vital drives, pessimistic estimates of the persons position, somato-vegetative disorders. Patients exhibit sad look and hunched posture. They are concentrated on the negative moments of psychotrauma situations. When someone mentions this situation, they become brisk, try to vent the soul. Express ideas of self-guilt and blame. The mood background is lowered. Only the formal self-criticism is expressed Several clinical varieties of situational depressions are isolated: Disturbing depression evolves more often on the background of the somatogenic asthenia. First, communication of anxiety with psychotraumatic conditions is noted, and then on the background of depression aggravation by the disturbing experiences, become less and less coherent with a situation. Patients get detached from the traumatic situation and expand their attitude to all life events. Psychomotor exaltation can periodically evolve. Anxiety depression is one of the brightest expressions of the somato-vegetative conditions. Dysphoric depression is exhibited in persons with organic brain inferiority and epileptoid persons. It is characterized by the combination of the lowered mood and tendency to accumulate negative affects, manifested by fits of anger, fear, anxiety and raised aggression. Hysterical depression is encountered in persons with hysterical character traits and is manifested by the expressiveness, grotesqueness and dramatic nature of the depressive symptomatology, designed for spectators. Hysterical constriction of the consciousness, evolving in the hysterical stupor, is possible. Psychogenic twilight stupefaction is manifested by acute affective constriction of consciousness of hysterical type with attention fixed on psychotraumatic situations. Course of the disease is wavy with deep stupefaction. Thus, the surroundings are perceived fragmentary. Verbal products of patients, pantomimes are colorful, grotesque, expressive and reflect attitude to the psychotrauma. Patients exhibit hallucinative experiences and willingly tell about them. Statements exhibit abundant delirious spots. Emotional lability is noted with oscillations of from delight through tears and sobbing. Expressed vegetative disorders in the form of tachycardia, sweating and hyperhydrosis of palms and feet are observed. Duration of a morbid state is 5-6 days. Pseudodementia evolves predominantly in the persons with organic brain damages and mentally defective persons. Fear fits cause hysterical constriction of the consciousness, manifested specific
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intellectual disorders. Clinical pattern of a pseudodementia develops from the affectively reduced state of consciousness, false, apparent aphrenia, loss of basic knowledge and skills, signs of the wrong answers and activities. Patients look half-witted and star. When thinking they tensely wrinkle forehead. Patients exhibit lack of the elemental data, ignorance of their age, name, military rank. Simple questions are either answered incorrectly, or in opposition to a right answer, sometimes with answers being similar to correct, but with deliberate gross errors. The question, how many is 2+2? cause them to answer 7 or give irrelevant answers. The patients may exhibit signs of psychotraumatic experiences. They wear clothes incorrectly, for example, try to put boots on arms or strike a match from the wrong end. Do not engage in active contact, preferring to be left alone. Ganser syndrome evolves on the background of agitation, less often depressive mood, retardation. Questions are answered tersely, restricted to phrases I dont know or I dont remember. Repeatedly iterate the same words concerning a situation. Manifest loss of knowledge and skills. The puerilism is characterized by a childlike motility and baby talk. Name surrounding persons as uncles and aunties, imitate child plays. Patients are capricious, easily offended. The syndrome of psychics regress is manifested in imitation of animalistic behavior or behavior of wild human. Patients growl, creep, drink from a bowl, show teeth. On the background of chaotic behavior, they exhibit separate statements related to psychotraumatic situation. Duration of a pseudodementia seldom exceeds several days, then aphrenia completely vanishes. The psychogenic paranoid is a rare shape of reactive psychosis. It is often formed in people with disturbing-hypochondriac character traits. Psychogenic paranoids are preceded by somatic asthenization, forced insomnia, or personal features related to raised suggestibility and autosuggestibility. It evolves gradually, from rising anxiety, sense of troubling, fear, depressed mood. If combined with the delirious syndrome, related to specific and ordinary subjects, connection to psychotrauma and lacking generalization. Patients become vigilant in relation to the ward neighbors and medical personnel. They are also convinced in presence of enemies or malevolent persons. The persecution complex solidifies. The verbal illusions are possible. Psychogenic paranoid lasts for 12 months.

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Chapter XI CHANGES OF INTERNAL ORGANS CAUSED BY EXPLOSION DAMAGES

From the therapist standpoint, uniqueness of an explosive damage as a complex of multifactor actions on the human organism is caused by the following moments: frequency of damages to the internals, comprising, according to different authors, 90-100 % [Habibi V., 1988; Kirillov of M.M., 1993. et. al.]; extremely high specific severity of combined and plural traumas and wounds (>90 %), which essentially complicates course and outcome of the wound sickness [Nechaev E.A. et.al., 1994]; influence of the climatic, ecological and geographical factors inherent to combat conditions, in many respects defining mechanisms of evolution of pathological and compensatory-adaptive, defense responses [Zakurdaev V.V. et. al., 1987]; background adverse action of the combat stress. By the leading mechanism of traumatic damage: closed damages to internals caused by the blasts of mine munitions, characterized by the evolution of general contusion-commotio syndrome with morphofunctional disorder at the organ level; closed damages of internals due to action of lateral shock, inflicted by wounding projectile, caused in 20 % cases on the average; wounds to the internals. Specificity of MT therapeutic aspects in many respects is defined by the most frequent varieties of combat damages, causing therapeutic pathology of the internals, no less significant than the surgical pathology. In particular, if injury is inflicted by the shock wavea propellant blast effect and demolition inside the armored vehicle (when the armor protection is intact) or a gunshot (bullet, fragment), which did not penetrate an armored vest. Genesis and evolution of the vital organs systemic disorders is related to the formation of contusion-commotio syndrome with characteristic distant damages and closed craniocerebral trauma. Famous N.I.Pirogov wrote: ... Concussion from a bomb is passed on to all organs in general; it can be detected without visible attributes of disrupted integrity in tissues or with rather small disruption. The general concussion is one of the most important trauma elements.
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Changes of internals pathogenetically related to the mine-explosive traumas, can be divided into primary, caused by injuring factors of an explosion and secondary, caused by the complications of inflammatory and dystrophic character [Nechaev E.V., 1994; Gembitskij E.S., et.al., 1994; Ruhljada N.V, et.al., 2001].

11.1. PRIMARY DAMAGES OF INTERNALS 11.1.1. Circulatory system

Early primary damages after the explosive traumas include: bruises of heart; cardiac rupture - penetrating into cavity of pericardium with tamponade and nonpenetrating; traumatic heart diseases; traumatic myocardial infarction; acute posttraumatic pericarditis; acute posttraumatic cardiomyopathy. During the first hours after MT, entire set of factors is formed, adversely affecting a myocardium. Hypocirculatory syndrome evolves with significant (3050 % from proper) decrease of cardiac output, deficit of CBV and globular volume, increase of the peripheral resistance, especially in the small circle vessels, tachycardia with reduced diastolic time and persistent hypotension. The major role is played by the arterial and respiratory hypoxemia with evolution of metabolic acidosis. A major cause of cardiodepression is the high level of catecholamins in the myocardium, combined with hypopotassemia and hyperproduction of 11-oxycorticosteroids, serotonin and kinins. Early endointoxication, inherent for MT, also causes direct cardiotoxic effects [Derjabin I.I., et.al., 1987; Borisenko 1990]. As the result, myocardium oxygen demand promptly elevates and conflicts with the acute restriction of blood delivery. This causes destruction of cardiomyocytes, growth of intracellular calcium and depletion of glycogen reserves. Progressing decrease of myocardium contractive capabilities leads to an acute cardiovascular failure with possible evolution of cardiogenic lung edema. Heart Bruise Heart bruise or contusion results from the direct, propellant or armor-piercing blast effects,
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causing rapid horizontal acceleration or deceleration with concussion of a heart with a thoracic wall, its compression by lungs and diaphragms, hydraulic shock of a blood in cardiac cavities. Another possible mechanism is a lateral shock, accompanying penetrating fragmentation chest wounds. One of the first descriptions of the closed heart damage, caused by the blast wave is given back in 1901 by A.A.Chugaev. Incidence of this pathology during MT attains 15 %, in addition in 5 % cases there is combination of a heart and lung bruises, which makes up 80 % of all primary heart damages. Diagnostics of the heart bruise on the background of polytrauma clinical pattern is considerably impeded, and is adequate only in 2030 % cases. During the first day after MT heart bruise becomes an immediate cause of lethal outcome in 6.5 % casualties. The lethality after the severe bruises exceeds 60 %. According to autopsy data, attributes of the closed heart traumas, caused by MTs, are found in almost 70 % cases [Ivashkin V.T., 1993; Gembitskij E.V., et. al., 1994; Gumanenko E.K., 1997]. Thus, the morphological changes in bruised region are presented by fine sections of cardiomyocytes necrosis, irreversible changes to nerves and microvessels, hemorrhages in the myocardium and shell. The region of microcirculatory disorder is 23 times wider than the bruised region. Starting from the third day, myocardium cells dystrophy starts [Soroka V.V., 1985]. It is also necessary to consider such prominent features of the clinical pattern as the unusually severe condition mismatching a degree of injury to organs of a chest, a skull and extremities. Thus even a rational surgical treatment of other damaged regions on a background of an intensive care, not only does not produce a positive effect, but reinforces progressing cardiovascular failure. Heart bruise clinical pattern involves the complaints on dyspnea, pain behind the chest bone, intractable by analgetics or segmental novocaine blockages, palpitation, sensation of missing beat, increasing general weakness. Objective examination shows the tachycardia up to 12013/min, arrhythmia, increase of heart dullness, hypotension with decrease of a systolic pressure to 90100 mm.Hg., maintained for 35 days, attenuation of 1st tone and systolic noise the top, audible during the first week after MT. Less encountered signs are: pericardium friction noise, which appears by the end of the first day, accent of 2nd tone above the lung artery, 3rd tone at the tope, galloping rhythm. It also deserves an attention that even the transportation of a casualty and sparing rearrangement
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from a hand frame to operating table causes 1520 mm drop in arterial pressure and rising tachycardia. Most severe conditions in case of the progressing pulmonary-cardiac failure is observed in case of heart and lungs combined bruise. The cyanosis, dyspnea up to 44/minute, deep hypotension with drop of a systolic pressure to 7080 mm.Hg, tachycardia up to 140 beats/min, progressing rhythm disorders [Bisenkov L.N., 1993] are characteristic. X-ray exam during heart bruise reveals moderate cardiomegaly in some cases. Until recently ECGs underlaid entire set of the instrumental diagnostics. Most typical attribute of the electrocardiogram, if taken in early terms, is occurrence of the two-phase or negative peak , maintained during 710 days after the MT moment. Except for that, surgeons usually discover: decrease of R peaks voltage, inversion of ST interval for more than 2 mm, maintained for 23 weeks, deformation of peak P. In more severe cases, the syndrome of myocardium electrical instability is manifested: ventricular extrasystoles, including group variety, often during the very first day, less often the ciliary tachyarrhythmia, reentrant tachycardia, threat of ventricles fibrillation is possible. Disorders of conductance are represented usually by blockages of Hiss bundle legs, especially persistent during damages to an interventricular septum, less often atrioventricular blockage of IIInd degrees. Electrocardiographic changes, accompanying the heart bruise, essentially do not vary during accomplishment taking functional samples of potassium, beta-blockers and also after novocaine blockages of rib fractures. Duration ECG changes, as a rule, does not exceed 2530 days with gradual positive dynamics. The ECG decline o 57 days after a heart bruise can testify to the affixing posttraumatic myocarditis. The central hemodynamics at combined wounds and traumas with a heart bruise is defined by the myocardium pathology[McMurty, McLellen, 1989]. Integrated body rheography and echocardiography usually indicate drop of the shock coefficient, reflecting single-time cardiac efficiency by 2540 %, operation of a left ventricle 3035 %, reserve coefficient 25 %, [Gajduk S.V., 2000], essential decrease of the minute and shock circulation volume and output fraction. Ultrasonic heart examination allows also to detect regional hypo- and akynesia of a myocardium, disorders of aortal and mitral valves activity due to the damaged chordal lines, dysfunctions of papillary muscles, dilating cavity of a left ventricle, decrease of a stroke output and output fraction, in some cases prolapse of the mitral valve folds with blood regurgitation in the left auricle. Diagnostic significance of the enzyme study creatine kinases, lactadehydrogenase and
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transaminase, is insignificant for MTs with massive damage to skeletal muscles, bones and bruises of o abdominal cavity organs, lungs and brain.

Cardiac rupture As a rule, casualties with these damages represent extreme form of closed heart traumas, comprising almost 1/3 of all cases. Considering extreme severity and rates terminal states evolution, it is necessary to expect that the number of casualties with the cardiac rupture, forwarded to the stage of the qualified (specialized) aid, will be very small. Left ventricle ruptures are more frequent, about 30 % is comprised by multi-chamber damages. The same incidence is related to the ruptures of a pericardium. The physician isolate external ruptures with a cardiac tamponade; internal ones with a damage to the valve mechanism. According to Besson, Saegesser (1983) heart bruise can be combined with the septum rupture (8 % cases) or valve folds (3 % cases). Clinical pattern is dominated by the severe shock, signs of persistent heart attack, varieties of arrhythmia down to fibrillation of ventricles. Auscultatory, physical complex is discovered, which is inherent to a heart disease, depending on localization and volume of damages. In presence of penetrating ruptures, the hemopericardium and a cardiac tamponade is a menacing complication, frequently leading to the lethal outcome. Overwhelming majority of cardiac rupture cases demands urgent operative measures under vital indications. The therapeutic aid thus includes participation of the therapist in emergency clinic and ECG-diagnostics of heart damages, improvement of their localization, diagnostics of early complications and intensive care. Traumatic heart disease. Traumatic heart diseases are caused by the hydrodynamic shock of a blood with damage to intracardiac structures, first of all, valves, papillary muscles and chordal lines. The most frequent type of damage is the rupture of an interventricular septum. Aortal, atrioventricular valves suffer to a much lesser degree, and even less often tricuspid vales are damaged. In some cases, combined damages essentially worsen the forecast. The clinical pattern of interventricular septum traumatic damage is dominated by the signs of shock, acute right ventricle failures (due to blood bypass to the systole from a left ventricle) frequent thready pulse, hypotension, paleness and cyanosis of integuments, bloating and pulsations of cervical veins, enlargemenent and liver morbidity. Auscultatory, systolic noise is
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recorded at the level of third-fourth intercostal spaces above the chest bone or at its left edge. The ECG exhibits attributes of damaged 2nd and 3rd standard leads, overload of right ventricle and blockage. The rupture presence of is verified by the ultrasonic heart exam. Surface tears or separations of aortal valves folds cause overload of the left ventricle with its gradual dilatation, decrease of diastolic pressure and blood fill of coronary vessels. Complaints on giddiness, pains in the heart region are possible. Objective exam shows amplification of the cardiac impulse, diastolic noise with maximum in the Botkin-Erba point and impairment of cardiac tones. X-ray exam shows amplification of aorta pulsing and the left ventricle contractions, ECG shows attributes of a left ventricle overload. Insulated pathology of atrioventricular and tricuspid valves of traumatic genesis, shaping classical physical pattern, is rarely accompanied by significant heart failure manifestations. Long-term neutralization in general is characteristic for the majority of traumatic diseases, which allows delaying operative measures.

Traumatic myocardial infarction Mechanism of the myocardial infarction, when caused by MT, is related, as a rule, with direct damage or wound of coronary vessels with the subsequent clotting, fatty embolism, characteristic for MT, aerial embolism caused by the blast wave, compression of the vessel by the hematoma, formed after the myocardium damage. It is necessary to consider also that under influence of the combat stress, the hazard of myocardial infarction increases due to existing atherosclerosis of coronal arteries. Frequency of the infarction, characterized by the high lethality, attains from 8 % to 15-17 % after the severe chest MT Almost in 70 % cases, the anginal form dominates in clinical manifestations. Acute left ventricular failure, accompanied by the lungs edema, is characteristic. Severe arrhythmias evolve somewhat less often. As a rule, considering the mechanism of blast wave action and other MT factors, the region of myocardium damage is localized in the anterior and lateral sides of the left ventricle. Macrofocal, less often microfocal, infarctions are encountered. Clinical attributes of traumatic myocardial infarction are manifested immediately or several hours after MT. The clinical picture includes: retrosternal pains attack, unstoppable by analgetics, progressing left ventricular failure, collapse, attributes of the lungs edema, in some cases reentrant tachycardia and ciliary arrhythmia. Diagnostics, including physical, is considerably impeded by the presence of traumas or chest wounds, especially with the rib fractures. The major
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role is played by the electrocardiography, including dynamics after administering anesthesia to the fracture regions. The most frequent antero-lateral localization exhibits classical changes of interval ST and peak in the 1-st and 2-nd standard leads, aV1. V3-V6 with formation of complex QS in case of transmural myocardium damage. The traumatic myocardial infarction, similar to the heart bruise, is unlikely to be revealed through the diagnostics of elevated enzymes (LDG, KK-MV, transaminases).

Acute posttraumatic pericarditis. Among the causes of an early posttraumatic pericarditis are the ruptures of cardiac bursa after MT, insulated wounds of the pericardium and its distant damages. The frequency of a pericarditis attains 25-30 %. According to the autopsy data, reactive changes of a pericardium were noted in 50 % cases during the very first days, and up to 75 % were found during 2-5 days. The set of typical complaints include: moderate dull aches, sometimes treading, without an irradiation, with intensity varying during motions, cough, increasing during the deep breath, dry cough, a dyspnea and interruptions. In most cases the temperature is of subfebrile level. Characteristic auscultatory sign of the dry pericarditis is pericardial friction noise, audible above the entire heart surface or locally, non-conductive and gradually fading as the discharge accumulates in the pericardial space. It is necessary to underline, once again, significant difficulties of physical diagnostics during MT, related with the pain syndrome, restriction of casualties mobility, the pulmonary ventilation, presence of bandages, possibility opportunity of subcutaneous emphysema. Early ECG attributes are: rise of interval ST in standard and majority of thoracic leads and bias of interval PQ , which can be combined with attributes of myocardium damage. The onset of exudate pericarditis is related to the increasing dyspnea, sense of heaviness in the heart region, tachycardia, disappearance of the cardiac impulse, expansion of cardiac dullness boundaries, auscultatory dullness of tones with the advent of a metal tone. Further accumulation of the fluid in the pericardial cavity can cause hemodynamic disorders: CVP rise to 150-180 mm.water and hypotension. X-ray exam shows expanded heart shade with the rounded contours, decrease of the pulsations amplitude. The electrocardiogram, as a rule, shows decreased voltage of QRS complex peaks. Of crucial importance for diagnostics is ultrasonic examination, capable of revealing echonegative space between the surface of heart chambers and a pericardium as an attribute of
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fluid presence; the hyperkinesia of an interventricular septum and disorder of the atrioventricular valve motions, which are considered to be the indirect signs of a heart compression. Application of a 2D location regime in some cases allows reveal the phenomenon of a floating heart [Shevchenko., Kucherenko A., 1999]. Rapid build-up of the discharge volume in the pericardium cavity causes terrible complication cardiac tamponade. Clinically, it is manifested by the treading pain in the antecardial region, sense of fear. The casualty tends to hold the elevated position; exhibit skin paleness, cyanosis, cold clammy sweat, frequent thready arrhythmic pulse. Physicals show bloating and the reinforced pulsing of cervical veins, pastosity of the face and neck, further expansion of the cardiac dullness boundaries, the liver magnification, lack of the cardiac impulse, the expressed dullness of heart tones. CVP grows on the background of a hypotension. If MT casualties are diagnosed with heart tamponade, pericardium puncture should be performed immediately together with the intensive therapy.

Acute posttraumatic cardiomyopathy Unlike classical myocardial dystrophy, the complicated course of wound sicknesses (sepsis, etc.), known back during WWII, recent military conflicts describe similar changes of a heart muscle during 30-40% combat traumas and wounds. These changes are currently termed as the acute myocardial dystrophy or cardiomyopathy. Basic pathogenesis mechanism in this case is a complex effect of a massive hemorrhage, hypoxia of the mixed nature, metabolic shifts, combat stress, direct cardiotoxic effects of the biologically active materials and endotoxins [Gembitskij E.V. et. al., 1994]. The posttraumatic cardiomyopathy morphology is manifested by the dystrophic changes of myocardium cells, wide spectrum of microcirculatory disorders and stromal edema, in some cases small necrosis foci. As a rule, basic manifestations of acute posttraumatic cardiomyopathy evolve 15 days after MT. and have rather non-specific clinical pattern. Transient cardialgias, arrested by the antibiotics, are rather typical signs together with palpitation and intermittent heartbeat. Physical exam reveals auscultatory impairment of 1st tone above a heart peak, transient systolic noise in the same region for up to 710 days. Taking into account objective examination of wounded and casualties with MT, more important is to use an electrocardiography during the acute period dynamics. This period is accompanied by the voltage decrease, expressed heartbeat lability with the tachycardia, which is acutely rising even after a small stress and sometimes even replaced by
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the bradycardia; formation of two-phase or negative peak with its gradual normalization 23 weeks after MT. In comparison with bruises of heart, arrhythmias, disorders of conductance, ventricular extrasystoles (preferentially isolated, lasting no more than 5-7 days) are much less often noted. Another difference between the above two syndromes, is positive ECG functional test with a potassium, which confirms presence of dysmetabolic shifts during the posttraumatic cardiomyopathy. Treatment of heart damages after a MT Effective therapy for virtually all primary internals pathologies during MT is determined by the adequacy and timeline of the antishock and operative provisions. General principles of heart damages treatment during MT are: delaying some operative measures, in particular on extremities, until normalization of hemodynamics, restitution of myocardium contractive abilities, arrest of electrical heart instability are achieved. liquidation of pain syndrome; restitution of a hemodynamics; improvement of a myocardium propulsive function; normalization of the pace, electrical excitability, conductance, optimization of the hear muscle metabolism; prophylaxis of contagious complications; adequate energoplasty maintenance. In case of severe bruises, myocardial infarction etc., the casualties require a confinement to bed for 5-10 days with the individual program of activization and aftertreatment, complex of medical exercises and physiotherapy. The pain syndrome during heart damages, including combined traumas and wounds, demands, alongside with block anaesthesia, introduction of anesthetizing drugs of the central activity. In addition to that, the arrest of coronagenic pains is required. Use of Fentanyl and Droperidol combination, parenteral nonsteroid analgetics, narcotics (Morphine, Promedol) and sedative drugs is possible along with IV drop introduction of nitrates under the hemodynamics monitoring. Infusion-transfusion therapy, directed on the normalization of a hemodynamics, has certain features. It is, first of all, restriction of volumes of fluid parenteral introduction to 11.5l using the hemodilution. Physicians should apply solution of sugar, Ringer, polyglucinum, rheopolyglucinum, including intraaortally. Transfusion therapy should be, whenever possible,
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componential, with broad use of reinfusions, maximal restriction of whole blood transfusions, which can cause many post-transfusion complications and side effects starting from pulmonary microembolism to the extent of erythrogenesis inhibition and anemia aggravation [Sheluhin V.A., 1979; Wagner E.A. et. al., 1986]. The laboratory criteria of hemotransfusions are hematocrit values less than 0.30 l/L and hemoglobin below 90 g/l. Physicians also use IV drop introduction of inotropic drugs Dopamine with an average rate 1 g/kg per minute and mandatory requirement absent threat of cardiac tamponade; glucocorticosteroids: Prednisolone IV 400-600 mg average, Dexamethasone, Hydrocortisone. Disorder of contractive ability of myocardium with clinical pattern of a circulatory failure demands parenteral introduction of cardiac glycosides, often Corglycon 0.5-1 ml 2-3 times a day. In case of lungs edema development, physicians should use Strophantine up to 1 ml, Furosemide IV, Atropine SC, Morphine, inhalations of the moistened oxygen with defoamers (alcohol, antifomsylan). Pace disorders (extrasystoles, a ciliary arrhythmia, reentrant tachycardia) are arrested using Lidocaine 610 ml, novocainamid up to 10 ml, dropwise beta-blockers, calcium antagonists. Development of atrioventricular blockages and bradycardia requires SC injections of Atropine sulfate SC 0.51 ml. Threatening complication fibrillation of ventricles requires urgent antishock provisions. Maintenance of plastic processes and provision with energetic substrates is carried out during acute period of wound sickness by parenteral feeding in cases of traumas and wounds to the abdominal cavity organs, extensive enterectomies, traumatic pancreatitis, an incompetence of an enteroalimentation for other MT localizations. Except for already mentioned glucose-insulin mixtures (up to 2l), the polyionic solutions, physicians use fatty emulsions (up to 1 l), aminoacid drugs (up to 800 ml), albumin at the rate of 25 g protein per 1 kg of body mass per day. Simultaneous introduction of anabolic hormones raises efficiency of parenteral feeding. Nutritive value should not be less than 30 kcal per kg of body mass per day. The parenteral feeding through the probe is possible in case of the intact gastrointestinal section with introduction of glucose mixture during the first day, monomer electrolytic solutions Orasan, Rehydron, Gastrolith, aminoacids, in the subsequent nutrient mixture Inpitan, Ovolact, Enpit, polymerous balanced mixtures Isocal, Nutrison, etc. in combination with peptic enzymes and peristaltic stimulation [Shanin V. Yu. et. al., 1993]. Heart bruises additionally require anti-inflammatory therapy with introduction of Contrical up to
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40 Ku, nonsteroid anti-inflammatory drugs (Voltaren, Indomethacin, Ibuprofen, etc.) Restitution of microcirculation is performed by applying anti aggregation agents - Tyclid, Trental. The question of Heparin administration still remains unsolved. Traditionally, heparin is used in elderly patients, mentioning recommencing bleedings threats, stratification of a myocardium. Undoubtedly, the presence of fresh ruptures in the myocardium and increasing hematomas bar using Heparin, at least, before surgery. On the other hand, massive damages of tissues, significant shock incidence, inherent to MT damages, threaten with acute disseminated intravascular clotting (DIC) syndrome. Its evolution and the advance progression in acute or even hyper acute cases, are capable of determining the outcome. Thus, at lack of clinical contraindications, problem of heparinization can be solved by estimating results of simple laboratory tests [Barkagan Z.S., 1988]. They may include increase of fibrinogen degradation products, blood clotting time, prothrombin time, presence of an intravascular hemolysis attributes (level of free hemoglobin, indirect bilirubin), drop of fibrinogen levels, quantity of thrombocytes down to 100 k, drop of antihtrombin-3. All these parameters, to some extent, reflect initial or transient cases of DIC syndrome and demand immediate IV administration of Heparin: 10 kUnits single dose, then dropwise in infusion 30 kU daily. Combination of Heparin with the freshfrozen plasma may be effective during the active infusion therapy. The problems, posed to the therapists, in the presence of traumatic cardiorrheses are, first of all, participation in intensive preoperative preparation with elimination of life-threatening states, restitution of vital functions, prophylaxis of contagious complications and treating wounded and casualties with heart traumas during a postoperative period jointly with the personnel of intensive care units. The evolution of traumatic heart diseases in connection with an opportunity to delay a surgical intervention (around several months), makes the highest priority a therapy, directed on maintaining contractive ability of a myocardium, normalization of its metabolism, arresting the basic signs of formed circulatory failure. It is important to define also the boundary, after which conservative therapy cannot stop decompensation of cardiac activity any more, and when it is time to select optimum approach to the surgical treatment. Traumatic myocardial infarction can be basically treated with the standard complex of medical provisions. Existing peculiarities are the presence of heart bruise in all cases, possibility of the infarction combination with the surface tears of a myocardium, hemorrhages, traumas of the valved structures, which should be considered when estimating the condition severity and
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choosing the medical tactics. Evolution of acute posttraumatic pericarditis in early terms demands immediate action at the stage of dry process, so that the adequate arrest of the pain syndrome can be achieved, including administration of the nonsteroid anti-inflammatory drugs to inhibit discharge-related and proliferative elements of the reactive inflammation and antibacterial prophylaxis of the infection contamination. A formation of exudation pericarditis does require rapid activization of the therapy pericardiocenteses with its drainage. In case of the rapid discharge accumulation, physicians should start administering steroid hormones (Hydrocortisone, Prednisolone, Dexasone slurry) in a pericardial cavity. Fibrin adnations and deposits require administering the proteolytic enzymes, Terrilytin, Terridecase through the drainage; use of diuretics and cardiac glycosides in case of a circulatory inefficiency (unless there is a threat of tamponade!). The restitution of metabolic processes in a heart muscle during acute posttraumatic cardiomyopathy, requires transfusions of up to 400 ml/day glucose-insulin mixture, solutions of potassium, magnesium, calcium and reamberin amber acid based antihypoxant. It is recommended to double daily doses of an ascorbic acid and vitamins B1. B6; start parenteral introduction of Riboxin, blockers of calcium channels, antyhypoxants: Olyphen, vascular protectors: Complamin, Trental; anabolic hormones.

11.1.2. Respiratory system

Lung bruises; Acute respiratory failure. Respiratory distress-syndrome in adults; Ruptures of lungs, bronchi, pleura. Hemothorax and pneumothorax; Lung atelectasis; Primary posttraumatic pneumonia; Posttraumatic pleurisy; Acute lungs emphysema; Thromboembolism of a pulmonary artery.

Lungs bruise The basic mechanisms of a lungs bruise are related with propellant or armor-penetratings factors of MT, the blast wave effects, direct lung damages during penetrating or nonpenetrating wounds
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if a body armor is present. The morphological pattern is represented by the focal hemorrhages, ranging from fine superficial to extensive lobar ones, lengthwise the vessels and peribronchially; the microruptures of lungs parenchyma, alveolas, capillars, bronchioles, pleurae; interleaving emphysema and microatelectases foci. These changes are bilateral in almost 80 % casualties. Histological attributes of intraalveolar and interstitial edema and generalized microcirculatory disorders are encountered [Nechaev E., et. al., 1994]. The damage to parenchyma, fractures of ribs, ruptures of bronchi and diaphragms are accompanied by the extensive hemorrhages and hemopneumothorax. This results in the ischemia of alveoli, obturations of bronchi, disorder of breathing biomechanics, drop of surfactant synthesis, hypercoagulation. Transmittivity of alveolar-capillary diaphragms grows. Microembolism and clotting with formulated elements, fatty particles and microatelectases evolve. Formed interstitial edema, diffuse disorders of microcirculation, regions of atelectasis, alongside with the drop of myocardium contractive abilities cause the reduction of respiratory lungs surface, increase of the general pulmonary resistance, bypassing of venous blood in an arterial bed, lung hypoperfusion. These phenomena shape ventilation and parenchymatous elements of ARF with hypoventilation, acute disorders of oxygen diffusion, displacements of the ventilation-perfusion relationships. Progressing hypoxemia and metabolic uncompensated acidosis are the results of these multifactor changes. Clinical pattern of the lung extensive bruises consists of the following signs: complaints on the stethalgias, increasing during breathing, persistent cough with bloody sputum and dry cough; palpitation, general weakness; exams show the retardation, the enforced raised position, a dyspnea, cyanosis, increasing during the motions, subfebrile temperature and hypotension; physical exam shows dullness of percussion sound, restriction of lower lung edge mobility, the rigid, acutely attenuated breathing, toneless damp rales, sometimes a pleural rub noise. Restricted lung bruises of are accompanied by the lack of pneumorrhagia, lack of significant displacements in the external respiration and hemodynamics functions. ARF is clinically demonstrated by breathing arrhythmia, hyperventilation and drop of LVC. Later breathing is becoming less frequent, phenomena of decompensated respiratory acidosis and cyanosis increase. Lack of timely and adequate therapy can lead to transition of ARF into the extreme expression
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respiratory distress-syndrome in adults, a.k.a. syndrome of the acute lung damage. Adult respiratory distress-syndrome complicates severe MT on the average in 511 % cases. In presence of extensive lung bruises the incidence of the respiratory distress syndrome reaches 30 %, becoming immediate cause of death for casualties during the first 23 days in 35 % cases. This syndrome represents total disorder of ventilation, perfusion and gas exchange owing to the microcirculatory bed damage, destruction of alveolar-capillary diaphragms, generalized clotting and microvessels embolism. As a rule, it evolves during the first two days, being shaped since the first hours after MT. Among the risk factors, it is necessary to isolate massive hemotransfusions, manifestations of the disseminated intravascular coagulation syndrome and inadequate oxygenation. The clinical pattern of an initial stage includes tachypnea up to 40 /min, tachycardia to 120130/min, drop of arterial pressure, anxiety, cyanosis, auscultatory dry whistling rales and rigid breathing. Hypoxemia evolves with the drop of a partial oxygen pressure in arterial blood down to 55 mm.Hg. X-ray exam reveals interstitial edema with an amplified lung pattern. Expanded stage is comprised of a mental disorder to the extents of hallucinations, noisy bubbling breathing with the expressed dyspnea, inadequate breathing with participation of auxiliary muscles, cough with massive bloody sputum; auscultatoryrigid attenuated breathing, fine moist rales over the entire lung surface. The arterial hypoxemia with oxygen pressure drop below 5055 mm.hg is noted. The terminal stage of an acute lung damage syndrome is manifested by the severe pulmonary-cardiac failure with a lethality reaching 5070 %. Lung bruise X-ray image is shaped by the end of the first day in the form of solitary or plural foci or confluent foci of low-intensity shading with no precise boundaries, more often in the peripheral lung departments. During the second day, lung picture is amplified by the lung root expansion from the damaged side. Radiological attributes the lobar atelectasis, segments, less often intralobary, are seen. After 710 days, as a rule, radiological signs disappear completely, distinguishing lung bruise from pneumonia and other processes. Instrumental diagnostics of an external respiration and central hemodynamics manifests LVC drop (lung vital capacity) down 30 % from normal, depleted reserves of breathing and decreased oxygen utilization coefficient, decrease of myocardium contractive abilities. ECG reveals overload of heart dextral departments. Major method of diagnostics is fiber-optic bronchoscopy, allowing to tap a lung bruise in dynamics, reveal damages to trachea and bronchi, presence of a blood aspiration, foreign bodies etc. [Bechik S.L., 1996]. The lung bruises are manifested by the
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characteristic and submucosal hemorrhages in the lobar and segmental bronchi, submucosal edema with constriction of bronchial orifices of 34 orders, clots in the fine bronchi with their obturation. Wash-out during bronchoalveolar lavage is filled with either neutrophils (typical for evolution of the subsequent pneumonia), or lymphocytes, related to more congenial prognosis.

Ruptures of lungs, bronchi, pleuras. Hemothorax and pneumothorax Severe mine-explosive traumas in some cases cause closed damages of lungs parenchyma, bronchi and pleurae with their ruptures. Thereof, incidence of bronchi damages during the combined chest MT comprises 16 % [Brusov P.G. et.al., 1998] and is rarely accompanied by the ruptures of a pleura or diaphragm. As a rule, they combine well with pulmonary bleedings. In a clinical symptomatology, the shock pattern is dominated by the expressed pain syndrome, tachycardia, tachypnea, drop of an arterial pressure, cough with barmy blood sputum, expressed cyanosis, cold clammy sweat, superficial breathing, spread subcutaneous emphysema. Hemothorax accompanies closed chest damages, according to various authors, in 1025 % cases. Its incidence for mine-explosive penetrating wounds attains 40 % [Bisenkov L.N,, 1993]. Depending on the blood volume in a pleural cavity, physicians isolate small (only in pleural sinuses), average (up to a level of middle blade) and major hemothorax. Physical examination manifests bias of mediastinum organs towards the healthy side, acute dullness of percussion and impairment or even lack of breathing at the damaged side. Diagnostics, in addition to X-ray exams, is performed by the thoracoscopy and fiber-optic bronchoscopy, carried out on the background of resuscitatory provisions. The pneumothorax, discovered at the stage of qualified or specialized aid, as a rule, refers to strained or closed mechanisms. Its incidence during closed MD comprises from 5 to 30 % according to the different authors. Objective exams manifest smoothness of intercostal spaces, acute restriction or lack of the respiratory excursions at the damaged side, extremely impeded breathing, tachypnea, bias of mediastinum organs towards the healthy side. The diagnosis is verified by the dynamic X-ray inspection. Traumatic atelectasis Frequency of the lung atelectasis after chest MT comprises 2-6 % cases. It preferentially sets in during the first-second days (70 %). The genesis of collaboration in fraction or entire lung is related to obturations of bronchi by clots or slime in combination with surfactant system inactivation.
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Objective exam shows the expressed dyspnea up to 40/min, cough with scant or no sputum. Physical exam shows light face cyanosis, smoothness and constriction of intercostal spaces with reduction of the respiratory excursions volume from the damaged side; higher lower lungs boundary, breathing dullness and acute impairment from the side of an atelectasis, sandbox sound during percussion over the contralateral lung, displacement of mediastinum organs towards the damaged side, damp crepitating rales. Casualties try to assume reclining position on the damaged side, turning causes acute increase of dyspnea. X-ray exam shows attributes of the lung complete or partial collapse with the homogeneous dimming and elevated diaphragm position from the side of an atelectasis. Primary posttraumatic pneumonia The posttraumatic pneumonia refers to the most widespread organ-pathologic combat trauma manifestations, in many respects shaping course and outcome of a wound process. Its incidence during MT comprises, according to certain authors, 29-37 % [Komarov V.I., 1989; Storozhenko A.A., 1994; Nechaev E.A. et. al., 1994]. At the same time, according to V.T.Ivashkin (1993), the most severe MTs cause the primary pneumonia in 64 % cases. As a rule, peak incidence of posttraumatic pneumonia falls on 3rd -4th day after MT. Nevertheless, already during the first day, presence of damages to the thoracic cavity organs manifests clinical pneumonia precursors [Gembitskij E.V. et. al., 1994; Novitsky A.A., et. al., 1994]. In overwhelming majority of cases (up to 95 %) it originates on the background of a massive hemorrhage and shock [Gayduk V.A., 2000]. Starting from 5-6th day from the MT moment, the pneumonia takes a lead among the immediate causes of lethal outcomes (up to 1/3 cases), maintaining this place up to the remote outcomes stage. According to the combat trauma mechanisms, the leading part is played by the mine-explosive damages, first of all, during armored vehicles blasts. Under these conditions primary pneumonia is diagnosed in >50% casualties. Contact blasts and the fragmentation wounds, inflicted by proximal MW, cause posttraumatic pneumonia in 15 to 25 % cases [Nechaev E.E., et. al., 1994]. It is necessary to isolate entire group of risk factors, causing evolution of the primary posttraumatic pneumonia. Among them are the thoracic cavity organs damages and their aftereffects: bruise of lung, an atelectasis, a hemopneumothorax, the acute emphysema, complicated by an acute respiratory failure, the respiratory a distress-syndrome, a thromboembolism of pulmonary artery branches;
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fatty vascular embolism of a small circle; a bruise of heart with acute drop of myocardium contractive abilities; multiorgan failure; massive hemotransfusions of stored blood with a microthromboembolism of lungs, redundant infusions of crystalloid and colloid solutions, accompanied by lung edema [Viasitski P.O.,et.al., 1989; Bisenkov L.N., 1993]. The leading part in the posttraumatic pneumonia pathogenesis is played by the respiratory disorders, damages of lungs parenchymas, oppression of the bronchial tree drainage function, thromboembolism of microvessels; aseptic and contagious inflammation; drop of the general organism reactivity under the influence of combat trauma factors and stress [Shchukarev K.A., 1953; Molchanov N.S., Stavkaia V.V., 1971]. Early clinical symptomatology (1-2 days after MT) is rather poor and presented by the dyspnea higher than 24/min, light cyanosis, cough with a scant sputum, physically by the dry rales and local impairment of breathing. 34 days later, the clinical pattern of a primary posttraumatic pneumonia can be observed. In 50% cases, the manifestations of respiratory failure predominate. The acute beginning is characteristic, along with the stethalgia, cough with bloody sputum, progressing dyspnea, cyanosis and fever lasting for 10-12 days. Physical examination reveals shorting of the percussion sound, attenuated rigid breathing, and audible fine moist rales at the restricted sections of lungs. X-ray imaging shows the pneumonic infiltration in 80 % cases to have micro- or macrofocal character, less often with a trend to confluence; infarct-pneumonias are extremely rare; localization is single-sided, including that in a contralateral lung - up to 30 % cases. It is possible to consider frequent localization in the intact lung to be the feature of early pneumonias. In later terms pneumonic process evolves preferentially in the wound region. Various predominating localizations of mine-explosive damages and wounds frequently show the primary pneumonia to have distinctly-contoured characteristic features. Hence, after craniocerebral MT, the clinical pattern of pneumonia manifests already during the first day, originating in 1525 % casualties with often bilateral, focal localization and poor symptomatology. Pneumonias, caused by MT in maxillofacial region , are distinctively different. Evolving after 34 days, they are pathogenetically related to the expressed aspiration syndrome, begin acutely with a rough course, accompanied by the elevated fever and intoxication and inclined to the infiltration foci confluence, often become complicated by the acute lungs
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destruction. Pneumonias during chest MTs are diagnosed in 2030 % of cases. Their morphological basis is the lung bruise foci with extensive sections of hemorrhages or atelectasis, region of a pulmonitis around the wound of canal. Starting from 34th day, the pneumonia often has a focal character and, in many respects, depends on a wound process course. This pneumonia can be timely cured by the adequate surgical provisions. Mine-explosive wounds and damages of spinal column create certain pneumonia specifics due to nerve-reflectory component with disorders of breathing biomechanics and expressed hypostasis. This pneumonia originates slightly later, with incidence up to 40 % cases and inclined to form confluent infiltration foci, is lengthy, very resistant to the standard treatment and frequently have lethal outcomes. MT of the abdominal cavity organs is combined with the primary pneumonia in 30% cases. Pneumonia onsets during 3th-4th day, with the acute beginning and is often macrofocal. When traumas and wounds are localized in the upper abdomen, 30% cases manifests region of lung bruise in the basal departments due to the wound, with formation of extensive hemorrhages, atelectasis and interstitial lungs edema. The course, as a rule, is frequently complicated. horacobdomenal MD are especially severe due to the simultaneous damage of two internal organ groups and comprise up to 10 % of all lethal outcomes with the relative rarity of the given localization. They cause lung gunshot bruise in more than 60 % and hemopneumothorax in half cases. They can also cause heart bruises, acute posttraumatic cardiomyopathy, pericarditis. In addition to the wounds of a diaphragm and abdominal cavity organs they acutely restrict breathing biomechanics and perfusion of lungs. Thus, resulting in high incidence of primary pneumonia (over 80 % cases) peaking at 35th day with the typical acute beginning, tendency to the thromboembolic complications, lungs edema, multiorgan failure, including ARF. Contact MW of extremities defines features of a primary pneumonia due to the distant damages of the thoracic and abdominal cavity organs, causing lung and heart bruises and significant multifunctional disorders. Characteristic feature of this combat trauma is the significant incidence of fatty embolism (up to 15 %) cases with acute disorders of a blood flow in the lungs, brain and kidneys. Primary posttraumatic pneumonia is diagnosed in 1520 % cases and often accompanied by lungs edema and atelectasis (up to 20 %) and lethal outcome in early terms. Bacteriological examinations with a sputum inoculation are used for diagnostics, with the priority given to hemolytic streptococcus in associations with staphylococcus and catarrhal micrococcus.
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Recently, the attention is being paid to inoculation by the blue pus bacillus, E.coli, Friedlander's bacillus, proteus, pseudomonad bacteria, enterobacteria. Instrumental examinations of the external respiration during the pneumonic process at its earliest stages reveal the drop of lungs vital capacity (LVC) and forced LVC, in severe cases, up to 20-30 % of normal quantity, decrease of velocity parameters through an entire bronchial tree up to 30-35 % of normal value. It reflects immixed, obstructively-restrictive character of the functional disorders, caused by oppression of bronchial tree drainage, bronchospasm and damages to lungs parenchyma.

Posttraumatic pleurisy Onset of the reactive pleurisy after MT, mainly after the chest traumas and wounds, takes place during the first three days with clinical manifestations peaking on 45th day. Frequency of pleurisy oscillates, according to various sources from 7 to 13 % [Storozhenko A.A., 1994; Novitsky A.A. et. al. 1994]. Initially the pleurisy can evolve after the hemothorax evacuation. As a rule, the symptomatology is manifested gradually starting with complaints on a stitch during breathing with irradiation to a shoulder, neck, abdominal wall, dry cough, weakness and sweating; temperature is often subfebrile. As the amount of discharge grows, the pain subsides, however the growing dyspnea evolves together with the sense of heaviness in a chest. Casualy, as a rule, tries to assume reclining position on the damaged side. The survey reveals delayed breathing, expansion and protrusion of intercostal spaces from the pleurisy, the voice tremors are acutely attenuated. Dullness of a pulmonary sound is revealed through the percussion, when the discharge volume exceeds 300 ml. Dullness region has the skewed upper bound peaking at the back axillary line. The tympanic sound is noted above the fluid level. Auscultation from the damaged side shows attenuated breathing and may be entirely silent for the significant discharge amount. Pleural rub noise is heard at the full depth of an inhalation, which is mainly defined during pleurisy and is characterized by two-phase nature and intermittent creaking snow sound. Reactive character of posttraumatic pleurisy is confirmed by the pleurocentesis , where the hemorrhagic discharge is detected in less than 50% cases. On the other hand, hematocrit in the evacuated hemorrhagic pleural contents should be seen. If the hematocrit exceeds 50 % of that in the peripheral blood, hemothorax is indicated with the appropriate surgical provisions [Lajt R.U., 1986]. Diagnosis of posttraumatic pleurisy can be improved by the X-ray inspection , revealing defined
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triangular paracostal dimming in the initial stages, often in the anterior costal-diaphragm sinus, displacement of mediastinum towards the healthy side. Massive discharge is, as a rule, characteristic. Major diagnostic test is the puncture of a pleural cavity , clarifying the discharge presence and character. In 15 % cases the posttraumatic pleurisy acquires prolonged course with trend to commisura formation, discharge encystment and relapses. Occasionally (in 14 % case) its course becomes complicated by plural empyema. Acute focal emphysema of lungs Acute MT-related emphysema of lungs is caused by the barotrauma, inflicted by a blast wave. Instantaneously expanding compression and rarefication wave causes the rapid rise in intrapulmonary pressure. This rise, in turn, inflicts damages to the respiratory paths, causing ruptures of trachea and bronchi. Alveoli are first compressed by the high-pressure wave, which is followed by their explosion. Direct correlation of damage severity and distance from an explosion is usually noted. The symptom-complex of the general contusion-commotio syndrome, as a rule, serves as an unfavorable background. Morphological pattern for an acute emphysema is presented by the microhemorrhages, plural ruptures of interalveolar septum, walls of terminal bronchi with edema onset during the very first day, infiltration by the neutrophils and monocytes with secondary alveolar destruction [Tyurin M.V. et. al. 1998; Tyurin M.V., 2000]. Clinical manifestations are related to the formation of interstitial emphysema with air bubbles penetrating into an interstitial tissue, spreading to mediastinum fat, neck, face, upper half of a trunk with expressed subcutaneous emphysema. In some cases, the amotio and rupture of visceral pleura is possible, accompanied by the spontaneous pneumothorax. The evolution of mediastinum emphysema can cause extremely dangerous compression of the superior vena cava with disorder of hemodynamics, demanding an urgent surgical intervention with punctured frontal mediastinum. Certain WWII authors [Kushelevskiy B.P. 1951] also described bronchial spasms, similar to those during asthma attacks. The most typical complaints are the dyspnea, difficulty of breathing, husky voice. An exam shows the enlarged neck, spherically-shaped face, constriction of palpebral fissures. Palpation reveals the subcutaneous crepitating in the upper trunk and neck departments. Percussion above the lungs reveals the sandbox sound, expansion of boundaries and significant decrease of lower lung edges mobility. Auscultatory exam shows the attenuated breathing. Gravity of the condition is preferentially caused by concomitant extensive lung and heart bruises; in these cases clinical pattern is dominated by the phenomena of pulmonary-cardiac failure.
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Thromboembolism of pulmonary artery Usually, physicians isolate the instantaneous shape of pulmonary artery thromboembolism (TEPA) with the massive obturations of stem and main branches of the pulmonary artery; acute form with obturations of lobar arterial branches; subacute and relapsing forms with damage to the fine branches [Zilber A.P., 1990]. Duration of the acute shape (several hours) and, especially, lightning TEPA, make them almost improbable at the stage of qualified or specialized aid. Frequency of TEPA after MT comprises 35 % cases with preferential development at the 2nd 4th - day [Storozhenko A.A, 1994]. Contributing factors are the shock and massive hemorrhage, damages of locomotorium, fatty embolism, heart failure and coagulopathy. Genesis of TEPA involves mainly sudden occlusion of the pulmonary artery branches with evolution of vasoconstriction of small circle vessels, rapid rise of vascular resistance and acute pulmonary arterial hypertension. This is also accompanied by the acute disorder of ventilatory-perfusion relations and diffusion of lung gases. After that, the syndrome of an acute pulmonary heart and acute respiratory failure are formed almost synchronously. The clinical pattern is dominated by the complaints to treading retrosternal pains, cough, pneumorrhagia, sense of air shortage. The exam shows the acute paleness with subsequent facial and upper trunk cyanosis, bloating of cervical veins (due to CVP increase), tachypnea to 4050/min, sometimes apnea and a loss of consciousness. Physical exam reveals tachycardia up to 140 beats/min, hypotension to the extents of collapse, displacement of heart boundaries to the right, pulse arrhythmia, galloping rhythm, 2nd tone accent above a pulmonary artery, rough systolic and short diastolic noises. Damp rales can be auscultated above the lung surfaces. ECG reveals the acute overload of dextral heart departments, attributes of a myocardial ischemia, in some cases formation of pathological peak Q in 3-rd standard lead aVF. X-ray imaging shows buildups of lung stagnant phenomena. Modern methods of diagnostics are more informative: perfused scintigraphy of lungs with a technetium-labeled albumin, angiopulmonography. These methods facilitates making justified decisions on the necessity of embolectomy.

Treatment of respiratory system changes after MT Restitution of the vital functions is a priority task, solved by the surgical provisions. These include: the drainage of a pleural cavity with liquidation of hemopneumothorax, lungs
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straightening, reliable bleeding arrest, including use of endoscopic video surgery. Main principles of pathological treatment after MT are: arrest of acute respiratory failure; restitution of the respiratory paths passability; recovery of CBV deficit; effective analgesia; the therapy of cardiovascular failure; restitution of microcirculation; elimination of a hemic and histic hypoxia; prophylaxis of contagious complications. Severe bruises of lungs and attributes of acute respiratory failure, respiratory distress-syndrome require the procedure of pulmonary ventilation with elevated pressure at the end of an exhalation (5-15 cm.water) 3-4 sessions a day 15-20 min each. In more severe cases, this therapy should be continued, until the basic manifestations are arrested. Efficiency of the tracheobronchial tree early sanation using medical fiber-optic bronchoscopy with bronchoalveolar lavage is proven and allows reducing the number of pulmonary complications by a factor of 2. In presence of aspiration syndrome, the bronchoscopy procedures are conducted each two hours with introduction of antiseptics (0.5 % solution of Dioxydin), Chymotrypsin. At the later stages the procedure is conducted once a day. Combined multilevel analgesia includes IM administration of central activity drugs Fentanyl, neurovegetative blockage (Droperidol 5.0 ml three times a day IM), retropleural blockage with administration of Lidocaine 1 % solution 1520 ml, segmental and vagosympathetic novocainic blockages. Peculiarity of infusional therapy during lung bruises is an essential restriction of volume no more than 1.5 l. The first stage of controllable hemodilution is IV dropwise administration of the crystalloid solutions 5 % glucose, Ringer solution, colloid solutions: Polyglucinum, Rheopolyglucin, Rheogluman and albumin. After the arrest of an acute respiratory failure, the resorts of parenteral feeding are complemented by the glucose-insulin mixture, aminoacid solutions. Optimal transfusion medium is reinfusate of blood, leaked into the pleural cavity. In addition to that, it is feasible to use component-based transfusion program. If there is no replacement for stored blood, it is necessary to use special filters reducing danger of microthromboembolism of small circle vessels by aggregates of thrombocytes and erythrocytes. Hemotransfusions are conducted before achievement of hematocrit 0.30 l/L.
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Antibacterial therapy for the lung bruises is initially conducted to prevent the contagious complications, thus, uses average doses of Penicillin and its semisynthetic derivatives, cephalosporins. If there is a threat of aspiration complications (Mendelson's syndrome etc.) dosages should be immediately increased. For example, the daily dosage of Penicillin can comprise 18-24 million units, of them up to 12 million units IV. Simultaneously, physicians should introduce gentamycin up to 240 mg/day and up to 1.5 g Metronidasol daily IV. Prevention of lung microembolization and microcirculation restitution, alongside with rheologically active solutions, require administration of antiaggregants (Trental, Pentoxyfilin, Tyclid). The lack of bleeding signs requires administration of Heparin 20-30 kUnits/day. The arrest of hypotension, stabilization of alveolar-capillary diaphragms and prophylaxis of the RDS-syndrome are achieved using IV introduction of the glucocorticosteroids (daily dosage of Prednisolone of 5-10 mg/kg body weight), complemented by the ascorbic acid solution and antihistamine drugs. Cardiac activity is supported, if there are signs of possible failure, by Corglycon 1.0 ml 23 times a day IV, diuretics (Furosemide 40-80 mg/day), Riboxin, potassium drugs. IV use of Euphyllin allows achieving broncholytic effect in combination with the drop of arterial pulmonary hypertension. Additionally, to improve sputum excretion, physicians may use Mucolytics, expectorating drugs, aerosol inhalations with baking soda, proteolytic enzymes and steam-oxygen inhalations. Provided there are no contraindications to an arrest of the histic hypoxia, both oxygen therapy and the hyperbaric oxygenation (34 sessions) are used. Since the first day after a lung bruise, physicians should widely use various methods of physiotherapy: respiratory gymnastics with the diaphragm respiration accents, vibratory and postural massages, promoting better sputum excretion, medicamental electrophoresis and physiotherapeutic exercises. Upon completion of the pressing surgical interventions, treatment changes to the complex intensive therapy for 3-4 days or until stabilization of external respiration and circulation with possible subsequent treatment in the therapeutic pulmonary hospital. Treatment of primary posttraumatic pneumonia is based on the provisions against an infection contamination, restitution of tracheobronchial tree passability, an arrest of the general intoxication syndrome, maintenance of the cardiac activity. Antibacterial therapy is conducted for no less than 7-10 days, until the general intoxication is resolved and, as a rule, begins with Penicillin (up to 4-6 million units/day), or semisynthetic
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derivatives (Ampiox, Oxacillin 26 g/day), in more severe cases in combination with gentamycin 120 mg/day. Further tactics of antibiotics prescription is corrected with respect to the investigation of a microflora. Improvement of bronchi drainage function requires IV administration of Euphyllin, Mucolytics and expectorants (Bromhexine, Mucaltin, Acetylcysteine PO), aerosol inhalations with Heparin, proteolytic enzymes, baking soda and steam-oxygen inhalations, the massage of a thorax, the respiratory gymnastics and physiotherapy. The presence of cardiac failure signs requires IV dropwise introduction of polarizing mixture with glycosides, potassium drugs, Riboxin. In addition, physicians should prescribe vitamin C, vitamins B, antihistamine drugs. Adequacy of treatment is verified through the X-ray inspection, estimate of function of an external respiration and the dynamic microbiologic analysis. Posttraumatic pleurisy. Provided there is an adequate antibacterial and anti-inflammatory therapy , the small aseptic exudates can self-heal. Nevertheless, certain situations require intensive evacuation of pleural fluid with introduction of antibacterial drugs, proteolytic enzymes, and if the contents are sterile steroid hormones (Hydrocortisone). The pain syndrome requires introduction of non-steroid anti-inflammatory drugs and analgetics IM. Physiotherapeutic methods are widely used, including respiratory gymnastics, medical exercises, massage, the electroprocedures targeting diffusion of an exudate. Basic therapeutic provisions for acute lung focal emphysema target the elimination of respiratory failure, restitution of passability and drainage of the tracheobroncial tree function, arrest of bronchospastic syndrome, prophylaxis of contagious complications and cardiac activity support. The treatment requires infusion of a polarizing mixture and rheologically active solutions (Rheopolyglucin) with total amount no more than 0.8-1.0 l, Euphyllin 10-20 ml IV dropwise, in presence of circulatory failure Corglycon 12 ml. The respiratory distress-syndrome prophylaxis requires daily injection of the Prednisolone 5-10 mg /kg body weight for the stabilization of alveolar membranes IV stabilization. The onset of lung edema pattern additionally demands use of a Strophanthin 0.51 ml, Furosemide 80-120 mg IV. Sanation of the tracheobronchial tree is performed through the fiber-optic bronchoscopy, performing also a diagnostic function. In addition to Mucolytics and expectorants, physicians appoint antihypoxants and steam-oxygen inhalations. Provided there are no ongoing bleedings, physicians usually prescribe Heparin up to 20 kUnits/day and antiaggregants to promote the microcirculatory bed normalization. The prophylaxis of contagious complications is done using
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average doses of Penicillin or its semisynthetic analogs. Thromboembolism of pulmonary artery. The basic medical provisions are performed in the conditions of the intensive care unit. The medicamental thrombolysis is done using single-dose introduction of up to 2 million units Streptokinase during 6 hrs with simultaneous infusion of Heparin up to 20-30 kUinit/day. The duration of treatment by Heparin is up to 23 weeks. In addition, it requires IV dropwise administration of Rheoplyglucin and the neuroleptanalgesia perform. The optimal choice of Streptokinase introduction is the pulmonary artery catheterization under the X-ray monitoring. The thrombolysis is executed again during the next 12 days according to the same plan. Additionally, the preventive treatment of infarct-pneumonia is performed using aerosol inhalations with heparin, proteolytic ferments and bronchomucolytics.

11.1.3. Digestive system

Primary pathological changes in the digestive system organs after MT are: damages to parenchymatous organs of abdominal cavity; damages to hollow organs of abdominal cavity; ruptures of diaphragm; acute erosions and ulcers of gastrointestinal section; posttraumatic non-calculous cholecystitis. Damages to abdominal cavity organs happen in > 20 % cases of abdominal closed MT and in 20% of entire set of MW casualties. Thus, the ratio of parenchymatous and hollow organ traumas comprises 3:1. 30% cases are related to the combined damages; 56 % of those are plural damages. According to autopsies data, pathological changes of abdominal cavity organs are found in 82 % cases [Bisenkov L.N., 1993; Nechaev E.A., et. al., 1994]. The set of disturbing factors in the digestive system is promoting functional-morphological disorders during the very first hours [Shanin V.Yu, Gumanenko E.K, 1995; Shulenin S.N., 1997]. The pathogenesis is based on shock, massive hemorrhage inherent to severe MTs. They cause essential perfusion decrease in the abdominal cavity organs, generalized disorder of microcirculation and histic hypoxia. Gastro duodenal dysfunction with stomach hypokinesia evolves to the extent of gastrostasis on the background of severe intestinal motorics degradation. Conditions for the microflora rapid growth are created in the intestine, combined with increased mucosal transmittivity, leading to the progressing endointoxication. [Abbasov R.Yu, 1982],

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including a pyloric failure and duodenal-gastric reflux. Secretory dysfunction usually occurs at the same time, most frequently accompanied by the acid-peptic factor [Miziev I.A., 2000]. Reduced mucosal resistance is related to the disorder of its trophicity, which in combination with depressed secretion of protective mucus, can possibly produce plural damages to the gastrointestinal path walls.

Damage to parenchymatous organs of the abdominal cavity Liver damages Closed mine-explosive traumas breach liver integrity in 57 % cases, with bruises of parenchyma comprising 5 % and ruptures 2 %. Additionally, gunshot liver damages after MW comprise up to 30 % of all abdominal cavity organ wounds. As a rule, liver damages have plural and combined character (in 80 % cases) and is frequently accompanied by the closed chest traumas. Morphological changes appear during the very first day from the moment of trauma and represent disorders of protein structures, ischemic tissues, traumatic embolization of the microvessels; early focal albuminous or, less often, fatty dystrophy of hepatocytes, the edema of stromal elements. The above causes focal necrosis of hepatocytes with a cellular infiltration region around the destroyed sections. Since the second day, in presence of liver bruises or ruptures, the symptom-complex of the functional-morphological disorders is starting to form, which is treated as hepatopathy [Storozhenko A.A., 1994], and representing posttraumatic reactive hepatitis per se [Podymova S.D., 1993]. Among the leading mechanisms are vasoconstriction with the drop of intrahepatic perfusion to 3040 % and acute microcirculation decline; organ hypoxia; endointoxication related to disorder of the intestinal barrier function. These factors damage the cellular membranes and cause the hepatocytes necrosis, leading in turn, to a systemic disorder of liver metabolism. Outcome is the acute post-wound liver failure [Shanin V.Yu, 1994], manifested by the following syndromes: Cytolytic with increased levels of transaminases, LDH, GTH, other enzymes, in many respects matching the activity of the liver pathological process; Hepatodepressive reflecting depressed detoxification and secretory functions, decrease of the general protein, albumin, procoagulants and presence of disproteinemia; Mesenchymal-inflammatory caused by the activation of monocyte-macrophage cells,
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lymphocytes, polymorphonuclear neutrophils, accompanied by the immunopathologic response; Cholestatic with aprogressing intrahepatic cholestasia and buildup of hyperbilirubinemia. In less severe cases, the reactive hepatitis being formed, is characterized by the weakness, severity and dull aches in dextral hypochondria, moderate liver enlargement, inappreciable hyperbilirubinemia, increase of AlAt and alkaline phosphatase. If the wound process takes the uncomplicated course, disrupted liver functions are restored after 23 weeks, i.e. failure can be reversible. The pyoinflammatory complications evolution causes the functions to decline again, but with more unfavorable forecast. It is necessary to remember also that the liver failure of certain manifestation degree (more often with no bright symptoms) is caused by the most severe traumas and wounds with extrabdominal localization. Severe liver damages with massive bleeding, crush, ruptures and tissues fragmentation, require participation of the therapist in antishock provisions and the urgent surgical interventions. Insulated traumas with the liver bruise and subcapsule hematoma can still be accompanied with the satisfactory casualty condition. Clinical pattern is dominated by the pain syndrome, especially after capsule damage, liver is enlarged due to an edema. The pain subsides in 23 days and is replaced by the subfebrile temperature and growing leukocytosis in peripheral blood. More severe bruises may cause the central hematomas (up to 1 l volume), filled by blood and gall; late complications in the form of abscess, formation of a traumatic cyst, hemophilia with the strong pains, jaundice and hemorrhagic syndrome. The complications also include a pneumonia, less often a basal pleurisy from the damaged side, peritonitis and hepatorenal failure (HRF) [Kozlov I.Z. et. al., 1988]. The basic role in timely diagnostics of liver bruises is played by the instrumental methods: laparocentesis, laparoscopy, ultrasound, radioisotope scanning, radiopaque examinations of bile-excreting paths, angiography and CAT exams. Spleen Damages The spleen traumas take leading place within the structure of mine-explosive abdominal damages, comprising up to 20 % cases. This is, in particular, related to the large amount of blood in the organ if subjected to the hydraulic shock, small mobility and capsule fragility. Combined traumas of liver, colon and mesentery are rather frequent. Physicians isolate spleen bruises with surface tears of parenchyma and intact capsule, capsule ruptures without parenchyma damage, demonstrated by the blurred clinical pattern. Instant ruptures of capsules and parenchyma are
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most frequent. In some cases (about 10 %) the dual-stage spleen rupture takes place, when the primary tissues rupture can be supplemented by the subsequent capsule rupture. The majority of spleen traumas require urgent surgeries due to the expressed bleedings, which cause the acute abdomen clinical pattern. Dual-stage ruptures delay this symptomatology and are manifested by early increasing anemia for no apparent reasons, pains in left hypochondria with irradiation to the left brachium and shoulder blade. The diagnostics is performed using laparocentesis, laparoscopy, ultrasound, angiography. The splenectomy, being performed mainly under pressing indications, entails essential impairment of humeral immunodefence with antibodies production disorder. It can act as an accessory in forming the late contagious complications [Pavlovskiy M.P. et. al., 1986]. During the early terms, the most frequent complications are the secondary bleedings and peritonitis. The thrombophylic effect of postoperative thrombocytosis can manifest slightly later and cause 23 fold increase of the blood platelet, demanding medicamental prophylaxis. Damages of a pancreas Mine-explosive abdominal damages cause trauma of a pancreas in 24 % cases [Kozlov I.Z. et. al., 1988; Nechaev E.A et. al., 1994]. As a rule, it combines with damages to liver, spleen and stomach. In the worst case, it is combined with duodenal damages. Physicians should distinguish: bruise of pancreas with the capsule remaining intact, complete pancreas rupture, partial rupture of pancreas parenchyma. Gunshot wounds of pancreas during MW comprise 23 % of all abdominal cases. Any variety of an extensive pancreas trauma can be accompanied by the significant bleeding, shock condition, acute abdomen syndrome that demands urgent surgical intervention on the background of complex antishock therapy. At a later time, up to 60 % cases become complicated with acute posttraumatic pancreatitis. At the first stage of its pathogenesis, it is manifested in perfusion decrease, disorders of microcirculation, pancreas hypoxia, disorder of Wirsungs duct due to an edema, duodenal dyskinesia. At the second stage , activated proteases in the pancreas cause tissue damages and injection of enzymes. This, in turn, results in the enhanced proteolysis, increased activity of the quinine shock-system mediators, coagulopathy with the disseminated intravascular coagulation syndrome and direct cardiotoxic effects. The aseptic pancreas inflammation evolves initially, which later transgresses into the extrapancreal necrosis foci with serous-hemorhhagic peritonitis and others organ damages [Tolstoy A.D., 1983].
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The clinical pattern is originally dominated by the pain syndrome, described by the sudden beginning, strong pains, often in anticardium, irradiating to the loin left side, tachycardia, drop of the arterial pressure, meteorism, nausea and vomiting. During the first hours, there is moderate strain of epigastreal muscles without any typical signs of the peritoneal irritation. The blood and urine exhibits substantial increase of an amylase, to a lesser degree glucose. Light bruises of pancreas and extrabdominal MTs manifest the acute pancreatic enzymopathy starting from 4th or 5th day [Derjabin I.I., Nasonkin O.K., 1987; Shanin V.Yu, 1994; Zubarev P.N., 1999]. Unlike pancreatitis, it is underlaid by the acute and early dystrophic changes of pancreas tissue with the moderate functional failure onset. Light damages of the pancreas can be complicated by fistulas (19 %), pseudocysts (12 %), abscesses (5 %), an acute pancreatitis (3 %) cases [Nechaev E.A. et. al., 1994].

Damages of the hollow abdominal organs Stomach Damage Mine damages lead to the closed stomach traumas in 38 % cases. At the same time, incidence of mine-explosive stomach wounds comprises up to 20 % of all abdominal wounds [Ivashkin V.T., 1993; Nechaev E.E., et. al., 1994]. Among stomach damages, physicians isolate bruises and subserous hematomas of walls and ligamentary mechanism, incomplete surface tears of only serous or muscular layers with intact mucosa and complete wall rupture. The unfavorable role is played by the full stomach at the moment of a trauma or wound. Bruises in combination with surface tears of a serous layer and hematoma, refer to the less severe damages. Nevertheless, the clinical pattern of intra-abdominal bleeding symptomatology tracks the distinguished attributes of peritonitis with the subsequent short bright gap. The patients manifest pains in epigastria and vomiting with blood presence. Complete wall ruptures have clinical pattern similar to gunshot wounds with the shock or acute abdomen. Timely performed diagnostics, including laparocentesis, laparoscopy, radiological search for the free gas in an abdominal cavity, determines the indications to urgent surgeries. 20-25% MT casualties with no immediate stomach damages exhibit clinical-morphological pattern of acute hemorrhagic gastritis during the first 7-10 days. The pattern exhibits layering of epithelium, subepithelial edema, cellular infiltration, in some cases fine erosions with hemorrhages to the mucosal layer. Complaints on the lack of appetite, hypersalivation and abdominal pains are clinically defined. Patients manifest vomiting at the peak of complaints,
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sometimes with blood; diarrhea at the end of the first day (due to joined acute enteritis) with a threat of dehydration. The abdomen is swollen and the palpation is morbid, with no attributes of peritoneal irritation (valuable for diagnostics). The diagnosis is confirmed by the fiber-optic dynamic gastroscopy, showing the pattern of the superficial gastritis. Uncomplicated course suggests normalization of motoric-evacuatory function and the reflux arrest after 1014 days, but the complete histological restitution happens after 46 weeks. Duodenal damages Closed abdominal MD seldomly cause duodenum traumas with incidence of 2-5 %, which, in many respects, is explained by the reliable anatomical protection. On the other hand, its restricted mobility is an additional hazard during blunt traumas. As a rule, damages of duodenum are accompanied by colon damages in almost 50 % cases. The intraabdominal department of duodenum is damaged most frequently. Bruises with wall hematomas, incomplete and full ruptures are possible as well. The clinical pattern in many respects depends on localization of the damaged department. Therefore, the damage of an intestine intraabdominal section is accompanied by shock, interior bleeding and peritoneal irritation during the first hours. Anti-shock provisions should be performed before the urgent surgery with participating therapist. Traumas of duodenal retroperitoneal department can manifest the tumescence in lumbar region due to hematomas in the retroperitoneal space. Leakage of the intestinal contents through the dextral lateral canal is manifested by pain, localized dextrally and expressed as a renal colic. The symptomatology of an intestinal damage during the first hours is vague; peritonitis with the expressed general intoxication syndrome evolves later. After 816 hrs the intestinal necrosis can start with inflammation expanding through the peritoneum, because the duodenal contents includes aggressive enzymes. Uncomplicated bruises exhibit the clinical pattern of acute hemorrhagic duodenitis with the phenomena of the expressed pain syndrome, accompanied by the hungry pains and their irradiation to the right, tendency to inflammatory-spastic pyloroduodenal obstruction with frequent vomiting. Characteristic complications are the duodenal fistulas, pancreas head necrosis and retroperitoneal phlegmon with the unfavorable forecast. Improvement of the duodenal damage diagnosis can be achieved through the growth of leucocytes in the peripheral blood up to 25K and amylase activity in the urine after 68 hrs. The final diagnosis is performed through the laparocentesis,
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laparoscopy, fiber-optic gastroscopy and X-ray analysis of an abdominal cavity. Intestinal Damages Intestine anatomical location causes it to be the likely subject of traumas and wounds during MT. Consequently, depending on localization of its departments, the incidence of closed damages ranges from 8-10 to 15-20 % for the abdominal cavity organ traumas [Kozlov I.Z. et. al., 1988; Nechaev E.A. et. al., 1994]. The incidence of intestine gunshot wounds during MW is even higher, comprising >60 % of all abdominal cavity organs wounds [Shaposhnikov Yu.G. et. al., 1986; Zubarev P.N., Bisenkov L.N., 1993; Shejanov S.D., 1996]. The pathogenesis disorders of a homeostasis during intestine traumas and wounds, is underlaid by shock, hemorrhage with acute disorder of blood flow and microcirculation, further evolution of hypoxia and damages to the cellular structures. Another characteristic feature is aggressive action of proteolytic enzymes on tissues. Motility disorders, starting from the 2nd day, secretory, digestive and absorptive functions causes a syndrome of acute intestinal failure [Ivashkin V.T., 1993]. The significance of intestinal activity disorders in the onset and advanced stages of early endointoxication is extremely high. Expressed features are edema, cellular infiltration and hemorrhagic necrosis of the intestine barrier structures, in combination with the functional shifts leading to rapid microflora growth in an intestine, its translocation to the blood channel and the endotoxic effects generalization. High percentage of infectious-inflammatory and purulent-septic complications (by various sources from 60 to 90 %) is typical for the intestinal MT, which is also accompanied by the organ complications of therapeutic type: cardiomyopathies, pericarditis, pneumonia, nephropathy and hepatorenal failures. Small intestine damages. Traumas of small intestine accompany more than 20 % of all damages to the organs of an abdominal cavity and surface tears of serous shell, mesentery ruptures, full wall ruptures. They are divided into the wall bruises with subserous or submucosal hematomas. Due to the stronger bracing, the ileal intestine suffers frequently, jejunum suffers less often. In many cases damages are of the combined character and combined with traumas to other organs of abdominal cavity, chest, pelvic bones and the inferior extremities. In the functional sense, the disorders of motility, full or partial lockout of the fissile digestive region, leading to acute disorders metabolism are the most significant. The clinical pattern , accompanying 80 % of combined and 35 % of the insulated damages,
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exhibits the symptomatology of shock and an intra-abdominal bleeding (especially expressed in case of mesenterial ruptures) and peritonitis. The less severe traumas cause evolution of the pain syndrome, being aggravated by the motions, increased temperature. The acute abdomen syndrome is not expressed in 10-15 % cases. This condition is followed by the bright gap, lasting from several hours to several days. Further dynamics depends on the amount of damages and, provided the course is uncomplicated, is implemented in clinical manifestations of acute enteritis: expressed diarrheas, spastic pains and malabsorption. The most frequent complications are: peritonitis, intestinal obstruction, pneumonia, clotting of mesenterial vessels, thromboembolism and acute renal failure. The diagnostics is performed using laparocentesis, laparoscopy, radiographic analysis of the free gas, ultrasound exams of the abdominal cavity organs. Colon damages. MT of colon originate in 1015 % cases of all damages to the organs of abdominal cavity and differ by the special severity, high incidence of the purulent-septic complications, reaching 90 % in the combat conditions [Shejanov S.V., 1996]. Usually, physicians distinguish the bruise and hematoma of an intestinal wall with deserousation, rupture and hematoma of a mesentery, separation of an intestine from mesentery and the complete wall rupture. The intestine and mesentery are often damaged. Clinical manifestations have certain features depending on localization of the defective intestinal section. The trauma of intra-abdominal department causes, as a rule, catastrophic pattern in an abdominal cavity with the phenomena of shock, bleeding and, peritonitis. Damage of an extraperitoneal department manifests vague symptoms, with possible period of the relative condition stability. Endoscopic examination of terminating intestine departments in early terms after the hemorrhagic proctosigmoiditis clinically manifest the syndrome of intestinal dyspepsia. Radiological survey for the closed colon damages is effective in 1/3 cases. The laparocentesis, laparoscopy and diagnostic laparotomy are the most reliable choices. Diaphragm Rupture This kind of trauma originates preferentially after abdominal MD with incidence of 3 % [Bryusov P.G. et. al., 1998], is frequently combined with the closed chest trauma, damages of other abdominal cavity organs, especially spleen. Physicians isolate surface tears and the full rupture of diaphragm, overwhelmingly localized at the left side. Clinical pattern includes pains in the left section of thorax and abdomen with an irradiation towards the left-hand brachium, tachycardia, difficult breathing, dyspnea, aggravated in vertical
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position and dysphagia. The survey reveals ainesia of the left thorax half. Percussion exam shows dextral displacement a mediastinum and tympanitis or, on the contrary, shorting of a sound above the left lung, auscultatory impairment of breathing, peristaltic noise in a thorax. Thus, physical data in each specific case depend on what organs are dislocated to the pleural cavity parenchymatous or hollow. The evolution of a compressed lung and mediastinum displacement forms the clinical pattern of an acute pulmonary-cardiac failure. Doubtless difficulties of diagnostics are related with the significant likeness of diaphragm rupture clinical manifestations and many therapeutic nosologies of the cardiologic or pulmonary character, also frequently combined with the traumas of lungs, spleen, liver and intestine. Of diagnostic worth is a dynamic ECGF to exclude an acute coronary pathology and severe heart bruise, X-ray inspection of thoracic and abdominal cavities, including that with a contrast matter; ultrasound and CAT scans. Acute erosions and ulcers of gastrointestinal section This type of the pathology, which is pathogenetically related to MT, is one of the most widespread ones. Therefore, according to various authors, its incidence comprises 60- 80 % [Ivashkin V.T., 1993; Osipov I.S., 1998], and can reach 100% for severe MT with extremity avulsions [Shulenin S.N., 1997]. Autopsies analysis after contact MW indicates presence of acute erosions and ulcers almost in 40 % cases [Gritsanov A.I., Rybachenko P.V., 1992]. As a rule, onset of acute erosions and ulcers takes from several hours to about three day with a maximum at the 1st -2nd day. The morphological pattern is represented by edema, hyperemia, loosening of mucosa, submucosal hemorrhages, plural fine foci of the covering epithelium destruction. Basic differences between erosions and ulcers also have the histological content former evolve as a surface defect with linear or oval shape and sizes up to 0.5 cm, in 60 % cases having plural character; latter are deeper, attaining submucosal layer with precise edges and flat or deepened bottom, 2 cm wide with with hyperemic edge. Acute erosions happen during the first 612 hrs after MT and are followed by the acute ulcers. Leading parts in pathogenesis of this process is played by the acute disorders of organ blood flow and microcirculation with histic hypoxia and progressing endointoxication. They are followed by the motoric-evacuatory disorders with hypokinesia, pyloric incompetence, duodenal-gastral reflux. Secretory dysfunction in some cases is realized by increased function of covering cells with transient enhancement of acid-peptic activity for the most severe traumas. Of essential value
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is oppression of mucin production due to dystrophia and decrease of trophicity in the gastrointestinal section walls with disorder of protective properties. Multiorgan failure, peritonitis and other purulent-septic complications are the risk factors for acute erosions and ulcers along with the acute intestinal obstructions, thromboembolisms, concomitant peptic ulcer, gastritis, duodenitis, long-term presence of nasogastral probe (with possible decubituses). Major acute erosions and ulcers are formed in a stomach up to 80 %, duodenum more than 30 %, espohagus1012 %, small intestine 34 %, colon 1 % [Hoholia V.P., 1985; Gritsanov A.I., Rybachenko P.V., 1992]. According to E.A.Nechaev and coworkers (1994), 80 % cases of acute erosions and ulcers show no symptoms. The most frequent clinical manifestations of uncomplicated acute erosions and ulcers: localization in an esophagus the expressed retrosternal pains, aggravated during swallowing and eating, reflux, less often vomiting with blood; gastroduodenal acute erosions and ulcers early pains after eating, stomach dyspepsia, if the localization is in stomach; late and hungry pains in the region of dextral hypochondria, gastrointestinal dyspepsia in case of duodenal localization; intestinal acute erosions and ulcers spastic pains in the inferior abdominal departments, intestinal dyspepsia and meteorism. Complications of the acute erosions and ulcers, representing the greatest danger bleedings peaking at the second day [Storozhenko A.A., 1994], originating in 5-30 % cases and perforation in 8-30 % cases. Clinical symptomatology of an ulcerative bleeding, as a rule, is disguised by the basic damages and is complicated to diagnose. Moreover, 1/3 cases are manifested by the arterial pressure drop, less often coffee ground vomiting and melena. Perforation is seldom manifested by acute megalgia, weakness, paleness, collapse, aches in epigastris region; approximately 30 % cases manifest peritoneal irritation, followed by the vomiting, melena, paresis of an intestine. In rare cases perforation of an ulcer in the inferior third of esophagus in a pleural cavity, alongside with collapse, causes ARF signs. Diagnostics, especially in lack of bright clinics of acute erosions and ulcers, is underlaid by the early fiber-optic gastroduodenascopy. This procedure should also be performed after surgeries on the abdominal cavity organs, accounting for risk factors of acute erosions and ulcers. Endoscopic exam should be performed once in three days, if necessary ( craniocerebral trauma or convulsive syndrome, etc.) the exam can be performed under narcosis.
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Posttraumatic non-calculous cholecystitis (Galstones) Acute non-acalculous cholecystitis (AAC) complicates course of the combined mine-explosive damages and wounds with incidence up to 1 %, especially during traumas of pelvic bones, skulls, column, accompanied by the shock, hemorrhage, acute disorders of hemodynamics and microcirculation, disseminated intravascular coagulation syndrome. AAC arises in some cases after 310 days [Shaw, 1970; Lindberg, 1970], sometimes later after 23 weeks. The following mechanisms share genesis of posttraumatic cholecystitis: long-term malfunction of intestine after parenteral feeding; decrease of the cholic bladder contractive ability, usually accompanying severe MT by the end of the first week; stagnation in bladder in reply to the longterm application of Morphins; increase of bile concentration and viscosity after massive hemotransfusions with penetration of erythrocytes hemolysis byproducts in the cholic paths. Clinical pattern is dominated by the pains in dextral hypochondrium, vomiting, fever, paresis of intestine with the phenomena of dynamic intestinal obstruction. Irritation of peritoneum is not typical. In certain cases, pathological processes have mute character. The diagnostics is underlaid by X-ray and ultrasound exams of bile-excreting paths and abdominal cavity organs. Treatment of the abdominal cavity organs after MT Early stages of MT treatment for the abdominal cavity organs should target the antishock provisions with restitution of vital functions during pre-surgery preparations. A post-surgery period and easier damages require joint monitoring by surgeons and resuscitators, nasogastral stomach sanation, constant intestine decompression and fractional peritoneal lavage. Major principles of the pathogenetic therapy for primary organ-pathologic changes to the digestive system after MT are: arrest of multiorgan failure; effective anesthesia; treatment of an endointoxication; treatment of microcirculation and a coagulopathy disorders; blockage of proteolytic enzymes; restitution of the motoric-evacuatory functions of a gastrointestinal section; correction of the secretory disorder; prophylaxis and treatment of infectious-inflammatory and is purulent-septic complications; treatment of secondary immunodeficiency. Liver damages with evolution of acute hepatic failure, reactive hepatitis demand a sparing diet
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within the limits of a Table 5. 5(a) with 4-6 meals a day and total calories 2-3 kcal, wide application of enpyte compositions. Infusional therapy includes glucose-insulin mixture and other crystalloids, rheologically active solutions with a total amount up to 2.5-3 l. Optimal hemotransfusion medium is blood reinfusate, leaked into an abdominal and other cavities, except for cases of hollow organs damage. Membrane stabilization is performed using steroid hormones up 10 mg/kg a day. Artificial diuresis can be stimulated by administering diuretics PO. Arrest of endointoxication is performed through the efferent therapy plasmosorbtion, plasmolysis with hemoxygenation, hemosorption, enterosorbtion. Evolution of hepatorenal failure demands additional rapid hemodialysis or peritoneal dialysis, higher dosages of the diuretics. In addition, physicians apply hepatoprotectors PE Essentiale Forte IV, B and C vitamins and cholykynetics. After restitution of liver function, administration of aminoacids and anabolic drugs is expanded. If the antibiotics are chosen for prophylaxis (course up to 5 days) and treatments of complications, it is necessary to consider possible hepatotoxic effect of Tetracyclins. Damages of pancreas with evolution of acute pancreatitis or pancreatic enzymopathy demand administration of parenteral feeding with gradual introduction of enteral diet starting from the third day; massive infusional therapy by crystalloids and up to 3-6 l rheologically active solutions (restricting strong solutions of glucose); IV and intra-abdominal (drainage) introduction of antienzyme drugs Contrycal, Trasilol, Gordox (aprotinin) in the peak doses, with duration up to 3-5 days An effective arrest of pain syndrome is performed using Atropine 1.0 ml IV/IM up to 2-3 times a day, spasmolytics Baralgin, Platyphyllin, narcotic analgetics (except for Morphine, due do its spastic action on the Oddis sphincter).Externally-secretory activity of pancreas is restricted using Sandostatin. Inhibition of acid-peptic activity factor, which stimulates pancreatic secretion, is achieved using antacids and blockers of H2-hystamin receptors for 23 weeks. Motoric-evacuatory functions of stomach and duodenum are through use using of the hypermotility spasmolytics and cholinolytics (drugs of belladonna, Methacin, Platyphyllin); arrest of hypokinesia require administration of metoclopramide (Cerucal) and Motilium. Intestinal therapy after bruises and other intestinal damages, including complicated peritonitis, includes small intestine lavage with enterosorbents (Polyphepan), early application of enteral probe feeding by the mixture of Inpitan, Ovolact, complemented by the conductive decompression of the upper small intestine departments. Prophylaxis and treatment of the
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intestinal paresis, alongside with arrest of hypovolemia, anemia, disorders of water-salt exchange and endointoxication, requires administration of ganglyoblockers IM each 6 hrs (Benzhexol, Pentamin) while monitoring AP; alpha-adrenolytics (Pyrroxan or Butirroxan). Drugs are administered through the nasogastral probe under effective peridural analgesia. The plan including early administration of Cerucal parenterally or PO for 23 days can be used for the medicamental prophylaxis of acute erosions and ulcers. The plan may include antacids each two hours PO during 714 days, Cimetidine up to 600800 mg/day PO [Hoholia V.P., 1988]. Uncomplicated acute erosions and ulcers are treated using a diet within the levels of 11. 16 with gradual expansion and using the following drugs: a) blockers of stomach secretion: blockers of -hystamin receptors (Cimetidine 400 mg, Ranitidine 300 mg, Famotidine 40 mg/day); blockers of 1-cholynoreceptors (Atropine, Platyphyllin); retarders of +/K + P (Omeprasol single-dose 40 mg); b) antacids (Almagel, Phosphalugel, Maalox, once a day after a meal); c)retarders of proteases decreasing aggressiveness of stomach contents; d) film-forming drugs (colloid bismuth, sucralphate 30 min before a meal and before sleep); e) cytoprotectors (Misoprostol, Cerucal, Trichopol, Retabolil (Nandrolone). Therapy of acute erosions and ulcers, if complicated with bleeding, begins with the conservative provisions including rigorous confinement to bed, parenteral or probe enteral feeding during the first day, aspiration of stomach contents through the nasogastral probe, gastric lavage by using ice 2 % baking soda solution or a solution of aminocaprone acid until there is no blood in a rinsing water. Parenteral administration of Dicynone 24 ml three times a day, IV dropwise administration of Acidum aminocapronicum 100 ml three times , plasma and erythroconcentrate. Administraion of pathogenetic drugs should continue: blockers of stomach secretion, antacids, film-forming drugs etc. Endoscopic treatment is performed through the fiber-optic gastroscope by injecting Noradrenalin around damaged mucosal regions, irrigations by Acidum aminocapronicum or Kaprofer solution. Most effective are the laser or thermal coagulation of bleeding point. The surgery is performed if the effect is still not achieved. Postoperative period requires complex conservative treatment, prophylaxis of acute erosions and ulcers relapse. Evolution of post-traumatic non-calculous cholecystitis in presence of acute cholic hypertension
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demands urgent surgical intervention with decompression of gal bladder. Postoperative period requires participation of therapist when developing plan of diet therapy, infusional therapy, course of spasmolytics and cholykinetics.

11.1.4. Kidney damages and diseases

During the 20 years of various local conflicts, incidence of mine-explosive wounds to kidneys comprises 16-24 % urological damages and about 90 % of them are combined [Petrov S.B., Shpilenia E.S., 2000]. Closed kidney damages are encountered frequently as well, amounting, according to different authors, to 2/3 of all combat kidney traumas. Autopsies analysis indicated presence of kidneys damages in 57 % cases [Gembitskij E.V. et. al., 1994]. Severity of kidney damages is caused by the typically massive hemorrhage, expressed pain syndrome, extensive urinary infiltration of tissues, disorder of other internals functions, high incidence of early and late complications [Efimenko N.A. et. al., 1999]. Base mechanisms of renal dysfunctions after MT are: acute drop of renal blood flow up to 30-40 % from initial, pathological disorders of microcirculation and histic ischemia. Excretion of vasopressor activity endothelins, activation of system renin-angiotensin-aldosteron and fatty embolism cause spastic strictures and increase of pressure in the inlet arterioles with the subsequent significant drop of glomerular filtering. The circulatory bed is supplied with large amount of myoglobin from the defective muscles, endotoxins, byproducts of erythrocytes hemolysis after massive hemotransfusions, thus causing tubular blockages, epithelial dystrophy, damage to basal membranes with secretion inhibition, damage to reabsorptive and other canal functions, to the extent of tubulonecrosis after 23 days. These multifactor actions frequently result in renal failure. Basic varieties of kidneys damages and diseases primarily related to MT: bruise of kidneys; acute interstitial nephritis; acute pyelonephritis; clotting of renal vessels; acute renal failure (AReF). Bruise of kidneys Among the damages of internals, caused by MT, the bruise of kidneys, according to certain authors, takes the third place, comprising from 10 % [Gembitskij E.V. et. al., 1994] to 40 %
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[Ivashkin V.T., 1993] cases. Approximately 1/5 are caused by fragment-related lateral injury during MW. The rest is related to the propellant or distant MT effects. Their incidence, in many respects, depends on predominating localization of damages. Consequently the chest traumas, and traumas of upper extremities result in 20 % incidence. Fractures of pelvic bones, femur and spinal column are combined with the kidney bruises in 5560 %. Up to 90 % of all kidney damages are either combined or plural. The following kidney bruises are conditionally separated :light with the surface tears of a capsule with perinephric hematomas; average- with small surface tears of a capsule and parenchyma without damages of the cavitary system; severe with kidneys crush, trauma of vascular pedicle, rupture of cavitary system with extensive hematomas and urinary leaks in the retroperitoneal space. Avulsion of a vascular pedicle is a rare and utmost severe trauma. Morphological pattern of kidneys bruise is presented by hemorrhages in cortical layer, diffuse disorders of microcirculation with collapse of the glomerular capillars, stagnation hyperemia, dystrophy of a canalicular epithelium, dilating and obstruction of the canal clearance, an edema and cellular infiltration of the interstitial space, tubular necrosis sections. Clinical manifestations of kidney bruise evolve during the first hours and can last between 1-2 and 7-14 days from the MT moment. Early stages are manifested by the pain syndrome with possible irradiation and intensity similar to that of a renal colic, dysuria, gross hematuria single or continuing up to 1-2 days. At the same time, it can be missing in approximately 1/3 of severe bruises, including separation of ureter. Objective examination manifests tumescence of the loin region (due to urohematoma after 2-3 days), palpatory and percussion morbidity from the damaged side over the kidney projection. Urinary syndrome in 3/4 cases is accompanied by hematuria, proteinuria, less often leukocyturia. Urine microflora exam shows E. coli, staphylococci, proteus and microbial associations. Functional tests demonstrates disorders of both glomerular and canalicular functions with drop of filtering and resorption decrease of the relative specific urine density. Thus, it is necessary to consider that the formation of a shock kidney due to the deep hemodynamics and microcirculatory disorders during in first hours after traumas or wounds is accompanied by the significant drop of blood flow, glomerular filtering and other functional parameters. However, adequate and well-timed restore of CBV deficit rapidly changes dynamics to positive, on the contrary from the severe kidneys bruises. Most likely, the evolution of shock kidney and its aftereffects is related to the allegedly high
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incidence of acute focal glomerulonephritis during the combat traumas. Aside from the now conclusive fact that the acute glomerulonephritis is a rare disease of kidneys (less than 1 % of glomerulonephritises cases), it seems that Gembitsky E.V. and coworkers (1994) standpoint that the microhematuria, proteinuria, edemas and other nonspecific clinic-laboratory signs, treated as focal glomerulonephritis without morphological confirmation, actually reflect disorders of microcirculation, clotting of kidney vessels etc. Evolution of such complications, as acute renal failure, peritonitis, pneumonia, thromboembolism is possible in early terms. Chronic pyelonephritis, urolithiasis, posttraumatic kidney cysts, urinary fistulas and chronic renal failure can become associated later. Instrumental diagnostic of kidney bruise is based on application of X-ray methods survey radiographic analysis, excretory urography, especially intraoperational; retrograde pyelographies should be performed no earlier than 712 days after hematuria disappearance. Of important value for the separate estimate of kidneys condition is the isotopic renograhy, including dynamics, kidney scans, which together with ultrasound allows refining character and amount of damages. Of high information value are the CAT scans, angiography, dynamic renal scintigraphy, first of all, during early terms after MT. Acute interstitial nephritis Acute infectious-toxic nephritis is known back from WWII casualties treatment experience. The urinary syndrome was associated with the leukocyturia, cylindruria, proteinuria of 12% track. The process lasted from several days to 23 weeks and resolved completely. In the subsequent time, the most widespread term was infectious-toxic nephropathy, evolving 1-3 days after wound or trauma, manifested mainly by the urinary syndrome, with rare extrarenal manifestations, lack of azotemia. V.T.Ivashkin (1993) allocated up to 70 % of MT urinary syndrome for the at infectious-toxic nephropathy. According to A.A.Storozhenko (1994), the infectious-toxic nephropathy is discovered in almost 60 % MT cases, and is found in 100 % casualties. There are also descriptions of traumatic and posttraumatic nephropathy , originating 1-3 days after in more than 50 % of closed kidney MTs. All these different terms, as one would expect, are united by the general morphological pattern predominating damage of the tubular mechanism with dystrophy or atrophy of canalicular epithelium, edema and cellular infiltration of interstitium with polymorphic-nuclear leucocytes, monocytes and plasmocytes, intact glomuluses, relative rarity and focal character of
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tubulonecrosis. Generalizing clinical-laboratory and morphological data, it is possible to state that the pathology of kidneys in early period after MT is underlaid by the acute tubulointerstitial nephritis [Sheluhin V.A. et. al., 1997]. Leading mechanism of a pathogenesis is the aseptic inflammation of an interstitial tissue and canals caused by the certain factors. Among them are large doses of antibiotics (Penicillin and its semisynthetic derivatives, aminoglycosides), prescribed in early terms; obstruction of canals by the myoglobin during traumas of the soft tissues, donor erythrocytes destruction products after massive transfusions. Consequences are also immunopathologic processes at the level of the most vulnerable epithelium. Risk factors of the acute interstitial nephritis are the severe traumas and surgeries with acute drop of CBV, massive hemorrhages, hypotension; extensive damages of a muscular tissue, significant transfusions of a homologous blood; application of antibiotics, analgetics, especially in combination with diuretics; introduction of X-ray contrast drugs. Clinical pattern is frequently manifested by the acute beginning during the first two-three days, less often stage of latency lasting for 23 weeks. Typical signs are: fever, disorder of renal functions with very early and resistant hyposthenuria, polyuria; the urinary syndrome being poor and presented by ahematuria, sometimes with the erythrocyte cylinders, the moderate proteinuria, a leukocyturia; eosinophilia presence in the blood is often noted. Hydropic syndrome and arterial hypertension evolve seldom. Starting from the first days the blood creatinine, whose level is regarded as the important measure of process severity, raises. Acute interstitial nephritis causes 20% cases of AReF, however, unlike usual AReF, there is either no anuria or only short term anuria; the hyperpotassemia is not characteristic as well. The latter is related to above mentioned morphological feature rarity and focal character of the tubular necrosis, giving the reversible character to acute interstitial nephritis. Adequate therapy causes the level of creatinine to normalize on the average of two weeks [Shulutko B.I., 1995]. The diagnosis is acknowledged by using ultrasound, CAT, tracer techniques (renography, kidney scan, dynamic scintigraphy). Radiological contrast methods are not indicated, at least, until azotemia is arrested. Acute pyelonephritis Any variety of mine-explosive damages to kidneys and urinary paths, as a rule, are accompanied by the shock and hemorrhage. These damages create conditions for an acute pyelonephritis [Gembitskij E.V. et. al., 1994]. It, first of all, causes acute oppression of mucosal resistance of
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kidneys and ureters pyelocaliceal system; disorders of urodynamics impairment of peristalsis, obstruction related with edemas, hematomas, traumas, different urine refluxes; tubulopathy with disorder of canal functions. Urostasis usually elevates pressure in the cavitary system of the defective kidney, and, along with diagnostic and medical invasive procedures, promotes ascending infection with its extension to the tubulointerstitial region. Etiologically significant are, first of all, Gram-negative bacteria: E. coli, proteus, klebsiella, pseudomonades; less often enterococci, micrococci, golden staphylococcus; if the number of microbes exceeds 105 /ml. Morphological examination during acute pyelonephritis reveals focal cellular infiltration of interstitium, mainly by the polymorphonuclear leucocytes, sections of involution and expansion of canals, strain and ruptures of tubular basal membrane; lack of appreciable changes in glomuluses. Acute pyelonephritis is characterized by the rapid onset, expressed syndrome of the general intoxication with cold fits, permanent hectic fever, hyperhydrosis, nausea and vomiting. Back pains, dysuric disorders are possible, rigidity of an abdominal wall can be found from the damaged side, morbidity can be defined during the palpation and concussion in kidney projection. Urine blockage can lead in severe cases to oliguria, bacterial shock, acute renal failure, urosepsis, paranephritis, kidneys abscesses. Peripheral blood analysis manifests leukocytosis with neutrocytosis and stab detrusion, while urine manifests bacteriuria, leukocyturia and hematuria. At the same time, difficulty of urine reflux from the damaged kidney, may virtually eliminate pyuria. Strong azotemia evolves early. In some cases, the transient azotemia is observed. Contrast X-ray exams are possible only after reliable restitution of urine passage. Diagnosis refinement can be aided by using ultrasound, isotopic renography and CAT scans. Thrombosis of renal vessels Rare but rather dangerous complication of kidney damages is the renal vessels thrombosis [Kozlov I.Z. et. al., 1988]. Complete and partial occlusions of the basic renal artery or its intraorganic branches are isolated; accompanied by the acute or chronic renal veins thrombosis [Mazhdrakov G., Popov N., 1980; Hollenberg, 1995]. Acute thromboembolism of an artery or its intrarenal branches can evolve after closed MD of abdominal or loin region. Thromboembolism may also be caused by the fatty embolism, inherent
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to mine-explosive traumas. Occlusion of small branches rapidly causes necrosis of the cuneiform parenchyma sections. Clinically, these disease varieties can proceed asymptomatically. Damages to larger vessels can lead subitaneously to increased pains in a side or upper abdomen, fever, macro- or a microhematuria, peripheral blood leukocytosis. Single-sided full occlusion sometimes proceeds without disorder of kidneys function, especially in case of numerous previous occlusions with possible evolution of collaterals. Developed pattern of kidney functions depression is more frequent, including azotemia, oliguria etc., thus demanding both pressing diagnostics and pressing treatment. Chronic occlusion of renal veins with formation of venous collaterals does not cause severe disorders of kidney functions. Nevertheless, they lead to gradual buildup of intrarenal pressure, disrupting normal operation of glomerular filters with onset of proteinuria. In the subsequent, nephritic syndrome can evolve with the characteristic clinical-laboratory manifestations: hydropic syndrome, hypo -and a disproteinemia, arterial hypertension, slow formation of chronic renal failure. Instrumental diagnostic is based on contrast examinations of arteries and veins, intravenous urography, ultrasound and a dynamic scintigraphy of kidneys. Acute renal failure Incidence of the acute renal failure (AReF) after MT comprises 8 %, including, in case of damages to organs of thoracic and abdominal cavities 1315 %, in cases of severe kidney bruises it can reach 30-50% [Gembitskij E.V. et. al., 1994]. Lethality from posttraumatic AReF during the recent conflicts ranges from 10 to 50 %. Following basic AReF varieties are known [Shanin V.Yu., 1994; Shulutko B.I., 1995; Kostjuchenko A.L., et. al., 1999]: 1. Prerenal caused by circulatory disorders, such as hypovolemia after massive hemorrhage, shock; decrease of cardiac output during the heart damages; disorder of a vascular regulation with a systemic vasodilation during the sepsis; renal hypoperfusion and syndrome of hyperviscosity during coagulopathies. 2. Renal caused by immediate damage of renal vessels, glomuluses or canals during occlusion of vessels, traumatic rabdomiolisys with a myoglobinuria, intravascular hemolysis, activity of endotoxins and acute tubulointerstitial nephritis. 3. Postrenal caused by obstruction of urinary path at any level after traumas, edemas, hematomas etc. Regardless the shape of renal failure, morphological changes are reduced to the necrosis of canals with predominance of proximal departments damages, exfoliation of tubular epithelium
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with their occlusion and dilation; acute edema extending to ruptures of crimped regions; in the most severe cases - with formed regions of cortical necrosis and irreversible glomerular damage. The following phases are distinguished during the AReF process: a) initial with origination of circulatory collapse, manifestations of trauma or wound symptomatology, intoxication; b) oliguric originates in the first three days, lasts for two weeks, preservation up to 4 weeks and longer is related to cortical necrosis and severe forecast. The urinary syndrome is demonstrated by the proteinuria, hematuria and cylindruria. Since the first days the level of blood creatinine, carbamide, urinary acid, potassium builds up. Circulatory disorders, lungs edema on the background of a hypotension, disorders of pace tale the leading part among the causes of lethal outcomes. Course of this phase can become complicated by the hemorrhagic and anemic syndromes, dyspepsia, encephalopathy and water-electrolytic balance and metabolic acidosis; c) restitution of diuresis with an initial stage of 5-10 days, when the quantity of excreted urine grows independently on the fluid intake and the urinary syndrome is arrested. This stage is followed by the polyuric period, lasting for 34 weeks, exhibited by the canalicular functions recovery. If joined by infection contamination, it can be complicated by arterial hypertension and salt-loosing kidneys syndrome; d) complete recovery with the basic functions normalization within one year. Severe damages can possibly cause nephrosclerosis with the subsequent incomplete restitution of kidneys function and chronic renal disorders. Treatment of kidneys damages and diseases The major directions in therapy of kidney damages and diseases related to MT, are: acute renal failure arrest; restitution of systemic and renal hemodynamics; liquidation of microcirculatory disorders; restitution of urinary paths passability; normalization of water-electrolytic exchange and acid-base balance; prophylaxis and treatment of contagious complications. Treatment of pre- and post-renal AReF complex is performed through by arresting shock and vasodilation, recovery of CBV, struggle against uremia, acidosis and restitution of normal urine passage. Evolution of renal AReF demands urgent provisions, targeting liquidation of hypovolemia, struggle against thromboembolic episodes, fatty embolism, endointoxication and
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hemolysis. Prophylaxis of AReF is necessary component of intensive care after shock, massive hemorrhages with large volumes of homologous hemotransfusions, extensive crush of the soft tissues, MT-specific extremity avulsions. For this purpose, physicians use osmotic diuretics, IV dropwise introduction of Mannitol 1.01.5 g/ kg of body weight. The diet during AReF should provide up to 3000 kcal/day where the protein content in a daily ration is restricted up to 0.5 g per kg of body mass, or with 10-20 g aminoacid solutions IV. Parenteral feeding is a possible option. In presence of a hydropic syndrome or arterial hypertension, the quantity of salt should be reduced 34 g daily. Infusional therapy should be conducted to replenish all types of fluid losses, exceeding 400500 ml. The therapy should be conducted while monitoring CVP and sodium level. AReF requires restriction of albuminous solutions, and using preferably crystalloids and rheologically active solutions. The transfusion program should be constructed on the basis of blood elements usage with respect to practical complexity of reinfusions in presence of damaged urinary paths. Diuretics Furosemide (Lasix) is administered until the urine volume reaches 500 ml. Once the oligoanuria is arrested, Mannitol is administered 2030 g IV dropwise. Threat of hypotension can be averted by parenteral introduction of steroids. In view of hyperpotassemia threat, the spironolactones should be avoided. Hyporpotassemia is prevented by IV introduction of glucoseinsulin mixtures, calcium gluconate 50100 ml, sorbitol solution internally. The patients ECG should be strictly monitored. Choice of the antibacterial therapy in case joint infection contamination is based on the minimal drug nephrotoxicity (fluorquinones, inhibitor-protected Penicillines, cephalosporins, Levomycetin). Expressed endointoxication, liver failure and inefficiency of AReF conservative therapy with rising levels of creatinine, carbamide and potassium are indications to efferent therapy: plasmasorbtion, plasmolysis, hemodialysis, peritoneal dialysis. Clinical pattern of lungs edema suggests ultrafiltration. Casualties with bruises of kidneys are administered conservative therapy with immediate urologist participation. This therapy can be conducted in general or nephrology branches unless there are damages penetrating into the cavitary system of kidneys. In addition to general therapy (diet,analgesia, treatment of electrolytic disorder, antibiotics) the local hypothermia is conducted, in combination with a to bed and hemostatics. Evolution of acute tubulointerstitial nephrosis, first of all, requires canceling drugs, which possibly cause the response. The diet with restricted protein and antihistamine drugs are
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prescribed along with steroid hormones IV unless there is significant arterial hypertension. Prophylaxis of electrolytic disorders requires IV dropwise administration of glucose-insulin mixture, isotonic solution of sodium chloride. Decrease of azotemia level points on adequate treatment and successful outcome. In rare cases of severe azotemia, it is arrested by using the hemodialysis. Acute pyelonephritis demands joint medical efforts of the urologist and therapist. Hence, active antibacterial therapy can be started only after restitution of urinary paths passability. Drug choice should be based on the spectrum of ethilogically significant actuators, their possible resistance to antibiotics (in particular, more than 30 % strains of E.coli are tolerant to semisynthetic Penicilline) and relative nephrotoxicity. General intoxication syndrome is arrested by the infusional therapy, preferentially with crystalloids. After termination of antibacterial therapy, whose efficiency is monitored by dynamic urine inoculations, it is possible to use short course of uroantiseptics internally (Palin, Nevigramon). Physicians should be vigilant on using sulphanilamides due to their crystallization at the canalicular level.

11.2. SECONDARY PATHOLOGY OF INTERNALS

Unlike immediate damages and diseases of internals in early terms after the mine-explosive trauma, being a direct consequence of it, the later stages are related with the diseases, where the traumatic genesis plays only a secondary role while the priority belongs to the purulent-septic and infectious-inflammatory processes. These processes determine the severity of wound course sicknesses in the tertiary period and become the most frequent immediate cause of lethal outcomes.

11.2.1. Circulatory system

Pathology of cardiovascular system in later terms after MT is comprised of: inflammatory diseases of heart muscles and heart shells; myocardial dystrophy; neurocirculatory dystonia. inflammatory diseases. As a rule, these pathologies originate starting with the third week of wound sickness, representing essential share of the generalized purulent-septic complications clinical pattern.
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Their incidence for severe MTs comprises 10-12 % cases. Infectious-toxic myocarditis evolves during 3-4th week after a trauma or wound. The leading part in the genesis is played by endointoxication, severe disorders of microcirculation and histic metabolism of a heart muscle. Infectious-septic myocarditis, inherent to > 80 % cases of traumatic sepsis [Gembitskij E.V. et. al., 1994] has usually extremely severe course. Characteristic clinical features are subacute course, poor symptomatology moderate attributes of circulatory inadequacy and extrasystoles. Physical data show the systolic noise and impairment of the 1st tone at the heart top. ECG manifests decrease of R peak, protraction of interval PQ, changes in peak and frequently sinus tachycardia. Medicamental functional ECG tests are, as a rule, negative. The echocardiography can reveal the drop of propulsive myocardium ability. Diagnostic significance of temperature response, level of acute-phase tests on the background of active generalized infection, is negligible. Pericarditis is often caused by the thoracic mine-explosive trauma with immediate heart damages. In these cases, chronic adhesive pericarditis is formed in the late terms, often without heart compression. It is preceded by the slow formation of adhesions in the pericardium cavities, swelling and hardening of cardiac ascus external leaf. The clinical pattern develops from the attributes of chronic circulatory inefficiency bloating of cervical veins, enlarged liver, hydropic syndrome, including ascites, tachycardia, dullness of cardiac tones. ECG manifests decrease of voltage, flattening or inversion of T peak. Central hemodynamics exam detects decrease of strike and minute blood volumes and heart output by 10-20 %. In presence of pleural empyema, subphrenic abscesses and severe sepsis, evolution of acute pericarditis is still rare. Acute infectious endocarditis is even less frequent pathology. According to the autopsy data, its incidence during WWII was 0.41 %. This pathology leads to characteristic damages of mitral and aortal valves, originating on the background of traumatosepsis with colonization of the valve mechanism, parietal endocardium and vessels endothelium. Clinical pattern is determined by the failures of aortal or mitral valves, expressed general intoxication syndrome, spleen enlargement, anemia and urinary syndrome. Deposits of fresh clot masses on the surface of valves can lead to severe tromboembolic complications. Alongside with clinical data, diagnostics is based on the dynamic blood inoculations, radiological and ultrasonic heart examinations. Myocardial dystrophy Dystrophic changes in the heart muscle on the background of purulent-septic complications are
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often clinically manifested by the end of the first month. Their formation is influenced by the aftereffects of heart bruises, long-term endointoxication effects, deep disorders of myocardial electrolytic exchange, wound depletion and anemia. WWII experience points on the presence of the myocardial dystrophy in 13-21 % cases of traumatosepsis, depending on localization. This percentage peaks for the thoracic wounds. The peak of this incidence, as a rule, falls on the casualties older than 30 years of age. Characteristic complaints are dyspnea, palpitation, cardialgias with uncertain localization; tachycardia sometimes together with the bradycardia. Physicals exams and X-ray inspection shows expanding heart boundaries, frequently to the left. Auscultatory impairment of Ist tone and systolic noise are noted, mainly at the top. ECG manifests moderately expressed diffuse muscular changes, sometimes extrasystoly and drop of intraventricular conductance. Ultrasound heart exams during the initial manifestations of circulatory inadequacy show the decrease of shock and minute volume and output cardiac fraction. Neurocirculatory dystonia Uncomplicated MT course causes the neurocirculatory dystonia to originate in the later terms for casualties with distant damages, more often after craniocerebral trauma (more than in 40 %), traumas of pelvis and spinal column (about 20 %), thoracic trauma (10-12 %). The genesis is dominated by the posttraumatic disorders of neuro-humeral and metabolic regulation of cardiovascular systems with the subsequent evolution of inadequate responses to both usual and extraordinary irritants. The hypertonic and immixed varieties predominate the clinical pattern, described by the vegetovascular disorder, cardialgias, transient rise of arterial pressure up to 150-160/90-95 mm.Hg, pulse lability and emotional instability. In more severe cases, the occurrence of resistant extrasystoles is possible, decrease of tolerance to exercise stresses and a vegeto-vascular crisis. ECG showed transient changes of peak with its flattening or inversion, as well as positive ECG tests with potassium or Obsidan. Treatment of cardiovascular system secondary pathologies When treating secondary pathologies it is necessary to remember that the therapy is based on the treatment of severe infectious-inflammatory and purulent-septic complication of wound sicknesses. Only its rationality and adequacy, when combined with the optimal tactics of surgical treatment, allows achieving restitution of internals functions after diseases.
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The inflammatory processes originating in heart muscles, are treated under traditional plans using active antibacterial therapy, provisions of circulatory inadequacy arrest during the individualized rehabilitational program. Presence of dystonic functional disorder demands complex corrections engaging nutritionists, psychotherapists, physiatrists, application of sedatives, vegetative adaptogens and beta-blockers.

11.2.2. Respiratory System

Direct lung damages and early, preferentially posttraumatic, pneumonias in later terms are replaced by the diseases of respiratory system with predominating role of infection contamination. Of essential value are the hospital (nosocomial) pneumonias [Sinopalnikov A.I., 1996]. In addition to that, secondary immunodeficiency, hypostasis, endointoxication and traumatosepsis become more obvious. Raised hypersensitivity of bronchi is formed together with the impairment of tracheobroncheal tree defense mechanisms. These factors can participate in the subsequent chronic nonspecific diseases of lungs and bronchial asthma. Of greatest interest are the following diseases of respiratory system: secondary pneumonia (hypostatic, aspiration, ventilator-associated) addressed in the separate section; acute infectious lung destruction. Hypostatic pneumonias. Preferentially evolve in casualties with the long-term confinement to bed after damages of skull, spine, organs of abdominal cavity, pelvis and the inferior extremities. Their causes are stagnant phenomena in vessels of small circulatory circle, decrease of ventilation in retrobasal lung departments. Formation of hypostatic pneumonias begins at the end of 2nd week, but half of cases are manifested during 20 days after the trauma or wound moment. Staphylococci and pneumococci are the typical pathogens, together with klebsiella and bacteroids etc. Clinical attributes have the gradual onset and lengthy subacute course. The weakness and increased dyspnea are noted. The cough and high leukocytosis are unusual. Pneumonic infiltration is frequently focal and localized in the basal segments of the lower lobes. Fine and medium moist rales are auscultated above their surfaces. X-ray exam shows venous and lymphatic stasis in the inferior lung departments. Aspiration pneumonias. Often complicate gunshot and closed mine-explosive traumas of skull, maxillofacial region, upper respiratory paths, esophagus and stomach. Originate often 7-10 days
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after the aspiration syndrome, causing aspiration of blood, food and stomach contents in the respiratory paths. Localization, as a rule, encompasses the lower lobes, preferentially to the right, due to wide, direct and short bronchus, or bilaterally. The clinical pattern is manifested by the high general intoxication with fever, significant leukocytosis; bronchitis with the phenomena of bronchospasm, productive cough, stethalgias; auscultation exhibits damp or sometimes attenuated bronchial breathing, different moist, and in case of a bronchospasm dry, rales. X-ray exam shows a pattern of focal infiltration with a trend to confluence. Severe shapes of aspiration pneumonia are complicated by the suppurative processes in lungs. Ventillatory-associated pneumonia originates in the ventilated patients after the second day of artificial lung ventilation (ALV). Risk factors of the disease, along with severe MT, include consciousness disorders of any genesis, aspiration syndrome, long-term ALV and secondary immunodeficiency. Physicians isolate early forms with terms of evolution 27th day and late forms, after 8th day. Lethality, according to various data, ranges from 20 to 80 %. The characteristic microflora is comprised of various associations of Gram-negative pathogens (klebsiella etc.), anaerobes, Chlamydia, mycoplasma, fungus, legionella and CMV. Clinical-laboratory criteria of the ventilatory-associated pneumonias include combinations of the developed pneumonic process (audible rales, shorting of a percussion sound) and the purulent sputum, appearing for the first time, the isolated pathogen (hemoculture, contents of bronchiaalveolar lavage with microbial concentration >104 /ml). Radiological diagnostics is based on the newly formed segmental infiltrates, infiltrations or cavities in the lung tissue, the discharge in the pleural cavity. Of high diagnostic significance are virus or viral antigen presence in the respiratory secret, inoculations of blood in the anaerobic flora, analysis of blood and respiratory contents for Chlamydia, mycoplasma, legionellas, mycosis. Conforming histological pattern of pneumonia after the transthoracic or transbronchial lung biopsies is considered to be the reliable indicator. However the hazards of complications after biopsy during the pulmonary ventilation restricts use of invasive examination only at the life-threatening conditions, inefficiency of treatment and the resistance to antibiotics. Acute contagious lung destructions. Formations of acute abscesses in lungs on the third week after severe traumas and wounds considerably complicates course of MT and worsens the forecast. Among causes it is necessary to mention traumatic abscesses in the bruised region, hematomas, mine-explosive wounds of the lungs parenchyma; aspiration syndrome during
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comas, wounds and traumas of maxillofacial region, esophagus and stomach; influence of the generalized traumatosepsis; abscessing of secondary pneumonias on the background of an immunodeficiency. Key factor is the disorders of tracheobronchial tree passability. The etiology of contagious acute lung destructions includes Gram-negative flora klebsiella, proteus and other enterobacteria; conventional anaerobes a pyocyanic bacillus and golden staphilococcus. In almost 60 % cases, including associations with Gram-negative flora and staphilococci, anaerobes are the main actuators. Participation of some viruses is possible as well. The clinical pattern is typically characterized by the acute beginning, expressed general intoxication, long-term fever, dry cough; stethalgias and a friction noise due to the involved pleura from the damaged side; shorting of pulmonary sound, rales can be absent in the beginning. X-ray exam shows segmental or lobar pneumonia with the subsequent formation of cavities. The intoxication, therefore, builds up, together with the local necrosis and purulent melting of the lung tissue. Abscesses can possible burst in the bronchus opening path to the large amounts of purulent sputum. Lengthy course is also possible, lasting for 2-3 months and characterized by the subfebrile condition, pneumorrhagia, anemia and extrapulmonary organ damages. Complications include acute contagious destructions of lungs, frequently purulent (or reactive serous), pleurisy depending on localization of lung abscess or presence of peritonitis and subphrenic abscess in abdominal cavity, pleural empyema, pulmonary bleeding, bacterial shock and respiratory distress-syndrome. Diagnostic tests include dynamic X-ray tomography, CAT, fiber-optic bronchoscopy, microbiologic blood analysis and analysis of broncho-alveolar lavage for possible actuators (pathogens), including anaerobes. Treatment of secondary lung diseases Treatment is based on the rational use of antibiotics. It is necessary to consider that incidence of resistant strains of Strept. pneumonia to Penicillin comprises 1530 %, erythromycin up to 35 %. Level of resistance to gentamycin is high as well. In this connection, macrolides are widely used now Rovampin 1.5-3.0 million units 23 times a day IV, Rulide up to 600 mg and Sumamed 500 mg PO; aminoglycosides Amikacin 10-15 mg or Tobramycin 3-5 mg/kg IV; Cephalosporins IIIIV generations: Cephobid, Cephtriaxone, Rocephin IV. Combinations of aminoglycosides with Co-amoxiclav or cephalosporins are also effective. Nosocominal, in particular ventilatory, pneumoniasrequire application of Tienam up to 2 g/day, Fluorquinones (Pefloxacin etc.). Depending on clinical varieties and character of pathogens, the antibacterial therapy has a number of features. Combination of the ventilatory pneumonias with
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chronic obstructive bronchitis demands using Amoxycyllin with last-generation fluorquinones and cephalosporins. Presence of neutropenia and Gram-negative flora suggests using Tienam or IIIrd generation cephalosporins with aminoglycosides (Amikacin). In case of pneumonias fungal nature it is necessary to include Amphotericin B or much less toxic Shprakonasol (Orungal). Late ventilatory pneumonias require use of Carbapenems (Meronem) together with IVth generation cephalosporins, fluorquinones , which can be used for monotherapy against most probably pathogens, if the pneumonias are not severe. In the there is no improvement in severe cases, the antibiotic should be replaced after 4872 hrs. The major role in treatment of secondary pneumonias is played by the rational respiratory therapy, sanation of tracheobroncial tree, restitution of microcirculation, detoxification, boosting organism resistance and active rehabilitative treatment. Acute contagious lungs destructions require antibacterial therapy by the rational combinations of aminoglycosides (Amikacyn, Tobramycin), last generation cephalosporins (Cephtazidime, Rocephin), Augmentin, Metronidasol. Optimal paths of introduction are endarterial, endolymphatic; drugs are also administered while draining the foci with their catheterization. Permanent sanation of the tracheobronchial tree is done using bronchomucolytics. The syndrome of endointoxication is arrested by active infusion-transfusion and efferent therapies including plasmolysis, plasmasorbtion and plasmapheresis combined with hemoxygenation, laser irradiation of blood; hyperbaric oxygenation. Rheocorrection demands use of rheopolyglucin, Trental, Heparin and fresh-frozen plasma.

11.2.3. Digestive system

Aftereffects of abdominal cavity organs traumas and late complications are dominated by the manifestations of endointoxication: acute stomach and intestine erosions and ulcers; diarrhea syndrome with hypermotility of small intestine and colon oppression; syndrome of intestinal paresis with acute motility disorder, diselectrolyte disorders, activation of intestinal microflora, including pathogenic; depression of parietal and cavitary digestion [Kostjuchenko A.L. et. al., 1999]. The following diseases are related to the late complications of the digestive system diseases.

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Chronic pancreatitis By the end of the first month after MT, casualties sometimes develop posttraumatic chronic pancreatitis as a consequence of damages to parenchyma or pancreas ducts. Basic clinicallaboratory manifestations include the moderate pain syndrome; digestive disorders caused by the extrasecretory failures, partial failure of the insular apparatus and cholic hypertension. Diagnostics of pancreatitis is performed by endoscopic and ultrasonic methods, retrograde cholangiopancreatographies, angiographies, examinations of amylase level, increase of lipase, Trypsin and its inhibitor. Pseudomembranous coloenteritis Frequency of this complication during combat trauma attains 8 % [Ivanov G.A., Lebedev V.F., 1998]. By genesis, the pseudomembranous coloenteritis refers to antibiotic-associated colitis and is formed on the background of antibacterial therapy after the beginning and up to 4 weeks from the moment of cessation [Kostjuchenko A.L et. al., 1999]. The pathogenesis is based on the intestinal dysbiosis caused by the prolonged antibiotic treatments, more often linkosamids, cephalosporins, semisynthetic Penicillin. The microbial toxins, first of all the most frequent actuator Clostridium difficile, and drugs, both damage cells of intestinal epithelium with oppression of barrier function, causing diarrhea, encephalopathy, fever, nausea, vomiting, arterial pressure drop and oliguria. Clinical and laboratory pattern of endointoxication evolves. Physicians isolate the following disease shapes: choleroid, shock and paretic. Among complications are thromboembolisms, peritonitis, pneumonias and endocarditis. Damages to the intestinal walls can cause perforation. Bacteriological examinations, measuring levels of staphilococcus, proteus, pseudomonades and toxin Cl. difficile, colonoscopy with exposure of pseudomembranes on intestinal surface (fibrinous plaques coating the lesions), often, sigmoid colon, cross-sectional colon are of diagnostic value. Ultrasound or CAT scans, revealing the significant swelling of colon wall, should not be ruled out. Treatment of digestive organs secondary diseases Similar to other localizations of late MT complications, treatment includes adequate and welltimed sanation of purulent-septic and inflammatory processes, including surgical. Joined reactive hepatitis does not demand intensive provisions. The main resorts are diet, cholagogue drugs and hepatoprotectors, leading to gradual healing of the functional disorders and
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normalization of laboratory indicators. Chronic pancreatitis is arrested using rigorous sparing diet, in some cases temporary parenteral feeding. Arrest of pain syndrome using spasmolytics and narcotic analgetics. Extrasecretory activity of pancreas is inhibited by using regulatory peptides Sandostatin and Dalargin. Application of antienzymal drugs Contrycal and Pantripin is possible. Infusional therapy includes Rheopolyglucin, albuminous and electrolytic solutions. The detoxification is performed using plasmapheresis and hemosorption. Enzyme drugs are used when the patient switches back to normal feeding. Treatment of pseudomembranous colitis begins with cessation of the previous antibiotics, infusional introduction of saline solutions Acesol, Hlosol etc. and hemodynamics restitution. Pathogenetically important is administration of drugs, effective against the basic actuators Metronidasol 0.5 g triple a day for 1214 days, Vancomycin 0.5 g 34 times a day or Ornidasole 0.5 g twice a day a day for 10 days. Sanation of an intestine is performed using Chlorophyllite, Eubiotics: Linex, Hilac, Bactisubtil, Bifidumpacterin. Diarrhea syndrome requires using drug Enterol 0.5 g twice a day for five days, inhibiting growth of Cl. difficile and stimulating proteolysis of a toxin. Enterosorption is used 2-3 days after cessation of antibiotics for 710 days until stool is normalized (Polyphepan, Enterocat, Smecta). Adequate and timely treatment the shows clinical effects after 4-5 days.

11.2.4. Secondary pathology of kidneys Late complications originate, as a rule, after traumas of renal parenchyma and cavitary system, damages of ureters with disorders of urodynamics and infection of urinary paths, on the background ongoing urosepsis and purulent-septic processes of other localization.

Secondary chronic pyelonephritis. Caused in casualties with MT-related wounds of kidneys and urinary paths. 50 % cases happen between 2 and 4 weeks. It is usually combined with the spinal column damages, fractures and avulsions of upper extremities. The brightest clinical pattern is inherent for the bilateral process with an intoxication, edemas, oligurias, azotemias, pain and dysuric syndromes. The urinary syndrome is represented by the decrease of relative specific density, hematuria, leukocyturia and bacteriuria. The forecast of secondary pyelonephritis for single kidney is unfavorable in case of posttraumatic nephrectomy
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with threats of urosepsis and renal failure. Diagnostics is based on radiological, radioactive and ultrasonic methods in dynamics, urine inoculations and complex functional examination of kidneys. Chronic tubulointerstitial nephritis (toxic nephritis ) It is most often observed in casualties with septic complications (more than 70 % cases). The base is the long-term toxic and medicamental canalicular damage with chronic inflammation in tubulointerstitial region, and then with involvement of glomuluses. Along with primary action of various antibiotics, the role of analgetics, diuretic and other drugs is essential. Clinical pattern is comprised of salt-losing kidney with polyuria, deficit of electrolytes; gradual evolution of chronic renal failure, possible anemic syndrome and cardiovascular disorders. Diagnostics is based on dynamic estimates of the basic functional parameters glomerular filtering, canalicular resorption, electrolytes of blood and urine, daily urine, level of nitric byproducts, immunologic indicators and ultrasonic methods, radioactive renography etc. The course of contagious or toxic-medicamental nephropathies after mine-explosive wounds and damages of kidneys and urinary paths, is well known from WWII experience. This course can be complicated by the urolithiasis, especially if combined with spinal column damages, gunshot fractures of bones and osteomyelitis. The following phenomena can participate: disorder of urodynamics, generalized osteoporosis in later terms after MT, redundant eduction of calcium and phosphorus salts with urine, disorders of salt elimination during posttraumatic coloenterites. In addition to that, both secondary chronic pyelonephritis and tubulointerstitial nephritis in certain cases can be complicated by the late acute renal failure related with tubular necrosis and bacterial shock. Treatment of secondary kidney damages Infectious-inflammatory tubulointerstitiary diseases, including chronic pyelonephritis, are underlaid by the use of antibacterial drugs. When choosing drugs, one should consider the following issues. Drugs with the greatest nephrotoxicity are the aminoglycosides (Gentamycin, Tobramycin etc.) causing undesirable responses 525 % cases. These drugs may cause damages of an epithelium of proximal canaliculuses, evolution of neoliguric AReF. In addition to that, they may have cochleotoxic effects, occasionally nervo-muscular blockage with the paralysis of respiratory muscles. Nephrotoxic effects increase forcombinations of cephalosporins,
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Clindamycin, Vancomycin and diuretic drugs. Independent toxic effects of cephalosporins on kidneys are noted for the significant excesses of the therapeutic dosages. Allergic responses are often caused by the semisynthetic Penicilline; including high level of the typical pathogens resistant strains. Optimal groups of antibiotics for the treatment of secondary chronic pyelonephritis in MT casualties are fluoroquinolones: Pefloxacin 400 mg twice a day, Norfloxacin in the same dose, Grepafloxacin 400600 mg once a day. Nephrotoxic effects are slightly more frequent for Ofloxacin and Ciprofloxacin. Fluoroquinolones are incompatible with Tetracyclines. Much less often allergic responses are encountered during treatment by cephalosporins IIIV generation, having less nephrotoxicity: Cephuroxim 2 g triple a day IV, Cephotaxim same dose, Cephpirom 2 g twice a day IV. In severe cases it is possible to combine them with Amoxyclav and Metronidasol. Wide use of traditional Nitrofuranums (nitrofurantoin, furasidin), Chinolins (Nitroxolin), Nalidixic Acid is now revised in connection with high incidence of undesirable effects (over 40 % cases), including acute allergic damages of lungs, dyspepsia, disorders of CNS and acute hemolytic anemia. Use of phytotherapy resorts with antiseptic and diuretic activity during the aftertreatment remains a viable option. Drug therapy can be effective only after entire cycle of urological provisions, targeting the restitution of urodynamics, including lithotripsy during nephrolithiasis. The long course of the endointoxication syndrome demands using methods of efferent therapy plasmasorption and plasmadialysis. Evolution of chronic tubulointerstitial nephritis demands canceling possible damaging medicines, starting infusional therapy with the glucose-insulin mixtures, the diet restricting albuminous load and intake of enterosorbents in case of an azotemia buildup. Antihistamine drugs should be included as well; short course of steroid hormones for stabilization of canalicular basal membranes; provisions of diselectrolyte disorders arrest.

11.3. CLINICAL PRECURSORS AND MECHANISMS OF SECONDARY PNEUMONIAS, CAUSED BY THE EXPLOSIVE DAMAGES
Clinical observations over 143 Afghan soldiers with mine-explosive traumas allowed isolating three basic groups of casualties by the damage character. First group (37 persons) included critically wounded patients, who received damages being inside the combat vehicles. Main
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injuring factor was blast wave from the munitions, exploding under the vehicle. Casualties exhibited insulated and multiple fractures of bones, bruises and internals. In 78.3 % cases, the condition severity was defined by craniocerebral trauma, brain bruises and intracranial hemorrhages. The second group included 48 persons, who received mine-explosive wounds (MW) through the major factors of munitions explosion blast waves, flames and gases, primary fragments, secondary projectiles. All casualties manifested extremities avulsions or crushed segments, concomitant fragmentation wounds and bruises of the internals. In 1/3 cases the brain contusion was found with less expressed clinical symptomatology and easier course, than that in the first group. Casualties of the third group (58) were primarily injured by the fragments, produced by the close mine munition explosions. These damages were referred to MW, although their character and severity tended to be typical for gunshot wounds. Frequency of pneumonias during MT comprised 28.7 %, and for the wounded54 %, 24.9 % and 15.5 %, accordingly. Three factors are known to participate in the pathogenesis of pneumonias local lung changes, organism response and character of the infection contamination [Shchukarev K.A., 1953]. Subjects of study were represented by the local changes in lungs during MT, mechanisms of evolution and clinical characteristics of the secondary pneumonias in the explosion casualties. Casualties were forwarded to the stage of the qualified medical care within 1.5 0.22 hrs, and were, as a rule, in severe or extremely severe conditions. The shock was diagnosed in 72.9 % cases. Lack or consciousness retardation was accompanied by disorders of the respiratory and cardiovascular systems. It was manifested by the tachy- and bradypnea, Cheyne-Stokes breathing, tachycardia, decreased arterial pressure. Casualties manifested shallow breathing, disorder of cough reflex, delay of sputum excretion. Attenuated breathing, individual dry and moist rales were auscultated in the lungs. Disrupted regulation of the respiratory and swallowing acts in the casualties with craniocerebral trauma posed danger of aspiration syndrome, caused by the blood and stomach contents entering the respiration paths. Two casualties developed expressed bronchospasm and lungs edema due to this condition. Until the antishock (reanimation, surgical) provisions were initiated, all casualties manifested the hypovolemia due to the internals hemorrhages in the internals, pleural and abdominal cavities and soft tissues. Similar traumas, according to Clark, are accompanied by 20-30 % blood volume
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loss [Vinogradov V.M. et. al., 1975]. Hypovolemia, tissue fracture related toxemia and commotio-contusion vascular damages caused the rheologic blood properties changes, disorder of microcirculation in the internals, including lungs. This condition was confirmed by the histological exam. Five perished casualties exhibited blood stasis, aggregation of erythrocytes, sludging phenomenon during the first hours after a trauma. Additionally, the microcirculation disorders are proved using biomicroscopy of an eyeglobe conjunctiva with the subsequent estimating changes and deducing general conjunctival coefficient (GCC) for 15 casualties with MD. It was raised up to 7.43 0.3 rel.units (Normally 3.72 0.24. <0.01). Aggregation and sludging of erythrocytes in lungs capillars causes the ischemia of a pulmonary tissue, disorder of surfactant production, slowing of the regional blood flow and the dissemination of microatelectases. Latter was found in all (22) casualties who perished. Onset of microatelectases is assisted by the disseminated intravascular clotting (disseminated intravascular coagulation syndrome (DIC) caused by the blood flow deceleration and acid blood response [Negovskiy V.A. et. al., 1979]. The evolution of the disseminated intravascular coagulation is related to increasing concentration of the thromboplastin, thromboxan A2 adenosine diphosphate (ADP) as a result of cellular fractures and ischemia of tissues. 8-10 fold boost concentration of myoglobin concentration and increased content of the middle molecular peptides testified to the introduction of the biologically active materials from the defective tissues into the blood flow. In turn, the hypoventilation and disorder of bronchi drainage function promoted the alveolar and acinusal collapse [Shchukarev K.A., 1953; Zilber A.P., 1984]. Improvement or restitution of rheologic and coagulative blood properties in many respects depends on how early the antishock (intensive) therapy is initiated at the stage of first medical or qualified medical aid. The changes, related to DIC syndrome can cause various complications during the postresuscitatory period [Nemchenko N.S. et. al., 1987]. Observation over casualties showed that once provisions of the qualified medical care are completed, casualties expressed dyspnea (24-40 breathings in a minute) for 2 days, breathing was, as a rule, superficial, rigid, uniform or locally attenuated with the delay in a half of the thorax. Individual dry and moist rales and pleural rub noises were auscultated. Percussion revealed local shorting of a percussion sound. The cough was impeded or missing. The sputum did not excrete. Progressing ARF in 12 casualties required lengthy artificial lung ventilation. 10 casualties were examined using Pulmo-82 device to study the function of an external respiration. It was characterized by the decreased LVC and maximal expiratory flow volume
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(MEFV) values by 20-30 % of the normal quantity. The same decrease was noted in the forced exhalation volume during the 1st and 2nd second (FEV1 and FEV2), exhalation time during MEFV was reduced as well. Velocity of an airflow was reduced through all sections of the bronchial tree by 2535 %. Obtained data manifested mixed various disorders of breathing (obstructivelyrestrictive) caused by the bronchospasm, disorders of the sputum excretion and parenchymatous changes in lungs. The latter can be completely described by the radiographic analysis of the thoracic organs. In lack of lungs bruise, casualties exhibited diffuse enhancement of pulmonary pattern and smallfoci shades, regarded as hemorrhages effects, stagnant phenomena and interstitial edema. The lung bruise (in 29.7 % cases) was accompanied by the larger shaded regions with illegible contours. These changes were mainly caused by the massive hemorrhages in pulmonary tissue, edema, necroses and lung ruptures. 9 cases were confirmed by the autopsies. Congenial course of traumatic sickness in two cases during 2 days showed positive radiological dynamics with restitution of pulmonary tissue pneumatization. Combination with the pneumonia in 8 cases, on the contrary, was accompanied by the intensified shading in the lungs projection. Clear sections around the hemorrhages are usually attributed to the acute emphysema. Radiographic analysis manifested difficulties in the differentiation of fine disseminated hemorrhages, microatelectases and interstitial edema. Only the dynamic X-ray inspection allowed interpreting existing changes correctly. For example, the edema caused rapid either positive or negative dynamics of pathological process. Diagnostics of the lobar and segmental atelectasis in lungs did not pose any difficulty. Two casualties had barotrauma-like damages with ruptures of trachea, bronchi, interalveolar septa and acute focal emphysema. X-ray patterns showed focal shades in the region of lung roots, attributes decreasing pneumatization in all segments. The general conjunctival coefficient in the first day after the qualified medical care was downgraded to 6.74 0.23. Casualties with MD showed expressed hypoxia: partial pressure of oxygen (2) in arterial blood comprised 61.36 3.98 mm.hg, venous 30.72 3.63 mm.hg, base balance deficit increased up to 6.92 mmol/L. Metabolic acidosis with decrease of below 7.37 had the compensatory character due to the external respiration overstress. It was proved by the active washout of CO2 from blood and decrease of pCO2 both in arterial and venous blood (accordingly 31.22 0.64 and 36.4 0.71 mm.hg). Pathomorphologic lung studies in casualties during the first two days after MT before the
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pneumonia onset (7 casualties) and during 2-14th days of the evolved pneumonia (15) manifested expressed disorders of microcirculation in capillars, presence of microthrombs and fatty emboli, microatelectases, hemorrhages, necrosis and edema. The basic role in these changes is played by the hypoxia. Being a powerful stimulator of sympaticoadrenal system, the hypoxia causes progressing disorders of microcirculation and changes of blood coagulative properties. This period is known for the recurring decrease of the surfactant formation and microatelectases evolution. Increment of metabolites concentration in blood due to an acidosis is accompanied by the bronchospasm, increase of a capillary walls transmittivity with an exit of fluid and its accumulation in interstitial tissues. All these issues cause peribronchial and perivascular edema. Additionally, improved perfusion of peripheral tissues and organs causes washout of clots from fine veins (aftereffect of the disseminated intravascular coagulation) and their drift in a lung capillars, acting as an original mechanical filter. Microthromboembolism, which strengthens after the blood transfusions, fatty embolism and disorders of microcirculation, cause blockages of the capillary filter, decline of lungs respiratory functions [by Zilber A.P., 1984], increasing concentration of biologically active materials, first of all, in the lungs parenchyma. It reinforces sputum formation, which corks fine bronchi and causing atelectasis. The ventilatory-perfusion and alveolar-capillary diffusion processes are disrupted. Increment of blood flow through the arteriovenous bypass due to perfusion of non-ventilated alveoli and the increased volume of transported blood amplifies hypoxia and creates vicious feedback. The buildup of hypoxia is also promoted by the reduced volume of circulating blood, anemia and toxemia caused by the defective tissues decay products entering the blood flow. Disrupted drainage of respiratory paths and traumatic changes in lungs create congenial conditions for activization of the internal microbes. The infection contamination, promoting the fine veins clotting, disorders of microcirculation, ischemic damage of organs and tissues, increase of the microatelectases and fluid transudation, aggravates course of pathological process in the damaged region [Cybuliak G.H., 1976]. MD casualties with the earliest contagious complications, manifested tracheobronchitis in combination with pneumonia (6) and pneumonia (8) during the first three days. Early onset of the tracheobronchitis and pneumonia in 2 casualties (end of the 1st day - beginning of the 2nd day) was related to aspiration of blood, spit and stomach contents. Maximum number of pneumonia cases (12) was registered on 34th day after the trauma. Certain casualties showed later pneumonia (7-8th day), i.e. after the trauma became complicated with suppuration, peritonitis or
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meningocephalitis. In one observation, pneumonia was preceded by the massive fatty embolism 13 hrs after MT. Targeted exams showed fatty microembolism in MT casualties in 30 %. Meanwhile, according to Masson (1962), it attains 80100 % in the perished severe trauma casualties Zilber A., 1984]. The thromboembolism of average and fine branches of the pulmonary artery, evolving at the third day after MT (one case), caused subsequent (5th day) evolution of a pneumonia, lung edema and death by 6th day. It was preceded with a posttraumatic clotting of the femoral veins. Thus, among the above pathological processes, caused by the MT factors, it is possible to isolate local changes in lungs, being with morphological substrate for evolution of pneumonias: atelectasis, hemorrhages, necroses, interstitial edema (stagnant phenomena), acute focal emphysema, thromboembolism (clotting) of the pulmonary artery branches and the fatty embolism. Difficulties of their early diagnostic determine the necessity of the dynamic observation over casualties, recurring diagnostic examinations and careful estimates of an organism conditions, first of all, bronchipulmonary and cardiovascular systems. Pathoanathomical and histological examinations of lungs in 22 MD casualties showed all local changes: atelectasis, edema, ARF syndrome: 11 cases had expressed hemorrhages, 9 had a bruise of lungs; 5 manifested fibrin clotting in lung capillars on the background of the expressed microcirculatory disorders (Table. 11.1) Table 11.1 Changes in lungs for dead explosion casualties during 12nd days (first group) and 214-days (second group) Morphologic lung changes First group First group (no pneumonia) (pneumonia) Hemorrhage, acute focal emphysema, 1 0 atelectasis, necrosis, edema Hemorrhage, acute focal emphysema, 1 1 atelectasis, edema Hemorrhage, atelectasis, edema 1 7 Atelectasis, acute focal emphysema, edema 4 1 Atelectasis, edema 0 4 Fatty embolism, atelectasis, edema 0 1 Thromboembolism, atelectasis, edema 0 1 In total 7 15 The data generated during the survey of survivors, allow concluding that considered morbid conditions and syndromes meet are encountered more often in those who have suffered

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pneumonia. Hence, casualties whose clinical pattern is dominated by the brain damage, are, in addition to the lungs local changes, more prone to pneumonia. These changes, first of all, include disseminated atelectasis, edema and hemorrhages of lungs. Basic clinical expression of these changes is ARF. Bronchitis and pneumonias are the earliest contagious complications for these casualties, aggravating course of traumatic sickness. Aspiration syndrome accelerates onset of the pneumonia. Local changes in lungs and the mechanisms of their formation were studied for 48 mine/explosive casualties of anti-personnel mines, and in 58 casualties with proximal damages. All casualties were affected by the same factors of explosion shock wave, flame and gases, primary fragments and secondary projectiles. Difference consisted in different strength of the blast shock wave impulse, which decreases with increasing distance from an explosion epicenter. Damages from contact blasts of the mine munitions were always characterized by avulsions of extremities or gunshot crushing of their segments, massive fracture of the soft tissues. In 29.6 % cases these damages combined with a bruise or the fragmentation wounds of a brain, in 16.7 % internals were simultaneously injured. In 20.8 % observations, the extremity damages were accompanied by the wounds of internals. Others manifested insulated damages of extremities with blurred manifestations of a contusion-commotio syndrome. Course of pneumonia harbingers after the contact mine-explosive wounds, accompanied by the brain bruise or wounds, are similar to those for casualties with mine-explosive damages (MD). Expressed hemorrhage within the limits of 23.5 l has an adverse influence on the course. At the same time, brain bruises were characterized by easier, than during MD, course. Thus, there was no inhibition of the vital body functions, bulbar disorders, pathological types of breathing and bradypnea. The penetrating fragmentation head wounds were an exception. Bruises and wounds of the lungs, abdomen (especially upper half), were accompanied by the acute decline of breathing functions. Most casualties entering stage of the qualified medical care during 23 hrs after MW were in the average severity condition, provided there were no brain and internals damages, significant hemorrhage and defective extremities were immobilized with the anesthesia executed at the previous stages. Combined wounds caused shock (41.6 %) and ARF. Entire group manifested tachycardia 90140 beats/min, drop of arterial pressure, tachypnea up to 30-40 beats/min. Percussion and auscultation of lungs revealed no specifics. When estimating the functional state of respiratory organs using Pulmo-82 , the casualties with
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insulated extremities damages at the 2nd and 3rd days after MW manifested the uniform decrease of LVC and air flux velocity for exhalation by 4050 %. Relative velocity indicators were within the normal range (8085 %). Casualties showed the mixed variety of breathing disorders, expressed to a lesser degree than that after MD. It is necessary to note that the group of casualties with the insulated damages of extremities should be considered conditionally, as attributes of the brain concussion and, possibly, light bruise, related with contusion-commotio syndrome, were manifested during this period by hypotaxia, cutaneous sensitivity, disorders of speech, pyramidal disorders, dysfunction of vegetative nervous system. Analysis of such indicators as pH, pCO2. pO2 in venous and arterial blood, in the first day after a trauma has shown that MW causes onset of metabolic acidosis, base deficit, depression of pCO2 and small increase of pO2 mainly due to the hyperventilation. By 34th - day after MW the attributes of a hypoxia increased. Decrease of pO2 in the arterial blood and reduction of an arteriovenous oxygen difference (ABpO2) pointed on the hypoxia and decline of oxygen comprehensibility, related to maintained disorders of microcirculation increased blood flow in the arteriovenous bypasses, including those in lungs. Radiographic lungs analysis in casualties with the insulated damages of extremities and uncomplicated course of traumatic sickness showed no changes during 1st -3rd days. Deposits in the form of fatty or thromboembolisms in the pulmonary artery branches were radiographically manifested by the enhanced pulmonary pattern, expanded shades of the lung roots, attributes of the lung edema increase. Casualties with combined wounds showed enhanced pulmonary patterns, focal shades, pneumonic infiltrations, attributes of atelectasis and emphysemas already during the 1st or 2nd day. Hystomorphologic examination of lungs in 6 casualties 12 days after MW (before the pneumonia onset) manifest attributes of the microcirculatory disorders blood stasis, erythrocyte clots in capillars, atelectasis, necroses, hemorrhages, fibrin clots, fatty emboli, emphysematous regions and an edema. Changes in lungs, discovered in 14 casualties during 3rd 15th and onset of the pneumonia showed just a little differences, from the one described above. The only difference is encountered leukocyte clots and necrosis regions (infarct) encircled by the leukocyte infiltration (infarct-pneumonia). General difference of the traumatic sickness clinical pattern and the local lung changes for MW casualties are the manifestations, caused by the frequent (27 %) evolution of fatty and thromboembolism in the branches of a pulmonary artery. Fatty embolism originated usually in
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the first day after MW with concomitant damage of the brain and kidneys vessels, was clinically manifested by the increasing respiratory failure on the background of cerebral signs with promptly evolving lungs edema. Thromboembolism was usually found during 3-5th day in the persons with the peripheral vein clots and caused rapid death or massive lung infarctions, being extremely difficult to diagnose. Microthromboembolism played the leading part in the evolution of microatelectases. They are related both to massive transfusions of stored blood, and with drift of the clots caused by the raised thrombogenesis in the peripheral veins. In addition to hat, evolution of necroses (infarcts) of a pulmonary tissue is contributed by the local clotting of vessels after the lungs bruises or wounds and by the aftereffects of microcirculatory disorders caused by the local manifestations of the disseminated intravascular coagulation syndrome. Evolution of pneumonia in MW casualties was preceded by ARF (100 %), lung bruises (16.7 %), pulmonitis (14.6 %) and aspiration syndrome (4.2 %). Changes in the respiratory system of 58 persons (18 perished during 2-14 days after a trauma), caused by the proximal blasts have been closely related to localization of the fragmentation wound, massiveness of fractures and level of hemorrhage, evolution of shock, elapsed time between the MW moment and rendering of the qualified medical care, i.e. the same factors as those in group with bullet wounds [Shchukarev K.A., 1953]. Damages localization defined incidence, pathogenesis and time of pneumonia onset. We shall consider character of local changes to the lungs, depending on localization of penetrating wounds: head neck, abdomen pelvis, chest and extremities. All casualties with proximal MW during the first hours after trauma exhibit general disorders of microcirculation. Their depth and character match to degree of the shock and hemorrhage, amount of damages, elapsed time from the wound moment. Dynamic observation of the microcirculation condition after the qualified medical care is rendered, showed that severe disorders are maintained to the extents of lethal outcome and their expression, in many respects, is caused by the traumatic complications (fatty embolism, pneumonia, sepsis, etc.) Active and timely therapy in combination with adequate surgical treatment had the positive influence on the microcirculation in lungs and other organs. Similar to casualties with contact MW, they expressed disorders of external respiration and acid-base balance. Kussmaul and Cheyne-Stokes breathing, bradypnea were observed only in casualties with penetrating skull wounds and disorder of a brain, involving direct damages of the breathing centers. Casualties with penetrating wound to head and neck (14 observations) exhibited changing depth
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and respiration rate, disrupted coughing reflex leading sputum delay. In the first days after rendering qualified medical aid, casualties still exhibited attributes of hypoventilation, shorting of percussion sound, local impairment of breathing, dry and damp rales. X-ray lung images showed stagnant phenomena in the form of vascular pattern amplification and attributes of beginning edema in the form of focal shades. Local changes were manifested by the macro-and microatelectases, focal hemorrhages, emphysema and edema. Evolution of pneumonia exhibited trend to focal confluence or inflammatory infiltration, abscesses. ARF and an aspiration syndrome preceded pneumonias. Lung wounds (10 persons) were accompanied by reduction of pulmonary tissue respiratory surface due to its damage, compression-related hemopneumothorax and formation of massive atelectasis. Local changes were characterized by the presence of the contusion region including clotted wound canal with shreds of the destroyed interalveolar septa and other structures, region of necrosis with leukocytary infiltration and region of the molecular concussion with sections of atelectasis, hemorrhages and emphysemas. Wound canal with region of necrosis and leucocytary infiltration of the pulmonary tissue is designated as pulmonitis [Molchanov N.S., 1951] in pulmonary practice. We consider it to be the pre-pneumonic syndrome, accompanying the gunshot lung wounds. During the pneumonia onset, essential role is played by the local changes in the region of the molecular concussion, caused by the lung bruise after a gunshot wound [Kolosov A.P., Bisenkov L.N., 1986], and by the organism general response to a trauma. The damage of an osteal thorax skeleton and intercostal muscles caused reduction of breathing depth, disorders of the sputum excretion. Thrombosis in the defective vessels, microcirculatory disorder and local manifestations of the disseminated intravascular coagulation syndrome promote lung infarcts and pneumonias in the periinfarct region. Dyspnea, pneumorrhagia, shorting of percussion sound, local impairment or lack of breathing were clinically noted. Radiological observations pointed the stagnant phenomena and massive hemorrhages. Improvement of bronchi drainage function, drainage of pleural cavity and restitution of thoracic bones integrity promoted elimination of respiratory failure and resolution of local changes. ARF-specific pre-pneumonic syndromes included: pulmonitis and lung bruise. Perforating wounds of a abdomen and pelvis with a damage to internals always led to disorder of function of an external respiration due to reflectory effects and changes of a homeostasis. Of great value are the abdominal wounds to the upper half, accompanied by the disorders of diaphragm and breathing muscles. Expressed hypoventilation and disorder of sputum excretion
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are the basic attributes of similar wound. One of the leading elements of post-contusional pneumonias pathogenesis are lung bruises, resulting in temporary pulsing cavity in the wound canal [Ozeretskovskij L, et. al. 1975]. Morphological lung changes during initial stage of traumatic sickness were characterized by macro- and microatelectases, hemorrhages. However, early preventive provisions directed on the improvement of ventilatory and drainage functions promptly eliminated these disorders. The peritonitis, intestinal obstruction and other purulent complications, accompanied by the massive bacterIal intoxication, acutely complicated ventilatory and microcirculatory lung disorders, promoted pneumonia onset. Therefore, prevention of pneumonias in these casualties is closely related to prophylaxis of purulent complications. Clinical observations over 16 casualties during 12 days after MW revealed that the breathing was usually superficial, attenuated in the lower lung departments, weak dry rales were auscultated. X-ray image showed disc and lamellar atelectasis. Addition of the wound complications was accompanied by the ARF onset, amplification of pulmonary pattern and dilation of lung roots at the X-ray images. Further exams revealed the edema and pneumonic infiltration of the pulmonary tissue. Pre-pneumonic syndromes, ARF and lung bruise were noted. Effects of extremity wounds (8 observations) on breathing function are caused by localization and extensiveness of their damage. More expressed changes occurred after the femoral gunshot fractures with fracture of large veins and nerve stems. Onset of complications in the form of fatty or thromboembolisms of the pulmonary artery branches were accompanied by the rapid edematization of lungs and onset of ARF. Two cases of thromboembolism led to lungs infarct. Disorders of microcirculation and coagulative properties of blood in the lung capillars, related to the general response of an organism to a trauma and the formed microatelectases after early antishock therapy usually were promptly exposed to an involution. Purulent complications of extremity wounds and their manifestation in the form of purulent-resorptive fevers, sepsis and gas gangrene reinforced disseminated microatelectase lung edema and ARF. Effective prophylaxis of embolic and purulent complications allowed preventing pneumonias entirely after the extremity wounds. General deduction from the presented clinical observations is that the same mechanism is responsible for the formation of acute respiratory failure and pneumonia during traumatic sickness. The pneumonia evolution causes advance of ARF. Prophylaxis of the pneumonia provides the same measures as prophylaxis of the acute respiratory failure.
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Chapter XII
DEVELOPMENT OF PROTECTION MEANS AGAINST THE ANTI-PERSONNEL MINES
When stationed in the Afghanistan, authors have witnessed large numbers of mine blast casualties. This reality stipulated troops to seek makeshift means of the foot protection. E.g. reconnaissance units and sappers used shortened skis for blast protection, worn over the standard boots, for blast protection. Individual data on the personnel, equipped by the makeshift leg protection, reconfirmed its efficiency for the extremities avulsions prevention. Large number of amputations, performed by surgeons on a daily basis, was bound to draw an attention of the Central Military Academy researchers, stationed in the Afghanistan. Thus, the important problem was addressed prophylaxis of explosive foot damages through the development of individual protective footwear. Numerous clinical studies also justified feasibility of the special footwear design. Cumulative experience on treatment of more than 800 casualties, injured by the anti-personnel mine blasts (especially by the Italian mines with 50 g HE charge) showed that 4.7 % casualties suffered feet avulsions and 2.3 % of those - shin avulsions in the inferior third. Therefore, the extent of avulsions region near the ground source was 120-160 mm for 74 % casualties. These numbers proved that 12-16 cm is the most dangerous region and an artificial lifting of the human body at this height will allow reducing the damage severity degree. These facts were also reconfirmed by the foreign publications, based on the experimental data. In particular, US researchers 1 found that the dynamical load of the corpse extremity, created by the explosion of US anti-personnel mine -14 was characterized by the peak pressure per unit surface and total momentum. Peak pressure in the plastic mine shell after the explosion achieved 40.4 kbar. Produced impulse was characterized by the instant pressure rise and its gradual decline during 3.5 s. Total impulse per unit square was impossible to measure precisely, however it ranged as .21.28 kg /(s* cm2). With the impulse level 34 times smaller .071 kg / (s * cm2) , the maximal pressure on the corpse foot comprised 211 kg/cm2 . This was the threshold value, causing heavy damages to the foot tissues and, eventually, its avulsion. Comparison of these data
1

Fuinaka I., McDonald J. Studies and design of explosion-protective footwear, its manufacturing and testing, Test report of US Army Material Command. Chicago Technological Institute, Chicago, July 1966

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with other results reconfirmed chosen course of the protective footwear development, regarding the fact that the pressure of the gas explosion fades as a reverse cube of distance. Researchers took also into account US Army protective footwear, designed by the protective wedge insertion. The wedge was made of stainless steel, filled by the aluminum balls and covered by the aluminum plate. The wedge protected heel region and medial foot region by diverting the blast wave. According to the available data, military personnel wearing running shoes required amputations in 29 % cases while those wearing military boots in 100 %. These data confirmed well-known fact that the energy transfer from the wounding projectile resembles tissue explosion if meeting a solid obstacle (e.g. bone) and causes much more severe damages than during encounter with the soft tissues (e.g. muscles), absorbing the energy gradually. Data of clinical and experimental studies underlaid theoretical studies of the protective shoes prototypes. Projected protective shoe, from our point of view, should provide strong attenuation of the blast wave impulse. It could be achieved by "uplifting" body above the ground at the optimal distance, and introductions of the dissector, which changes the direction of a shock wave and jets of explosive gases. Injuring effects on the foot tissues can be reduced by filling the dissector with the damping material. The footwear sole should be made of light materials with highest attenuation to provide maximal absorption of the shock wave and, at the same time, possess optimal functional parameters for walking. Injuring fragments effects can be reduced by using protective shields for the foot and shin, made of the reinforced material, like Kevlar. Noted conceptual demands to the protective shoe design have defined research areas as follows: estimate character and scales of tissue damages in the unprotected corpse leg; establish mechanism of HE explosion effects on the tissues of the lower corpse extremity; compare the efficiency of protective properties of the trial and production footwear samples; define key parameters of the locomotorium functional state in the person for standing and walking positions, when wearing the special footwear. When estimating efficiency of the protective footwear, characteristics and scale of the tissues fractures in the biologic objects were used to evaluate the footwear prototypes. Thus, the considered damage character of tissues, footwear, scatter of the destroyed parts of dummies and biologic objects, position of the cadavers extremity after the corpse blast. Damages of anatomical structures in all the control experiments (9 blasts) were equal. All extremities after the blasts were scattered in the 3060 cm radius from a funnel, fragments of
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boots and clothes within the 3 m radius. The destroyed shin fragments were scattered over the unidentifiable area. Visual inspection of extremities revealed feet avulsions at the astragalus level with extensive fracture of heel region tissues and the ankle joint region (Fig. 12.1). X-ray inspection and preparation of showed fractures of the astragalus remains, fracture of the calcanean tuber and in two observations comminuted fractures of the tibial bone distal metaepiphysis with damages of the osteal material, in the others fractures of ankle-bone were noticed. Main vessels of the extremity showed no damages to the avulsion level, as well as the sciatic nerve and its shin branches. Thus, the blasts of the standard HE charges (40 g) under the medial department of unprotected foot allows to draw the following anatomical diagnosis: feet avulsions, shattered fractures of distal metaepiphysis of shin bones, extensive fractures of the soft tissues up to inferior shin third level. The clinical forecast in the given tests series could be shin amputation at the level of lower or medial thirds. Extents of the tissues fracture were much greater for the blasts of C4 charges with the mass 5. 60 and 70 g (Fig. 12.2). Experimental data demonstrated that the explosion of C4 charges with 4. 5. 60 and 70 g muss under the medial department of unprotected corpse leg caused damages very similar to the typical clinical data: in all observations foot avulsions were noted, fracture of shin bones. The extent of fractures to the soft tissues was defined by HE yield. When studying the mechanism of the basic effects during the explosion of C4 charges, it was stated that the energy transmitted in biological tissues was recorded, through the entire biologic object with a small time delays, thus the peak energy was released into the support foot structures with the following linear decay through the entire extremity. Excessive pressure of the detonation wave caused complete fracture and separation of a foot. Penetration of the explosive gas jets and a blast wave under the skin and inside shin a wound caused amotio of tissues from a bone and their layering over the significant length, which is confirmed by the morphological exams data. High-speed photography revealed the light flash, produced by the hot gases and blast wave was spherical, which defined coagulative necroses of the outstanding shin bones and the soft tissues at the level of separation and the characteristic fragments scatters.

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Fig. 12.1. X-ray imaging of foot before blast (a) and after (b1), (b2)

Fig. 12.2. Damage to shin soft tissues after blasts by 50; 60; 70 g C4 charges

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Obtained data confirmed that the effective way to attenuate blast wave is to lift a person and introduce the dissection wedge in the footwear (Fig. 12.. a and b). Tests of multicomponent protective prototypes, made of the materials with high acoustic admittance (plates from stainless steel), less conductive (plates from the crimped aluminum) and high attenuation (foam rubber, porous rubber etc.) testified that despite absence of avulsions (except for one observation), the character of the feet tissues and basic structures fractures still required massive amputations at the different shin levels in all observations (11 experiments). Scale of damages to the soft foot tissues were a little less significant than for those, attributed to polymers use (Fig. 12.4). Test results of the prototypes developed in the Central Medical academy were qualitatively different. Use of such design features as increased distance between a foot and a fuse and the dissecting wedge installation, was sufficient to prevent any damages after the standard C4 charge blast (Fig. 12.5 and 12.6).

Fig. 12.3. Prototype of the protective shoe: (a) diagram, (b) general view

Fig. 12.4. General view of an extremity in the fixed installation before blast (a), damages to foot after blast (b)
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Design features of the prototypes and production samples of the protective shoes made them detachable and capable to be worn over the standard military footwear. Protective footwear consists of the top section, the cuneiform dissector and the running gear, made as the elastic base with the sole. The cuneiform dissector plays the basic role, therefore was changed many times during the tests. Four designs of the cuneiform dissectors have been tested: the first design from the sheet titanium BT-5 as an isosceles triangle 3 mm thick; the second one from the same material, but is reinforced in traversal cross-section by the special ribs.

Fig. 12.5. Biologic object affixed in installation before blast

Fig. 12.6. Lack of damages to boot and deformation to the test fixtures

Both designs were welded manually without any technological equipment. Third and fourth designs were unified for 46 size soldier's boot. Prototypes for the right and left feet were identical. Basic design features was an absence of the rigid support under the soldiers boot since the interior wedge surface was filled by the damping material (foam polyurethane) with support surface shaped as either left or right boot. The dissectors were made as the OT-3 2 mm titanium sheets using argon-arc welding in vacuum and reinforced by the internal ribs. Other dissector was made of the aluminum-magnesium alloy AMG-6 BM 3 mm sheet using cold-stamping by the lead-zinc die. The height of the running gear in the first two designs comprised 180 mm, in the latter 120 mm. Locomotorium functions survey in standing and walking positions showed no essential changes of the dynamic characteristics and power consumption, thus confirming feasibility of its using in the all-terrain conditions. Test results for the first prototype exhibited strained wedges with a rupture of the weld seam and fragmentation fractures of the heel bones. The integuments and vessels remained intact. Use of the reinforced wedges during the demolition of the standard HE charged showed no damages. As
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the charge of C4 was increased to 50 g, occluded fractures of the heel bones with the no fragments displacement were revealed (Fig. 12.7). Blasts of the prototypes in the standard conditions and recurring blasts with the wedge made of AMG-6 BM alloy (40 g HE) or titanium (50 g HE) showed no damages to either design or extremities. The blasts of prototypes with aluminum -magnesium wedges and HE charge 50-60 g, despite causing no damages of the soft tissues and basic foot and shin structures, caused small strains in the wedge between reinforcing ribs in the first observation and significant strains during the second test series.

Fig. 12.7. Lack of damages to tissues of feet and shin in a blasted biologic object

Fig. 12.8. X-ray images of the foot and shin bones protected by the prototype footwear after a mine blast; (a) no fractures; (b) edge fracture of V metatarsal bone. Test results of the protective shoe prototypes with the aluminum-magnesium cuneiform dissector showed that the further increase of HE charge can cause damages to the basic foot structures (Fig. 12.8). Therefore, the blast resistance can be boosted by using additional reinforcing ribs. Considering low cost of these alloys in comparison with titanium, wedge resistance can be
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increased using AMG-61 material, possessing greater strength. Secondary tests of a the prototype (Fig. 12.9) with the titanium dissector showed no damages to the foot after 70 g C4 charge blasts, which allows to assume feasibility of the wedge efficiency against the high-yield charges (up to 100 g).

(a) positions

(b)

Fig. 12.9. Trials of the protective footwear functional parameters for standing (a) and walking (b)

(a)

(b) charge in protective footwear

(c)

Fig. 12.10. Lack of damages to the soft tissues (a) ,osteal structure (b,c) after blast with 40g C4

Trials of the protective shoe prototypes proved the design concepts and high protection efficiency against most deployed anti-personnel mines. Naturally, any protection mean is not capable of entirely preventing severe damages of the personnel, as confirmed by the explosion tissue deformation data. However these damages can not be compared with those in the lack of

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protection. Expected economic benefit of the individual means of leg protection per casualty may comprise tens thousands rubles. Test outcomes were estimated positively, which underlay the production of the trial prototype batch (Fig. 12.10).

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CONCLUSION
Last two decades of the 20th century domestic health system maintained constant alert to solve large scale tasks regarding medical aid rendering, treatment and rehabilitation of explosion casualties. For the first time this problem arose in its entirety during the Afghanistan war (1979-1989). That time Soviet and Afghan government military forces faced the unexampled growth of explosion injuries in the structure of combat sanitary losses, which consequently enabled historians to characterize the Afghanistan war as a mine war. There were several reasons for that. Positional character of the war, its guerilla nature and subsequent peculiarities of warfare, the possibility to disable the significant number of enemy soldiers without endangering friendly troops, affordability and availability of engineer mine munitions resulted in the wide application of mines. The superiority of Soviet and Afghan government forces in the heavy firepower equipment and aviation, guerilla tactics of antigovernment forces (ambush assault, sudden assault of fortified regions) lead to the rare occurrence of gunshot wounds in this war, and explosion ammunition injuries prevailed in the structure of combat sanitary losses. Soviet military doctors have done large scope of work on generalization of the experience in the explosion injuries treatment; conducted multiple experimental studies, simulating mine trauma and amplifying particular stages of its pathogenesis. The range of studies on mine trauma in the navy and shallow waters was performed in the Naval and General Surgery, Urgent Surgery and Topographic Anatomy Departments of the Military-Medical Academy the unique research never included into scientific projects before. Scientific developments, experimentally substantiated and confirmed, have lead to the breakthrough in views on the pathogenesis of such explosion trauma components as distant injuries of internal organs, arterial air embolism, segment character of extremities injuries and their circular dispersion. Military-medical vocabulary has been definitely supplemented by mine trauma terminology, and its classification criteria have been established. Recommendations on the explosion injuries treatment at medical evacuation stages have been published in the new edition of instructions on field surgery, the basic guidance document defining principles of surgery in wartime. That time it seemed that the analyzed and generalized Afghan war experience took a firm place in educational programs. However, rapid political developments in the nineties and the subsequent social and political situation in the country enforced another view on this problem. The society encountered terrorism not a very well known social-political phenomenon in our country before. Television news releases picturing destroyed buildings, blasted vehicles, and dismayed crying people are in everyones memory. Antiterrorist operations in the North Caucasus also enable to refer to the problem of
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adequate medical aid rendering to explosion casualties as an urgent problem. In contrast to the eighties when the wounded in Afghanistan were treated mainly by military doctors, nowadays this task is already outside the scope of urgency and importance only for army medical service. Today general readiness to render medical aid to explosion casualties is a must. Considering that terrorist acts and man-made disasters mostly take place in big cities and industrial centers, there should be set a practical task of possible early narrow specialists engagement into the system of medical aid administering to explosion casualties. A situation arises when doctors of different specialties in one medical institution are given the opportunity to conduct a complete complex of remedial and rehabilitation measures taking into account a predominant injury. As a rule, such system can not be implemented under field or other extreme conditions. From this point of view this manual is called to fill the existing gap in medical scientific-practical literature. Written according to the unified plan the Manual includes in corresponding chapters particular data on pathogenesis and recommendations on treatment of various injuries. Preceding monographs on the mine trauma problem, based on the Afghan war experience and highly estimated by medical society [Bisenkov L. N. Et al., 1993; Nechaev Ye. A.et al., 1994; Ruhliada N. V. Et al., 2001; Minnullin I. P. Et al., 2001], have been dedicated to general questions or specific aspects of the problem. We are sure that as this Manual is published a practicing doctor receives an indispensable source of unique and practically approved information on the problem in question. Extensive chapters on the history of the problem, human and legal aspects and characteristics of applied munitions, preventive and protection means, organization of the medical provision system under local war and extreme conditions impart encyclopedic character to this paper. Authors will deeply appreciate all comments and wishes of an interested reader.

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NECHAYEV Eduard Aleksandrovich

FOMIN Nikolay Fiodorovich

MINNULLIN Ildar Pulatovich GRITSANOV Aleksandr Ivanovich

RUHLIADA Nikolay Vasilyevich

ShAPOVALOV Vladimir Mihaylovich

Eduard Aleksandrovich Nechayev Aleksandr Ivanovich Gritsanov Ildar Pulatovich Minnullin Nikolay Vasilyevich Ruhliada Nikolay Fedorovich Fomin Vladimir Mihailovich Shapovalov EXPLOSION INJURIES Manual for doctors and students Editor Yu. N. Pahomov Corrector N. D. Pyleva Computer layout S. V. Arefyev Saint-Petersburg IKF Foliant License LR #062429 from 04.01.1998

Translated in English: Yaroslav Tkach, Svitlana Duka E-mail: tkachduka@google.com

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