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Fragmentation injuries

Distribution¶

More patients die from fragmentation mines than from blast mines. Of 10 patients injured by fragmentation mines, 6 have injuries to important organs. Many victims are hit by two, three or more fragments. The body may be able to survive one severe injury. But two severe injuries at the same time are far more dangerous. Death rate is around 30% even with good life support.

• Injury to the limbs 30%
• Injury to the head 10%
• Injury to the chest 15%
• Injury to the abdomen 15%
• Several severe injuries 20%
• Superficial injuries 10%
  

Injuries¶

Injuries to limbs¶

Although the inlet wounds look small, the damage inside can be massive: A stone hitting water makes waves. Our body is 70% water. A mine fragment sends pressure waves into the tissues. The waves are very fast and hit the tissues like a blow. How the tissues are damaged depends on how elastic they are (how easily they stretch).

• The skin is very elastic. It stretches when the fragment passes through and then springs back without much damage.
• But muscle is not very elastic. The pressure waves tear a wide and ragged wound track through the muscle. Because muscles have a rich blood supply, muscle wounds bleed a lot.
• Bones are not at all elastic. When a fragment hits bone, the fragment is suddenly brought to a complete stop. Exactly at that point a massive pressure wave is formed. The wave hits the surrounding tissues like the splash from a flat stone hitting water. All the force carried by the fragment becomes tissue damage.
  

Artery injuries¶

Fragments from the mine or pieces of bone may tear the wall of the artery. Small tears are plugged by platelets and don’t bleed a lot. Wide tears bleed a lot. But note – the artery bleeding is hidden! Because the wound track is narrow you will seldom see blood pumping out through the limb wound. Still 1-2 liters of blood may collect inside the limb. Then – as a result of the blood loss – the blood stream inside the artery slows down. The platelets plug the artery tear and the bleeding temporarily stops. When you arrive at the site of the injury, the patient is not bleeding. This may fool you. If you start IV infusions without having packed the wound track with gauze or clothes, the blood clot in the artery will be flushed away when the blood pressure rises, and the wound will start bleeding heavily. Therefore you should know the signs of artery injury.

The signs of limb artery injury

In all artery injuries the limb is cold: Compare the skin temperature of both limbs. Weak or absent pulse below (distal to) the wound is not a reliable sign.

Fractures bleed a lot¶

Fractures bleed from the bone marrow and from torn blood vessels running close to the bone. There can be a lot of blood inside a swollen fractured limb.

Pooled blood at fractures (estimates)

• Arm fracture 1 L
• Forearm fracture 0.5 L
• Thigh fracture 2 L
• Lower leg fracture 1 L
  

Injuries to head¶

Injuries to the skull mean airway problems. As most victims with severe head injuries die within an hour in the field, we can do nothing to save them. For those who survive more than one hour, blocking of the airway is the main problem:

• In drowsy and unconscious victims, the tongue slips backward and blocks the airway.
• If the victim vomits but is too weak to cough, then vomit enters the lower airway and may block it.
  

Note that the symptoms may come on slowly during the journey to hospital. That is why head-injured victims who are not fully awake and clear should be carried in the recovery position.

Injuries to face¶

Injuries to the face mean airway problems. The blood supply to the face is rich, so face injuries bleed a lot. Often there is associated brain damage, so the patient is weak and cannot cough properly. This is why blood or bone fragments may block the airway.

Injuries to chest¶

Injuries to the chest mean breathing problems and sometimes problems due to blood loss: Most victims who are hit in the middle of the chest die within one hour from tears of the heart or major blood vessels. Most patients hit at the sides of the chest survive if the life support is good and starts early. The main problem is not the lung injury itself: The lungs are very elastic and can take a fragment wound without much bleeding. The main problem is the fragment wound in the chest wall: Blood from broken ribs and torn rib arteries collects between the lung and the chest wall and compresses (squeezes) the lung. Air leaking from the lung and through the chest wall wound also makes the lung collapse. This causes poor breathing – and the body suffers from oxygen starvation.

Injuries to abdomen¶

Injuries to the abdomen mean blood loss and poor breathing. Blood loss: The villagers saw the wounds on Ahmed’s belly but they could not tell if blood was pooling inside. There are so many bloodrich organs inside the abdomen such as the liver, kidneys, spleen. The main signs of injury inside the abdomen are the signs of blood loss: The victim’s limbs are cool, the heart rate increases, the blood pressure falls, and the victim becomes drowsy. You may think that the belly will swell if there is bleeding inside. This is not true. The abdomen can collect 2-3 liters of blood without showing any swelling. Poor breathing: Injuries to the abdominal organs block the movement of the diaphragm. This means that the lung suction pump cannot work properly. So, besides having less blood circulating around the body, the blood also carries less oxygen due to shallow breathing.

In brief¶