Bomb blast causes combinations of blast injury, multiple penetrating injuries and burns. The injury pattern to the head and neck includes intracranial haemorrhage, brain swelling with multiple intracranial metal and bone fragments, cervical and facial vascular injury, pharyngo-laryngeal injury, acute airway compromise, facial and scalp burns, large scalp defects, and extensive skull base fractures. Head and neck teams consisting of neurosurgeon, head and neck (ENT) surgeon, ophthalmologist, and facio-maxillary surgeon are an integral part of the US Combat Surgical Hospitals in Iraq treating these often horrific injuries and serve as an excellent model of care for the civilian system. The principles of management include early tracheostomy, vigorous replacement of blood loss and correction of coagulopathy, nasal packing, neck exploration and management of carotid injury, early generous craniectomy, intracranial haematoma evacuation, removal of accessible fragments and debridement of devitalized cerebral tissue, ventriculostomy, duroplasty, and use of broad spectrum antibiotics. Repair of ocular injury or eye removal is often deferred. CT (if available) is invaluable for planning the extent of the neurosurgery and CT angiography is useful when cervical vascular injury is suspected. The timing and extent of the neurosurgery and facio-maxillary surgery must be balanced against the relative priorities of the other injuries and the state of physiological stabilisation. The neurosurgery we have performed for these injuries is generally more extensive and aggressive than that which has been described for penetrating brain injury in the literature from previous wars. Civilian and military surgeons should become familiar with the injury patterns and management of bomb blast injury to the head, neck and spine. The challenge of training the generalist to manage these injuries in an austere isolated location will be presented.
Contact author: BRIG Jeffrey Rosenfeld, 428 Dandenong Road, Caulfield North, Vic, 3161