=====Iraq=====
Severe [[Pediatric traumatic brain injury]] During the Iraq and [[Afghanistan]] Conflicts.

A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-[[Hospital mortality]].

Klimo et al. identified 647 children with severe isolated head injuries: 337 from Operations Enduring Freedom (OEF), 268 from Iraqi Freedom (OIF), and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor.

This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts
((Klimo P Jr, Ragel BT, Jones GM, McCafferty R. Severe Pediatric Head Injury
During the Iraq and Afghanistan Conflicts. Neurosurgery. 2015 Jul;77(1):1-7. doi:
10.1227/NEU.0000000000000743. PubMed PMID: 25812072.)).

----

The [[protocol]] for treating penetrating head and neck trauma in a war zone differs from the standard protocol. Rather than first securing an airway, as is standard in civilian trauma cases, the primary emphasis is on assessing and controlling hemorrhage because it is the leading cause of morbidity and mortality in a battlefield setting. Once that has been addressed, we shift to standard advanced-trauma life-support protocols. We describe two cases we encountered at our combined medical clinic in Western Baghdad--one involving a 4-year old Iraqi child with an ammunition round lodged in her neck and one involving a 38-year-old female U.S. soldier with a round lodged in her right superolateral orbit. Both cases were transferred to combat support hospitals for further treatment after our initial assessment and treatment, and both had successful outcomes
((Sarkar D, Demma A, Stulz D, Hsue G. Expect the unexpected: two cases of
penetrating head and neck trauma from Operation Iraqi Freedom. Ear Nose Throat J.
2009 Sep;88(9):E19-21. PubMed PMID: 19750465.
)).


Pediatric patients represent a significant proportion of the neurosurgical patient volume at field medical hospitals in the Iraqi theater. The mature medical theater environment present in 2007 allowed for remarkable diagnostic evaluation and treatment of these patients. Penetrating and closed craniospinal injuries were the most common indication for consultation. Disease and nonbattle injuries were also encountered, with care provided when deemed appropriate. The deployed environment presents unique medical and ethical challenges to neurosurgeons serving in forward medical facilities
((Martin JE, Teff RJ, Spinella PC. Care of pediatric neurosurgical patients in
Iraq in 2007: clinical and ethical experience of a field hospital. J Neurosurg
Pediatr. 2010 Sep;6(3):250-6. doi: 10.3171/2010.6.PEDS1031. PubMed PMID:
20809709.
)).

Pediatric patients account for approximately 10% of all combat support hospital (CSH) admissions in Afghanistan and Iraq. Burns and penetrating head injury account for the majority of pediatric mortality at the CSH
((Creamer KM, Edwards MJ, Shields CH, Thompson MW, Yu CE, Adelman W. Pediatric
wartime admissions to US military combat support hospitals in Afghanistan and
Iraq: learning from the first 2,000 admissions. J Trauma. 2009 Oct;67(4):762-8.
doi: 10.1097/TA.0b013e31818b1e15. PubMed PMID: 19820583.)).