Emergency Management of High-Energy Shell Fragment Midface Complex Injuries

Distinctive mechanisms of heavy artillery and improvised explosive device detonation result in a blast and "spray" of high-energy fragments of diverse shapes, sizes, and characteristics. Associated midface complex injuries differ in both severity and complexity of the anatomical structures involved. Management challenges begin with lifesaving, which is complicated by airway compromise, severe hemorrhage, and unique injuries of the maxillae, nose, and naso-orbitoethmoid.The patients presented fragment impact on the face lateral side directed to other side leads to tissues blown away at the point of high-energy exits, while no survival seen of enface shrapnel hit directed antroposterior toward "cervical spine, intracranial, internal and external carotid arteries and internal jugular vein."Twenty-two patients were selected from unquantified patients who had sustained massive midface shell fragment injuries. To preserve midface architecture, healing, and function, iodoform paste on ribbon gauze packs were utilized successfully. An iodoform paste on ribbon gauze pack serves the dual purpose of preserving the shape and scaffolding of the crushed maxillary sinus wall and buttresses fragments in position for healing. It also acts as a wet pack dressing for denuded bone fragments, stopping bleeding and having antimicrobial properties for severely lacerated wounds. For total or partial nasal tissue loss, a successful procedure consists of definitive early scaffolding stabilization using an intranasal, modified portex tracheostomy tube stent to preserve the internal shape of the nasal pyramid.