How did it all start?

Youth Movements

6th of April Movement

A peaceful revolution

Kefaya (enough)

selmeyya Social media/ blogging/YouTube Documenting/cell phones/cameras/ videos Graffiti/songs/poetry/ art

Under attack: Rock throwing Molotov cocktails

Twitter and Social Media Explosion over Time

Infograph

of Graffiti The Power

Then it all turned violent

Clashes

Batons

Jan 28-2011

Protesters were fought with

Rubber Bullets

Tear Gas

Live Ammunition

Marble Rocks

Molotov Cocktail

Batons

Watercanons

Shotguns (Pellets)

Motor Vehicles Camels and horses!

Water canons

Tear Gas

Rubber Bullets

Shotguns (Pellets)

Orders: Shoot in torso or aim high up at eyes and head

Eye hunted

Famous blogger activist Ahmed Harara (dentist)

Revolution Eye Doctors

Eye Injuries

Shotgun pellets Rubber bullets Broken glass Broken marble Tear gas bombs

Eye Injuries

Rupture globe Scleral penetration Intraocular FB Optic nerve destruction Orbital bone fractures Disfigurement

Extent of Injuries

> 90% of cases complete visual loss 15% disfigurement

Mena Daniel Sheikh Emad Effat

Famous Revolution Icons Murdered

Maspero Copts massacre

Christian/Moslem Unity

Women: Virginity tests, humiliation

Nowhere to run nowhere to breathe

Mass Casualties

1. Remove victim from hostile site of injury 2. Placement where they become patients 3. Without worsening the effects of injury

Sinson et al., 2004

Hospital Measures: Cancelation of all elective surgeries Use of all available resources (beds, ICU, OR) All doctors/nurses back

The Famous A B C D E (F & G)

Patient Assessment

Prehospital evaluation

Airway Breathing Circulation Disability Exposure and environmental control Foley Gastric (NG) tube

Secondary Assessment

Diagnostic studies (labs, imaging)

Destination and management plan

Merlino et al., 2007

Way of the Ambulance

Motorcycle Ambulances?

Makeshift Hospitals In Mosques and Churches

Kasr ElDobara Church

Omar Makram Mosque

Mostafa Mahmoud Mosque

Field Makeshift Hospitals

January 25 Revolution: Mass Casualties in Kasr ElAiny

Ayman Salah; Professor General Surgery, Head of Casualty Department

Friday of Anger Surgeons Assistant Professors: Tarek Amer, Amr Ibrahim

Lecturers: Ahmed ElSayyed, Hussein Elwan, Amr AbdelRahim, Mohamed AbdelRasool

Assistant Lecturers: Ahmed Reyad,Tarek Seif, Youssef

Khashaba, Mohamed Diaa, Abd Rabbo Mashoor, Mahmoud Elfikky, Hossam Elmahdy, Hamed Kadry,Baker Mostafa, Amr Abdelkhalek

Residents: Michel Reda, Hossam Anas, MarwanYosry, Ahmed

Maher, Ahmed Alaa, Ahmed Gamil, Ali Fahim, Ahmed Nabil, Ahmed Assem, Mohamed Saed, Assem Albarashy, Mohamed Tomy, Bashir, Mohamed Sabry,Ahmed Samy,Ahmed Ali,Ahmed Rammah,Ramy Salah Mohamed Salah

January 25 Revolution: Jan 26 to Feb 4

Admissions: 453 patients

Age: 17-45 y (mn 27 yrs)

Gender: 444 males 9 females

Number of mortalities: 48

16

Number of Gen Surgeons: 32

Day No. GSurg Ophth Neuro Ortho Cardioth Deaths

Jan 26 1 1

Jan 28-29

302

106

126

27

13

30

20

Jan 30 36 12 9 4 10 1 5

Jan 31 18 12 9 4 10 1 5

Feb 1 20 6 8 3 3 - 2

Feb 2 51 8 20 12 1 10 4

Feb 3 24 11 - 7 6 - 6

Feb 4 2 - - - 1 - 1

Total 453 149 173 54 36 41 40

Revolution Admissions Kasr ElAini Jan26-Feb 4 2011

0

20

40

60

80

100

120

140

160

180

Ophth Gsurg Neuro Ortho Cardioth Mortality

Revolution Admissions Kasr ElAini Jan26-Feb 4 2011

Mortalities (48 cases)

Time/Cause of Death Number

Immediate (at resuscitation) 33

PBI 20

Bullet in chest 6

Bullet in neck 2

Bullet in abdomen 3

Bullet in thigh 1

Crushed by vehicle 1

Mortalities without intervention 5

PBI 3

Burn from tear gase 2

Postoperative Mortality 8

Tear gas bomb (after 1 day) 1

*Bullets in (popliteal vessels/int iliacs/ femoral artery/ chest/liver,diaphragm and lung/loin/liver and iliacs)

7

*Time of death (4hrs/2days/ 3days/ few hours/ 8days/ 2days/3hrs

PBI died after 2 d no intervention

Bullet in Liver, right hepatic vein , diaphragm & lung Treated by Debridement + packing, Repair of the right hepatic vein + control of liver bleeding + packing, 3.Resuturing of the diaphragm+ packing, Removal of the packs. Died after 8 days of DIC/ ARDS/ Septic shock

Operations as per specialty Number

Gen Surgery 90/149

Liver 10 (debridement and packing) Splenectomy 3 Pancreas 1 (repair) Diaphragm 7 (repair) s. intestine 8 (resection anastomosis), Colon 11 (lt.4-ostomy) (rt.5 hemicolectomy, TS colon 2 (repair1/ostomy1) Stomach 2 (repair), Pharynx 1 repair, Trachea 2 (ostomy) Nerve injuries 4 (femoral, common peroneal, median, ulnar nerves) delayed repair Maxillofacial 5 fixation2, delayed fixation 3 Vascular 29: IJV 3 (ligation 2/repair 1), axillary 2–brachial 4 (saphenous graft), femoral a 6 – popliteal v 1 (repaired), femoral v 3 ligated 2, repair 1 fasciotomy 7 (LL 6, UL 1) Negative explorations: abdomen 9, neck 3, femoral triangle 2 Urology Nephrectomy 1, Repair of UB 1, ureter 1, urethra 1, Orchidectomy 1, penile reconstruction 1

Ophthalmology 154/173

134 ruptured globes 9 bilaterally

Neurosurgery 31/54

Cmpd depressed # 12, Extradural htoma 8, PBI 4, acute SDH 3, IV Hge 1 IC He 1, bullet to spine 1

Cardiothoracic 6/41

Stab hrt 1, Explor for air leak 2, Wnd debridemnt 1, 2 died on table

Orthopedics (mostly long bone #) 36/36

Projectile Brain Injury

History: (witnesses)

If concious:

headache Nausea, vomiting Confusion Seizure activity

Time elapsed Talked then deteriorated? Type of weapon (caliber/force)

General Examination

Vital signs, BP, RespRate, pulse oxi, GCS, temperature

Head exam: palpation, look for fractures, echymoses CSF leakage, projectile entry/exit

Neck exam: midline trachea, edema, jugular vein distension, spinous process step-off, crepitation, auscultation for carotid bruit.

Thorax/Abdomen: Insp-Palp-Ausc

Examination for the presence of spinal injuries

Verbal response (V) Score

Oriented and converses 5

Converses but not oriented 4

Inappropriate words 3

Incomprehensive sounds 2

No sounds to painful stimuli 1

Motor response (M) Score

Obeying commands 6

Localizing to pain 5

Withdrawal to pain 4

Flexion to pain (decorticated) 3

Extension posturing to pain

(decerebrated)

2

No response to pain 1

Eye opening (E) Score

Spontaneous 4

To speech 3

To pain 2

No response to pain 1

GCS

Kirkham et al, 2006

Category Activity Best

response

Eye opening

Spontaneous 4

To speech 3

To pain 2

None 1

Verbal

Coos, babbles 5

Irritable 4

Cries to pain 3

Moans to pain 2

None 1

Motor

Normal spontaneous

movement 6

Withdraws to touch 5

Withdraws to pain 4

Abnormal flexion 3

Abnormal extension 2

None 1

PGCS

Severity of TBI Finding

Mild Mental status change or LOC < 30 min.

Moderate Mental status change or LOC 30 minutes to 6

hours.

Severe Mental status change or LOC > 6 hours.

Severity of TBI and duration of loss of consciousness

Greenwald et al, 2003

Cranial nerves

Unilateral dilated fixed uncal herniation

brainstem / lung apex

Traumatic III Oculocephalic/oculovestibular Corneal reflexes- V & VII

Gag swallowing (manip of endotracheal tube)

Motor Function Scale

Motor Function Grade

Normal power 5

Moderate weakness 4

Severe weakness (antigravity) 3

Severe weakness (not antigravity) 2

Trace movement 1

No movement 0

Sensory Responses

Nail bed, glabella, jaw pressure Nipple pinching

Reflexes in the comatose

etc not of grave importance spinal reflexes may persist after brain death

Respiration

Diffuse cortical injury Cheyne-Stokes ----hypercarbia --- elevated ICP

Pontine Deep spontaneous hyperventilation --- hypocarbia

Medulla Irregularities

Biomechanics of Firearms

Classification of Firearms (Size Muzzle velocity Type of projectile)

Lower velocity muzzle shorter barrel Classified according to Caliber (9mm, 0.22 rifle, 0.4 mm magnum = more powder hence velocity)

Single or multiple pellets larger collective mass Classified according to Gage Least number of balls made from 1 lb of lead (454) 12 gage = 1/12 lb 20 gage=1/20 Types of shell 00 (9 pellets) 12 (2385 pellets)

Handguns vs rifles

Shotguns

Wound Ballistics J Trauma 2001

Bullets, shrapnel, and low-velocity objects ability to

penetrate the brain and produce damage depends on:

Energy E=1/2 mv2 Shape Angle of approach, Characteristics of intervening tissues (skull, muscle, mucosa, etc.) Esposito, 2009

Effects of Projectiles

Laceration and tissue crushing

Just as in hand weapons and sharp objects

Shock waves

Spherical shock wave very short duration

with distant damage

Cavitation

At first large temporary cavity (almost 30x

missile diameter) creating vacuum sucking in

debris, bacteria

Later collapses to the definitive smaller

permanent cavity

Tangential

Penetrating

Ricochet Perforating

Classification of Missile Wounds to Head

Cushing WW I, Matson WW II

Perf

At the heart of the Islamic Arabic world

Why Egypt?

Some form of Egypt is mentioned in the following books: In the Old Testament: Genesis, Exodus, Leviticus, Numbers, Deut., Joshua, Judges, 1 & 2 Samuel, 1 & 2 Kings, 2 Chronicles, Isaiah, Jeremiah, Ezekiel, Micah, Lamentations, Daniel, Hosea, Joel, Amos, Nahum, Haggai, Zechariah, Nehemiah, Ezra In the New Testament: Matthew, Acts, Hebrews, Jude, Revelation So of the 66 books of the Bible, Egypt is mentioned in 29 of them! Egypt, obviously, plays an important role in the Bible. In Genesis 10, Egypt is called "Mizraim"

Egypt's role in the Bible. "Egypt" is mentioned 614 times in the Bible, "Egyptian" 37 times, and "Egyptians" 91 times.

Egypt is mentioned in the Quran 5 times (Mecca only 2).

Quote from Metternich who stated: France sneezes all Europe

catches a

the whole world catches a cold

When Egypt rocks the whole world blows!

“Medicine's role is to entertain us while Nature takes it course”

Voltaire. The quote from 18th-century