ORIGINAL ARTICLE

Trauma Attenuating Backing Improves Protection Against Behind

Armor Blunt Trauma
Anders Sondén, MD, PhD, David Rocksén, PhD, Louis Riddez, MD, PhD, Johan Davidsson, PhD,
Jonas K. Persson, MD, PhD, Dan Gryth, MD, PhD, Jenny Bursell, and Ulf P. Arborelius, MD, PhD

Background: Body armor is used by military personnel, police officers, and

mands on body armors leading to debate regarding their
security guards to protect them from fatal gunshot injuries to the thorax. The
effectiveness.3,4
protection against high-velocity weapons may, however, be insufficient. In the process of defeating the bullet, the back face of
Complementary trauma attenuating backings (TAB) have been suggested to body armor is deformed, causing an acceleration of the
prevent morbidity and mortality in high-velocity weapon trauma. thoracic wall and underlying organs. The trauma elicited by
Methods: Twenty-four Swedish landrace pigs, protected by a ceramid/ such a stroke is denominated behind armor blunt trauma
aramid body armor without (n ⫽ 12) or with TAB (n ⫽ 12) were shot with (BABT).5 The mechanical BABT effect may be quantified as
a standard 7.62-mm assault rifle. Morphologic injuries, cardiorespiratory, impression in ballistic plasticine. Such an impression is
and electroencephalogram changes as well as physical parameters were commonly used as a criterion for body armor quality. Ac-
registered. cording to US National Institute of Justice (NIJ) standard
Results: The bullet impact caused a reproducible behind armor blunt trauma 0101.04, the armor is considered effective if the impression is
(BABT) in both the groups. The TAB significantly decreased size of the lung ⬍44 mm. This standard has been widely adopted and used far
contusion and prevented hemoptysis. The postimpact apnea, desaturation, outside the range that it was originally validated for, i.e., hand
hypotension, and rise in pulmonary artery pressure were significantly atten- gun bullets.
uated in the TAB group. Moreover, TAB reduced transient peak pressures in Using a porcine model, we have previously shown that
thorax by 91%.
high-energy weapons inflict a severe lung contusion with
Conclusions: Our results indicate that ordinary body armor should be
50% mortality, when the plasticine impression is 40 mm or
complemented by a TAB to prevent thoracic injuries when the threat is
high-velocity weapons.
more.6 We have also demonstrated that BABT behind a
Key Words: Body armor, Behind armor blunt trauma, Trauma attenuating
complete Swedish defense body armor protection, allowing
backing, Lung contusion, High-energy missiles. only a 28-mm impression after a high-energy impact, is
associated with a lung contusion with hemoptysis, impaired
(J Trauma. 2009;67: 1191–1199) cardiorespiratory function, and electroencephalogram (EEG)
changes.7 Therefore, we have concluded that a body armor
that allows a 28-mm impression does not provide sufficient

M ilitary personnel, police officers, and security guards

use body armor to protect them from fatal gunshot
injuries to the thorax. The vests have proved to be an
protection if the threat is a high-energy weapon, although it
would be life saving in many instances.7
It has been suggested that trauma attenuating backings
effective shield against small arms fire and shell fragments (TABs) placed behind the body armor reduce the trauma to
and have probably prevented thousands of casualties.1,2 How- the body.8 These low-density materials could decrease de-
ever, the spread of high-energy weapons has set new de- flection of the body wall and thus lead to improved protection
against high-energy projectiles. Our aim with this study was
to investigate whether a TAB could reduce the pathophysio-
Submitted for publication June 4, 2008.
Accepted for publication March 6, 2009. logical effects observed after high-energy BABT. We com-
Copyright © 2009 by Lippincott Williams & Wilkins pared a group wearing a TAB (consisting of low-density
From the Department of Clinical Science and Education (A.S.), Karolinska foam) and the complete Swedish body armor to a control
Institutet at Södersjukhuset, Stockholm, Sweden; Sections of Surgery (A.S.)
and Prehospital Care (D.G.), Stockholm, Sweden; Department of Defence group wearing the complete Swedish body armor protection
Medicine (A.S., D.R., J.K.P., U.P.A.), Swedish Defence Research Agency solely (noTAB group).
(FOI), Stockholm, Sweden; Department of Molecular Medicine and Surgery
(L.R.), Karolinska Institutet, Stockholm, Sweden; Department of Applied
Mechanics (J.D.), Vehicle Safety Division, Chalmers University of Technol- MATERIALS AND METHODS
ogy, Goteborg, Sweden; and Department of Clinical Neurophysiology
(J.K.P.), Karolinska Institutet at Karolinska University Hospital, Stockholm, Experimental Design
Sweden.
Supported by the Swedish Armed Forces. The study included three different experimental proto-
Address for reprints: Anders Sondén, MD, PhD, Department of Surgery, Söd- cols to study different aspects of BABT. Protocol 1 focused
ersjukhuset, Sjukhusbacken 10, SE 118 89 Stockholm, Sweden; email: anders. on the deformation of the body armor with or without TAB
[email protected].
(noTAB) using ballistic clay. Protocols 2 and 3 included
DOI: 10.1097/TA.0b013e3181a5b0e1 animal experiment. Protocol 2 focused on the pathophysiol-

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009 1191
Sondén et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009

ogy after BABT, whereas Protocol 3 focused on the measure- A standard assault rifle (Swedish Armed Forces Mark
ment of transient intrathoracic and intracerebral pressure AK4) equipped with a laser aiming device (Diode laser type
waves generated by the rapid deformation of the body armor. S 1889; Melles Griot, Täby, Sweden) was used for shooting.
In Protocol 3, the possible prevention of hemoptysis with The weapon was attached to a small gun-carriage 10 m in
TAB was also emphasized. front of the body armor. The ammunition was of Danish
issue, NATO type, 7.62 ⫻ 51 mm (M/94; Ammunitions-
Anesthesia and Surgical Procedure in Animal Arsenalet, Frederikshavn, Denmark). Projectile velocity was
Experiments measured with an optical shutter device (Chronograph Beta
The investigation was approved by an ethics committee model; Shooting Chrony, Inc., Mississauga, Ontario, Can-
and was performed according to the “Guide for the care and ada). Mean bullet impact velocity was 802 m/s (799 – 806
use of laboratory animals” (National Institutes of Health m/s). The depth of the crater in the plasticine was measured
Publication 85-23, Bethesda, MD; revised in 1985). from the surrounding plane surface. Four tests per protection
Swedish landrace pigs, in total 24 animals (females or level were performed.
castrated males), with a mean body mass of 62 kg (45–79 kg)
were used for experiments. Anesthesia was maintained with Protocol 2: BABT Pathophysiology
infusion of ketamine hydrochloride 50 mg/mL (Ketalar, Seventeen pigs were divided into two groups, anesthe-
Parke-Davis, Pontypool, Gwent, Great Britain). The infusion tized and surgically prepared as described earlier. When
rate was 0.5 mL 䡠 kg⫺1 䡠 h⫺1. preparation was completed, the animals were allowed to rest
Tracheotomy was performed, and the animal was me- and the ventilator was switched to spontaneous breathing 30
chanically ventilated during preparation in a volume-con- minutes before the shot. The body armor without (n ⫽ 10) or
trolled mode with room air (Siemens Servo Ventilator 900C; with TAB (n ⫽ 7) was firmly attached to the right side of
Siemens-Elema, Solna, Sweden), at a rate of 20 breaths per thorax with two 3-cm broad girdles. The firing of the gun was
minute. Tidal volume was adjusted to achieve normoventila- manually synchronized to the endpoint of the inspiratory
tion. Through a cervical incision, a polyethylene catheter was phase and aimed toward midclavicular line, rib 7 to 8.
inserted in the left carotid artery to measure mean arterial Conditions were kept identical to the ones of the plasticine
blood pressure (MAP). impact tests (above) and agreed in general with those pro-
An optical pulmonary thermodilution catheter (Opti- posed by the NATO task group BABT (TG-BABT ⫽ TG
cath, Abbot, 7 French Critical care systems, AJ Zwolle, HMF-001) as standard for this kind of experiments.9 The
Netherlands) was inserted into the right external jugular vein experimental setup has been previously described in detail.7
for measurements of mean pulmonary artery pressure Apnea was manually observed and registered with a
(MPAP), cardiac output (CO), mixed venous saturation timer. Breathing movements were registered with a piezo-
(SvO2), and body core temperature. CO, SvO2, and body core electric accelerometer placed on the body surface in the
temperature were monitored with an Oximetrix 3 (Abbott midline over the diaphragm and monitored at one channel of
Critical Care Systems, Abbot Laboratories, Chicago, IL). the EEG-recorder. Hemoptysis was recorded as bleeding
Electrical activity from the brain cortex was registered visible in the tracheal tube. Respiratory rate, tidal volume,
by bipolar EEG. Registration of the EEG-signal was per- and minute volume were registered from the ventilator. Elec-
formed with four electrodes screwed into the outer part of the trocardiogram, heart rate, MAP, central venous pressure, and
skull bone in the midline over the frontal and parietal lobes MPAP were measured and monitored on a Biopac MP 150
and bilaterally over the temporal lobes. Measurements were (BIOPAC Systems Inc, Santa Barbara, CA).
registered with a mobile eight-channel EEG recorder (Model Blood samples were obtained from the arterial line for
No. EEG-7209; Nihon Kohden Corporation, Tokyo, Japan). analysis of blood saturation (SaO2), PO2, PCO2, Na⫹, K⫹,
Two ground electrodes were placed subcutaneously in the Ca2⫹, pH, base excess (BE) (GEM Premier 3000; Instrumen-
neck. tation Laboratories, Lexington, MA), lactate (Miniphotom-
eter, 8; DR Lange GmbH, Berlin, Germany), whole blood
Protocol 1: Measurement of Back Face hemoglobin (Hemoglobin Photometer Electrolux; Mecha-
Deformation tronics AB, Helsingborg, Sweden), and blood glucose (B-
Before animal experiments, the deformation of the Glucose analyzer; Hemocue AB, Ängelholm, Sweden).
body armor, without or with trauma attenuating backing All circulatory, respiratory parameters, and laboratory
(TAB), was measured as impression in ballistic plasticine samples listed above were recorded at baseline, 1, 5, 10, and
according to the US NIJ Standard 0101.04. The body armor 15 minutes after impact, and thereafter for every 15 minutes
was a specially manufactured vest segment, corresponding to until the end of the experiment at 120 minutes.
the Swedish Armed Forces standard issue, Mark M/94 (Åkers The EEG recording started 5 minutes before the firing
Krutbruk Protection AB, Åkers Styckebruk, Sweden), size of the weapon to get a baseline-pattern and was continued
255 ⫻ 300 mm, consisting of a ceramic plate, 14 underlying until 15 minutes after the impact followed by 2-minute
layers of aramid fabric, and a total of three layers of hard recordings for every 15 minutes, throughout the experiment.
woven cotton. Its total weight was ⬃3,700 g and thickness The EEG pattern was graded into one of five levels according
was 25 mm. The TAB-material consisted of 12-mm plastic to the estimated change in frequency and amplitude over
closed cells foam TAB with a weight of 35 g (Åkers Krutbruk time: (1) Slight to moderate reduction in frequencies, i.e., a
Protection AB, Åkers Styckebruk, Sweden). reduction of the fast frequency band (slowing in frequency

1192 © 2009 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009 TAB Improves Protection in Behind Armor Blunt Trauma

range). (2) Pronounced reduction in frequencies, i.e., a dom- RESULTS

inance of the slow frequency band (marked slowing in fre-
quency range). (3) Overall reduction in amplitudes of 50% or Body Armor Deformation
more (depression pattern). (4) Short bursts of slow activity The back face deformation of the body armor was
with an otherwise global suppression of all cortical activity studied before animal studies using ballistic plasticine placed
(burst-suppression pattern). (5) A totally suppressed EEG behind the body armor. In subsequent experiments, the ex-
pattern (isoelectric pattern). The preexposure baseline pattern posed pigs were protected by equivalent body armor. The
was graded as zero (0). bullets, made up of a lead core with full metal jacket, were
At 120 minutes, animals were euthanized with 70 mL defeated in the ceramic plate. The brass jacket was frag-
pentobarbital (60 mg/mL), i.v. A postmortal examination mented together with part of the ceramic material. All shots
was performed. Animals were examined for gross pathol- induced an impression that was shaped similar to a sphere.
ogy and rib fractures, and the area of the lung contusion Mean impression without TAB was 28 mm (range, 24 –31
was measured. mm) and with TAB 19 mm (range, 17–21 mm).

Protocol 3: Measurement of Pressure Waves Pathophysiology

in BABT One of the animals with noTAB did not resume breath-
Seven pigs were divided into two groups (noTAB, n ⫽ ing after impact and was declared dead 9 minutes after the
2; TAB, n ⫽ 5). In addition to the preparation described in shot. All the other animals in the two groups survived the
“Anesthesia and surgical procedure,” above, transducers for whole observation period of 120-minute postinsult.
registration of transient pressure were inserted. Thus, a pres-
sure transducer, consisting of a silicon sensor chip attached to Morphologic Injuries
the tip of am optical fiber (Samba Sensors AB, Västra Beneath the body armor point of impact, circular skin
Frölunda, Sweden), was introduced to the level of the right lesions with subcutaneous hematomas were evident in both the
atrium through the right external jugular vein and connected noTAB and the TAB group. Although the skin was intact in all
to a SAMBA 3000 Monitor. The insertion was carried out so animals, some specimens displayed a cylinder-shaped laceration
that the sensor chip was protected by a PTFE tube during the under the skin. These skin changes were considerably less
introduction of the sensor and measurements. Similarly, a pronounced in animals protected by the TAB (Fig. 1).
Sentron (Model OEM-625; Sentron Europe BV, Roden, As shown in Table 1, rib fractures were seen in both the
Netherlands) was inserted in the left external jugular vein to groups but were significantly less frequent in TAB animals.
the same recording site and connected to a Dewetron strain In the lung lobe, beneath the impact area, discrete contu-
gauge amplifier (DAQP-Bridge-B; Dewetron Ges.m.b.H., sions were observed in both the groups (Fig. 2). The surface area
Graz, Austria). Through a 3 cm craniotomy, another pair of of the hematomas was significantly smaller in the TAB group
transducers was introduced 10 mm into the cerebral cortex 5 (Table 1). Moreover, none of the animals in the TAB group
mm lateral of fissura longitudinalis cerebri. The analog mea- exhibited hemoptysis. In contrast, all animals with noTAB
surement signals were sampled by means of an oscilloscope exhibited hemoptysis, when suction of the bronchial tree was
(TDS3032; Tektronix Inc., Richardson, TX) or by means of a performed (Table 1).
data acquisition system connected to a laptop (DAQ-card
6062E; National Instruments, Austin, TX). Respiratory Effects
Animals were subjected to BABT using the same ex- The bullet impact caused an immediate apnea in ani-
perimental setting as in experimental Protocols 1 and 2. Peak mals with noTAB. Median apnea period was 28 seconds
pressures and pulse duration in the thorax and the central (range, 10 –50 seconds). One animal with noTAB did not
nervous system (CNS), generated by the bullet impact, were resume breathing and was declared dead 9 minutes after the
recorded. Apnea was registered with a timer. No EEG re- shot. In the TAB group, only one animal had an apnea period.
cordings were performed. In contrast to experimental Proto- Median apnea period in the TAB group was 0 seconds (range,
col 1, suction of the bronchial tree was performed to detect 0 –10 seconds), and the difference between the groups was
hemoptysis not visible in the bronchial tube. At 30 minutes, highly significant (Table 1).
animals were euthanized and examined as previously de- As a consequence of the apnea (in animals with no-
scribed. Animals were examined for gross pathology and rib TAB), respiratory minute volumes (MV) were difficult to
fractures, and the area of the lung contusion was measured. estimate during the first-minute postinsult. Mean minute
volumes values at 5 minutes and 10 minutes were below
Statistical Analysis baseline values but differences did not reach significance (not
The experimental design was two groups followed over shown). In the TAB group, MV had a tendency to increase
time. Measurements were performed at 12 predefined time the first 15-minute postinsult, but there were no significant
points. Because of differences in variance between time differences. No significant differences in MV between the
points, a linear mixed-effects model was used to explore groups were seen.
statistical differences between and within groups, using the The arterial saturation (SaO2) in animals with noTAB
statistical package SPSS. In figures, means are depicted decreased 22% (significant) by the trauma, which resulted in
inside 95% confidence intervals, and p values of 0.05 or less a mean SaO2 of 73% (SD, 16.8%) 1-minute postinsult (Fig.
were considered significant. 3). This dramatic decline was followed by a gradual recovery

© 2009 Lippincott Williams & Wilkins 1193

Sondén et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009

In response to the trauma, the MPAP, in animals with

noTAB, significantly increased 41%, from 22 mm Hg (SD, 6
mm Hg) to a peak level of 32 mm Hg (SD, 6 mm Hg) at 1
minute (Fig. 6). In animals with TAB, no significant rise in
MPAP could be demonstrated. MPAP levels in the noTAB
group gradually decreased toward baseline values, but signif-
icant differences between the groups were seen throughout
the experiment, as indicated in Figure 6.

Laboratory Parameters
No decrease in blood hemoglobin count, indicating
major bleeding, was seen. As a response to the trauma, a
significant increase in hemoglobin was seen in animals with-
out TAB with a peak at 10 minutes to 15 minutes (data not
shown). No statistical difference was seen between the
groups. No overall differences in K⫹, Na⫹, iCa⫹, and blood
glucose were seen within or between groups.

Markers of Acidosis
In animals without TAB, base excess (BE) significantly
decreased during the first 5 minutes after the trauma, from
baseline levels of 10.0 mmol (SD, 2.7 mmol) to 7.1 mmol
(SD, 2.8 mmol). Mean BE in this group remained at this level
during the following experimental course (Fig. 7). In animals
with TAB, BE was not affected by bullet impact. An overall
significant difference was shown between the groups.

EEG
There were no differences in the baseline EEG pattern
between animals without or with TAB or between the indi-
vidual animals in groups. All the exposed animals showed
changes in the EEG pattern within 30 seconds after the shot.
Figure 1. Skin lesions after impact without (A) or with TAB (B).
TAB protected animals showed less suppression of EEG and
earlier recovery compared with animals without TAB (Fig. 8)

during the experimental course, but mean SaO2 never reached Peak Pressures in the Thorax and CNS
baseline values. Animals protected by TAB did not display The TAB dramatically reduced the transient positive
any significant desaturation (Fig. 3). A significant difference mean peak pressures in the thorax by 91%, from 148 kPa
between the TAB and noTAB group was seen between 1 (SD, 89 kPa; n ⫽ 3) to 13 kPa (SD, 9 kPa; n ⫽ 5). Similarly,
minute and 30 minutes, as indicated in Figure 3. the peak pressures in CNS decreased from 92 kPa (SD, 24
SvO2 in animals with noTAB rapidly fell from baseline kPa, n ⫽ 4) to 0 kPa (SD 0 kPa, n ⫽ 4). Pulse duration of
values of 72% (SD, 6.7%) to a SvO2 of 55% (SD, 18%) the transient positive pressure increased considerably in
15-minute postinsult, which was statistically significant (Fig. both the thorax and CNS (Table 2). When possible to
4). The corresponding values for TAB animals were 76% compare, the SAMBA and Sentron sensors systems pro-
(SD, 5%) and 73% (SD, 5%), respectively, i.e., no statistical duced similar results (Table 2).
decline was seen. The difference in SvO2 drop between the
groups was significant. A significant overall difference in DISCUSSION
SvO2 between the TAB and noTAB group was seen between Body armor has been proven to be an effective shield
1 minute and 15 minutes (Fig. 4). against conventional weapons and fragments. However, the
level of protection needs a continuous adaptation to meet
Circulatory Effects demands of newer projectiles and weapons. Soft vests are
At bullet impact, in animals with noTAB rapidly fell often improved by adding extra armor plates made of ceram-
38%, from 115 mm Hg (SD, 11 mm Hg) to 71 mm Hg (SD, ics (e.g., aluminum oxide), titanium, or fiber packs creating
21 mm Hg) (Fig. 5). At 5-minute postimpact, the animals had body armors similar to the complete Swedish defense body
recovered their with a tendency to super shoot the initial armor, used in this study. Allowing only 28-mm impression
values. The corresponding blood pressure drop for the TAB in ballistic plasticine, as shown in this study, the complete
group was 15%, from 129 mm Hg (SD, 24 mm Hg) to 110 Swedish body armor clearly fulfils the demands of standard
mm Hg (SD, 20 mm Hg). Difference in blood pressure drop (NIJ) 0101.04 Level III⫹. This standard, initially not in-
between the groups was significant. tended to be used for high-energy weapons, however, does

1194 © 2009 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009 TAB Improves Protection in Behind Armor Blunt Trauma

TABLE 1. Injury Parameters From the Pig Experiments

Experimental Duration of Apnea (s), Size of Lung Injury
Protection N Length (min) Median Hemoptysis Rib Fractures (cm2), Mean
Without TAB 10 120 30 (13–50), 1ND ND 4/10 56 (SD, 22)
TAB 7 120 10 (0–10) ND 1/7 ND
Without TAB 2 30 10, 1 ND 2/2 0/1, 1ND 51 (SD, 15)
TAB 5 30 0 (0–0) 0/5 0/5 19 (SD, 9)
Two separate experimental protocols with different experimental lengths were used to study different aspects of TAB. The length of the apnea was shorter in animals protected
by TAB, hemoptysis was not seen, rib fractures were less frequent (p ⬍ 0.01), and the size of the lung contusion smaller.
ND ⫽ not determined.

Mean arterial saturation ( SaO ) TAB

2 noTAB
100

90

SaO (%) 80
2

70

60

50
Figure 2. The pulmonary contusion (arrows) generated by -20 0 20 40 60 80 100 120 140
the BABT without (A) or with TAB (B). Pictures show the
Time (minutes)
right inferior lobe. The contusion surface area was signifi-
cantly smaller when TAB was used (p ⬍ 0.05; n ⫽ 17). Figure 3. The mean arterial saturation (SaO2) recorded at
baseline and 1 minute to 120 minutes after impact. Means
with 95% confidence intervals from animals without
not take into account effects of pressure waves transferred to (squares) and with TAB (circles) are shown. Significant differ-
the individual but merely focus on the deformation of the ences in SaO2 between TAB and noTAB group were seen be-
armor. Studies by our group and others have indicated that tween 1 minute and 30 minutes (p ⬍ 0.05; n ⫽ 17).
other criteria’s than body armor deformation need to be
considered when predicting BABT caused by high-energy This conclusion is supported by a previous study on BABT
weapons.7,10,11 Our study further supports this issue. where animals were connected to a ventilator and thus pro-
Common features of high-energy thoracic BABT are tected from the initial respiratory arrest.7 These animals
transient apnea, lung contusion with hemoptysis, and a sud- exhibited a slightly delayed (compared with this study) de-
den in drop blood pressure. In a previous study, we have crease in SaO2 equivalent to the noTAB animals after 5
shown that the sudden desaturation is mainly due to the apnea minutes. We believe that the rise in MPAP, in animals
caused by the impact.12 This apnea was shown to be depen- without TAB, was an effect of the pulmonary contusion
dent on vagus transmission, because it was abrogated when causing congestion in lung circulation. The partial recovery
the vagus nerve was transected. We concluded that the apnea, after about 45 minutes may be explained by redistribution of
most probably, was initiated by a reflex generated by rapid blood flow in the lungs. At this time point, the lung ventila-
distension of the lung parenchyma by the incoming pressure tion and circulation were probably better matched, which led
wave. In this study, only one of the animals protected by TAB to a recovered SaO2. We thus believe the beneficial effects on
had an apnea period. It was thus expected that these animals MPAP and SaO2 in animals protected with TAB was due to
would not exhibit the initial desaturation, seen in the noTAB the significantly decreased pulmonary contusion size in this
group. Probably, TAB decreases/slows down the distension group. The significant decrease in SvO2 was probably an
of the lung parenchyma ensuing that the reflex is not initiated. effect of the lowered SaO2 because we did not expect any
The differences in saturation levels between the groups effect on the oxygen extraction ratio.
(Fig. 3), from 5 minutes and ahead, are more likely to be The sudden drop in MAP immediately after impact may
dependent on the pulmonary contusion per se than the apnea. partially be explained by reduced preload (caused by the rise

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Sondén et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009

TAB TAB
Venous saturation ( SvO ) noTAB noTAB
2 Mean pulmonary arterial pressure (MPAP)
100 50

45
90

40

80
35

MPAP (mmHg)
SvO2 (%)

70 30

25
60
20

50
15

40 10
-20 0 20 40 60 80 100 120 140 -20 0 20 40 60 80 100 120
Time (minutes) Time (minutes)

Figure 4. The systemic venous saturation (SvO2) recorded at Figure 6. The MPAP recorded at baseline and 1 minute to
baseline and 1 minute to 120 minutes after impact. Means 120 minutes after impact. Means with 95% confidence in-
with 95% confidence intervals from animals without tervals from animals without (squares) and with TAB (circles)
(squares) and with TAB (circles) are shown. Significant differ- are shown. Although the major differences between the
ence in SvO2 between the TAB and noTAB group were seen groups were seen at 1 minute to 15 minutes, the two
between 1 minute and 15 minutes (p ⬍ 0.05; n ⫽ 17). groups differed significantly up to 120 minutes (p ⬍ 0.05;
n ⫽ 17).

TAB
noTAB
Mean arterial pressure (MAP) TAB
Base excess (BE) noTAB

160 20

140
16

120
MAP (mmHg)

BE (mmol)

12
100

80
8

60

4
40
-5 0 5 10 15 20 25 30 35
Time (minutes -20 0 20 40 60 80 100 120
Figure 5. The MAP was recorded at baseline and 1 minute Time (minutes)
to 120 minutes after impact. Graph illustrates the first 35 Figure 7. The base excess (BE) measured at baseline and 1
minutes. Means with 95% confidence intervals from animals minute to 120 minutes after impact. A significant decrease
without (squares) and with TAB (circles) are shown. A signifi- in BE was seen after impact in the noTAB group. This differ-
cant difference in MAP between the TAB and noTAB group ence maintained up to 120 minutes (p ⬍ 0.05; n ⫽ 17).
was seen 1-minute postimpact (p ⬍ 0.05; n ⫽ 17).

in MPAP) in animals without TAB. However, MAP returned cardiovascular system, similar to what have been described in
to baseline levels within 5 minutes, i.e., long before MPAP blast trauma,13 should to be considered as a complementary
levels declined. A direct effect of the pressure wave on the explanation. This might explain why TAB animals exhibited

1196 © 2009 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009 TAB Improves Protection in Behind Armor Blunt Trauma

EEG effect may contribute to the pathophysiology explaining why

2
high energy impacts impose such a threat.
Using a numerical model of the BABT, Ouellet et al.8
have shown that low-density TABs, such as the one used in
our study, allow the imposed energy to be transferred grad-
EEG levels

noTAB ually to the thorax during the foam compression. He pre-

1
TAB dicted that TAB slow down the displacement of the thorax
wall thus reducing the viscous effect but also the transferred
peak pressures. Our study shows that the low-density TAB
reduces the intrusion into the thoracic wall caused by the
0
deformation of the ceramic plate. More important though, we
-20 0 20 40 60 80 100 120 demonstrate that TAB reduces peak pressures in the thorax by
Time (minutes)
95%. TAB pressure profiles (not shown) were also modu-
lated; they had longer rise time and longer pulse duration
Figure 8. EEG levels (median) in the TAB and noTAB groups (over 50 times longer than without TAB). It is widely ac-
measured at baseline and 1 minute to 120 minutes after cepted that pressure waves with a longer rise time is less
impact.
harmful, which is in agreement with our results.17,18 The
increased pulse duration, however, could theoretically worsen
a significant blood pressure drop although only a minor effect the injury since it would increase the inflicted impulse.19
on MPAP was recorded in this group. This, however, presuppose high pressure levels, which was
In contrast to blunt thoracic trauma in general, high- not the case when animals were protected with TAB.16
energy thoracic BABT and blast lung injury are frequently An important effect of the reduced energy transfer is the
associated with hemoptysis.14This is assumed to be due to the prevention of hemoptysis. Possible obstruction of the airways
rapid movement of the thoracic wall and high peak pressures, with blood may be the most potentially life-threatening feature
which causes a different pathophysiology, compared with in thoracic BABT, especially since the individual may al-
low-energy hits.14 The energy transfer to the body of the ready be hypoxic from an apnea period. The reduction of the
individual wearing the protective vest is known to be linked pulmonary contusion size is of course also of clinical value
to the degree of injury sustained.5,10 Viano et al.15 noted that but even the largest contusion in animals without TAB in our
a small, but fast, compression of the thoracic wall, in some study, we would not expect to be a severe clinical problem.
cases, induced a fatal damage to the internal organs. This has This is supported by the small differences in recorded car-
been referred to as the “viscous” or “inertial” effect and can diorespiratory parameters after 30 minutes. Conclusions
be explained by the fact that human tissue is damaged when about possible late effects of the trauma, such as the inflam-
deformed at high velocity. For example, low-density alveolar matory response, cannot be drawn from this study. Future
structure may be stripped from the underlying tissue as they work will evaluate this.
accelerate at different speed.9 A complementary pathophysi- As described in the section “Materials and Methods,”
ology in high-energy BABT is the shearing effect caused by the detection of hemoptysis was emphasized in experimental
stress waves at gas/tissue interfaces.9,16 The shearing effect, Protocol 3 by suction of the bronchial tree. This was done
which is dependent on high peak pressures, may rupture the since two animals in the initial experiments showed over
alveolar/bronchiolar capillary lining, resulting in a pulmonary bleeding in the tracheal tube. Therefore, we suspected that
contusion and hemoptysis. Effects of the two mechanisms are more animals suffered from hemoptysis, although not visible.
difficult to discern. In fact, both the viscous and the shearing The limited number of animals in the group without TAB in

TABLE 2. Peak Pressures and Pulse Durations Registered Without or With TAB
Thorax CNS
Peak Pressure Pulse Duration Peak Pressure Pulse Duration
N (kPa) (mean) (ms) (mean) N (kPa) (mean) (ms) (mean)
SAMBA transducer
Without TAB 3 148 (SD, 89) 0.17 (SD, 0.02) 4 92 (SD, 24) 0.30 (SD, 0.21)
TAB 5 13 (SD, 9) 5.62 (SD, 1.38) 4 0 (SD, 0) NA
Sentron transducer
Without TAB — NA NA — NA NA
TAB 5 9 (SD, 2) 6.20 (SD, 1.48) 5 1 (SD, 2) NA
Transient peak pressures and pulse durations after BABT, with TAB or without TAB, were registered in the thorax and CNS. To strengthen the physical data, two different
pressure transducers were used. TAB dramatically reduced the mean peak pressures in the thorax and CNS. Pulse duration of the transient positive pressure increased considerably
in both the thorax and CNS. When possible to compare, the SAMBA and Sentron sensors systems produced similar results.
NA ⫽ not available.

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Sondén et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009

experimental Protocol 3 might be considered a weakness. We not display hemoptysis and had a significantly smaller pul-
have, however, to this date exposed 23 consecutive animals to monary contusion than animals in the control group. The
the same BABT without TAB in another study and demon- respiratory and circulatory changes in animals protected by
strated hemoptysis in 100% of the animals, indicating the TAB were not life threatening in any case. Therefore, we
accuracy of the results. conclude that low-density TAB could be applied to minimize
Discussing the beneficial effect of TAB, it should be the trauma by high energy impacts. However, the transient
mentioned that our experimental setting gives a maximal effects on the brain were still significant with TAB protection
exposure of the lung and a lesser exposure of the heart. Strikes and further investigations should be undertaken to try to find
against the midsternum have been shown to cause sternal frac- the peak pressure level, which does not cause any patophysi-
tures, cardiac contusion, and arrhythmias such as ventricular ological effects after BABT.
fibrillation.20 Most probably TAB would reduce these effects but
no direct conclusions can be drawn from this study. ACKNOWLEDGMENTS
In human, pressure wave effects, directly or indirectly We thank Jakob Bergström for his help with statistical
transmitted to the CNS, have been proposed to cause the analysis.
acute behavioral disturbances and mental blockings described
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The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 6, December 2009 TAB Improves Protection in Behind Armor Blunt Trauma

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