Systematic survey in ATLS
\r\n\tKnowledge Management Systems. Therefore, the support for knowledge management lies in how each meaning of knowledge is embedded in information models as defined in ontologies. Shareable ontologies would also allow different information systems to interoperate and cooperate with each other to accomplish goals. Thus, developing ontologies that cover domain and application characteristics can be used to not only support system integration by using standardized vocabularies but also system development by reusing these ontologies. By using the same “language”, the common problems that occur during applications interoperability will be prevented and solved.
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He was a visiting fellow in Centre for lifelong learning, Universiti Brunei Darussalam, Brunei Darussalam, in July 2016 till March 2017. He received the B.S. in Informatics Engineering from UPN “Veteran” Yogyakarta, Indonesia in 2005, M.Eng. in Electrical Engineering from Gadjah Mada University, Indonesia in 2009, and Ph.D. in Computer Science from Universiti Brunei Darussalam, Brunei Darussalam in 2015.",institutionString:"Universiti Tenaga Nasional",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:{id:"216902",title:"Dr.",name:"Marini",middleName:null,surname:"Othman",slug:"marini-othman",fullName:"Marini Othman",profilePictureURL:"https://mts.intechopen.com/storage/users/216902/images/system/216902.jpg",biography:"Professor Marini Othman is the director of the Institute of Informatics and Computing\nEnergy, Universiti Tenaga Nasional, Malaysia. She received her B.Sc. in Computer\nScience from Indiana State University, USA in 1986, M.Sc. in Computer Science\nfrom Western Kentucky University, USA in 1987, and her Ph.D. in Industrial\nComputing from Universiti Kebangsaan Malaysia, Malaysia in 2010.",institutionString:"Universiti Tenaga Nasional",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"9",title:"Computer and Information Science",slug:"computer-and-information-science"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"286446",firstName:"Sara",lastName:"Bacvarova",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"sara.b@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Trauma is the second largest cause of hospital admission with 16% of global burden of all health cost. As per the estimate of the World Health Organization, by 2020, trauma will be the first or second leading cause of years of productive life lost for the entire world population [1].
The liver remains the most frequently and seriously injured abdominal organ due to trauma. About 31% patients of polytrauma have abdominal injuries. Almost 13% and 16% of cases have spleen and liver injuries, respectively, and pelvic injuries are seen in about 28% of cases. In close location of many organs, it is difficult to make differential diagnosis between pelvic or intractable abdominal injuries [2, 3].
In abdominal injuries, liver trauma is the leading cause of death. The most common way liver gets injured is in blunt abdominal trauma. By trauma, the identification of serious intra-abdominal injuries is a challenging task; many injuries may not be apparent during the initial assessment and treatment period. Since the liver gets frequently injured with other abdominal organs following abdominal trauma, associated injuries contribute significantly to mortality and morbidity and may cause the liver injury to be masked and diagnosis delayed. The management of hepatic injuries has evolved over the past 30 years. Previously, a diagnostic peritoneal lavage (DPL) was done to find out active bleeding and to diagnose missed intra-abdominal injuries needing surgical intervention. If DPL is positive for blood, it was an indication for exploratory celiotomy. Nowadays, it is recognized that between 50% and 80% of liver injuries stop bleeding spontaneously. In addition, there is better imaging of the injured liver by computed tomography (CT). Both these factors have led progressively to the acceptance of nonoperative management (NOM) and a resultant decrease in mortality rates [4, 5].
Injury to liver ranges from major and serious to minor non serious injuries. It can extend from minor subcapsular hematomas and small capsular lacerations to major deep parenchymal lacerations, major crush injury, and vascular avulsion. Many factors contribute to the vulnerability of liver to injury in trauma. The liver is the biggest solid abdominal organ. It is surrounded by many organs and have attachments with peritoneal ligaments, giving it a relatively fixed position. Liver is anterior in the abdominal cavity in right upper quadrant. It is highly vascular in nature and has fragile parenchyma. The support of Glisson’s capsule is easily disrupted making this organ vulnerable to injury. Motor vehicle accident is the most common cause of blunt liver injury.
Not surprisingly, even in the penetrating abdominal trauma, the liver is the second most commonly injured organ [6]. Most common cause of penetrating liver injury are due to knife assaults and gunshot wound. The severity of penetrating injury depends upon the trajectory of the missile or implements. The injuries can range from simple parenchymal injuries or serious and major vascular laceration [7].
During respiration, the liver margin, which can usually be palpated 2 to 3 cm below the right rib margin, rises and falls with the diaphragm. With expiration the dome of the liver rises as high as the level of nipple which is T4. This association with chest wall also makes liver vulnerable during injuries to chest. Furthermore, the penetrating injuries in the lower abdomen can cause serious trauma to liver as the inferior margin of the liver descends to as low as T12 with deep inspiration. [8].
Mechanism of blunt liver trauma and the type of liver injury
The right liver lobe is more often involved, owing to its larger size and proximity to the ribs. Compression against the fixed ribs, spine or posterior abdominal wall generally result in predominant damage to posterior segments (segments 6, 7, and 8) of the liver (>85%). Inversely, a blow to the right hemithorax may propagate through the diaphragm producing contusion of dome of right lobe of liver. Liver’s ligamentous attachments to diaphragm and posterior abdominal wall act as sites of shearing forces during deceleration injury. Liver injury can also occur as a result of transmission of excessively high venous pressure to remote body sites at the time of impact. Weaker connective tissue framework, relatively large size, and incomplete maturation and more flexible ribs account for higher chance of liver injury in children compared to adults. Deceleration injuries producing shearing forces may tear hepatic lobes and often involve the inferior vena cava and hepatic veins. While a steering column injury can damage an entire lobe. In general, liver trauma may result in subcapsular/intrahepatic hematomas, lacerations, contusions, hepatic vascular injury, and bile duct injury [9, 10].
Based on the mechanism and site of blunt liver trauma, the liver injury could be classified into two types, type A and B as described in (Figure 1) [11].
The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is similar. Most commonly, the initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma are based upon protocols from the Advanced Trauma Life Support (ATLS) guidelines, established by the American College of Surgeons Committee on Trauma (Table 1) [12].
\n\t\t\t\tPrimary examination\n\t\t\t | \n\t\t|
\n\t\t\t | Airway | \n\t\t
\n\t\t\t | Breathing | \n\t\t
\n\t\t\t | Tension pneumothorax | \n\t\t
\n\t\t\t | Open pneumothorax | \n\t\t
\n\t\t\t | Flail chest | \n\t\t
\n\t\t\t | Massive hemothorax | \n\t\t
\n\t\t\t | Circulation | \n\t\t
\n\t\t\t | Massive hemothorax | \n\t\t
\n\t\t\t | Cardiac tamponade | \n\t\t
\n\t\t\t\tSecondary examination (thoracic injury that endanger life) | \n\t\t|
\n\t\t\t | Simple pneumothorax | \n\t\t
\n\t\t\t | Pulmonary contusion | \n\t\t
\n\t\t\t | Tracheobronchial lesions | \n\t\t
\n\t\t\t | Closed cardiac injuries | \n\t\t
\n\t\t\t | Traumatic aortic rupture | \n\t\t
\n\t\t\t | Traumatic diaphragm injury | \n\t\t
\n\t\t\t | Lesions crossing the mediastinum | \n\t\t
Systematic survey in ATLS
Accordingly, hemodynamically unstable trauma patients need to be transferred immediately to the operating room for emergency explore laparotomy for better life-saving evaluation and management. If the clinical setting allows, a Focused Assessment with Sonography for Trauma (FAST) exam, DPL, or CT may be performed [13].
Plain films obtained during the trauma evaluation are generally nonspecific but may demonstrate right-sided rib fractures, which increase the suspicion for liver injury [14].
Trauma generally causes irritation of diaphragm and patient complaints of pain in the right upper abdomen, right chest wall, or right shoulder. The suspicion for liver injury increases if patient gives history of trauma to the right upper quadrant, right rib cage, or right flank. Clinically, most apparent findings like abdominal pain, tenderness, and distention are seen in cases of severe abdominal hemorrhage, including hemorrhagic shock.
Even though the most common findings indicative of intra-abdominal injury are abdominal tenderness and other peritoneal signs, these findings are not sensitive or specific for liver injury. Commonly seen physical findings due to liver injury include generalized abdominal tenderness or localized tenderness on right upper quadrant or lower chest wall, presence of abdominal wall contusion or hematoma (e.g., seat belt sign), or chest wall instability due to rib fractures. Sometimes significant liver damage can occur without a wound in close proximity to site of injury. Any penetrating injury to right chest, abdomen, flank, or back increases the seriousness of injury. A negative history and normal physical examination does not reliably exclude liver injury.
Many times, physical examination findings can be unreliable due to many reasons. Such mechanisms of injury often result in other associated injuries and that can divert the physician’s attention from serious life-threatening intra-abdominal pathology. The injury can be underestimated due to nonspecific signs and symptoms, an altered mental state, drug and alcohol intoxication, and interpatient variability in reactions to intra-abdominal injury [1].
In about 80% of patients, other concurrent injuries can be present with blunt liver injury, which can include lower rib fractures, pelvic fracture, spinal cord injury, or combination of injuries. Such concurrent injuries can lead to rupture of vena cava, colon, diaphragm, right lung, duodenum, kidney, and extrahepatic portal structures [15].
Assessment of trauma patient
The physical stress of trauma is common in patients of liver injury, and this can cause disturbed biochemical blood test. Initial rise in white blood cell count and low red blood cell count is a nonspecific finding. The degree of anemia correlated to the volume of blood loss. Such loss can be from liver or other than the liver. Other causes include amount of crystalloids or colloids used during initial resuscitation. In posttraumatic hemorrhage, the duration and course of developing anemia is variable and as already explained related to the frequency, amount, and rapidity of exogenous fluid administration and endogenous fluid shifts. Therefore, it is important to anticipate that significant liver trauma-related bleeding can happen irrespective of the presence or absence of anemia at the time of initial patient presentation.
In the hemodynamically stable patient, diagnosis of liver injury may be suspected based upon history of mechanism of injury, findings on physical examination, or laboratory findings of blood or other body fluids [16].
Imaging, especially using computed tomography (CT) with intravenous contrast of the abdomen, confirms the injury and also helps in defining the grade of injury. The characteristic pattern of pooling of intravenous contrast in or around the liver suggests ongoing bleeding and thus warrants the need for intervention. The imaging with the help of CT scan is also useful in identifying concurrent intra-abdominal and chest injuries [2, 17, 18].
The role of FAST examination comes when patient is hemodynamically unstable. However, in cases of intraparenchymal injuries, a negative FAST examination is not sufficient to exclude liver injury. Signs of liver injury on FAST examination include the presence of a hypoechoic (black) rim of subcapsular fluid, fluid in Morrison’s pouch (hepatorenal space), or intraperitoneal fluid around the liver. The main objective of this investigation is quick bedside assessment for hemoperitoneum and hemopericardium. The primary utility of this investigation is identifying the presence of blood and bleeding and not the identification of or defining the degree of organ injuries [19, 20] (Table 2).
⋅ It detects free fluid in the abdomen or pericardium ⋅ It will not reliably detect less than 100 mL of free blood ⋅ It does not identify injury to hollow viscus ⋅ It cannot reliably exclude injury in penetrating trauma ⋅ It may need repeating or supplementing with other investigations | \n\t\t
Value of The Focused Assessment with Sonography in Trauma (FAST)
Even if diagnostic peritoneal aspiration or lavage (DPL) has largely been replaced by the FAST examination, it may still be useful in selected patients, if the FAST is equivocal. In addition, the ATLS still includes DPL modality, and it remains one of the skills that physicians need to learn for ATLS certification. However, a recent Cochrane review has put a question mark on the reliability of ultrasonography for early diagnostic investigations in patients with suspected blunt abdominal trauma [21].
Detailed systematic abdominal ultrasound examination in the radiology suit and/or magnetic resonance imaging (MRI) is time consuming and not feasible in the setting of hemodynamic instability of trauma in the initial diagnosis of liver injury. Furthermore, it puts the patient in a location remote from trauma management area. However, MRI may be useful in a subset of hemodynamically stable patients who cannot undergo CT scan (e.g., IV contrast allergy), and patients with suspected bile ductal injury. Arteriography is generally reserved for patients who have indications for hepatic embolization to manage intrahepatic arterial hemorrhage [22, 23].
Recently, studies have tried to find out other markers that will help in grading the severity and deciding the conservative management of blunt hepatic injury. Koca et al. [24] found that liver transaminases can predict the hepatic injury with higher accuracy as the grade rises, and it can be superior to FAST in terms of determining the need for laparotomy.
Out of multiple modalities available for evaluating stable patients, CT scan along with hemodynamic stability are best in evaluating which patient requires surgery or in deciding which patient can be safely discharged from emergency. The main drawbacks of CT scan are its cost, low sensitivity in detecting bowel injuries, and hemodynamically unstable patients [1]. In
Table 3 some important summary points regarding investigation of blunt abdominal trauma [25].
⋅ The diagnosis of abdominal injury by clinical examination alone is unreliable ⋅ FAST is the investigation of choice in hemodynamically unstable trauma victim ⋅ CT scan with IV contrast is the investigation of choice in hemodynamically stable trauma victim ⋅ Solid organ injury in hemodynamically stable patients with no associated injuries (requiring urgent surgery) can often be managed without surgery | \n\t\t
Investigation of blunt abdominal trauma: key points
One of the most widely accepted injury grading scale to grade hepatic injuries is the American Association for the Surgery of Trauma (AAST) classification system. A study done using the National Trauma Data Bank (NTDB) in 2008 about the solid organ injuries showed that about 67% of hepatic injuries are Grade I, II, or III [26].
The nonoperative management (NOM) can give rise to higher successful outcome for low-grade injuries (Grades I, II, and III) and less success in cases of high-grade injuries (Grades IV and V). The major benefit of AAST grading system is for predicting the likelihood of success with NOM (see Figure 3).
CT scan images show (A) Grad II Subcapsular, nonexpanding, 10-50% surface area; intraparenchymal nonexpanding <10 cm diameter; (B) Grad III liver injury with >3 cm laceration in the left lobe; (C) CT showing Grade IV liver injury with parenchymal disruption involving more than 25% of the liver.
Patients with Grade VI injuries are universally hemodynamically unstable and surgical intervention is required. The grades of hepatic injury are described in Table 4 [27-29].
\n\t\t\t\tGrade\n\t\t\t | \n\t\t\t\n\t\t\t\tType\n\t\t\t | \n\t\t\t\n\t\t\t\tInjury Description\n\t\t\t | \n\t\t
I | \n\t\t\tHematoma | \n\t\t\tSubcapsular, nonexpanding, <10 cm surface area | \n\t\t
Laceration | \n\t\t\tCapsular tear, nonbleeding, <1 cm parenchymal depth | \n\t\t|
II | \n\t\t\tHematoma | \n\t\t\tSubcapsular, nonexpanding, 10-50% surface area; intraparenchymal nonexpanding <10 cm diameter | \n\t\t
Laceration | \n\t\t\tCapsular tear, active bleeding, 1-3 cm parenchymal depth <10 cm in length | \n\t\t|
III | \n\t\t\tHematoma | \n\t\t\tSubcapsular, >50% surface area or expanding; ruptured subcapsular hematoma with active bleeding; intraparenchymal hematoma >10 cm or expanding | \n\t\t
Laceration | \n\t\t\t>3 cm parenchymal depth | \n\t\t|
IV | \n\t\t\tHematoma | \n\t\t\tRuptured intraparenchymal hematoma with active bleeding | \n\t\t
Laceration | \n\t\t\tParenchymal disruption involving 25-75% of hepatic lobe or one to three Couinaud’s segments within a single lobe | \n\t\t|
V | \n\t\t\tHematoma | \n\t\t\tParenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments within a single lobe | \n\t\t
Laceration | \n\t\t\tJuxtahepatic venous injuries (i.e., retrohepatic vena cava/central major hepatic veins) | \n\t\t|
VI | \n\t\t\tHematoma | \n\t\t\tHepatic avulsion | \n\t\t
Grading of liver injury based on the American Association of Surgery for trauma (AAST; 1994 revision) (data adopted from Moore EE, Cogbill TH, Gregory JJ, Shackford SR, Malangoni MA, Howard CR. Organ injury scaling: spleen and liver. J Trauma 1995;38:323-4)
In high-grade liver injury patients, liver-related complication rates are 11-13%. These can be predicted by the volume of packed red blood cells transfused at 24 hours post-injury and the grade of liver injury [30, 31].
In the last 30 years, the management of liver injury has evolved significantly. The advancement of imaging studies has played an important role in the conservative approach for management. A shift from operative to nonoperative management for most hemodynamically stable patients with hepatic injury has been prompted by the speed and sensitivity of diagnostic imaging, particularly due to CT scanning and by advances in critical care monitoring [32, 33].
The operative versus NOM strategy depends upon presence of other injuries and medical comorbidities, hemodynamic status of the patient, and grade of liver injury (Table 5).
A positive FAST scan and DPL in hemodynamically unstable liver trauma patient promotes emergency abdominal exploration to establish the source of intraperitoneal hemorrhage. If the source is liver itself, an exploratory laparotomy is performed. The bleeding is control may be achieved through a damage-control approach or by using specific techniques for liver hemostasis. The approach depends upon the extent of the liver injury and presence and extent of associated injuries.
Hemodynamically “normal” | \n\t\t\tInvestigation can be completed before treatment is planned. | \n\t\t
Hemodynamically “stable” | \n\t\t\tInvestigation is more limited. It is aimed at establishing whether the patient can be managed nonoperatively, whether angioembolization can be used or whether surgery is required. | \n\t\t
Hemodynamically “unstable” | \n\t\t\tInvestigations need to be suspended as immediate surgical correction of the bleeding is required. | \n\t\t
Classification of patients as per their physiological conditions after abdominal trauma
Hemodynamically stable patients with blunt liver injury who do not have other indications for abdominal exploration can be kept under observation. Patients with right-sided penetrating thoracoabdominal injuries, which can lacerate the liver, can remain hemodynamically stable. Such patients can also be kept under observation provided there are no associated intra-abdominal injuries. Nonoperative management generally fails in patients with higher-grade injuries than those with lower-grade injuries. Still such patients should be treated with NOM as long as they are hemodynamically stable. Other patients who suffer extra-abdominal injuries but requiring intervention can also be kept under observation. Nonoperatively managed patients who continue to bleed, and even with ongoing blood transfusion have hemodynamic instability need surgical exploration. It is also indicated in those patients who manifest a persistent systemic inflammatory response syndrome (SIRS), like presence of ileus, fever, tachycardia, and oliguria. Grade III and higher injuries often requires a combined angiographic and surgical management [34].
Nonoperative management (NOM) is widely accepted as the treatment of choice for hemodynamically stable patients with hepatic injury and with no other associated injuries indicating urgent intervention. Nonoperative management (NOM) consists of repeated assessment, close monitoring, and supportive intensive
2e care management with utilization of indicated arteriography and hepatic embolization. Furthermore, NOM is now recommended for penetrating injury (stab wound) as well as low-velocity gunshot wound to right upper quadrant in stable patients after exclusion of other injuries requiring urgent laparotomy. Most of the injuries that fall in this category are Grade I and II liver injuries [35].
In the positive response of trauma victim to initial fluid resuscitation with stable hemodynamic status, allows for further better imaging by CT scan of abdomen and pelvis. Angiogram and angioembolization are part of the management of all NOM algorithms if contrast extravasation is demonstrated to improve the success rate of NOM. Operative intervention is currently reserved to hemodynamically unstable patients, associated injuries requiring laparotomy, and failure of NOM [36].
The grade of liver injur4y alone and the volume of hemoperitoneum are not considered definitive criteria for selecting operative versus NOM [37].
Large retrospective reviews reported that more than 80% of patients with blunt hepatic injury could be treated by NOM with success rates more than 90% [38-40].
A recent Cochrane review also supported nonoperative management by concluding that currently there is no evidence to support the use of surgery over NOM for patients with abdominal trauma [41].
Some of the contraindications to nonoperative management of liver injury are listed in Table 6.
⋅ Hemodynamic instability after initial resuscitation ⋅ Other indication for abdominal surgery (e.g., peritonitis) ⋅ Gunshot injury (relative contraindication) | \n\t\t
Contraindications to nonoperative management
Patients with isolated penetrating hepatic injuries due to abdominal stab wounds has been managed using nonoperative approach but management of patients with gunshot wounds remains controversial. Up to one third of patients of gunshot wound, who are treated using NOM approach, showed failure due to continuous bleeding and development of abdominal compartment syndrome. One of the most important concerns is missed injuries to the gastrointestinal tract [42].
Patients that are managed by NOM needs to be admitted in hospital, placed on bed rest, and monitored continuously. If patients have a normal abdominal examination and stable hemoglobin for at least 24 hours, they can be discharged from hospitals. Large observational studies support this practice of discharging patients with liver injury regardless of the grade of injury. The clinical judgment of surgeon is important for deciding the length of observation [43]. Intensive care monitoring for at least 48-72 hours of hemodynamics and overall clinical condition is required for the rest of the cases. Other investigations and repeated clinical examinations and follow up investigations are done as indicated [44].
Thromboprophylaxis is indicated in patients with liver injury or other severe injuries who require hospitalization and are at a high risk for thromboembolism. At the same time, delay in the chemical thromboprophylaxis may be needed due to an increased risk of cerebral or bleeding from other sites. Success of pharmacologic prophylaxis is seen in patients in whom there are no other contraindications to pharmacologic prophylaxis and used when the hemoglobin gets stabilized with less than 1 g hemoglobin decrement over a 24-hour period of time [45].
Hepatic embolization can be very useful way for prevention of bleeding. Success rates for embolization depends on many factors. Factors that determine the success includes institution policy, technique of embolization, access to arteries, skill of operator, and type of embolization material used. A properly carried out hepatic embolization has replaced the need for initial operative intervention from many sites. The highest success of hepatic embolization appears to be when used preemptively in patients who demonstrate extravasation of contrast on the initial abdominal CT scan and when patient is hemodynamically stable. The technical success of this technique ranges from 68% to 87%. The incidence of recurrent hemorrhage is found to be low in retrospective reviews. Patients who have no success with observational management can be treated with hepatic embolization. It can also be used adjunctively to manage patients with ongoing bleeding or rebleeding from the liver after surgical treatment for liver injury [22].
One of the main advantages of nonoperative management is that it reduces the risks inherent to surgery and anesthesia procedures. However, one of the main disadvantages associated with NOM includes an increased risk of missed intra-abdominal injury, particularly hollow viscus injury, risks associated with embolization, and transfusion-related illness.
Blood transfusion is a life-saving measure during excessive bleeding and related complications. However, it is also associated with many complications. Commonly seen complications include intravascular volume overload (transfusion associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), immunologic and allergic reactions, as well as immunomodulation (transfusion-related immune modulation, TRIM), hypothermia, and coagulopathy. Hepatic embolization is also associated with additional risks. These includes risk of bleeding, complications at the arterial access site, necrosis of liver, abscess in the liver or subdiaphragmatic space, inadvertent embolization of other organs (e.g., bowel, pancreas) or lower extremities, arterial intimal dissection, contrast-induced allergic reactions, and contrast-induced renal toxicity and nephropathy. When embolization is performed following contrast CT scan, particularly in patients who with volume depletion, the risk of contrast-induced nephropathy is even greater. Repeated clinical monitoring and surgical intervention is a must if conservative treatment fails. Studies have shown statistically significant difference in terms of requirements for blood transfusion and intra-abdominal complications when comparing patients receiving operative and nonoperative treatment of liver injuries. However, it shows no difference in the length of hospital stay [46].
The underlying important requirement for use of conservative or NOM is that this should be under guidance of highly trained surgeons. This is because unexpected and difficult to manage complications can occur during observation, and surgeon should be able to convert this management to difficult surgical strategies [47].
Failure of NOM is defined as the need for urgent surgical intervention and is generally related to hemodynamic instability and bleeding that becomes apparent by the need for ongoing fluid resuscitation or transfusion. Patients who become hemodynamically unstable, by definition, have failed NOM. The option here is almost limited to the life-saving emergency exploration laparotomy. Arterial embolization is less favored after NOM failure, mainly due to the time needed to set up the interventional radiology suite, the complexity of the embolization procedure, and the possible failure that will delay a definitive surgical intervention [48].
Patient with Grade IV liver injury, as shown in Figure 3C, who was hemodynamically unstable and showed extravasation of contrast and was unfit for angioembolization underwent laparotomy and resection of the fragmented right posterior liver segment.
A number of complications should be anticipated in NOM. One of the most common complications is biliary tree disruption with formation of biloma and/or persistent bile leak. Furthermore, hepatic necrosis can be seen following angioembolization for hepatic injury. It may also be seen following other procedures like laparotomy and hepatorrhaphy. Factors that may contribute to or indicate failure of NOM include advanced age of patient, delayed bleeding, sudden and severe hypotension, and active extravasation of contrast not controlled by angioembolization [35, 49, 50].
The operative management of liver injuries that require surgical intervention can be a challenge even for experienced surgeons (Table 7).
⋅ Complex anatomical structure of the liver ⋅ Large size ⋅ High blood supply (vascularity), which is dual in nature ⋅ Rich and difficult-to-access venous drainage | \n\t\t
Operative challenges in the management of liver injury
Operative intervention is most commonly preferred for penetrating abdominal or thoracic injuries with hemodynamically unstable patients. If the injury is a result of a high-velocity gunshot wound and if there is associated hollow viscus injury, it is always the preferred approach [51]. Hemodynamic status rather than grade of injury is more important indication for operative management in patients with blunt abdominal and chest injuries. As a general rule, a higher-grade injury usually has higher potential for failure of nonoperative management. Emergency laparotomy is also indicated in NOM if there is rebleeding, constant decline of hemoglobin, and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels [52].
Various surgical methods that are described include direct suture ligation of the parenchymal bleeding vessel, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative, and/or postoperative angioembolization and perihepatic packing. Less preferred methods include anatomical resection of the liver, vascular ligation and use of the atriocaval shunt [53].
Damage control or damage limitation surgery is the concept originated from naval strategy, whereby a ship which has been damaged can be managed with minimal repairs to prevent it from sinking and definitive repairs can wait until it reaches port. One of the approaches includes perihepatic packing and closure of the abdominal incision using either a Bogata bag or a partial closure of proximal abdominal incision. With the similar approach, a minimum surgery is needed to stabilize the patient’s condition, and in the meantime, the physiological derangement can be corrected. Damage control surgery is done with main objectives, including stopping any active surgical bleeding and controlling any contamination. The timing of reexploration depends upon many factors, including the correction of acidosis, coagulopathy, and hypothermia (i.e. trauma’s lethal triad). The window considered safe during damage control surgery is 12-48 hours for reexploration and formal completion of the surgery [54, 55].
The algorithm for blunt liver trauma management is depicted in Figure 5.
Algorithm For Nonoperative Management of Blunt Hepatic Trauma (adopted from Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 67:1144–1148, 2009).
Mortality rates for hepatic injury vary as per grade of the injury, associated injuries, and general condition of the patient. The outcome has improved over the years, and the major contributing factors are the new approaches in form of nonoperative management strategies, damage control, and use of perihepatic packing. Since mortality is rarely seen with Grade I and II injuries, the reduction seen was difficult to perceive. However, reduction in operative mortality has seen a great decline especially for higher-grade liver injuries (Grades III, IV, and V). The overall mortality rate may vary from 10% to 42% as per the higher grade of injuries [31].
Many studies have evaluated factors determining the mortality of hepatic injury treated by surgical management. Various factors have been found to have strong association with rate of mortality, which includes hemodynamic instability, coexisting musculoskeletal and chest injury, high levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), long activated partial thromboplastin time (APTT), prothrombin time (PT), low fibrinogen levels, and platelet counts on admission. Not surprisingly, mortality is notably decreased when the liver trauma is managed by hepatobiliary surgeon if feasible [57].
Liver injury is a significant cause of morbidity and mortality in trauma patients, and being the largest solid organ within the abdominal cavity, it is easily injured.
Chest X-ray and FAST are useful preliminary investigations in order to determine a correctible major injury. Diagnostic peritoneal lavage (DPL) may be preferred over FAST where the latter is not available.
Further radiological assessment may aid diagnosis, but it is applicable if that is not delaying operative management of a patient in whom FAST is positive and patient is hemodynamically unstable.
If FAST is positive and patient is hemodynamically stable, then CT scan remains the gold standard investigation as it delineates the extent of liver injury, identifies other associated injuries, and directs management.
For hemodynamically stable patients with liver injury, irrespective of grade of liver injury, the nonoperative management is preferred over definitive surgical intervention.
Hepatic embolization may have better outcome for hemodynamically stable patients with liver injury who demonstrate pooling of intravenous contrast on initial or subsequent abdominal CT scan, rather than nonoperative management without embolization.
Hepatic embolization requires specialized imaging facilities and an appropriately trained interventionist experienced with celiac artery catheterization. Failure of hepatic embolization to control bleeding indicates the need for surgery.
Operative management involves initial control of hemorrhage and contamination followed by perihepatic packing and rapid closure, allowing for resuscitation to normal physiology in the intensive care unit and subsequent definitive reexploration.
If the patient is hemodynamically unstable despite attempts to halt bleeding, techniques such as Pringle’s maneuver (clamping of the hepatoduodenal ligament), simple suture and compression, hepatotomy and vascular ligation, or atriocaval shunt may be considered.
If these attempts also fail to achieve hemodynamic stability, transfer to a specialist liver surgery unit is advisable as there is substantial evidence to indicate that mortality is reduced when hepato-pancreato-biliary surgeons manage liver trauma.
A historical perspective provides an understanding of how the current state-of-practice for composite fuselage manufacturing has evolved. It also provides insight into what the future state of composite fuselage manufacturing might look like. Figure 1 shows a familiar graph that shows the increase in composites usage in military and commercial aircraft over time. Initial applications of carbon fiber reinforced composites (CFRP) in both commercial and military aircraft were limited mostly to non-structural applications such as fairings and flight control surfaces. Structural applications for military aircraft began to appear in the 1980s as composite usage grew to more than 20% of the weight of the structure. As the industry continued to mature, material and processes became better understood and cost effectiveness improved to the level that commercial aircraft manufacturers incorporated the technology into the latest generation of wide body and other new aircraft.
\nComposites usage.
Research and development of high performance composite materials and processes for aerospace applications in the Unites States was first conducted in the 1940s at Wright-Patterson Air Force Base in Dayton, Ohio [1]. The focus of this early research was primarily for military applications. This research has continued since that time and today, the Air Force Research Laboratory (AFRL), with support from industry, universities and other government agencies such as the Department of Advanced Research Projects Agency (DARPA) and the Department of Energy (DOE), continues to play a leading role in developing advanced materials for military applications. NASA initiated research devoted to the development of high performance composites for commercial aircraft and space vehicles in the late 1960s. Over the years, NASA has worked collectively with industry and academia to develop affordable technologies to improve safety and performance of aircraft and launch vehicles. The paper NASA Composite Materials Development: Lessons Learned and Future Challenges provides an excellent historical review of NASA’s role in the development of composite materials and processes [2].
\nA common characteristic shared between AFRL and NASA sponsored programs was the “building-block” approach for research and development programs that progressed through a series of steps, each one having an increase in complexity and cost that built upon the previous step. In general, programs started at a coupon level and looked at a wide range of samples to down select design approaches, materials of construction, tooling and manufacturing processes to build and test coupons, subcomponents and ultimately full scale components. Not unlike the Technology Readiness Levels applied to describe new technologies today, this approach was used successfully in programs such as the Air Force’s Large Aircraft Composite Fuselage (LACF) Program in the late 1980s and NASA’s Advanced Composites Technology (ACT) program in the mid 1990s.
\nThe B-2 Stealth Bomber program was also taking place during the 1980s and provided many lessons learned related to the manufacture of large composite primary structure. For the B-2, survivability performance was one of the primary reasons for the extensive use of carbon fiber composites—cost and producibility were not the most critical factors. Boeing was a prime subcontractor on the program and built the wing skins using Automated Tape Laying (ATL). This program presented the opportunity to demonstrate the productivity that was possible using automated lamination processes such as ATL and AFP.
\nAnother program which derived direct benefit from the ACT program is the V-22. Composites have been used extensively and aggressively in helicopters more than any other type of aircraft because weight is such a critical factor. The V-22 uses composites for the wings, fuselage skins, empennage, side body fairings, doors, and nacelles. AFP technology is used to fabricate the aft fuselage skin in one piece. Both Bell and Boeing also incorporate cocured, hat stiffened fuselage structures, using solid silicone mandrels, on their portions of the program.
\nThe LACF program was conducted in part by Northrop and was sponsored by the Air Force Wright Aeronautical Laboratory (AFWAL) during the 1980s. The program was part of an effort focused on manufacturing technology for the Linear Manufacturing of Large Aircraft Composite Primary Structure Fuselage. The multi-phase program was directed toward the definition and demonstration of manufacturing methods for cocuring stringer stiffened fuselage panels using (1) existing, qualified material systems; (2) automated skin fabrication; (3) inner mold line (IML) controlled tooling; (4) non-autoclave curing technology. Like many similar terms, in the 1980s “linear” manufacturing was a code word for “lean” and non-autoclave is referred to today as out-of-autoclave or OOA processes.
\nThe program followed a building-block approach through four phases (Figure 2):
Phase I—methods definition
Phase II—manufacturing methods establishment
Phase III—manufacturing verification
Phase IV—production demonstration
As the program moved through various phases, lessons learned where documented and applied to the next phase. Phase I lessons learned included:
Raw material required (tow bad, tape good) changes to improve panel quality using automated lamination equipment
Non-autoclave cured panel mechanical properties were equivalent to autoclave cured panels
IML tooling is very good at controlling stringer location and dimensions
IML provides very easy tool loading and bagging
Continuous roll forming can be used to preform preplied material into “C” channels ready for tool loading (Figure 3).
LACF program.
“I” beam formed from “C” channels.
Phase II lessons learned included:
Non-autoclave cure has risks associated with consumable bagging materials.
Integrally heated tooling strongly supports linear manufacturing.
Confirmed IML tooling is excellent for controlling stringer/skin dimensions and location.
Confirmed IML tooling and “I” beam stringer for part and tool removal.
Flat preplied laminates can be drape formed on gentle contours using IML cure tools.
Automation can be applied but presents reliability risks and potential equipment downtime.
Automation can produce a laminate that does not require additional debulking.
Roll forming of stringer “C” channels is important for linear manufacturing (Figure 4).
“C” channel roll forming machine.
Among the lessons learned as a result of Phases III and IV were the economics related to process scale up for both size and rate. This included ply cutting and kitting time for panel fabrication and backing paper removal and management issues affecting tow placement and stringer laminate preplying (Figure 5). Another lesson included gaining a better understanding of cocuring longitudinal “I” beams to the skin of a large fuselage panel. One nice feature of the “I” beam construction is that the tooling is not trapped after cure and the channel details that form the “C” of the “I” beam can be removed over any length. Disadvantages were also apparent including the number of laminate preform and tooling details needed to construct an “I” beam vs. the simplicity of the hat stiffener (Figure 6).
\nLaminate cross ply equipment.
“I” beam vs. hat stiffener.
Northrop developed hat stiffened fuselage skin manufacturing technology in support of the YF-23 (Figure 7). One critical problem to solve was the removal of hat stiffener mandrel tooling from the cured part. The fuselage tooling was OML controlled and constructed from CRFP prepreg to match the coefficient of thermal expansion (CTE) of the parts. The resin system used for the tooling was bismaleimide (BMI) and the tools were autoclave cured on male, machined monolithic graphite source tools. The hat stiffeners that run longitudinally along the skin were cocured using a silicone mandrel system developed by Northrop using Rubbercraft as a supplier.
\nYF-23 fuselage structure.
The silicone based solid mandrel system included a solid rubber mandrel, a butterfly caul and a resin end dam. The silicone mandrel was designed to be removed from the cured part after pulling and elongating the mandrel to reduce the cross section enough to release from the part. The butterfly caul was designed to help consistently control the OML of the hat stiffener. It also helped to greatly simplify the bagging process which allows for the use of a broader range of operators instead of relying solely on a highly skilled mechanic. The end dam was designed to be cheap and disposable and replace much of the inner bagging process complexity of sealing off the hat stiffener to prevent resin bleed during the cure cycle (Figure 8). This is not a hard process, but is critical and tedious.
\nSolid mandrel system.
Northrop subsequently applied this hat stiffener fabrication process technology to the fuselage of the F/A-18E/F as a prime subcontractor to Boeing on the program (Figure 9).
\nF/A-18E/F fuselage structure.
During this time period, it was recognized by many of the R&D programs that liquid molding processes presented the opportunity to use resins and fibers in their lowest-cost state by eliminating prepreg from the fabrication process. Other advantages included minimizing material scrap, simplifying raw material storage, and supporting non-autoclave fabrication processes. The development of net shape damage-tolerant textile preforms and the development of innovative liquid molding tooling concepts supported this opportunity. The Advanced Composites Technology (ACT) program included processes such as resin transfer molding (RTM) and pultrusion in the development efforts. The technologies have progressed to state-of-practice processes with both the 787 and the A350 programs using liquid molding and textile preform technology for fabricating fuselage frame elements.
\nThe objective of the ACT fuselage program was to develop composite primary structure for commercial airplanes with 20–25% less cost and 30–50% less weight than equivalent metallic structure [3]. The Advanced Technology Composite Aircraft Structure (ATCAS) program was performed by Boeing as the prime contractor under the umbrella of NASA’s ACT program and focused on fuselage structures. A large team of industry and university partners also supported the program. The primary objective of the ATCAS program was to develop and demonstrate an integrated technology that enables the cost and weight effective use of composite materials in fuselage structures for future aircraft.
\nThe area selected for study was identified as Section 46 on Boeing wide body aircraft (Figure 10). This section contains many of the structural details and manufacturing challenges found throughout the fuselage. This includes variations in design details to address high loads at the forward end and lower portions of the fuselage. The loads decrease toward the aft end and the upper portion of the fuselage, allowing for transitions in the thickness of the structure that are tailored to match the structural loading.
\nACT fuselage section [3].
A quadrant panel approach was selected for study as shown in Figure 11. The cross section is split into four segments, a crown, keel, and left and right side panels. The circumferential, four quadrant panel approach was selected with the idea of reducing assembly costs by reducing the number of longitudinal splices. This built-up assembly approach is baseline to metallic aircraft manufacturing and is similar to the approach Airbus selected for most of the fuselage of the A350.
\nACT quadrant panels [3].
Manufacturing process development and design trade studies contributed to the development of Cost Optimization Software for Transport Aircraft Design Evaluation (COSTADE) which allowed for defining and evaluating the cost-effectiveness and producibility of various designs. Included in the program were assessments of tooling, materials and process controls needed for future full-barrel fabrication like Boeing selected for the 787.
\nThe structural concepts studied included stiffened skin structures achieved by stand alone or combinations of cocuring, cobonding, bonding, and mechanical attachment of stringers and frames to monolithic or sandwich panel skins (Table 1). The crown section study selected fiber placed skins laminated on an IML controlled layup mandrel with the skin subsequently cut into individual panels and transferred to OML cure tools. Hat stiffeners used solid silicone mandrels located longitudinally along the IML of the skin panels for cocuring.
\nDetails | \nProcess | \n
---|---|
Skins | \nAFP (tow, hybrid AS4/S2) CTLM (contoured tape lamination machine, 12″ tape) | \n
Frames | \nBraiding/resin transfer molding (triaxial 2-D braid) Compression molding Stretch forming (thermoplastic, discontinuous fibers) Pultrusion/pull forming | \n
Stringers | \nHat—ATLM/drape forming (cocured, thickness variation) “J”—pultrusion | \n
Panel assembly | \nCocured/cobonded stringers, cobonded frames Cocured/cobonded stringers, fastened frames Sandwich panels, cobonded frames | \n
ACT structural concepts [3].
The recommended optimized panel design included cobonding of cured frame elements while cocuring the hat stiffeners and the skin. The cured frames were demonstrated using braided textile preforms and resin transfer molding (RTM). One of the main challenges of the crown panel concept was the bond integrity between the precured frames cobonded to a skin panel that is stiffened with cocured hat stringers. Alternative concepts the team considered during the review process included mechanically attached Z-section frames instead of cobonded J’s. The mechanically fastened frame approach greatly reduces the complexity of IML tooling needed to cocure the hat stiffeners and cobond the frames. This is especially true at the intersections of the frame and hat. Flexible caul plates and custom fit reusable bags became part of the tooling system needed to accomplish the fully integrated skin/stringer/frame structure. Producibility issues are complicated by the blind nature of the IML of the skin being completely covered by flexible cauls and the reusable bagging system. The structural arrangement shown in Figure 12 is very similar to the configurations that ended up on both the 787 and A350 programs.
\nACT crown panel structural arrangement [3].
The program studied the pultrusion process for producing skin stringers. Continuous resin transfer molding (CRTM) developed by Ciba-Geigy was one of the more promising technologies studied. Improved process control and reduced waste are among the perceived advantages; process maturity, constant cross-section stringers and costs associated with secondary bonding or cobonding are among the disadvantages.
\nAirbus has studied automating stringer fabrication using both pultrusion and RTM but felt limited by aspects of both processes. As an answer, Airbus developed their version of pultrusion RTM. Figure 13 shows equipment completed in 2011 that is being used to develop and qualify the process [4]. This hybrid fabrication approach allows the use of preform laminates instead of being limited to unidirectional reinforcements like traditional pultrusion and supports continuous production instead of batch processing associated with the traditional RTM. Instead of dipping the preform stack through a resin bath, it is pulled into an RTM tool that is open on both ends. To overcome resin being pushed out at both ends of the open tool, Airbus worked with resin suppliers to develop an epoxy resin with a parabolic temperature/viscosity curve. At 120°C resin viscosity is very low with high flow characteristics, but at both room temperature and at 180°C and higher, it is very viscous. The tool entry is cooled so the resin is too viscous to flow out; the middle is heated to obtain resin flow and cure; more heat is added at the end to increase resin viscosity to make sure it does not flow out and reduce cure pressure.
\nAirbus continuous pultrusion equipment [4]. Source: CTC Stade.
Even in the early days of development, industry leaders believed in the possibility of higher layup rates using AFP than was possible with hand layup, but the capabilities and the scale that the industry has achieved today is astounding. Almost as astounding as how the industry reinvented itself from a raw material cost saving technology to an enabling technology for large aircraft structural components.
\nIn the late 1980s and early 1990s Northrop and ATK/Hercules worked on several joint projects sponsored by the Air Force which included fiber placement development and application. The technology was in its infancy as ATK was developing tow placement (as it was more commonly referred to originally) from its roots in filament winding technology. The main prize in the early days was $5 per lb. high modulus carbon fiber and $15 per pound high temperature/high performance resin instead of the $60+ per pound price of prepreg. A wet process of running fiber through a resin bath prior to placement onto the layup mandrel was never able to realize the quality and consistency required by the design. This same process has been used in the large wind blade manufacturing process and it reminds us of how challenging (and messy!) that approach can be. In addition, the wind blade manufacturing industry has learned some valuable lessons from those early days of “build it as cheap as you can” using the lowest cost material you can deal with. While those early blades were built with lower manufacturing costs, the argument can be made that many of those blades failed very early in their lifecycle and required costly repairs or replacement to generate electricity. If the blade cannot turn because it has delaminated, it is not generating any electricity in addition to the cost of repair or replacement.
\nNot only did the technology not realize the cost savings of dry fiber and wet resin, it was forced to adopt prepreg technology into the process—namely dealing with backing paper and ADDING to the cost of unidirectional prepreg tape by requiring it to be slit into prepreg tows. At the time of the ATCAS program, the AFP process was still evolving from what was originally envisioned as a much lower raw material cost build up starting with a dry fiber/wet resin process instead of a costly unidirectional fiber prepreg. The baseline process the ATCAS program selected for fabricating fuselage skins was AFP using prepreg tow. The dry fiber/wet resin tow had evolved to prepreg tow in an attempt to improve process consistency. The process was selected based on several factors including the potential for reduced material cost (compared to prepreg tape), the potential to achieve high lay-up rates over contoured surfaces, and the potential to efficiently support a significant amount of ply tailoring. In addition, the fact that tow material does not require backing paper eliminated a perceived risk of greater machine downtime.
\nWhen compared with the quality and consistency of parts made with prepreg tape, tow preg and subsequent prepreg tow, was not acceptable. The variability seen in the quality of the resultant panels would require compensation in the design of the part, resulting in weight penalties. But this did not prove fatal to the technology, instead tow placement reinvented itself (Figure 14).
\nThere have been many studies of the AFP process that have helped to shape and refine the characteristics and capabilities that exist in today’s equipment offerings. But the ACT program allowed Boeing to better understand, study, define and refine the process to guide the technology development based on the needs of the user community. Everything from tack of the initial plies to the tool surface, to overlaps and gaps in the laminate; the most efficient ways to handle window/door cutouts, laminate thickness transitions, lay-up rates for flat, curved, cylindrical and duct shaped parts, etc., etc. What has ended up on production on the 787 is not the direct result of that ACT program, but the ACT program created the path for subsequent AFP development to follow and improve upon.
\nOne clear thread throughout the development of composite fuselage fabrication processes that was recognized and considered very early on, was tooling. The fabrication of large composite fuselage structures was also enabled by the tooling required to support it. The ability of industry to produce tools using specified materials and built to the size, scale and accuracy required by aerospace and defense applications were critical factors. Large scale machining, laser measuring systems, and innovative thinking supported the transition to today’s composite fuselage manufacturing capability.
\nThe ACT program demonstrated how the producibility of large, integrated, composite fuselage structures depend heavily on the tooling to ensure compatibility of the skin cure tool, the cocured or cobonded stringer tooling and the frame tooling. Controlling these elements is necessary to minimize gaps and interference fit between cured detail components. Understanding the effect of tolerance accumulations, warpage, liquid and hard shim allowances and fastener pull-up forces creates the ability to calculate the impact on fuselage structural arrangement and weight, part manufacturing cost and risk and fuselage assembly and integration time. These elements become even more critical as the size of the fuselage grows to 787 and A350 proportions.
\nOne important note was the need for the stringer tooling to be extractable after cure and flexible enough to be able to accommodate skin thickness variations—especially the “joggles” or transitions up-across-down at each of the frame stations. These requirements drove the team toward silicone or flexible laminate mandrels—reusability was also a key consideration. The mandrels needed to be rigid enough for handling or to be used as drape or vacuum forming mandrels; durable and capable of withstanding a 350°F autoclave cure cycle and still be able to conform to skin ply sculpting and tailoring; and be able to be extracted after cure.
\nWhile the use of silicone mandrels and the flexible IML tooling proved adequate for controlling hat stiffener shape, quality and location for the demonstration panels, it was also recognized that silicone mandrels presented many challenges in both scale-up and production scenarios. Boeing started to develop hat shaped silicone bladders that fed autoclave pressure into the bladder throughout the cure to provide uniform pressure throughout the stringer. After cure, pressure in the bladder is released making it possible to remove the bladder.
\nAt this same time Rubbercraft was working with engineers on the C-17 program to develop and manufacture inflatable silicone bladders for use on the replacement composite tail (Figure 15). In 1991 on aircraft 51, a composite tail was integrated into the program. Rubbercraft produced silicone bladders with FEP film molded to the OML of the bladders that were used in IML tools to cocure hat stiffeners to the skin of the horizontal stabilizers. The tooling, bladders and hat stiffener design allowed for the bladders to be manufactured with substantial excess length that supported multiple cure cycles despite the dimensional shrinkage of the bladder in the longitudinal direction. The reusability over multiple cure cycles is key to the cost effectiveness of the inflatable bladder system. Rubbercraft product improvement was focused on bladder attributes that supported increasing the number of cure cycles the bladder could be used for (Figure 16).
\nAFP process and tooling.
C-17 horizontal stabilizer.
While Boeing was developing flexible IML tooling for cocuring hat stringers and cobonding frames on the ACT program, they evolved away from one-piece overall cauls to separate, individual flexible cauls constructed from graphite/epoxy fabric with a layer of Viton® fluoroelastomer and an outer layer of FEP film. The fluoroelastomer was shown to be more resistant to the epoxy resin and thus more durable than silicones or other rubbers. An added benefit—but perhaps not as well understood at the time—is the added resistance to permeability offered by both the FEP film and the Viton rubber. This helps to minimize the amount of autoclave gas on the inside the bladder from being introduced into the laminate through the permeability of the bladder system. Fluoroelastomer bladder development continues today in support of new programs and applications.
\nA comparison of OML and IML cure tool approaches demonstrates some of the tradeoffs that must be considered. OML tooling is less complex, less expensive, can be initiated as soon as the OML of the aircraft is established and is more forgiving of change than an IML tool. The IML tool requires less labor and risk for locating and maintaining locations of stiffeners and other elements and is much more simple to bag (Figures 17–20).
\nInflatable bladder.
OML sector panel tool. Source: Premium Aerotec.
IML tool. Source: Boeing.
IML and OML cure tools [3].
The ACT program also looked at separate male winding mandrels for AFP and then transferring the uncured skin to an OML cure tool. The male layup mandrel improved layup rates and proved to be a less expensive approach to meet production rate than two cure tools. This also plays to the argument for a combined IML controlled layup mandrel and cure tool—as Boeing selected for the 787 program.
\nOne concern using IML controlled cure tooling is the ability to adequately control the aerodynamic shell of the fuselage. For the ACT program this meant meeting surface waviness criteria of ±0.025″ over a 2″ length using caul plates. The concern over aerodynamic surface control seems to be greatly diminished when you look at what has evolved on the 787 program. The recognition that every airplane has a slightly different OML based on a number of factors such as exact resin content percentage in the prepreg (within the nominal tolerance range of ±5%), the amount of resin bleed experienced during cure and the amount of cured material removed during the sanding, smoothing and preparation for painting process. The skin of a composite fuselage allows for greater tailoring of the skin thickness than is usually incorporated into a metal fuselage. At the base, the fuselage is skin is thicker because it carries more load related to passengers, cargo and landing gear. The structural loads at the top of the fuselage are limited primarily to overhead bins, air ducting, and electrical wiring and this allows for lower weight, thinner skins that predominantly function as aerodynamic surfaces. Regardless of where in space it exists, and even though it varies from aircraft-to-aircraft, the surface is sanded smooth enough to satisfy the surface waviness allowance and negligible difference between aircraft.
\nThe ATCAS team envisioned scenarios that included full one piece barrel fabrication. Significant cost savings were estimated from the elimination of longitudinal splices and the need to compensate for tolerance accumulation in assembly. Material out-time, segmented full barrel cure tooling and barrel warpage were the primary risks identified with full scale single piece barrel fabrication.
\nThe sector panel construction used on the A350 allows for the use of invar for all the fuselage tooling. This includes the IML controlled sector panels fabricated by Spirit for Section 15. The approach Spirit applied is very similar to the one used on the 787 with the exception of the use of sector panels instead of a one piece barrel breakdown mandrel (Figure 21).
\nOne enabling capability that supports the evolution of the current state-of-practice for composite fuselage manufacturing is large autoclaves. There are many, many, many, many research and historical, ongoing and planned for the future, development efforts focused on OOA (or non-autoclave as it was called in the 1980s) materials and processes with the goal of eliminating that monument, the autoclave. The goal is noble (and not new) and the development efforts are making great progress and will, someday in the future, represent a significant (if not all) portion of the composite structure on commercial passenger aircraft—just not today. We already see components made from liquid molding processes being used in specific applications and families of parts and components on aircraft like the 787 and A350, just not the primary fuselage panels and stringers—yet. The maturity, forgiving nature, and low risk of baseline autoclave cured systems made it an easy decision for programs like the 787 and A350 to progress knowing that it was just time and money required to build autoclaves large enough to meet the needs of the program. No new technology needed, just scale and incorporation of improvements being realized by the autoclave industry, such as control systems and operational efficiencies. Spirit even built their own liquid nitrogen generating plant onsite to service their large autoclaves (Figure 22).
\nIML and OML tooling.
Tooling. Source: Boeing, Coast composites.
Autoclaves. Source: Spirit, DLR.
The use of composites for high performance applications requires the ability to identify and ultimately eliminate structural defects that occur during manufacture, assembly, service, or maintenance. The entire field of nondestructive evaluation (NDE) has continued to develop and evolve in parallel to the growth of composite structure applications. It is both an enabling technology and one that has been driven by the market and the need. NDE of composites is a mature technology and has been used successfully for many years, however, the composite structures of today and tomorrow have grown in both scale and complexity. New and improved nondestructive testing (NDT) methods and technologies are necessary to improve detection capabilities, meet growing inspection needs, and address future nondestructive inspection (NDI) requirements. NDT methods currently used in aerospace applications span a broad range of technologies, from the simple coin tap test to fully automated, computerized systems that can inspect very large parts (Figures 23 and 24).
\nNDI methods [5].
Ultrasonic inspection.
Many of the newer NDI methods are “wide-area” inspection techniques, which enable more uniform and rapid coverage of a test surface which can improve productivity and minimize human error. Technical advances in both computing power and commercially available, multi-axis robots and/or gantry systems, now facilitate a new generation of scanning machines. Many of these systems use multiple end effector tools yielding improvements in inspection quality and productivity.
\nUltrasound is the current NDE method of choice to inspect large fiber reinforced airframe structures. Over the last 2 decades, ultrasound scanning machines using conventional techniques have been employed by all airframe OEMs and their top tier suppliers to perform these inspections. A limitation of ultrasonic inspection can be the requirement to use a couplant between probe and test part. VACRS (variable automatic couplant and recovery system) has helped changed the way very large area ultrasonic inspections are done [6]. The VACRS system uses a lightweight couplant and delivery/recovery system that makes it possible to conduct a C-scan with large ultrasonic arrays without the large water requirements. It works with Boeing’s mobile automated scanner (MAUS®) and other scanning systems on the market.
\nShearography and thermography are relatively fast, non-contact methods that require no coupling or complex scanning equipment. Laser shearography was initially applied to aircraft structure in 1987 by Northrop Grumman on the B-2 bomber. Since that time, laser shearography has emerged as an advanced, high-speed, high-performance inspection method.
\nAn enabler for more widespread use of bonded structure in commercial aircraft applications will be improvements in cost and capability related to quantification of real-time structural bond integrity. Adhesive bonds degrade slowly over time and are highly dependent on surface preparation. On older aircraft, the only gauge for bond integrity is age, environmental exposures and statistics — not the actual condition of bonds. The ability to detect weak adhesive bonds, before they disbond will lead to more integration of parts and reduced fastener count and a reduction in everything that is involved with creating holes in cured composite parts. Military air vehicle platforms are more aggressive in this pursuit and the “pay-for-performance” mindset, the lower production rates and the size, visibility, and objectives of the programs allow for more flexibility in bonded structure implementation. The commercial world is different and just like the widespread implementation of composite material on new aircraft, it will not happen unless there are compelling economic advantages and very low risk.
\nBoeing knew that the transport time required by land or marine shipping methods would not support a supply chain that included major partners located in Japan, Korea and Italy and that air transport would be the primary shipping method [7]. The Dreamlifter started as the Large Cargo Freighter (LCF) program and is a modified 747-400 freighter. The Dreamlifter and follows a historic trail of oversized or outsize aircraft, which includes the Airbus Beluga, that were borne out of the adage “necessity breeds invention”. The Dreamlifter is a dedicated transport used to deliver full 787 fuselage sections, wings, and horizontal tail from suppliers located across the US and the world. There are four Dreamlifters in operation supporting the 787 program.
\nThe innovation that was the Dreamlifter (Figure 25), also required equipment to support the loading and unloading of such large cargo. Hence was born the largest cargo loaders in the world. The first one designated DBL-100 (DBL has been reported as an acronym for “Damn Big Loader”), were designed for use exclusively with the Dreamlifter.
\nBeluga and Dreamlifter [7]. Source: Boeing, Airbus.
Airbus was originally a consortium formed by British, French, German, and Spanish aerospace companies. Historically, each of the Airbus partners makes an entire aircraft section, which would then be transported to a central location for final assembly—even after integration into a single company, the arrangement remained largely the same. When Airbus started in 1970, road vehicles were initially used for the movement of components and sections. As production volume grew quickly, a switch to air transport was required. Beginning in 1972, a fleet of four highly modified “Super Guppies” took over. These were former Boeing Stratocruisers from the 1940s that had been converted with custom fuselages and turbine engines. Airbus’ use of the Super Guppies led to the jest that that every Airbus took its first flight on a Boeing [8].
\nToday this need is handled by the Airbus A300-600ST (Super Transporter) or Beluga (Figure 25). The Beluga is a modified version of the A300-600 airliner adapted to carry aircraft parts and oversized cargo. The official name was originally Super Transporter, but the name Beluga, a whale, gained popularity based on the appearance of the airplane and has been officially adopted. Interestingly, the Beluga cannot carry most fuselage parts of the A380, which are instead transported by ship and road.
\nAirbus has an updated design, The Beluga XL, based on the larger Airbus A330-200. Five aircraft are planned to be built as replacements for the existing aircraft and used primarily for A350 work. The Beluga XL is designed with the capacity to ship two A350 wings simultaneously [9].
\nThe Boeing 787 and the Airbus A350 aircraft share many similarities in size, configuration, manufacturing methods and mission (Figure 26). The primary difference between the composite fuselage structures of the two programs is the exclusive usage of IML controlled cure tooling and full barrel fabrication applied by Boeing and the sector panel approach selected by Airbus with a high percent incorporation of cobonded fuselage skin stiffeners. The true results of these decisions will not be known until more information can be collected about actual fabrication and assembly costs being realized by Boeing and Airbus.
\n787 and A350 fuselage sections.
The ACT/ATCAS program had a tremendous influence on the direction Boeing selected for the 787 program. Lessons learned from all aspect of the program influenced everything from the material systems that were selected to the tooling materials, structural arrangement, and the selection of IML tooled, full barrel fuselage structures. Major considerations that influenced that decision were the concerns about the cost of the assembly of very large stiffened structure and the stresses induced on the structure due to assembly.
\nThe program helped Boeing better understand the assembly loads related to composite panel warpage from cured part spring back and cocured and/or cobonded stiffener or frame mislocation. At minimum, these loads need to be understood and accounted for in the part design. Boeing saw an opportunity to minimize these assembly related penalties to the design by the tooling and structural arrangement approach applied on the 787.
\nBoeing’s selection of the AFP process over a male mandrel that serves as both a layup and cure tool is forgiving enough to accommodate different caul plate approaches on different sections of the fuselage. All the fuselage sections use multiple caul plates that nest together to cover the entire outer mold line of the fuselage. The cauls are floating on the surface of the skin and move with the skin during cure to establish the cured part OML whenever and wherever it is at the time the resin gels and things stop moving. Shared characteristics of the cauls include the ability to be individually and positively located before cure and removed individually after cure. Also the ability to ensure the cauls do not interfere with each other during cure. However, differences do exist in the choice of material (either graphite reinforced composite cauls or aluminum cauls) and in the thickness of the caul. In some cases, the composite caul is very thick and stiff and will behave more rigidly during the cure cycle. In other barrel sections, a thin aluminum caul is employed, which will more closely conform to the surface of the as AFP laminated skin. Both extremes are successfully being used by different fabrication partners.
\nInvar was the material of choice for Sections 43, 44 and 46 and the tail. Invar tooling was not the right choice for Spirit as it designed the layup mandrel/cure tooling for Section 41. An invar tool of that size and weight would have imposed very expensive requirements on the foundation of the AFP machine that winds the skin. The size of the motors and energy required to turn and manipulate the mandrel during the fiber placement process was also determined to be prohibitive. Instead Spirit elected to fabricate graphite reinforced BMI mandrels fabricated on invar cure tools and then machined to final IML dimensions (Figure 27).
\nSpirit 787 Section 41. Photo: Bill Carey.
Composite tooling is also used for Sections 47 and 48. In addition to lower mandrel weight, faster heat up and cool down rates contributed to this decision.
\nAll the partners on the 787 program follow similar manufacturing processes for fabricating cocured, hat stiffened, full fuselage barrel sections. All use AFP over IML controlled male layup mandrels that also serve as cure tools. Each section (except the tail) uses multi-piece breakdown mandrels which are disassembled and removed from inside the fuselage after cure (Figures 28 and 29).
\n787 Section 43. Source: Boeing.
Sections 44 and 46. Source: Boeing.
Alenia manufactures Sections 44 and 46 of the 787. Section 44 is a composite half barrel section that covers the main wing box. The lower portion of this fuselage section is mostly metallic and the structure is designed to handle the primary loads from the wings and landing gear.
\nFabrication of fuselage barrel Sections 47 and 48 were originally contracted to Vought as part of their statement of work (SOW) on the 787 program. Financial pressures driven by initial program delays led to Boeing acquiring the Vought SOW including partnership in subassembly work with Alenia (Figures 30–32).
\n787 Sections 47 and 48. Source: Boeing.
787 Tail. Source: Boeing.
Airbus A350.
The tail is the only barrel section that does not require a breakdown cure mandrel. The natural draft angles allow for cured part removal by simply sliding the cured part off the mandrel.
\nBoeing achieved stretch version of the 787 by extending the fuselage sections on either side of the wing center of gravity. The 20′ stretch for the −9 was achieved by adding 10′ to Sections 43 and 47. The additional 18′ added for the −10 configurations was achieved by adding 10′ to the forward fuselage and 8′ aft end. When new AFP mandrels were added to meet production ramp-up rate needs and to meet the −9 configurations, the tools were designed to support −10 also.
\nWhile the focus of this paper has concentrated on developments in the United States, the composites community in Europe was just as active. There were many R&D programs that were directed at high performance composites design and manufacturing activities [10].
\nThe results of this work along with many lessons learned on historical programs fed into the approach taken on the A350XWB program (XWB stands for eXtra Wide Body). The A350 composite fuselage manufacturing approach is not as uniform as the method selected by Boeing on the 787.
\nThe A350 incorporates one complete barrel section, the tail, produced in Spain that uses an approach similar to the one used by Boeing and its partners on the 787 (Figure 33). The rest of the A350 fuselage follows a more conventional panel assembly approach, but with some unique manufacturing process used along the way. The use of AFP, invar tooling and longitudinally incorporated omega (like the Greek letter Ω) stiffeners, more traditionally called hat stiffeners, are also common between the programs. The panel approach used on the A350 supports long part lengths and this is reflected in Section 15 which is approximately 65′ in length. How the omega stiffeners are incorporated on the fuselage panels is quite different between sections and suppliers.
\nA350 fuselage panel and tail. Source: Airbus.
Spirit is a common key supplier on both programs and the fabrication approaches share some key characteristics. Spirit produces Section 15 of the A350 and applies the sector panel approach that is common throughout the fuselage. Spirit cocures the omegas using an IML controlled layup/cure tool with a stiff composite caul plate to control the aerodynamic OML surface smoothness. Uncured omega stiffeners are laminated, formed and located into troughs machined into the invar tool. Inflatable rubber bladders are located on top of the omega laminates and fill the void between the omega and the AFP skin that is laminated on top of over the assembly. The part is autoclave cured and the rubber bladders removed after cure leaving the cocured, and now hollow, omega on the panel (Figure 34).
\nA350 fuselage side panel. Source: Spirit.
The rest of the A350 fuselage structure uses cobonding to incorporate the omega stiffeners with the fuselage skin (Figure 35). Precured omega stiffeners are located onto green AFP skins with a layer of film adhesive between the elements and then autoclave cured (Figure 36). During the cobonding cycle shaped tube bags are located inside the cured stiffener and are open to autoclave pressure during the cure/cobonding cycle to ensure the already cured stringer does not collapse or become damaged when subjected to autoclave pressure (Figures 36 and 37).
\nA350 fuselage panel. Source: CTC Stade.
A350 precured omega stringers. Source: Deseret News, Jeffrey D. Allred; CW/Photos: Jeff Sloan.
A350 omega stringer cobonding [11].
Like the 787 program, liquid molding processes are used to fabricate fuselage frames which are mechanically attached to the skins. The structural arrangements and assembly methods used by both programs are remarkably similar.
\nOne significant difference (if not THE most significant difference) is the frame integration to the fuselage. The 787 incorporates a “mouse hole” in the frame that nests around the hat stiffener and is attached directly to the IML of the fuselage skin. Boeing can do this because the IML surface of the 787 is a tooled surface with features that have controlled heights and locations. This includes hat stiffeners and skin joggles. Both programs use fuselage frames produced using a closed molding process that tools the surface that mates with the skin. On the 787, this creates a tooled surface-to-tooled surface interface creating a very predictable assembly. Components fit together as well as it can be produced because early in the program, it paid the price of being designed for assembly (Figure 38).
\n787 fuselage.
The A350 fuselage frames are attached only at the crowns of the omega stiffeners using secondary clips. Airbus did not try to attach the frames directly to the skins because the IML of the fuselage skin is not a controlled surface. It is a bagged surface that might use caul plates to create uniform pressure and a smooth surface, but the IML surface “floats” depending on factors such as bagging, resin bleed and initial prepreg resin content. Just as the OML of each 787 fuselage “floats” and is different aircraft-to-aircraft depending on these same factors. Airbus uses a standard carbon fiber reinforced clip, molded from thermoplastic material, to absorb the skin fabrication tolerance in the assembly process (Figure 39).
\nA350 fuselage. Source: Borga Paquito.
There are several recently developed commercial aircraft, such as the Bombardier C Series, Mitsubishi’s MRJ, and Comac’s C919, that all have similar overall airframe architecture as the 787 and the A350. However, none of these aircraft incorporate an all composite fuselage. The advantages for composites on large, wide body aircraft have been validated by the short service history of the 787 and even shorter history of the A350. The debate regarding smaller aircraft achieving the same gains continues for Next Generation Single Aisles.
\nWide body aircraft spend much of their life cruising at 40,000 ft. and the structure is sized for pressure loads and structural needs—this provides adequate thickness for good damage tolerant designs. The fuselage designs for single aisle aircraft could be more efficient based on cabin pressure and structural loading alone. But, to provide for designs that will be tolerant of many more takeoff and landings and in service hazards such as luggage and catering carts, dropped tools and equipment, hail and bird strikes, the fuselage panels must be thicker and heavier, thus sacrificing weight.
\nWings are one area of implementation for composites on the single aisle upgrades and new aircraft of the future. The Boeing 777X has incorporated a composite wing into the design. A composite wing allows for a very high degree of laminate tailoring and can be designed and built for maximum efficiency. This creates an elegant wing that is incredible to watch in-flight, but appears alarmingly thin compared to conventional metal aircraft wings. But composite wings for high rates present challenges. Production rates of 12–14 per month for wide bodies have proven to be achievable. Building composite wings to support production rates as high as 60 aircraft per month for narrow bodies has not. Costs related to rate tooling alone can be daunting.
\nRemarkable advances in OOA technology might help provide a solution. Bombardier chose an OOA process for wings of the C-series and the MRJ is using an OOA system for the vertical tail wing box, a similar process to what United Aircraft (Russia) has announced for their MS-21 wing. Still, there are complex issues to resolve that will affect the timeline for OOA system usage on next generation, commercial, single aisle aircraft wings and fuselages. The industry is risk adverse and OOA systems are in their infancy compared to autoclave systems. The autoclave process has proven to be very forgiving and tolerant of variabilities that exist in raw materials, support materials, supply chain manufacturing processes and through final part fabrication. The effect of manufacturing variability is well understood and incorporated into efficient designs that contain minimal penalties for the unknown or less well understood. The same will not be true of OOA systems until more lessons learned have been earned. Many of these lessons will continue to come from military applications that are more aggressive in implementing new technologies. The benefit for the military is usually not cost; the benefit for the commercial world is always cost.
\nOn a little longer timeline affecting future composite fuselage construction is sensor and technologies related to structural health monitoring (SHM). This is a very large field with growing interest by many OEM’s in many applications by many industries, including aerospace, automotive, and power generation. Advances in this technical arena could be one of the next revolutionary changes or “step changes” (vs. evolutionary) to advance the industry. Advanced sensor technology could supplant many NDT applications by supporting in-situ “structural health monitoring.” Installed on or within composite structures, such systems would continuously monitor a component and detects degradation and damage as it occurs. This could eliminate the possibility of damage being overlooked and reduce costly downtime for manual inspections.
\nThe future of SHM and other smart composite structures includes morphing technology that changes part shape in-flight to create optimal flight conditions. Built-in sensing, computing, and actuation are emerging new frontiers for structures that self-tailor their properties for changing flight conditions. Similar developments include multi-functional composites—laminates that not only provide lightweight, load-bearing structures, but also perform additional functions such as energy harvesting and storage. The 20th International Conference on Composite Materials (July 19–24, 2015, Copenhagen, Denmark), featured more than 100 presentations on multifunctional composites [12].
\n3-D printing is another emerging technology that will impact the future of composite fuselage construction. Already making an impact in prototyping, early design and development, and tooling applications. Small, highly complex parts will follow the path being created by 3-D printed metallic parts. Larger applications are sure to follow. Nano technology may also develop as a viable standalone technology or perhaps integrated with 3-D printing. Remarkable innovations are surely on the horizon.
\nThe state-of-practice for dual aisle, wide body commercial aircraft fuselages has evolved over the past generation from minor aerodynamic composite fairings and flaps to entire composite fuselage structures. It has been a methodical, tenacious process that has included determined efforts by resources from the military and defense department, academia and many industry participants. It has been a global race between teams in the US and Europe with both competitors realizing a win-win outcome. Enormous technical advances were required on many fronts, from tooling to transportation. Equally enormous advances were requisite on the cost competitiveness of manufacturing and assembling composite materials in order to earn their way onto commercial aircraft platforms. New mid-market aircraft platforms from both sides of the Atlantic will be the launching pad for the next wave of technologies that have earned their way onto dual aisle commercial aircraft. After that, the industry anticipates direction on long awaited replacement designs for workhorse single aisle aircraft—composite fuselage or not?
\nA special “nod of the head” to my colleagues at Northrop and Rubbercraft and the many capable and knowledgeable engineers I worked with at Boeing, Spirit, Alenia, KHI and KAL (and others too numerous to callout).
\nNo conflict of interest exists with this research.
Special thank you to my family for your patience and support over the years—you know I love you.
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