Kobi Peleg

Gunshot and Explosion Injuries: Characteristics, Outcomes, and Implications for Care of Terror-Related Injuries in Israel

Context:An increase of terror-related activities may necessitate treatment of mass casualty incidents, requiring a broadening of existing skills and knowledge of various injury mechanisms. Objective:To characterize and compare injuries from gunshot and explosion caused by terrorist acts. Methods:A retrospective cohort study of patients recorded in the Israeli National Trauma Registry (ITR), all due to terror-related injuries, between October 1, 2000, to June 30, 2002. The ITR records all casualty admissions to hospitals, in-hospital deaths, and transfers at 9 of the 23 trauma centers in Israel. All 6 level I trauma centers and 3 of the largest regional trauma centers in the country are included. The registry includes the majority of severe terror-related injuries. Injury diagnoses, severity scores, hospital resource utilization parameters, length of stay (LOS), survival, and disposition. Results:A total of 1155 terror-related injuries: 54% by explosion, 36% gunshot wounds (GSW), and 10% by other means. This paper focused on the 2 larger patient subsets: 1033 patients injured by terror-related explosion or GSW. Seventy-one percent of the patients were male, 84% in the GSW group and 63% in the explosion group. More than half (53%) of the patients were 15 to 29 years old, 59% in the GSW group and 48% in the explosion group. GSW patients suffered higher proportions of open wounds (63% versus 53%) and fractures (42% versus 31%). Multiple body-regions injured in a single patient occurred in 62% of explosion victims versus 47% in GSW patients. GSW patients had double the proportion of moderate injuries than explosion victims. Explosion victims have a larger proportion of minor injuries on one hand and critical to fatal injuries on the other. LOS was longer than 2 weeks for 20% (22% in explosion, 18% in GSW). Fifty-one percent of the patients underwent a surgical procedure, 58% in the GSW group and 46% in explosion group. Inpatient death rate was 6.3% (65 patients), 7.8% in the GSW group compared with 5.3% in the explosion group. A larger proportion of gunshot victims died during the first day (97% versus 58%). Conclusions:GSW and injuries from explosions differ in the body region of injury, distribution of severity, LOS, intensive care unit (ICU) stay, and time of inpatient death. These findings have implications for treatment and for preparedness of hospital resources to treat patients after a terrorist attack in any region of the world. Tailored protocol for patient evaluation and initial treatment should differ between GSW and explosion victims. Hospital organization toward treating and admitting these patients should take into account the different arrival and injury patterns.

Patterns of injury in hospitalized terrorist victims

Acts of terror increase the demand for acute care. This article describes the pattern of injury of terror victims hospitalized at 9 acute-care hospitals in Israel during a 15-month period of terrorism. To characterize patients hospitalized as a result of terror injuries, we compared terror casualties with other injuries regarding severity, outcome, and service utilization. Using data from the National Trauma Registry, characteristics of casualties are portrayed. During the study period, 23,048 patients were recorded, 561 of them (2.4%) were injured through terrorist acts. Seventy percent were younger than 29 years. Seventy-five percent were males. Thirteen percent of terror victims compared with 3% with other traumatic injuries, arrived by helicopter. Injury mechanism consisted mainly of explosions (n = 269, 48%) and gunshot injuries (n = 266, 47%). One third of the population experienced severe trauma (Injury Severity Score > or = 16). One hundred-forty-two patients (26%) needed to be admitted to the intensive-care unit. Inpatient mortality was 6% (n = 35). Fifty-five percent of the injuries (n = 306) included open wounds and 31% (n = 172) involved internal injuries; 39% (n = 221) sustained fractures. Half of the patients had a procedure in the operating room (n = 298). Duration of hospitalization was longer than 2 weeks for nearly 20% of the population. Injuries from terrorist acts are severe and impose a burden on the healthcare system. Further studies of the special injury pattern associated with terror are necessary to enhance secondary management and tertiary prevention when occurring.

In-Hospital Resource Utilization During Multiple Casualty Incidents

Objective:To suggest guidelines for hospital organization during terror-related multiple casualty incidents (MCIs) based on the experience of 6 level I trauma centers. Summary Background Data:Most terror-related MCIs are bombings. The sporadic nature of these events complicates in-hospital preparation. Methods:Data were collected at all level I Trauma centers during/after MCIs for the Israel National Trauma registry. Patients were included if they were admitted or died in hospital following injury in suicide bombings (October 1, 2000 to June 30, 2003), which fulfilled Ministry of Health suggested criteria for MCIs (number of admissions, severity of injury). Results:Included were 325 casualties from 32 events, 34% of which had an Injury Severity Score >16. A third of the admissions arrived within 10 minutes and 65% within 30 minutes. Forty percent of the patients underwent CT scans directly from the ED. Operative procedures were performed on 60% of patients and 36% were transferred directly from the ED to the OR. Initiation of surgical procedures peaked at 1 to 1.5 hours, mainly multidisciplinary abdominal, thoracic, and vascular surgery. Orthopedic and plastic surgery predominated later. A third of the patients were admitted to ICUs, often (31%) directly from the ED. Conclusions:High staffing demands for ED, OR, and ICU overlap. Anesthesiologists, general, thoracic, and vascular surgeons are in immediate demand. ICU admissions occur simultaneously with ongoing patient arrival to the ED. Most patients operated within the first 2 hours require multidisciplinary surgical teams. Demand for orthopedic and plastic surgery and anesthesiology services continues for >24 hours.

Early Disaster Response in Haiti: The Israeli Field Hospital Experience

The earthquake that struck Haiti in January 2010 caused an estimated 230,000 deaths and injured approximately 250,000 people. The Israel Defense Forces Medical Corps Field Hospital was fully operational on site only 89 hours after the earthquake struck and was capable of providing sophisticated medical care. During the 10 days the hospital was operational, its staff treated 1111 patients, hospitalized 737 patients, and performed 244 operations on 203 patients. The field hospital also served as a referral center for medical teams from other countries that were deployed in the surrounding areas. The key factor that enabled rapid response during the early phase of the disaster from a distance of 6000 miles was a well-prepared and trained medical unit maintained on continuous alert. The prompt deployment of advanced-capability field hospitals is essential in disaster relief, especially in countries with minimal medical infrastructure. The changing medical requirements of people in an earthquake zone dictate that field hospitals be designed to operate with maximum flexibility and versatility regarding triage, staff positioning, treatment priorities, and hospitalization policies. Early coordination with local administrative bodies is indispensable.

Suicide Bombers Form a New Injury Profile

Background:Recent explosions of suicide bombers introduced new and unique profiles of injury. Explosives frequently included small metal parts, increasing severity of injuries, challenging both physicians and healthcare systems. Timely detonation in crowded and confined spaces further increased explosion effect. Methods:Israel National Trauma Registry data on hospitalized terror casualties between October 1, 2000 and December 31, 2004 were analyzed. Results:A total of 1155 patients injured by explosion were studied. Nearly 30% suffered severe to critical injuries (ISS ≥ 16); severe injuries (AIS ≥ 3) were more prevalent than in other trauma. Triage has changed as metal parts contained in bombs penetrate the human body with great force and may result in tiny entry wounds easily concealed by hair, clothes etc. A total of 36.6% had a computed tomography (CT), 26.8% had ultrasound scanning, and 53.2% had an x-ray in the emergency department. From the emergency department, 28.3% went directly to the operating room, 10.1% to the intensive care unit, and 58.4% directly to the ward. Injuries were mostly internal, open wounds, and burns, with an excess of injuries to nerves and to blood vessels compared with other trauma mechanisms. A high rate of surgical procedures was recorded, including thoracotomies, laparotomies, craniotomies, and vascular surgery. In certain cases, there were simultaneous multiple injuries that required competing forms of treatment, such as burns and blast lung. Conclusions:Bombs containing metal fragments detonated by suicide bombers in crowded locations change patterns and severity of injury in a civil population. Specific injuries will require tailored approaches, an open mind, and close collaboration and cooperation between trauma surgeons to share experience, opinions, and ideas. Findings presented have implications for triage, diagnosis, treatment, hospital organization, and the definition of surge capacity.

Lessons from Boston

The Boston Marathon bombing and the medical response offer several important lessons, including that the remarkably low mortality rate (1%) was attributable in part to several factors favoring the rescuers and that disaster preparedness still requires planning.

Enhancing Hospital Surge Capacity for Mass Casualty Events

TWO DAYS AFTER THE 2008 PRESIDENTIAL ELECTION, the Government Accountability Office identified 13 “urgent issues” President-elect Obama and the 111th Congress should address during the transition period and first year of the new administration. One of the issues, preparing for large-scale health emergencies, is particularly relevant to the US health care system. The Government Accountability Office posted on its Web site the following statement:

A new approach to the analysis of multiple injuries using data from a national trauma registry

Objective: To present a new systematic approach for summarizing multiple injury diagnosis data into patient injury profiles. Design:International Classification of Diseases, ninth revision, clinical modification injury diagnosis codes were classified using a modification of the Barell body region by nature of injury diagnosis matrix, then grouped by body region, injury nature, or a combination of both. Profiles were built which describe patients’ injury combinations based on matrix units, enabling the analysis of patients, and not only the study of injuries. Setting: The Israeli national trauma registry was used to retrieve patient demographic data, injury details, and information on treatment and outcome. Patients or subjects: All hospitalized patients injured in road traffic accidents and included in the trauma registry from January 1997 to December 2000 were included. Main outcome measures: Patient profiles consisting of body regions, injury natures, their combination, and their clinical outcomes. Results: The study population comprised 17 459 patients. Head and neck injuries were the most frequent in all subpopulations except for motorcyclists who sustained most injuries in the extremities. Fractures were the most common injury nature (60%). Pedestrians and drivers had the highest proportion of multiple injuries in both profiles. Forty eight percent of the patients had a single cell profile. The most frequent conditions as a sole condition were extremity fractures (14%), internal injuries to the head (11%), and injuries of other nature to the torso (6%). Mortality, length of stay, and intensive care unit treatment varied dramatically between profiles and increased for multiple injury profiles. Inpatient death was an outcome for 3.3% overall; however, in patients with an internal injury to the head and torso, inpatient death rate was nine times higher, at 31%. Conclusions: Profiles maintain information on body region and nature of injury. The use of injury profiles in describing the injured improves the understanding of casemix and can be useful for efficient staffing in multidisciplinary trauma teams and for various comparisons.

Incidence and severity of maxillofacial injuries during the Second Lebanon War among Israeli soldiers and civilians

PURPOSE To analyze the incidence and severity of maxillofacial injuries in the Second Lebanon War, that occurred during the summer of 2006, among Israeli soldiers and civilians. PATIENTS AND METHODS This is a retrospective cohort study of patients recorded in the Israel National Trauma Registry during the Second Lebanon War. Data refer to all general hospitals throughout the country. Data were analyzed according to the etiology of the injury, severity of trauma using the Injury Severity Score, trauma location, and duration of hospital stay. Cases with multiple injuries that included maxillofacial injuries were separated and further analyzed according to the above parameters. Patients with only dental injuries and superficial facial soft tissue lacerations were excluded because they were referred to the military dental clinics and not to general hospitals. RESULTS Maxillofacial injuries were found in 36 (6.4%) of the 565 wounded. Patients with maxillofacial injuries ranged in age from 20 to 44 years (mean age, 25.5 +/- 5.7 years). Greater than 50% of the injuries required more than 3 hospitalization days. Mortality rate of the maxillofacial injured was 2.8%. Most of the maxillofacial injuries (33; 91.7%) were combined with other organ injuries; 9 (25%) patients also had dental injuries. CONCLUSION In the Second Lebanon War, the incidence and severity of true maxillofacial injuries, without dental injuries alone, were relatively low compared with previous reports of other conflicts. However, because most injuries involved multiple organs, special attention is required when planning and providing emergency, as well as secondary and tertiary medical care to war wounded.

The severity of injury in children resulting from acts against civilian populations.

Objective:To characterize the injuries to children by acts against civilian populations (AACP). Summary Background Data:Only 2 articles have focused on the spectrum and severity of injuries to children by AACP. Methods:A retrospective case study of children 0 to 18 years old who were entered into the Israel National Trauma Registry as a result of AACP between September 29, 2000, and June 30, 2002. Results:A total of 158 children were hospitalized for injuries caused by AACP, accounting for 1.4% of all hospitalized injured children but for 10.9% of all in-hospital deaths for trauma. Explosions injured 114 (72.2%); shootings, 34 (21.5%); and other mechanisms such as stoning or stabbing, 10 (6.3%). Older children were injured by explosions more frequently than younger children (86.1% of 15- to 18-year-olds, 73.7% of 10- to 14-year-olds, 63.2% of 0- to 9-year-olds, P = 0.02). A higher percentage of children injured by explosions rather than by shootings were severely or critically injured (33.9% versus 18.8%, P = 0.10). The most frequently injured body regions were extremities (62.8%), head/face (47.3%), chest and abdomen (37.2%), and brain (18.2%). More than 1 body region was injured in 63.0%. Children injured by explosions as compared with shootings had a lower incidence of abdominal trauma (14.9% versus 20.6%), a similar incidence of chest trauma (16.7% versus 14.7%), but a higher incidence of extremity trauma (65.8% versus 53.0%). There were 7 in-hospital deaths, 6 due to severe head injury and 1 due to severe abdominal trauma; 6 of the 7 deaths were caused by explosions, and all but 1 occurred in children 15 to 18 years old. Conclusions:AACP cause significant morbidity and mortality in children, especially adolescents. Injury severity is significantly higher among children who are injured by explosions rather than by shootings.