Limor Aharonson-Daniel

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.

The impact of terrorism on children: a two-year experience.

OBJECTIVESnTo review and analyze the cumulative two-year, Israeli experience with medical care for children victims of terrorism during the prehospital and hospital phases.nnnMETHODSnData were collected from the: (1) Magen David Adom National Emergency Medical System Registry (prehospital phase); (2) medical records from the authors institutions (pediatric triage); and (3) Israel Trauma Registry (injury characteristics and utilization of in-hospital resources). Statistical analyses were performed as appropriate.nnnINTRODUCTIONnDuring the recent wave of violence in Israel and the surrounding region, hundreds of children have been exposed to and injured by terrorist attacks. There is a paucity of data on the epidemiology and management of terror-related trauma in the pediatric population and its effects on the healthcare system. This study focuses on four aspects of terrorism-related injuries: (1) tending to victims in the prehospital phase; (2) triage, with a description of a modified, pediatric triage algorithm; (3) characteristics of trauma-related injuries in children; and (4) utilization of in-hospital resources.nnnRESULTSnDuring the study period, 41 mass-casualty events (MCEs) were managed by Magen David Adom. Each event involved on average, 32 regular and nine mobile intensive care unit ambulances with 93 medics, 19 paramedics, and four physicians. Evacuation time was 5-10 minutes in urban areas and 15-20 minutes in rural areas. In most cases, victims were evacuated to multiple facilities. To improve efficiency and speed, the Magen David Adom introduced the use of well-trained first-responders and volunteer, off-duty professionals, in addition to scoop and run on-the-scene management. Because of differences in physiology and response between children and adults, a pediatric triage algorithm was developed using four categories instead of the usual three. Analysis of the injuries sustained by the 160 children hospitalized after these events indicates that most were caused by blasts and penetration by foreign objects. Sixty-five percent of the children had multiple injuries, and the proportion of critical to fatal injuries was high (18%). Compared to children with non-terrorism-related injuries, the terrorism-related group had a higher rate of surgical interventions, longer hospital stays, and greater needs for rehabilitation services.nnnCONCLUSIONnTerrorism-related injuries in children are severe and increase the demand for acute care. The modifications in the management of pediatric casualties from terrorism in Israel may contribute to the level of preparedness of medical and paramedical personnel to cope with future events. Further studies of other aspects of traumatic injuries, such as its short- and long-term psychological consequences, will provide a more comprehensive picture of the damage inflicted on children by acts of terrorism.

Unilateral flail chest is seldom a lethal injury

Background: The chest cage is a common target for traumatic damage. Although relatively rare, it is considered to be a serious condition with significant reported mortalities. As most flail injuries are accompanied by severe extrathoracic injuries, it is often difficult to pinpoint a single injury responsible for the patient’s death. Aim: To investigate the factors related to mortality when flail injury is diagnosed. Methods: Data from the Israel National Trauma Registry between 1998 and 2003 included 11 966 chest injuries (262 flail chest injuries) out of a total of 118 211 trauma hospitalisations. Mortality figures were analysed to determine which factors, singly or in combination, influenced flail chest mortality. Results: Road crashes accounted for most flail injuries (76%). The total mortality was 54 (20.6%) of 262 patients with flail chest injuries. 13 (20.4%) of the deaths occurred soon after admission to the emergency room and 37 (68.5%) within the first 24 h. Mortality in moderate to severe injuries (injury severity score (ISS) 9–24) was 3.6% and that in critical injuries 28.5% (ISS >24). Mortality increased with age: 17% in those aged <45 years, 22.1% in those between 45 and 64 years and 28.8% in those >65 years. Age remained a risk for inpatient death when adjusted for severity. Mortality in isolated unilateral flail injury was not more than 6%. Total mortality for traumatic brain injury (TBI) and flail was 34%. Flail, TBI and other major injuries increased the mortality to 61.1%. Conclusions: Advanced age is associated with higher mortality. Isolated unilateral bony cage instability infrequently leads to death in patients who make it to the emergency department but rather its combination with additional extrathoracic trauma.

THE EPIDEMIOLOGY OF TERRORISM CASUALTIES

Recent years brought about an increase in terrorist activities worldwide. Israel has been exposed to sporadic periods of terrorist activities for decades, with a noteworthy increase since September 29, 2000. By the end of 2003, 6049 persons have been injured and over 904 killed due to terrorism acts in the country (1). Many of these attacks are explosion of suicide bombers resulting in mass casualty events. Mass casualty events are incidents in which the medical system is overwhelmed and the balance between resources and demands is destabilized (2). These latest terror attacks were characterized by a new bomb makeup bombs that contain metal particles of various shapes that increase their wounding potential (3, 4). The consequences are more severe injuries than encountered before, bringing up the possible need for updating protocols for evacuation, triage and hospital preparedness (5, 6). Furthermore, since injuries were different from previously encountered trauma, the pattern of demand for resources, and the medical proficiency necessary for treating new terror victims were different than before (6–12). Additionally, as mass casualty incidents became a frequent event, there was need to maintain continuous preparedness of emergency care services and trauma centers in the country in order to cope with them. In the strive for better preparedness of hospitals and physicians to treat terror casualties, we aimed to learn as much as possible about the characteristics and epidemiology of this new disease. BOMB EXPLOSIONS

Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality

BackgroundPrevious analyses of the safety of the conservative versus the operative approach to the treatment of liver and spleen blunt injuries in children often failed to account for differences in quality of care and expertise among dedicated pediatric trauma center, non-pediatric centers, centers without trauma units, and non-trauma centers. To eliminate this potential bias, the present study examined changes in the rate of surgery and their impact on outcome within the same medical centers over time.MethodsThe Israel Trauma Registry was searched for patients <18xa0years who were treated for non-penetrating liver or spleen injuries from 1998 to 2004.Patients were grouped by period, 1998–2000 and 2001–2004, and compared for type of injury, severity of injury, type of treatment, and inpatient mortality.ResultsThe earlier period (1998–2000) was characterized by a significantly higher rate of operations compared with the later period (2001–2004) (Pxa0=xa00.001) and higher in-hospital mortality (Pxa0=xa00.04). Injury severity scores, type of organs injured, and accompanying injuries were similarly distributed in the two groups.ConclusionsDespite the similarity in the severity and characteristics of the intraabdominal injuries in 1998–2000 and in 2001–2004, the proportion of children treated conservatively increased over time, concomitant with a significant drop in inpatient mortality. We attribute this shift over a relatively short interval to increased experience and greater acceptance of conservative management in this setting.