Michael Rozenfeld

Poorer Outcomes for Mass Casualty Events Victims: Is It Evidence Based?

BACKGROUND The sudden influx of patients during mass casualty events (MCEs) may compromise the quality of care provided and possibly impact on the medical outcomes of these patients. To test this assumption, a comparison must be made between injuries sustained in MCE and non-MCE events caused by the same mechanism. The mechanism of injury selected for this study was gunshot wounds, which occur in both types of event. METHODS A retrospective study was carried out using the Israels National Trauma Registry data on patients hospitalized between November 1, 2000, and December 31, 2005, as a result of high-energy gunshot trauma. Descriptive statistics and bivariate analysis were used to characterize injury patterns, and multivariate analysis was used to determine factors influencing inpatient mortality. RESULTS Of 462 patients with gunshot wounds, 120 cases (26.38%) were defined as MCE and 342 (73.62%) as non-MCE. Both populations had ∼30% of severely injured patients (Injury Severity Score 16+). MCE patients had undergone significantly fewer operational procedures. No differences between MCE and non-MCE were found in intensive care units utilization. The likelihood of death as a result of MCE was 2.75 (CI 1.09-7.02) times higher than non-MCE. Factors influencing this difference are the number of injured regions and injuries to the brain, chest, and abdomen. CONCLUSIONS MCE patients have a significantly higher mortality than non-MCE patients, not manifesting substantial differences in the severity of injuries. The absence of difference in intensive care units utilization may be related to the effectiveness of existing protocols for dealing with MCEs.

A new paradigm of injuries from terrorist explosions as a function of explosion setting type

Objective:Examine the impact of setting on the magnitude and pattern of civilian injuries from terrorist explosions. This may help surgical staffs anticipate the resources required to treat victims of terrorist attacks. Methods:A retrospective study of 823 patients from 65 explosive events of the Second Intifada (2000–2005) in the National Trauma Registry. After verification all the events were divided into 5 categories: explosions inside buildings (CS), explosions near buildings (SO), explosions inside buses (IB), explosions near buses (AB), and explosions in an open space (OS). The categories were then compared in terms of sustained injuries, utilization of hospital resources and clinical outcomes. Results:CS and IB scenarios were found to cause the most severe injuries, demanded the most hospital resources and had the worst outcomes, but had several important differences in injury profiles. AB setting proved to be a stand-alone scenario with the lowest severity, possibly due to protection provided to the passengers by the bus. The high volume of blast injuries in SO scenario supports the idea that the explosion wave could be reflected onto the people standing outside a building next to its wall. OS patients had the lowest proportion of blast trauma and burns. Conclusions:The existing taxonomy of terrorist bombings, which distinguishes explosions in open spaces from those occurring in closed environments, does not fully differentiate patterns of injury that follow blasts in intermediate environments. Expanding the framework from 2 categories to 5 appears to provide greater precision and may be clinically useful to health care providers.

BASE EXCESS AS A PREDICTOR FOR INJURY SEVERITY IN PEDIATRIC TRAUMA PATIENTS

BACKGROUND Base excess is considered a predictor of mortality and severity of injury in trauma patients. Base excess had been widely examined in different settings. Only few studies have examined the role of base excess in pediatric trauma patients. OBJECTIVE To evaluate the value of admission base excess in pediatric trauma patients with respect to intensive care unit (ICU) admission rate and length of hospital stay. METHODS A retrospective study of pediatric trauma patients was conducted at a Level II trauma center. All patients aged 0-16 years for which a trauma team was activated over the years 2006-2009 were included. Study database included admission base excess, mechanism of injury, location and nature of injury, injury severity score, length of hospital stay, and ICU admission. RESULTS The study group consisted of 359 patients. There was a weak linear correlation between admission base excess, length of stay in the hospital, and ICU admission. Base excess seemed to show a stronger correlation for the youngest age group (0-6 years) and no correlation for the middle age group. There was a positive but weak correlation (R Spearman = 0.26) between admission base excess and Injury Severity Score (ISS). However, 40% of the children with an ISS score >25 had normal admission base excess values. The area under the curve of the receiver operating characteristic curves of base excess for predicting ICU admission was 0.66. CONCLUSIONS The admission base excess in pediatric trauma patients seems to be a weak prognostic factor in our facility.

Children and terror casualties receive preference in ICU admissions.

OBJECTIVE Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events. METHODS Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry. RESULTS All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU. CONCLUSIONS Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

Comparison of two successive earthquake awareness campaigns in Israel: improved methodology or a cumulative effect?

OBJECTIVES An effective way to reduce casualties from earthquakes is to increase population preparedness. During 2011 to 2013, Israeli authorities executed 3 national-level earthquake awareness campaigns. We aimed to assess the impact of these campaigns on the populace and the ability of the campaigns to produce a cumulative effect throughout the study period. METHODS Two surveys were conducted 2 weeks after the end of the first campaign and the third campaign in a similar randomly selected representative sample. RESULTS Exposure to the campaign proved to be a significant factor in increasing the knowledge of the respondents, giving a knowledge advantage of 1.5 times to respondents exposed to the campaign. However, the period of assessment proved to be an even more significant factor, with knowledge in 2013 being 2.3 times that in 2011. Additionally, a gap of up to 40% between the levels of trust and the perceived responsibility of respective authorities in the times of earthquake was found. CONCLUSIONS This study found an improvement in public knowledge regarding earthquake preparedness over the 3 years of the study. This may mean that an awareness campaign does not stand by itself, but should be part of an integrated long-term process in order to have a lasting effect on the population.