Shmuel C. Shapira

Blast Injuries: Bus Versus Open-air Bombings--a Comparative Study of Injuries in Survivors of Open-air Versus Confined-space Explosions

OBJECTIVES To compare injury patterns resulting from explosions in the open air versus within confined spaces. METHODS Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations. RESULTS A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001). CONCLUSION Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.

Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury?

STUDY OBJECTIVES To determine whether isolated eardrum perforation is a marker for concealed blast lung injury in survivors of terrorist bombings. METHODS Survivors who arrived at hospitals after 11 terrorist bombings in Israel between April 6, 1994, and March 4, 1996, were examined otoscopically by ear, nose, and throat specialists. All patients with eardrum perforation underwent chest radiography and were hospitalized for at least 24 hours for observation. The clinical course and final outcome of patients with isolated perforation of the eardrums and of those with other blast injuries were surveyed. RESULTS A total of 647 survivors were examined; 193 (29.8%) of them sustained primary blast injuries, including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (18 with isolated pulmonary blast injury, 31 with combined otic and pulmonary injuries, and 2 with intestinal blast injury). Blast lung injury was promptly diagnosed on admission by physical examination and chest radiography. No patient presenting with isolated eardrum perforation developed later signs of pulmonary or intestinal blast injury (mean 0%; 95% confidence interval, 0% to 2.7%). CONCLUSION Isolated eardrum perforation in survivors of explosions does not appear to be a marker of concealed pulmonary blast injury nor of a poor prognosis. Therefore, in a mass casualty event, persons who have sustained isolated eardrum perforation from explosions may safely be discharged from the emergency department after chest radiography and a brief observation period.

Accurate anatomical location of war injuries: analysis of the Lebanon war fatal casualties and the proposition of new principles for the design of military personal armour system

In this study we present a new approach to the design of the military personal armour system (MPAS). This approach is based on a computerized analysis of the exact anatomical location of 405 penetrating war injuries (290 shrapnel and 115 bullet injuries) in 164 soldiers killed in the Lebanon war. All the penetrating injuries (hits) were plotted on a computerized image of the human body. About 90 per cent of all hits were to the front of the body; 55 per cent of all hits were to the left side. About 45 per cent of all hits were to the torso, which is slightly more than the torsos proportion of total body-surface area (36 per cent). Of all hits to the torso, 64 per cent of the shrapnel hits and 73.3 per cent of the bullet hits were limited to the front mid torso (T4 to T9). The head at the level of the helmet received 9 per cent of all hits, most of which were over the frontal bones (72.4 per cent). The body part with the greatest density of penetrating injuries was the face, with 22.2 per cent of all penetrating wounds, and in particular the mid face, from the level of the lips to the level of the zygomatic bones, was especially vulnerable, sustaining 10 per cent of all the penetrating wounds. These findings suggest several possible modifications in the standard MPAS: an additional protective device over the front mid torso may be incorporated; the face may be protected by a transparent and lightweight face-shield; a horizontal margin added to the standard helmet may protect the upper face from missiles from above; a chin cover may protect the lower face.

Electrical injuries: current concepts

Electrical injuries are often dramatic accidents and are potentially fatal. The systemic involvement which characterizes many of these injuries, requires familiarity with the broad spectrum of clinical manifestations and possible complications. While many victims of electrocution are killed before help can be provided, survivors may suffer severe injuries that need proper treatment. The pathophysiological aspects of electrical injuries and therapeutic principles are therefore discussed in this review as well as preventive measures.

THE ABBREVIATED INJURY SCALE : A VALUABLE TOOL FOR FORENSIC DOCUMENTATION OF TRAUMA

Anatomic trauma scoring systems are fundamental to trauma research. The Abbreviated Injury Scale (AIS) and its derivative, the Injury Severity Score (ISS), are the most frequently used scales. We assessed the applicability of the AIS and the ISS systems for postmortem forensic documentation of trauma. In a prospective study, all trauma autopsies performed between January 1 and June 30, 1993, were coded according to the AIS and ISS method. All cases were reviewed by a consultant in forensic medicine and a traumatologist. Cases were grouped in three categories according to ISS values: 0-14, 16-66, and 75. These categories represent minor, major, and incompatible-with-life injuries, respectively. All autopsy findings in which ISS was < or = 14 were peer-reviewed to establish mechanism and cause of death. In the 6-month period, 279 trauma-related autopsies were studied. Age at death averaged 37.1 +/- 18.7 (mean +/- SD). Eighty-six percent of the victims were male. Penetrating trauma was the mechanism of injury in 67%. ISS was 0-14 in 19 cases, 16-66 in 150 cases, and 75 in 110 cases. In conclusion, AIS and ISS scoring systems are applicable to trauma forensic documentation. Using these methods for coding postmortem findings may help in establishing a database for trauma research, and this information could constitute a major part of continuous quality improvement of trauma management. Low ISS values may serve as a warning, sometimes indicating preventable death.

Cognitive knowledge decline after Advanced Trauma Life Support Courses

OBJECTIVE To assess the cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) program in Israel, to compare the rate of decline between surgeons and nonsurgeons, and to recommend appropriate timing for refresher courses. METHODS A prospective study based on multiple-choice question test results of 220 ATLS course graduates was conducted 3 to 60 months after course completion. These results were then compared with the examination results immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the study groups. RESULTS A significant decline of cognitive knowledge over time among ATLS graduates was demonstrated. This decline was significantly greater in the nonsurgical group. A critical point of 20% cognitive knowledge loss among 50% of the examined physicians was observed around the 180th week after completion of the course. CONCLUSION Physicians taking the ATLS course lose a significant part of their acquired cognitive knowledge after 3.5 years. Surgeons retain their cognitive knowledge for longer periods of time. Based on the study results, the optimal timing for a refresher course is between 3 and 4 years after the initial ATLS course.

Ketamine in the field: the use of ketamine for induction of anaesthesia before intubation in injured patients in the field

Intubating the subconscious, struggling patient in a pre-hospital setting can be a difficult task even in experienced hands. We performed a clinical prospective study to evaluate the applicability of ketamine for induction of anaesthesia before intubation in the field. Ketamine was distributed to all air medical rescue teams--trained reserve army volunteers from various medical specialties. Lectures and literature concerning the use of ketamine for anaesthesia induction before intubation were given. The physicians were instructed to administer ketamine, in a dose of 2 mg/kg intravenously, if a single intubation attempt failed. Following the administration of ketamine, a questionnaire was filled in by the physician. Analysis of the data was performed after 24 months. During the study period, intubation was indicated in 161 injured patients evacuated by air in Israel. In 29 patients (18 per cent) the first intubation attempt had failed and they were given ketamine. The reasons for failure of the first intubation attempt were restlessness or trismus in 23 patients and traumatic distortion of the upper airway anatomical landmarks in six. Following ketamine administration, intubation was successful in 19 patients (65.5 per cent) in all of whom the indication for ketamine administration was restlessness or trismus. All patients with upper airway anatomy distortion were given a cricothyroidotomy. There were no complications attributed to ketamine. All patients reached hospital alive. This preliminary study suggests that the use of ketamine in this pre-hospital setting is safe. The drug is effective in cases where the primary reason for failure to intubate is restlessness or trismus. The drug is not effective in cases of anatomical damage to the upper airway. In these cases, cricothyroidotomy should probably be performed as early as possible.

Internal and external auditing in health systems: an integrative approach.

Traditionally, auditors are apprehensive when it comes to auditing clinical decisions. A novel model might lead to better integration of auditors into the core activities of health system medical care, while creating common interests among all participants in the process.

Ethical Issues of Bioterror

Bioterrorism has global implications, especially with regard to the use of contagious bio agents or “epidemic generators” with a high potential for causing epidemics. The grave medical implications of a bioterror attack are obvious, but some of the related ethical issues are often overlooked. Moral issues associated with the threat and with the attack may carry long-term consequences, which may shake the rudiments of democratic societies. Some of these efforts may be aided by regulations, laws, and enforcement. The best results will be achieved by a sense of responsibility and understandings of the public.