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 > or = 16); severe injuries (AIS > or = 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.

The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry

PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes.

METHODS

REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported.

RESULTS

Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion.

CONCLUSIONS

This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era?

INTRODUCTION

According to the Advanced Trauma Life Support, portable pelvis radiography (PXR) is mandatory in multiple trauma patients, and is performed following initial clinical evaluation. The purpose of an early PXR is to identify pelvic fractures that may have haemodynamic consequences. Today, ultrafast multi-detector CT scanners (MDCT) are readily available and widely used in the evaluation of stable trauma patients. The objective of this study was to determine the impact of PXR in stable blunt multiple trauma patients, who required CT scan for full evaluation of the abdomen and pelvis.

METHODS

A retrospective review of all stable blunt trauma patients, suffering from pelvic fractures was performed from January 2001 until December 2004 at two high volume Trauma Centres. Patients' demographics and Injury Severity Scores (ISS) were abstracted from our trauma registry. Two certified radiologists and two certified orthopaedic surgeons retrospectively evaluated and compared PXR films and CT angiographies (CTA) of the abdomen and pelvis. We recorded each case when the management policy was altered due to the results of imaging and compared the clinical impact of both modalities.

RESULTS

One hundred and twenty-nine stable blunt multiple trauma patients with pelvic fractures underwent CTA of the abdomen and pelvis during their initial evaluation. Mean ISS was 16.5. Average Glasgow Coma Scale on arrival was 13.2 (range 3-15). Compared to CTA, sensitivity and specificity of the PXR was 64.4 and 90.0%, respectively. CTA diagnosed 35.6% more pelvic fractures than PXR (p<0.05). No changes in the therapeutic policy were observed following PXR results. In 19 (14.7%) patients, CTA findings led to pelvic angiography.

CONCLUSIONS

PXR in stable blunt multiple trauma patients did not change the therapeutic policy in our patients. CTA of the abdomen and pelvis is the imaging modality of choice in blunt multiple trauma, regardless of the findings of PXR. Benefit of routine PXR is questionable in hospitals where MDCT is available. Based on our results, we suggest re-evaluating the current practice of routine mandatory portable pelvis radiography.

Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre

OBJECTIVE

To assess the effect of teleradiology upon the need for transfer of head injured victims requiring hospitalisation but referred initially to a rural level 2 trauma centre without neurosurgical capacity.

METHODS

Head injured patients requiring hospitalisation, admitted to a rural level 2 trauma centre between August 2003 and August 2005, were identified. A digitalised copy of the computed tomographic (CT) scan was transferred to the neurosurgical referral centre via teleradiology and was available for review by the neurosurgeon on-call, who then, together with the trauma surgeon in the rural level 2 trauma centre, decided whether to transfer the patient to the neurosurgical referral centre.

RESULTS

Of 209 trauma victims with neurosurgical pathology in need of hospitalisation, 126 (60.2%) were immediately transferred while 83 (39.7%) of the patients were hospitalised in the rural level 2 trauma centre for observation. Two (2.4%) failed the intent to treat locally. One patient, suffering from multi-trauma, was stabilised after damage control laparotomy only to succumb to an enlarging epidural haematoma. Another patient was transferred 2 days after admission because of difficulty in clinical evaluation due to a previously existing neurological disorder, but no active treatment was necessary. All other 81 patients recovered uneventfully.

CONCLUSIONS

Selective head injured patients with pathological CT scan may be safely managed in level 2 trauma centres. A committed trauma team in the rural trauma centre, neurosurgical consultation and availability of a teleradiology system are requisites. Currently existing transfer criteria should be carefully re-evaluated.

Prehospital management of earthquake casualties buried under rubble

Earthquakes continue to exact a heavy toll on life, injury, and loss of property. Survival of casualties extricated from under the rubble depends upon early medical interventions by emergency teams on site. The objective of this paper is to review the pertinent literature and to analyze the information as a practical guideline for the medical management of casualties accidentally buried alive.

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.

Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method

BACKGROUND

To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

STUDY DESIGN

A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.

RESULTS

Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.

CONCLUSIONS

Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times.

Management of patients with traumatic intracranial injury in hospitals without neurosurgical service

BACKGROUND

Many patients with intracranial bleeding (ICB) are being evaluated in hospitals with no neurosurgical service. Some of the patients may be safely managed in the primary hospital without transferring them to a designated neurosurgical center. In Israel, there are three approaches to alert patients with ICB: mandatory transfer, remote telemedicine neurosurgical consultation, and clinical-radiologic guidelines. We evaluated the outcome of alert patients with low-risk ICB who were managed in centers without neurosurgical service.

METHODS

A retrospective cohort comparative study. Patients with ICB and a Glasgow Coma Score >12 were included. Low-risk ICB was defined as solitary brain contusion of <1 cm in diameter, limited small subarachnoid hemorrhage, or subdural hematoma of <5 mm in maximal width and length. The decision to transfer the patients to a neurosurgical center was based on one of the three models. Hospital A: mandatory transfer. Hospital B: telemedicine-based consultation with a remote neurosurgeon. Hospital C: clinical-radiologic algorithm-based guidelines. Primary endpoint was the neurologic outcome of patients at discharge.

RESULTS

There were 152 patients in group A, 98 patients in group B, and 73 patients in group C. All patients of group A were transferred to a neurosurgical center. Fifty-eight percent of patients from hospital B and 26% of patients from hospital C were hospitalized in the primary center despite a proven ICB. These patients were discharged without any neurologic sequel of their injury. Two patients from group B and one patient from group C needed a delayed transfer to a neurosurgical center. None of the patient needed delayed neurosurgical intervention.

CONCLUSIONS

Despite the small sample size of this study, the presented data suggest that some patients with ICB can be safely and definitively managed in centers with no on-site neurosurgical service. The need for transfer may be based on telemedicine consultation or clinical -radiologic guidelines. Further larger scale studies are warranted.

Precision of In-Hospital Triage in Mass-Casualty Incidents after Terror Attacks

Introduction:

Proper management of mass-casualty incidents (MCIs) relies on triage as a critical component of the disaster plan.

Objective:

The objective of this study was to assess the precision of triage in mass-casualty incidents.

Methods:

The precision of decisions made by two experienced triage officers was examined in two large MCIs. These decisions were compared to the real severity of injury as defined by the Israeli Defence Forces (IDF) classification of severity of injuries and the Injury Severity Score (ISS).

Results:

Two experienced trauma physicians triaged a total of 94 casualties into 77 mild, seven moderate, and 10 severe casualties. Based on the IDF criteria, there were 74 mild, five moderate, and 15 severe casualties. Based on ISS scoring, there were 78 mild (ISS &lt;9), five moderate (9 ≤ISS&lt;16), and 11 severe (ISS &lt; 16) casualties. Of 15 severely injured victims defined by the IDF classification of injury severity, the triage officers identified only seven (47%).

Conclusion:

Primary triage, even when carried out by experienced trauma physicians, can be unreliable in a MCI.

Selection of patients with severe pelvic fracture for early angiography remains controversial

BACKGROUND

Patients with severe pelvic fractures represent about 3% of all skeletal fractures. Hemodynamic compromise in unstable pelvic fractures is associated with arterial hemorrhage in less than 20% of patients. Angiography is an important tool in the management of severe pelvic injury, but indications and timing for its performance remain controversial.

METHODS

Patients with major pelvic fractures [Pelvic Abbreviated Injury Score (AIS) >or= 3] admitted to two high volume Trauma Centers from January 2000 to June 2005 were identified and divided into two groups: Group I patients did not undergo angiography, Group II patients underwent angiography with/without embolization. Demographics, hemodynamic status on admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pelvic AIS, blood requirement before and after angiography, arterial blood gases and mortality were evaluated. Patients with an additional reason for hemodynamic instability were excluded.

RESULTS

Charts of 106 patients were retrospectively reviewed. Twenty nine patients (27.4%) underwent angiography. Bleeding vessel embolization was performed in 20 (18.9%) patients. Patients who underwent angiography had a significantly higher pelvic AIS and a lower Base Excess level on admission. A blood transfusion rate of greater than 0.5 unit/hour was found to be a reliable indicator for early angiography.

CONCLUSION

A high pelvic AIS, amount of blood transfusions and decreased BE level should be considered as an indicators for early angiography in patients with severe pelvic injury.

Pre-hospital CPR and early REBOA in trauma patients - results from the ABOTrauma Registry

BACKGROUND

Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR.

METHODS

Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate.

RESULTS

Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from the median (range) 56.5 (0-147) to 90 (0-200) mmHg.

CONCLUSIONS

Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest

BACKGROUND

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry.

METHODS

Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome.

RESULTS

There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived.

CONCLUSIONS

Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database

INTRODUCTION

Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries.

METHODS

A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined.

RESULTS

Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group.

CONCLUSIONS

The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Early detection of life-threatening intracranial haemorrhage using a portable near-infrared spectroscopy device

OBJECTIVE

To determine whether infrared spectroscopy allows early recognition of epidural and subdural haematomas among trauma patients.

METHODS

Injured people admitted to two trauma units were enrolled in a prospective multicentre observational study, and infrared spectroscopy was performed before computed tomography of the head as a part of their initial evaluation. Subsequent CT findings suggestive of epidural or subdural haematoma served as controls.

RESULTS

Over 12 months, 110 patients were enrolled; 64 (58.1%) were men and 46 (41.9%) were women. Mean age was 56.2 years, and mean Glasgow Coma Scale on admission was 12.6. Infrared spectroscopy was 90.5% sensitive and 95.5% specific for epidural and subdural haematoma. Positive and negative predictive values were 82.6% and 97.7%, respectively.

CONCLUSIONS

Infrared spectroscopy allows early recognition of epidural and subdural haematomas in trauma cases. Further studies are needed to evaluate whether immediate confirmation or exclusion of epidural and subdural haematomas with portable near-infrared spectroscopy devices improves the decision-making process in the treatment of severely injured people.

A new technique of direct intra-abdominal pressure measurement: a preliminary study

OBJECTIVE

The purpose of this study was to determine if a 14-F polyvinyl chloride (PVC) round drain is a reliable tool for direct intra-abdominal pressure measurement.

DESIGN

A prospective interventional study.

SETTING

Department of Surgery B, intensive care unit, recovery room, Hillel-Yaffe level II trauma center.

METHODS

Forty patients undergoing abdominal surgery and treated postoperatively with intraperitoneal drains and intravesical catheters were included in this study. The indication for insertion of intraperitoneal drains and intravesical catheters was strictly medical. The decision of placing urinary bladder catheter and PVC round drain was done by a senior surgeon. Intra-abdominal pressures were measured simultaneously through the intraperitoneal drain and the urinary catheter. Using a sterile technique, the intraperitoneal drain was disconnected from the drainage bulb and connected to an invasive blood pressure monitoring system. Intravesical pressures were measured by inserting 50 mL into the bladder, and then the urinary catheter was connected to an invasive blood monitoring system. Measurements were done twice a day for 3 days or less if earlier removal of either the intraperitoneal drain or urinary catheters were medically indicated.

RESULTS

Two hundred twenty-even simultaneous measurements were performed. Pressures as measured through the intraperitoneal drain were found to be significantly correlated to pressures as measured intravesically (r = 0.962).

CONCLUSIONS

Direct measurement of the intra-abdominal pressure via a 14-F PVC round drain is a newly described technique. Our method is simple, safe, and credible. Future investigation is needed to confirm the reliability of this method for continuous postoperative measurement of the intra-abdominal pressure in selected patients.

Rib fractures: comparison of associated injuries between pediatric and adult population

BACKGROUND

Rib fractures are considered a marker of exposure to significant traumatic energy. In children, because of high elasticity of the chest wall, higher energy levels are necessary for ribs to fracture. The purpose of this study was to analyze patterns of associated injuries in children as compared with adults, all of whom presented with rib fractures.

METHODS

A retrospective cohort study involving blunt trauma patients with rib fractures registered in the National Trauma Registry was conducted.

RESULTS

Of 6,995 trauma victims who were found to suffer from rib fractures, 328 were children and 6,627 were adults. Isolated rib fractures without associated injuries occurred in 19 children (5.8%) and 731 adults (11%). More adults had 4 or more fractured ribs compared with children (P < .001). Children suffered from higher rates of associated brain injuries (P = .003), hemothorax/pneumothorax (P = .006), spleen, and liver injury (P < .001). Mortality rate was 5% in both groups.

CONCLUSIONS

The incidence of associated head, thoracic, and abdominal solid organ injuries in children was significantly higher than in adults suffering from rib fractures. In spite of a higher Injury Severity Score and incidence of associated injuries, mortality rate was similar. Mortality of rib fracture patients was mostly affected by the presence of extrathoracic injuries.

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

BACKGROUND

Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes.

METHODS

An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile.

RESULTS

650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust.

DISCUSSION

The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

Management of victims in a mass casualty incident caused by a terrorist bombing: treatment algorithms for stable, unstable, and in extremis victims

Bombs aimed at civilian populations are the most common weapon used by terrorists throughout the world. Over the last decade, we have been involved in the management of more than 20 mass casualty incidents, most of which were caused by terrorist bombings. Commonly, in these events, there may be many victims and many deaths. However, only a few of the survivors will suffer from life-threatening injuries. Appropriate and timely treatment may impact their survival. Due to the complex mechanism of injury seen in these scenarios, treatment of victims injured by explosions is somewhat different from that exercised in blunt and penetrating trauma from other causes. The intention of this article was to outline the initial medical treatment of the injured victim arriving at the emergency department during a mass casualty incident caused by a terrorist bombing. Treatment protocols for stable, unstable, and in extremis patients are presented.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

The contribution of the Israeli trauma system to the survival of road traffic casualties

BACKGROUND

According to the World Health Organization, over one million people die annually from traffic crashes, in which over half are pedestrians, bicycle riders and two-wheel motor vehicles. In Israel, during the last decade, mortality from traffic crashes has decreased from 636 in 1998 to 288 in 2011. Professionals attribute the decrease in mortality to enforcement, improved infrastructure and roads and behavioral changes among road users, while no credit is given to the trauma system. Trauma systems which care for severe and critical casualties improve the injury outcomes and reduce mortality among road casualties.

GOALS

1) To evaluate the contribution of the Israeli Health System, especially the trauma system, on the reduction in mortality among traffic casualties. 2) To evaluate the chance of survival among hospitalized traffic casualties, according to age, gender, injury severity and type of road user.

METHODS

A retrospective study based on the National Trauma Registry, 1998-2011, including hospitalization data from eight hospitals.

OUTCOMES

During the study period, the Trauma Registry included 262,947 hospitalized trauma patients, of which 25.3% were due to a road accident. During the study period, a 25% reduction in traffic related mortality was reported, from 3.6% in 1998 to 2.7% in 2011. Among severe and critical (ISS 16+) casualties the reduction in mortality rates was even more significant, 41%; from 18.6% in 1998 to 11.0% in 2011. Among severe and critical pedestrian injuries, a 44% decrease was reported (from 29.1% in 1998 to 16.2% in 2011) and a 65% reduction among bicycle injuries. During the study period, the risk of mortality decreased by over 50% from 1998 to 2011 (OR 0.44 95% 0.33-0.59. In addition, a simulation was conducted to determine the impact of the trauma system on mortality of hospitalized road casualties. Presuming that the mortality rate remained constant at 18.6% and without any improvement in the trauma system, in 2011 there would have been 182 in-hospital deaths compared to the actual 108 traffic related deaths. A 41% difference was noted between the actual number of deaths and the expected number.

CONCLUSIONS

This study clearly shows that without any improvement in the health system, specifically the trauma system, the number of traffic deaths would be considerably greater. Although the health system has a significant contribution on reducing mortality, it does not receive the appropriate acknowledgment or resources for its proportion in the fight against traffic accidents.

Variability in pediatric injury patterns by age and ethnic groups in Israel

BACKGROUND

. In Israel, nearly 10,000 children are hospitalized due to injury every year.

OBJECTIVES

To define injury patterns in subgroups of the pediatric population, in order to focus prevention programs on vulnerable groups.

METHODS

A retrospective study of Israel's National Trauma Registry (ITR) data on patients aged 0-17 years hospitalized between 1 January 1998 and 31 December 2002 due to trauma. Data includes patient demographic details, information on the injury, hospital resource utilization, length of stay and outcome. Descriptive statistics were used to characterize injury patterns and bivariate and multivariate analysis was used to compare injury severity and cause between population groups.

RESULTS

A total of 32,009 children were included. Falls were the cause of injury for 51% of the population, 6% of falls sustaining severe injuries (ISS 16+). Road traffic accidents (RTA) injured 23%, of which 14% were severe injuries. Burns (7%) accounted for long hospitalizations -- nearly 20% stayed for over 14 days. Crude data showed that the proportion of severe injuries and inpatient death rate among non-Jewish children was double that of Jewish children (12% vs 6% and 1% vs 0.5%, respectively (chi2, p<0.0001)). When looking at children from low socio-economic status (SES) townships, the difference in proportion of severe injuries between Jewish and non-Jewish children is reduced, yet it remains higher in non-Jewish than among Jewish children (7% vs 5%) (chi2, p=0.0001). These results were verified by multivariate logistic regression analysis adjusting for SES, age, gender and external injury cause. Non-Jewish children had a significantly higher rate of burns (10% vs 6%), falls from heights above 2.5 meters (16% vs 6% of all falls) and pedestrian injuries (51% vs 37% of all injured in RTA). When SES is taken into account, the only outstanding injury among non-Jewish children is fall from height: 13%, n=376 among non-Jewish children vs 8%, n=85 among Jewish children, living in townships with low SES cluster (1-4) (chi2, p<0.0001).

CONCLUSIONS

The findings of this study show that there is variability in external cause of injury and severity by age and ethnic group. Falls were most frequent among young children and burns among non-Jews. Non-Jewish children in SES clusters 1-4 are at high risk for falls from height, suggesting intervention and prevention activities should be directed in this direction.

Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient's Arrival to the Emergency Room

PURPOSE

To describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.

METHODS

We briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.

RESULTS

Three severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.

CONCLUSIONS

The interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.

Massive hemothorax caused by intercostal artery bleeding: selective embolization may be an alternative to thoracotomy in selected patients

Massive hemothorax is an indication for thoracotomy. We report a case of an 85-year-old debilitated patient, in whom massive hemorrhage from an actively bleeding intercostal artery was controlled by angiographic embolization. Angiographic embolization proved to be an effective alternative to thoracotomy in this patient, thus avoiding numerous postoperative complications and high mortality. Massive bleeding from an intercostal artery should be considered an indication for angiographic embolization in selected patients.

Incidence and injury characteristics of traumatic brain injury: Comparison between children, adults and seniors in Israel

AIM

To assess the incidence and injury characteristics of hospitalized trauma patients diagnosed with TBI.

METHODS

A retrospective study of all injured hospitalized patients recorded in the National Trauma Registry at 19 trauma centres in Israel between 2002-2011. Incidence and injury characteristics were examined among children, adults and seniors.

RESULTS

The annual incidence rate of hospitalized TBI for the Israeli population in 2011 was 31.8/100,000. Age-specific incidence was highest among seniors with a dramatic decrease in TBI-related mortality rate among them. Adults, in comparison to children and seniors, had higher rates of severe TBI, severe and critical injuries, more admission to the intensive care unit, underwent surgery, were hospitalization for more than 2 weeks and were discharged to rehabilitation. After adjusting for age, gender, ethnicity, mechanism of injury and injury severity score, TBI-related in-hospital mortality was higher among seniors and adults compared to children.

CONCLUSION

Seniors are at high risk for TBI-related in-hospital mortality, although adults had more severe and critical injuries and utilized more hospital resources. However, seniors showed the most significant reduction in mortality rate during the study period. Appropriate intervention programmes should be designed and implemented, targeted to reduce TBI among high risk groups.

Giant colon diverticulum: clinical and imaging findings in 17 patients with emphasis on CT criteria

PURPOSE

The purpose of the study was to review the clinical and radiologic features of giant colonic diverticulum (GCD).

METHODS

Medical records of 17 patients with GCD on computed tomographic (CT) examination were reviewed.

RESULTS

CT examination revealed the GCD in all patients as a predominantly gas-filled structure communicating with the adjacent colon. Thirteen patients showed a gas-filled structure on abdominal radiograph. The mean GCD diameter was 7 cm. Most diverticula were found in the sigmoid colon. Associated diverticulosis was present in 71% of patients.

CONCLUSION

Our experience suggests that GCD can often be diagnosed on the basis of the characteristic radiographic and CT findings in these patients.