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Debenham L, Khan N, Nouhan B, Muzaffar J. A systematic review of otologic injuries sustained in civilian terrorist explosions. Eur Arch Otorhinolaryngol 2024; 281:2223-2233. [PMID: 38189970 DOI: 10.1007/s00405-023-08393-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions. METHODS A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included. RESULTS The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I2 0.715%) and 21.0% (CI 11.9-34.3%, I2 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I2 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I2 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I2 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I2 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I2 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I2 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I2 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I2 0.689%) of ears 43.5% (CI 33.4-54.2%, I2 0.500) of people. CONCLUSION Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.
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Affiliation(s)
- Luke Debenham
- University of Warwick, University of Warwick Medical School, Coventry, UK.
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, UK.
| | - Naairah Khan
- University of Warwick, University of Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, UK
| | | | - Jameel Muzaffar
- Department of Ear Nose and Throat Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Alpert EA, Assaf J, Nama A, Pliner R, Jaffe E. Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023. Prehosp Disaster Med 2024; 39:224-227. [PMID: 38525545 DOI: 10.1017/s1049023x24000153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.
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Affiliation(s)
- Evan Avraham Alpert
- Department of Emergency Medicine, Hadassah Medical Center- Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Jacob Assaf
- Department of Emergency Medicine, Hadassah Medical Center- Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Ahmad Nama
- Department of Emergency Medicine, Hadassah Medical Center- Ein Kerem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Ruchama Pliner
- Department of Emergency Medicine, Hadassah Medical Center- Ein Kerem, Jerusalem, Israel
| | - Eli Jaffe
- Community Division, Magen David Adom, Or-Yehuda, Israel
- Department of Emergency Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Ramat Gan Academic College, Ramat Gan, Israel
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Hansen PM, Mikkelsen S, Alstrøm H, Damm-Hejmdal A, Rehn M, Berlac PA. The Field's mass shooting: emergency medical services response. Scand J Trauma Resusc Emerg Med 2023; 31:71. [PMID: 37919753 PMCID: PMC10621148 DOI: 10.1186/s13049-023-01140-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field's in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement. CASE PRESENTATION Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed. CONCLUSIONS The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges.
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Affiliation(s)
- Peter Martin Hansen
- The Mobile Emergency Care Unit, Department of Anesthesiology and Intensive Care, Odense University Hospital Svendborg, Svendborg, Denmark.
- Danish Air Ambulance, Aarhus, Denmark.
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Alstrøm
- Department of Anesthesiology and Intensive Care, Herlev and Gentofte Hospital, Herlev, Denmark
- Copenhagen Emergency Medical Services, Ballerup, Denmark
| | | | - Marius Rehn
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Dept. of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Anthony Berlac
- Copenhagen Emergency Medical Services, Ballerup, Denmark
- Department of Anesthesiology and Intensive Care, Hvidovre and Amager Hospital, Hvidovre, Denmark
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Korkmaz İ, Çelikkaya ME, Atıcı A. Secondary blast injury: radiological characteristics of shrapnel injuries in children. Emerg Radiol 2023; 30:307-313. [PMID: 37039928 DOI: 10.1007/s10140-023-02132-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE The aim of this study is to examine the radiological images of child victims suffering from secondary blast injuries, to reveal organ-based injury patterns and their interrelationships, and to record mortality rates that may develop due to injured systems. METHODS A total of 65 patients with secondary blast injury due to bomb explosion were included in the study. Injury findings due to shrapnel in radiologic images of the patients were examined. Injured systems and types of injuries were recorded. RESULTS The most common injuries were intra-abdominal injuries (63%) and fractures (58.5%). Lung injury was observed in 4 (9.8%) of 41 patients with intra-abdominal injury, while 37 (90.2%) did not, and this was statistically significant (p = 0.003). The most common intra-abdominal organ injury was a small bowel injury in 23 (35.4%) patients. The coexistence of small bowel injury and large bowel injury was present in 8 patients (34.8%), and it was statistically significant (p = 0.019). A total of 14 (21.5%) of the patients died. There was no significant relationship between mortality and gender (p = 319). Brain damage was present in 10 (71.4%) of the 14 (21.5%) patients who died, which was statistically significant (p < 0.001). CONCLUSION Our results showed that the most common injuries were intra-abdominal injuries, damage to different organs could occur at the same time, and deaths were especially associated with brain injuries. For this reason, it should not be forgotten that CT scans will have an important place in the triage of the patient, especially in victims with shrapnel at the abdominal and cranial levels in radiography examinations.
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Affiliation(s)
- İnan Korkmaz
- Department of Radiology, Faculty of Medicine, Hatay Mustafa Kemal University, Alahan Kampüsü, Antakya, Hatay, Turkey.
| | - Mehmet Emin Çelikkaya
- Department of Pediatric Surgery, Faculty of Medicine, Hatay Mustafa Kemal University, Alahan Kampüsü, Antakya, Hatay, Turkey
| | - Ahmet Atıcı
- Department of Pediatric Surgery, Faculty of Medicine, Hatay Mustafa Kemal University, Alahan Kampüsü, Antakya, Hatay, Turkey
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Muacevic A, Adler JR, Kaito D, Nakama R, Izawa Y. Blast Injuries by an Improvised Explosive Device in Japan: A Case Report. Cureus 2022; 14:e32118. [PMID: 36601169 PMCID: PMC9805535 DOI: 10.7759/cureus.32118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 12/05/2022] Open
Abstract
Blast injuries caused by an improvised explosive device (IED) are becoming more common in civilian settings. However, physicians may not be familiar with the treatment and management of blast-injured victims. To the best of our knowledge, this is the first case report of a blast injury caused by an IED in Japan. A 64-year-old man was admitted to our hospital's emergency department after sustaining a blast injury. His vital signs were stable, but he had multiple small wounds with embedded foreign bodies that were consistent with injuries sustained by IED victims. The patient was treated for his injuries and was moved to another hospital on day 37. Knowledge about blast injuries caused by IEDs and management strategies for mass casualties are both necessary.
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Pfenninger EG, Villhauer S, Königsdorfer M. [Hospital disaster planning in south-western Germany. A survey of 214 clinics]. Notf Rett Med 2022:1-10. [PMID: 35991807 PMCID: PMC9380686 DOI: 10.1007/s10049-022-01065-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/24/2022]
Abstract
Background Due to legal regulations in Germany, public acute and emergency (A&E) hospitals-along with responsible authorities, emergency medical services, and other institutions such as the state medical associations-are committed to participate in civil protection. This participation includes the need to create and update emergency plans for external and internal crises and to take part in disaster drills. In fact, so far there is only little literature to prove whether and to what extent hospitals fulfill their obligations on this topic. Objectives Using a standardized survey, the state of emergency planning in hospitals in Baden-Wuerttemberg was evaluated. Materials and methods Based on a listing provided by the Hospital Society of Baden-Wuerttemberg (BWKG), all 214 hospitals in Baden-Wuerttemberg were identified. The standardized questionnaire inquired about specific characteristics of the emergency plan, the availability and knowledge of this plan by the hospital workforce and other local institutions that take part in civil protection and, finally, participation in disaster drills were queried. Results Of the 214 hospitals in Baden-Wuerttemberg, 135 (63%) provided information using the questionnaire. Except for one hospital, all other clinics indicated having a special emergency plan ready. In most cases (79.3%), both external (e.g., mass casualty incidents) and internal (e.g., fire, failure of technical equipment) crises are covered. In the vast majority of cases (94%), the hospitals also indicated that they regularly update their emergency plan, whereby the frequency of updates varied markedly. Three quarters of the hospitals said that they also regularly simulate the use of the emergency plan in disaster drills. In two thirds of the cases, external forces such as emergency medical services or the fire department also take part in these drills along with the hospitals themselves. In some cases, knowledge gained from the drills was incorporated into the emergency plan or led to improvements in staff training. Conclusions The willingness of public hospitals to establish comprehensive disaster planning and to take part in related drills seems to have improved noticeably in recent years. However, there is still the need for improvement in keeping the concepts up to date at some hospitals. Especially smaller hospitals showed deficits in emergency planning, particularly concerning preparedness for internal crises, resulting from failure of technical equipment. More regular drills should be used to test existing concepts and to familiarize employees with the processes on a routine basis.
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Affiliation(s)
- Ernst G. Pfenninger
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081 Ulm, Deutschland
| | - Sabine Villhauer
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081 Ulm, Deutschland
| | - Manuel Königsdorfer
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081 Ulm, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Ulm, Deutschland
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Gebran A, Abou Khalil E, El Moheb M, Albaini O, El Warea M, Ibrahim R, Karam K, El Helou MO, Ramly EP, El Hechi M, Matar A, Zeineddine J, Dabar G, Al Hajj A, Abi Saad G, Hoballah J, Safadi B, Kaafarani HMA. The Beirut Port Explosion Injuries and Lessons Learned: Results of the Beirut Blast Assessment for Surgical Services (BASS) Multicenter Study. Ann Surg 2022; 275:398-405. [PMID: 34967201 DOI: 10.1097/sla.0000000000005322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This multicenter study aims to describe the injury patterns, emergency management and outcomes of the blast victims, recognize the gaps in hospital disaster preparedness, and identify lessons to be learned. SUMMARY BACKGROUND DATA On August 4th, 2020, the city of Beirut, Lebanon suffered the largest urban explosion since Hiroshima and Nagasaki, resulting in hundreds of deaths and thousands of injuries. METHODS All injured patients admitted to four of the largest Beirut hospitals within 72 hours of the blast, including those who died on arrival or in the emergency department (ED), were included. Medical records were systematically reviewed for: patient demographics and comorbidities; injury severity and characteristics; prehospital, ED, operative, and inpatient interventions; and outcomes at hospital discharge. Lessons learned are also shared. RESULTS An estimated total of 1818 patients were included, of which 30 died on arrival or in the ED and 315 were admitted to the hospital. Among admitted patients, the mean age was 44.7 years (range: 1 week-93 years), 44.4% were female, and the median injury severity score (ISS) was 10 (5, 17). ISS was inversely related to the distance from the blast epicenter (r = --0.18, P = 0.035). Most injuries involved the upper extremities (53.7%), face (42.2%), and head (40.3%). Mildly injured (ISS <9) patients overwhelmed the ED in the first 2 hours; from hour 2 to hour 8 post-injury, the number of moderately, severely, and profoundly injured patients increased by 127%, 25% and 17%, respectively. A total of 475 operative procedures were performed in 239 patients, most commonly soft tissue debridement or repair (119 patients, 49.8%), limb fracture fixation (107, 44.8%), and tendon repair (56, 23.4%). A total of 11 patients (3.5%) died during the hospitalization, 56 (17.8%) developed at least 1 complication, and 51 (16.2%) were discharged with documented long-term disability. Main lessons learned included: the importance of having key hospital functions (eg, laboratory, operating room) underground; the nonadaptability of electronic medical records to disasters; the ED overwhelming with mild injuries, delay in arrival of the severely injured; and the need for realistic disaster drills. CONCLUSIONS We, therefore, describe the injury patterns, emergency flow and trauma outcome of patients injured in the Beirut port explosion. The clinical and system-level lessons learned can help prepare for the next disaster.
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Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Elissa Abou Khalil
- Division of Pulmonary and Critical Care, Hôtel Dieu de France, Saint Joseph University, Beirut, Lebanon
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Obey Albaini
- Lebanese American University Gilbert and Rose Marie Chagoury School of Medicine, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | | | - Rand Ibrahim
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Karin Karam
- Lebanese American University Gilbert and Rose Marie Chagoury School of Medicine, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mohamad Othman El Helou
- Lebanese American University Gilbert and Rose Marie Chagoury School of Medicine, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Elie P Ramly
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
| | - Ayah Matar
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jana Zeineddine
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - George Dabar
- Division of Pulmonary and Critical Care, Hôtel Dieu de France, Saint Joseph University, Beirut, Lebanon
| | | | - George Abi Saad
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamal Hoballah
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassem Safadi
- Lebanese American University Gilbert and Rose Marie Chagoury School of Medicine, LAU Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
- Center for Outcomes & Patient Safety in Surgery (COMPASS), Massachusetts General Hospital, Boston, MA
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Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review. Eur J Trauma Emerg Surg 2022; 48:2613-2638. [PMID: 35024874 PMCID: PMC8757406 DOI: 10.1007/s00068-021-01858-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 11/03/2022]
Abstract
Purpose The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001. Methods PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018. Results Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied. Conclusions The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.
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Hansen PM, Jepsen SB, Mikkelsen S, Rehn M. The Great Belt train accident: the emergency medical services response. Scand J Trauma Resusc Emerg Med 2021; 29:140. [PMID: 34556163 PMCID: PMC8461896 DOI: 10.1186/s13049-021-00954-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022] Open
Abstract
Background Major incidents (MI) are rare occurrences in Scandinavia. Literature depicting Scandinavian MI management is scarce and case reports and research is called for. In 2019, a trailer falling off a freight train struck a passing high-speed train on the Great Belt Bridge in Denmark, killing eight people instantly and injuring fifteen people. We aim to describe the emergency medical services (EMS) response to this MI and evaluate adherence to guidelines to identify areas of improvement for future MI management. Case presentation Nineteen EMS units were dispatched to the incident site. Ambulances transported fifteen patients to a trauma centre after evacuation. Deceased patients were pronounced life-extinct on-scene. Radio communication was partly compromised, since 38.9% of the radio shifts were not according to the planned radio grid and presented a potential threat to patient outcome and personnel safety. Access to the incident site was challenging and delayed due to traffic congestion and safety issues. Conclusion Despite harsh weather conditions and complex logistics, the availability of EMS units was sufficient and patient treatment and evacuation was uncomplicated. Triage was relevant, but at the physicians’ discretion. Important findings were communication challenges and the consequences of difficult access to the incident site. There is a need for an expansion of capacity in formal education in MI management in Denmark. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00954-7.
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Affiliation(s)
- Peter Martin Hansen
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital Svendborg, Baagøes Allé 31, 5700, Svendborg, Denmark. .,Danish Air Ambulance, Olof Palmes Allé 34, 1. Sal, 8200, Aarhus N, Denmark. .,Faculty of Health Sciences, University of Stavanger, Kjell Arholms Gate 41, 4021, Stavanger, Norway.
| | - Søren Bruun Jepsen
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Søren Mikkelsen
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.,The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.,Department of Regional Health Research, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Postboks 414 Sentrum, Oslo, Norway.,Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Kjell Arholms Gate 41, 4021, Stavanger, Norway
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James A, Yordanov Y, Ausset S, Langlois M, Tourtier JP, Carli P, Riou B, Raux M. Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule. Eur J Emerg Med 2021; 28:136-143. [PMID: 33252375 DOI: 10.1097/mej.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKROUND Triage is key in the management of mass casualty incidents. OBJECTIVE The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. DESIGN SETTING AND PARTICIPANT This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. OUTCOMES MEASURES AND ANALYSIS The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. MAIN RESULT Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. CONCLUSION A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.
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Affiliation(s)
- Arthur James
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
| | - Youri Yordanov
- Sorbonne Université
- UMRS Inserm 1136
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- Department of Emergency, APHP
| | - Sylvain Ausset
- Department of Anesthesiology and Critical Care, Hôpital d'Instruction des armées (HIA), Clamart
| | - Matthieu Langlois
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- Service Médical du RAID, Bièvres
| | | | - Pierre Carli
- Service d'Aide Médicale Urgente 75, Hôpital Necker-Enfants Malades, APHP
- Université de Paris
| | - Bruno Riou
- Sorbonne Université
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- UMRS Inserm 1166, IHU ICAN
- Department of Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière
| | - Mathieu Raux
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- UMRS Inserm 1158, Paris, France
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Demirel ME, Ali İH, Boğan M. Emergency service experience following the terrorist attack in Mogadishu, 14 October 2017, a scene of lay rescuer triage. Am J Emerg Med 2020; 40:6-10. [PMID: 33326911 DOI: 10.1016/j.ajem.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A suicide bomber attack occurred in Somalia's capital city of Mogadishu on October 14, 2017. Over 500 people died, making it the third largest suicide bombing attack in world history. In this study, we aimed to share our experience and to discuss the importance of triage and prehospital care systems. METHODS These retrospective data included data from patients who suffered from severe explosions. Patient triage was performed using the START (Simple Triage and Rapid Treatment) triage algorithm at the entrance of the hospital. The patients included in the study were classified according to their age, sex, triage code, location of their major injury, department to which they were admitted, and discharge and/or exit status. RESULTS The patients included 188 (74.6%) males, and the mean age was 30.94 ± 12.23 years (range, 1-80 years). Eighty-six (34.1%) patients were marked with a red code indicating major injury, and 138 (54.8%) patients had superficial injuries. A total of 173 (68.7%) patients were managed in the emergency department (ED), and 7 (2.8%) patients died in the first 24 h. Multiple trauma injuries were detected in 43 (17.1%) patients, and 31 (12.3%) patients were admitted to the orthopedics department. CONCLUSION Disaster management in a terrorist event requires rapid transport, appropriate triage, effective surgical approaches, and specific postoperative care. In this event, almost all patients were brought to the ED by lay rescuers. Appropriate triage algorithms for the public can be designed; for instance, green code: walking patient; yellow code: patient who is moving and asking for help; red code: unmoving or less mobile patient who is breathing; black code: nonbreathing patient.
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Affiliation(s)
- Mustafa Enes Demirel
- Emergency Department, School of Medicine, Bolu Abant İzzet Baysal University, Turkey.
| | - İbrahim Hussein Ali
- Emergency Department, Somalia-Turkey Education and Research Hospital, Mogadishu, Somalia
| | - Mustafa Boğan
- Emergency Department, School of Medicine, Düzce University, Turkey.
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Pfenninger EG, Klingler W, Keiloweit T, Eble M, Wenzel V, Krüger WA. [Terrorist attack training exercise-What can be learned? : Baden-Württemberg counterterrorism exercise (BWTEX)]. Anaesthesist 2020; 69:477-486. [PMID: 32488534 DOI: 10.1007/s00101-020-00797-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is a risk of terror attacks in the Federal Republic of Germany, which might increase in the future. A timely comprehensive strategy for treatment and care of a large number of casualties helps minimize chaos and improve the outcome of patients. Adequate training is vital for successful implementation of an emergency plan. Therefore, the effectiveness of training should be assessed and evaluated; however, data collection capabilities for training events are extremely limited, so that publications on the topic are almost impossible to find. OBJECTIVE This study aimed to collect data from a simulated terrorist attack in order to draw conclusions from a clinical point of view concerning the improvement of preclinical and clinical management, taking interface problems into consideration. MATERIAL AND METHODS On 19 October 2019 the Ministry of the Interior, Digitalization and Migration of Baden-Württemberg conducted a large-scale simulation of a terrorist attack in the city center of Constance, called the Baden-Württemberg counterterrorism exercise (BWTEX). The simulation included an explosion of a car bomb as well as the use of firearms by terrorists. The large scale of the simulation with the high number of participants in combination with close cooperation between military and civil forces was unprecedented. The police force, the armed forces, civil protection forces, air rescue teams and staff from Constance, Friedrichshafen and Sigmaringen regional hospitals in southwest Germany worked together to treat simulated injuries to victims of the attack. The following parameters were recorded when the injured patients arrived at the hospital: prehospital triage time, prehospital triage score, initial treatment and quality of documentation on site as well as triage time, triage score, injury severity scale (ISS) score based on the specified injury pattern, treatment, and quality of documentation on hospital arrival. RESULTS Out of a total of 84 "injured patients" 55 were admitted to hospital and 80% were triaged at the scene. Injured patients of triage category 1 (TK1 red: life-threatening injury, immediate treatment) arrived at the hospital 198 ± 50 min after the attack, injured patients of triage category 2 (TK2 yellow: severely injured, urgent treatment) after 131 ± 44 min and injured patients of triage category 3 (TK3 green: slightly injured, non-urgent treatment) arrived after 157 ± 46 min. There was no significant difference in terms of arrival time at the hospital between the triage scores (r = 0.2) or between the ISS scores (r = 0.43). The authors assume that approximately 44% of TK1 patients would have died due to avoidable time delays. Prehospital medical documentation was insufficient in 78% and insufficient in 65% in the hospitals. CONCLUSION A mass casualty incident resulting from a terrorist attack differs greatly from a conventional mass casualty incident. The scene of the attack has to be evacuated as quickly as possible, which means that a large number of patients arrive untreated at the nearest hospitals. The setting up of treatment facilities in city centers and areas close to the city seems to be counterproductive because the time delay may result in higher mortality rates of victims. The particularities of mass casualties caused by a terrorist attack have to be incorporated into terrorist attack training.
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Affiliation(s)
- E G Pfenninger
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081, Ulm, Deutschland. .,Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Sigmaringen, Sigmaringen, Deutschland.
| | - W Klingler
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Sigmaringen, Sigmaringen, Deutschland
| | - Th Keiloweit
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
| | - M Eble
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee, Klinikum Friedrichshafen, Friedrichshafen, Deutschland
| | - V Wenzel
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee, Klinikum Friedrichshafen, Friedrichshafen, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
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Wallace RG, Kenealy MR, Brady AJ, Twomey L, Duffy E, Degryse B, Caballero-Lima D, Moyna NM, Custaud MA, Meade-Murphy G, Morrin A, Murphy RP. Development of dynamic cell and organotypic skin models, for the investigation of a novel visco-elastic burns treatment using molecular and cellular approaches. Burns 2020; 46:1585-1602. [PMID: 32475797 DOI: 10.1016/j.burns.2020.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Burn injuries are a major cause of morbidity and mortality worldwide. Despite advances in therapeutic strategies for the management of patients with severe burns, the sequelae are pathophysiologically profound, up to the systemic and metabolic levels. Management of patients with a severe burn injury is a long-term, complex process, with treatment dependent on the degree and location of the burn and total body surface area (TBSA) affected. In adverse conditions with limited resources, efficient triage, stabilisation, and rapid transfer to a specialised intensive care burn centre is necessary to provide optimal outcomes. This initial lag time and the form of primary treatment initiated, from injury to specialist care, is crucial for the burn patient. This study aims to investigate the efficacy of a novel visco-elastic burn dressing with a proprietary bio-stimulatory marine mineral complex (MXC) as a primary care treatment to initiate a healthy healing process prior to specialist care. METHODS A new versatile emergency burn dressing saturated in a >90% translucent water-based, sterile, oil-free gel and carrying a unique bio-stimulatory marine mineral complex (MXC) was developed. This dressing was tested using LabSkin as a burn model platform. LabSkin a novel cellular 3D-dermal organotypic full thickness human skin equivalent, incorporating fully-differentiated dermal and epidermal components that functionally models skin. Cell and molecular analysis was carried out by in vitro Real-Time Cellular Analysis (RTCA), thermal analysis, and focused transcriptomic array profiling for quantitative gene expression analysis, interrogating both wound healing and fibrosis/scarring molecular pathways. In vivo analysis was also performed to assess the bio-mechanical and physiological effects of this novel dressing on human skin. RESULTS This hybrid emergency burn dressing (EBD) with MXC was hypoallergenic, and improved the barrier function of skin resulting in increased hydration up to 24 h. It was demonstrated to effectively initiate cooling upon application, limiting the continuous burn effect and preventing local tissue from damage and necrosis. xCELLigence RTCA® on primary human dermal cells (keratinocyte, fibroblast and micro-vascular endothelial) demonstrated improved cellular function with respect to tensegrity, migration, proliferation and cell-cell contact (barrier formation) [1]. Quantitative gene profiling supported the physiological and cellular function finding. A beneficial quid pro quo regulation of genes involved in wound healing and fibrosis formation was observed at 24 and 48 h time points. CONCLUSION Utilisation of this EBD + MXC as a primary treatment is an effective and easily applicable treatment in cases of burn injury, proving both a cooling and hydrating environment for the wound. It regulates inflammation and promotes healing in preparation for specialised secondary burn wound management. Moreover, it promotes a healthy remodelling phenotype that may potentially mitigate scarring. Based on our findings, this EBD + MXC is ideal for use in all pre-hospital, pre-surgical and resource limited settings.
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Affiliation(s)
- Robert G Wallace
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland
| | - Mary-Rose Kenealy
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland
| | - Aidan J Brady
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland
| | - Laura Twomey
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland; Technological University Dublin, Ireland
| | - Emer Duffy
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland
| | - Bernard Degryse
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland; Integrative Cell & Molecular Physiology Group, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland
| | | | - Niall M Moyna
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland
| | | | | | - Aoife Morrin
- School of Chemical Sciences, Dublin City University, Dublin 9, Ireland
| | - Ronan P Murphy
- Center for Preventive Medicine, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland; Integrative Cell & Molecular Physiology Group, School of Health & Human Performance, Dublin City University, Dublin 9, Ireland.
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McDonald Johnston A, Alderman JE. Thoracic Injury in Patients Injured by Explosions on the Battlefield and in Terrorist Incidents. Chest 2019; 157:888-897. [PMID: 31605701 DOI: 10.1016/j.chest.2019.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 09/02/2019] [Accepted: 09/05/2019] [Indexed: 11/25/2022] Open
Abstract
Thoracic injury is common on the battlefield and in terrorist attacks, occurring in 10% to 70% of patients depending on the type of weapons used. Typical injuries seen include bullet, blast, and fragment injuries to the thorax, which are often associated with injuries to other parts of the body. Initial treatment prehospital and in the ED is carried out according to the principles of Tactical Combat Casualty Care or other standard trauma management systems. Immediately life-threatening problems including catastrophic hemorrhage are dealt with rapidly, and early consideration is given to CT scanning or rapid surgical intervention where appropriate. All patients should be given lung-protective ventilation. Treatment of these patients in the critical care unit is complicated by the severity of associated injuries and by features specific to combat trauma including blast lung injury, a high incidence of delirium, unusual infections such as colonization with multidrug-resistant Acinetobacter baumannii complex, and sometimes invasive fungal infections. A minority of patients with blast lung injury in published series have been successfully treated with prolonged respiratory support with high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. The role of newer treatment options such as resuscitative endovascular balloon occlusion of the aorta is not yet known. In this article we review the relatively sparse literature on this group of patients and provide practical advice based on the literature and our institution's extensive experience of managing battlefield casualties.
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Affiliation(s)
- Andrew McDonald Johnston
- Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research, University of Birmingham, Birmingham, UK; Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Joseph Edward Alderman
- Department of Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK; Birmingham Acute Care Research, University of Birmingham, Birmingham, UK
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Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury. Intensive Care Med 2019; 45:1231-1240. [PMID: 31418059 DOI: 10.1007/s00134-019-05724-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. METHODS This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. RESULTS 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. CONCLUSION The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. FUNDING Assistance Publique-Hôpitaux de Paris.
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Chuang S, Chang KS, Woods DD, Chen HC, Reynolds ME, Chien DK. Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion. Burns 2018; 45:964-973. [PMID: 30598266 DOI: 10.1016/j.burns.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To provide an insight into the challenges faced by the closest hospital to the Formosa Fun Coast Dust Explosion (FFCDE) disaster scene, and to examine how the hospital staff adapted to cope with the mass burn casualty (MBC) in their overcrowded emergency department (ED) after the disaster. MATERIAL AND METHODS The critical incident technique was used for the investigation. Data was gathered through in-depth individual interviews with 15 key participants in this event. The interview data was combined with the medical records of the FFCDE patients and admission logs to build a detailed timeline of ED workload. Process tracing analysis was used to evaluate how the ED and other units adapted to deal with actual and potential bottlenecks created by the patient surge. RESULTS Fifty-eight burn patients were treated and registered in approximately six hours while the ED managed 43 non-FFCDE patients. Forty-four patients with average total body surface area burn 51.3% were admitted. Twenty burn patients were intubated. The overwhelming demand created shortages primarily of clinicians, ED space, stretchers, ICU beds, and critical medical materials for burn care. Adaptive activities for the initial resuscitation are identified and synthesized into three typical adaptation patterns. These adaptations were never previously adopted in ED normal practices for daily surge nor in periodical exercises. The analysis revealed adaptation stemmed from the dynamic re-planning and coordination across roles and units and the anticipation of bottlenecks ahead. CONCLUSION In the hospital closest to the FFCDE disaster scene, it caused an overwhelming demand in an already crowded, beyond-nominal-capacity ED. This study describes how the hospital mobilized and reconfigured response capacity to cope with overload, uncertainty, and time pressure. These findings support improving disaster planning and preparedness for all healthcare entities through organizational support for adaptation and routine practice coping with unexpected scenarios.
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Affiliation(s)
- Sheuwen Chuang
- Graduate Institute of Data Science, Taipei Medical University, Taipei, Taiwan; Health Policy and Care Research Center, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Song Chang
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - David D Woods
- Department of Integrated Systems Engineering, The Ohio State University, OH, USA
| | - Hsiao-Chun Chen
- Health Policy and Care Research Center, Taipei Medical University, Taipei, Taiwan
| | - Morgan E Reynolds
- Department of Integrated Systems Engineering, The Ohio State University, OH, USA
| | - Ding-Kuo Chien
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan; School of Medicine, Mackay Medical College, Taipei, Taiwan.
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Cesareo E, Raux M, Soulat L, Huot-Marchand F, Voiglio E, Puidupin A, Claret PG, Desclef JP, Douay B, Duchenne J, Gloaguen A, Lefort H, Rerbal D, Zanker C, Cook F, Pelée de Saint Maurice G, Lachenaud L, Gabilly L, Prieto N, Levraut J, Gueugniaud PY. Recommandations de bonne pratique clinique concernant la prise en charge médicale des victimes d’une « tuerie de masse ». ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Dick E, Ballard M, Alwan-Walker H, Kashef E, Batrick N, Hettiaratchy S, Moran C. Bomb blast imaging: bringing order to chaos. Clin Radiol 2018; 73:509-516. [DOI: 10.1016/j.crad.2017.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
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Ellenberg E, Taragin MI, Hoffman JR, Cohen O, Luft-Afik D, Bar-On Z, Ostfeld I. Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations. Milbank Q 2017; 95:783-800. [PMID: 29226443 DOI: 10.1111/1468-0009.12299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Policy Points: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror. CONTEXT Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. Based on an 18-month follow-up of the Israeli civilian population following the 2014 war in Gaza, we describe and analyze the medical costs associated with rocket attacks and review the demography of the victims who filed claims for disability compensation. We then propose practical lessons to help health care authorities prepare for future confrontations. METHOD Using the National Insurance Institute of Israel's (NII) database, we conducted descriptive and comparative analyses using statistical tests (Fisher's Exact Test, chi-square test, and students' t-tests). The costs were updated until March 30, 2016, and are presented in US dollars. We included only civilian expenses in our analysis. FINDINGS We identified 5,189 victims, 3,236 of whom presented with acute stress reactions during the conflict. Eighteen months after the conflict, the victims' total medical costs reached $4.4 million. The NII reimbursed $2,541,053 for associated medical costs and $1,921,792 for associated mental health costs. A total of 709 victims filed claims with the NII for further support, including rehabilitation, medical devices, and disability pensions. CONCLUSION We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror.
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Hospital Surge Capacity: A Web-Based Simulation Tool for Emergency Planners. Disaster Med Public Health Prep 2017; 12:513-522. [DOI: 10.1017/dmp.2017.93] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractThe National Center for the Study of Preparedness and Catastrophic Event Response (PACER) has created a publicly available simulation tool called Surge (accessible at http://www.pacerapps.org) to estimate surge capacity for user-defined hospitals. Based on user input, a Monte Carlo simulation algorithm forecasts available hospital bed capacity over a 7-day period and iteratively assesses the ability to accommodate disaster patients. Currently, the tool can simulate bed capacity for acute mass casualty events (such as explosions) only and does not specifically simulate staff and supply inventory. Strategies to expand hospital capacity, such as (1) opening unlicensed beds, (2) canceling elective admissions, and (3) implementing reverse triage, can be interactively evaluated. In the present application of the tool, various response strategies were systematically investigated for 3 nationally representative hospital settings (large urban, midsize community, small rural). The simulation experiments estimated baseline surge capacity between 7% (large hospitals) and 22% (small hospitals) of staffed beds. Combining all response strategies simulated surge capacity between 30% and 40% of staffed beds. Response strategies were more impactful in the large urban hospital simulation owing to higher baseline occupancy and greater proportion of elective admissions. The publicly available Surge tool enables proactive assessment of hospital surge capacity to support improved decision-making for disaster response. (Disaster Med Public Health Preparedness. 2018;12:513–522)
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Abstract
The incidence of blast injury has increased recently. As the ear is the organ most sensitive to blast overpressure, the most frequent injuries seen after blast exposure are those affecting the ear. Blast overpressure affecting the ear results in sensorineural hearing loss, which is untreatable and often associated with a decline in the quality of life. Here, we review recent cases of blast-induced hearing dysfunction. The tympanic membrane is particularly sensitive to blast pressure waves, since such waves exert forces mainly at air-tissue interfaces within the body. However, treatment of tympanic membrane perforation caused by blast exposure is more difficult than that caused by other etiologies. Sensorineural hearing dysfunction after blast exposure is caused mainly by stereociliary bundle disruption on the outer hair cells. Also, a reduction in the numbers of synaptic ribbons in the inner hair cells and spiral ganglion cells is associated with hidden hearing loss, which is strongly associated with tinnitus or hyperacusis.
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Affiliation(s)
- Kunio Mizutari
- Department of Otolaryngology, Head and Neck Surgery, National Defense Medical College, Saitama, 359-8513, Japan
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Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise. Prehosp Disaster Med 2017; 32:662-666. [DOI: 10.1017/s1049023x17006793] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIn recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals’ true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital’s response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED “immediate bed availability (IBA)” as an objective, dynamic measure of an ED’s physical capacity for new arrivals.WaxmanDA, ChanEW, PillemerF, SmithTWJ, AbirM, NelsonC. Assessing and improving hospital mass-casualty preparedness: a no-notice exercise. Prehosp Disaster Med. 2017;32(6):662–666.
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Keller M, Sload R, Wilson J, Greene H, Han P, Wise S. Tympanoplasty following Blast Injury. Otolaryngol Head Neck Surg 2017; 157:1025-1033. [DOI: 10.1177/0194599817717486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives To assess outcomes following tympanoplasty for blast-induced tympanic membrane perforations in a military population. Study Design Case series with chart review. Setting Tertiary care medical centers. Subjects and Methods Military personnel (N = 254) undergoing tympanoplasty for blast-related tympanic membrane perforations sustained between April 2005 and July 2014 were identified from the Expeditionary Medical Encounter Database. Descriptive statistics were obtained regarding demographics, primary and revision surgery success rates, hearing status pre- and postsurgery, and frequency of ossicular reconstruction. Rates of successful perforation closure were assessed against perforation size and character (central vs marginal) and time to surgery. Rates and types of complications were additionally explored. Results There were a total of 352 operations among 254 subjects, with an 82.1% rate of successful closure following primary surgery. For successful primary tympanoplasty, the mean improvement in pure tone average was 11.7 ± 12.1 dB. Ossiculoplasty was performed in 9.1% (32 of 352) of cases. There was no significant relationship between successful perforation closure and perforation size, perforation character, or time between injury and surgery. Cholesteatoma complicated 4.3% (15 of 352) of cases. A significant relationship was identified between risk of cholesteatoma development and increasing perforation size and marginal perforations. Conclusion Tympanoplasty success rates for blast-induced tympanic membrane perforations are lower than for other common injury mechanisms. Due to appreciable rates of postoperative cholesteatoma development, close clinical surveillance is recommended.
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Affiliation(s)
- Matthew Keller
- Department of Otolaryngology–Head and Neck Surgery, Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
| | - Ryan Sload
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
| | - Justin Wilson
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
| | - Howard Greene
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
| | - Peggy Han
- Naval Health Research Center, San Diego, California, USA
| | - Sean Wise
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
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Kearns RD, Marcozzi DE, Barry N, Rubinson L, Hultman CS, Rich PB. Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century. Clin Plast Surg 2017; 44:441-449. [PMID: 28576233 PMCID: PMC7112249 DOI: 10.1016/j.cps.2017.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."
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Affiliation(s)
- Randy D Kearns
- Management Services Division, Tillman School of Business, University of Mount Olive, Mount Olive, NC, USA.
| | - David E Marcozzi
- The University of Maryland School of Medicine, 620 West Lexington Street, Baltimore, MD 21201, USA; USAR, US Army Special Operations Command, Ft. Bragg, NC, USA
| | - Noran Barry
- Acute Care Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Lewis Rubinson
- Critical Care Resuscitation Unit, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles Scott Hultman
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Preston B Rich
- Acute Care Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Surgical support during the terrorist attacks in Paris, November 13, 2015. J Trauma Acute Care Surg 2017; 82:1122-1128. [DOI: 10.1097/ta.0000000000001461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kulla M, Maier J, Bieler D, Lefering R, Hentsch S, Lampl L, Helm M. [Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®]. Unfallchirurg 2017; 119:843-53. [PMID: 26286180 DOI: 10.1007/s00113-015-0046-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive. MATERIAL AND METHODS A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed. RESULTS A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %). CONCLUSION This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.
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Affiliation(s)
- M Kulla
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - J Maier
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs-, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - R Lefering
- Institut für Forschung in der Operativen Medizin, Universität Witten-Herdecke, Witten, Deutschland
| | - S Hentsch
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs-, Hand- und Plastische Chirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - L Lampl
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - M Helm
- Klinik für Anästhesiologie und Intensivmedizin, Bundeswehrkrankhaus Ulm, Akademisches Krankenhaus der Universität Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
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Zhang Z, Liang Z, Li H, Li C, Yang Z, Li Y, She D, Cao L, Wang W, Liu C, Chen L. Perfluorocarbon reduces cell damage from blast injury by inhibiting signal paths of NF-κB, MAPK and Bcl-2/Bax signaling pathway in A549 cells. PLoS One 2017; 12:e0173884. [PMID: 28323898 PMCID: PMC5360309 DOI: 10.1371/journal.pone.0173884] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/28/2017] [Indexed: 12/29/2022] Open
Abstract
Background and objective Blast lung injury is a common type of blast injury and has very high mortality. Therefore, research to identify medical therapies for blast injury is important. Perfluorocarbon (PFC) is used to improve gas exchange in diseased lungs and has anti-inflammatory functions in vitro and in vivo. The aim of this study was to determine whether PFC reduces damage to A549 cells caused by blast injury and to elucidate its possible mechanisms of action. Study design and methods A549 alveolar epithelial cells exposed to blast waves were treated with and without PFC. Morphological changes and apoptosis of A549 cells were recorded. PCR and enzyme-linked immunosorbent assay (ELISA) were used to measure the mRNA or protein levels of IL-1β, IL-6 and TNF-α. Malondialdehyde (MDA) levels and superoxide dismutase (SOD) activity levels were detected. Western blot was used to quantify the expression of NF-κB, Bax, Bcl-2, cleaved caspase-3 and MAPK cell signaling proteins. Results A549 cells exposed to blast wave shrank, with less cell-cell contact. The morphological change of A549 cells exposed to blast waves were alleviated by PFC. PFC significantly inhibited the apoptosis of A549 cells exposed to blast waves. IL-1β, IL-6 and TNF-α cytokine and mRNA expression levels were significantly inhibited by PFC. PFC significantly increased MDA levels and decreased SOD activity levels. Further studies indicated that NF-κB, Bax, caspase-3, phospho-p38, phosphor-ERK and phosphor-JNK proteins were also suppressed by PFC. The quantity of Bcl-2 protein was increased by PFC. Conclusion Our research showed that PFC reduced A549 cell damage caused by blast injury. The potential mechanism may be associated with the following signaling pathways: 1) the signaling pathways of NF-κB and MAPK, which inhibit inflammation and reactive oxygen species (ROS); and 2) the signaling pathways of Bcl-2/Bax and caspase-3, which inhibit apoptosis.
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Affiliation(s)
- Zhaorui Zhang
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Zhixin Liang
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Huaidong Li
- Department of Respiratory Disease, The 88th Hospital of Chinese PLA, Tai’an City, Shandong Province, People’s Republic of China
| | - Chunsun Li
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Zhen Yang
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Yanqin Li
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Danyang She
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Lu Cao
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
| | - Wenjie Wang
- Department of State Key Laboratory of Explosion Science and Technology, The Beijing University of Technology, Beijing City, People’s Republic of China
| | - Changlin Liu
- Department of State Key Laboratory of Explosion Science and Technology, The Beijing University of Technology, Beijing City, People’s Republic of China
| | - Liangan Chen
- Department of Respiration, Chinese PLA General Hospital, Beijing City, People’s Republic of China
- * E-mail:
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Tresson P, Touma J, Gaudric J, Pellenc Q, Le Roux M, Pierret C, Kobeiter H, Julia P, Goeau-Brissonniere O, Desgranges P, Koskas F, Castier Y. Management of Vascular Trauma during the Paris Terrorist Attack of November 13, 2015. Ann Vasc Surg 2017; 40:44-49. [PMID: 28161564 DOI: 10.1016/j.avsg.2016.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/11/2016] [Accepted: 09/19/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND On November 13, 2015, Paris and Saint-Denis were the targets of terrorist attacks. The Public Hospitals of Paris Organization and the Percy Armed Forces Instruction Hospitals were mobilized to face the mass casualty situation. The objective of this study is to analyze the management of the victims presenting with a nonthoracic vascular trauma (NTVT). METHODS All the data relating to the victims of NTVT who required a specific vascular open or endovascular treatment were analyzed retrospectively. A 6-month follow-up was obtained for all the patients. RESULTS Among the 351 wounded, 20 (5.7%) patients had an NTVT and were dispatched in 8 hospitals (11 men of average age 32). NTVTs were gunshots in 17 cases (85%) or due to a handmade bomb in 3 cases (15%). Twelve patients (60%) received cardiopulmonary resuscitation during prehospital care. NTVT affected the limbs (14 cases, 70%) and the abdomen or the small pelvis (6 cases, 30%). All the patients were operated in emergency. Arterial lesions were treated with greater saphenous vein bypasses, by ligation, and/or embolization. Eleven venous lesions were treated by direct repair or ligation. Associated lesions requiring a specific treatment were present in 19 patients (95%) and were primarily osseous, nervous, and abdomino-pelvic. Severe postoperative complications were observed in 9 patients (45%). Fourteen patients (70%) required blood transfusion (6.4 U of packed red blood cells on average, range 0-48). There were no deaths or amputation and all vascular reconstructions were patent at 6 months. CONCLUSIONS The effectiveness of the prehospital emergency services and a multisite and multidisciplinary management made it possible to obtain satisfactory results for NTVT casualties. All the departments of vascular surgery must be prepared to receive many wounded victims in the event of terrorist attacks.
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Affiliation(s)
- Philippe Tresson
- Service de Chirurgie Vasculaire, Hôpital de la Pitié-Salpêtrière, AP-HP, Faculté de Médecine Pierre et Marie Curie, Université Paris 6, Paris, France
| | - Joseph Touma
- Service de Chirurgie Vasculaire, Hôpital Henri-Mondor, AP-HP, UPEC, Créteil, France
| | - Julien Gaudric
- Service de Chirurgie Vasculaire, Hôpital de la Pitié-Salpêtrière, AP-HP, Faculté de Médecine Pierre et Marie Curie, Université Paris 6, Paris, France
| | - Quentin Pellenc
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Bichat, AP-HP, Faculté de Médecine Denis Diderot, Université Paris 7, Paris, France
| | - Marielle Le Roux
- Service de Chirurgie Thoracique et Vasculaire, Hôpital Tenon, AP-HP, Faculté de Médecine Pierre et Marie Curie, Université Paris 6, Paris, France
| | - Charles Pierret
- Service de Chirurgie Vasculaire, Hôpital d'Instruction des Armées de Percy, Clamart, France
| | - Hicham Kobeiter
- Service de Radiologie, Hôpital Henri-Mondor, AP-HP, UPEC, Créteil, France
| | - Pierre Julia
- Service de Chirurgie Vasculaire, Hôpital Européen Georges-Pompidou, AP-HP, Faculté de Médecine Paris Descartes, Université Paris 5, Paris, France
| | - Olivier Goeau-Brissonniere
- Service de Chirurgie Vasculaire, Hôpital Ambroise-Paré, AP-HP, Boulogne-Billancourt, Université de Versailles Saint Quentin en Yvelines, Versailles, France
| | - Pascal Desgranges
- Service de Chirurgie Vasculaire, Hôpital Henri-Mondor, AP-HP, UPEC, Créteil, France
| | - Fabien Koskas
- Service de Chirurgie Vasculaire, Hôpital de la Pitié-Salpêtrière, AP-HP, Faculté de Médecine Pierre et Marie Curie, Université Paris 6, Paris, France
| | - Yves Castier
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Bichat, AP-HP, Faculté de Médecine Denis Diderot, Université Paris 7, Paris, France.
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Haverkort JJM, de Jong MB, Foco M, Gui D, Barhoum M, Hyams G, Bahouth H, Halberthal M, Leenen LPH. Dedicated mass-casualty incident hospitals: An overview. Injury 2017; 48:322-326. [PMID: 28024651 DOI: 10.1016/j.injury.2016.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/21/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hospitals worldwide are preparing for mass casualty incidents (MCIs). The Major Incident Hospital in the Netherlands was constructed 25 years ago as a dedicated hospital for situations wherein a sudden increase in medical surge capacity is mandated to handle an MCI. Over the years, more initiatives of dedicated MCIs have arisen. Herein, we compared the MCI facilities from three countries considering the reasons for construction and the functionality. METHODS Three dedicated mass casualty hospitals and one hospital with a largely fortified structure were compared. The centres were located in the Netherlands, Italy, and Israel. Between August 2015 and January 2016, structured interviews were conducted with representatives of the hospitals' medical operations. The interviews focussed on general information regarding the need for MCI preparedness and scenarios that require preparation, reasons for construction, hospital missions, and the experiences gained including training. RESULTS All dedicated MCI hospitals had a common policy wherein they sought to create normal work circumstances for the medical staff by using similar equipment and resources as in normal hospitals. The MCI hospitals' designs differed substantially, as determined by the threats faced by the country. In Europe, these hospitals are designed as a solution to surge capacity and function as buffer hospitals offering readily available, short term, additional medical capacity to the local health care system. Israel faces constant threat from long-term conflicts; during the 2006 war, several hospitals suffered direct missile impacts. Therefore, Israeli MCI hospitals are designed to be fortified structures offering shelter against both conventional and non-conventional warfare and intended as a long-term solution during siege situations. CONCLUSION Several dedicated MCI hospitals are presently being constructed. During construction, the local circumstances should be taken into account to determine the functionality for both short-term solutions for surge capacity and as fortified structures to withstand under-siege situations.
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Affiliation(s)
- J J Mark Haverkort
- Major Incident Hospital, University Medical Center Utrecht, UMC Utrecht, Utrecht, CX, 3584, The Netherlands.
| | - Mirjam B de Jong
- Major Incident Hospital, University Medical Center Utrecht, UMC Utrecht, Utrecht, CX, 3584, The Netherlands
| | - Maurizio Foco
- Policlinico A. Gemelli Hospital, Catholic University of Rome, Rome, 00168, Italy
| | - Daniele Gui
- Policlinico A. Gemelli Hospital, Catholic University of Rome, Rome, 00168, Italy
| | | | - Gila Hyams
- Rambam Health Care Campus Hospital, Haifa, 3109601, Israel
| | - Hany Bahouth
- Rambam Health Care Campus Hospital, Haifa, 3109601, Israel
| | | | - Luke P H Leenen
- Major Incident Hospital, University Medical Center Utrecht, UMC Utrecht, Utrecht, CX, 3584, The Netherlands
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Carles M, Levraut J, Gonzalez JF, Valli F, Bornard L. Mass casualty events and health organisation: terrorist attack in Nice. Lancet 2016; 388:2349-2350. [PMID: 27845090 DOI: 10.1016/s0140-6736(16)32128-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Michel Carles
- Pole Anesthesie Reanimation Urgences, Faculté de Médecine de Nice, Universite Nice Sophia-Antipolis, 06000 Nice, France.
| | - Jacques Levraut
- Pole Anesthesie Reanimation Urgences, Faculté de Médecine de Nice, Universite Nice Sophia-Antipolis, 06000 Nice, France
| | - Jean François Gonzalez
- Institut Universitaire Locomoteur et Sport, Pasteur 2 Hospital, Faculté de Médecine de Nice, Universite Nice Sophia-Antipolis, 06000 Nice, France
| | - François Valli
- Pole Anesthesie Reanimation Urgences, Faculté de Médecine de Nice, Universite Nice Sophia-Antipolis, 06000 Nice, France
| | - Loic Bornard
- Pole Anesthesie Reanimation Urgences, Faculté de Médecine de Nice, Universite Nice Sophia-Antipolis, 06000 Nice, France
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Dussault MC, Smith M, Hanson I. Evaluation of trauma patterns in blast injuries using multiple correspondence analysis. Forensic Sci Int 2016; 267:66-72. [DOI: 10.1016/j.forsciint.2016.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/20/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
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Gregory TM, Bihel T, Guigui P, Pierrart J, Bouyer B, Magrino B, Delgrande D, Lafosse T, Al Khaili J, Baldacci A, Lonjon G, Moreau S, Lantieri L, Alsac JM, Dufourcq JB, Mantz J, Juvin P, Halimi P, Douard R, Mir O, Masmejean E. Terrorist attacks in Paris: Surgical trauma experience in a referral center. Injury 2016; 47:2122-2126. [PMID: 27578051 DOI: 10.1016/j.injury.2016.08.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 07/09/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.
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Affiliation(s)
- Thomas M Gregory
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Thomas Bihel
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pierre Guigui
- Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jérôme Pierrart
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Benjamin Bouyer
- Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Baptiste Magrino
- Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Damien Delgrande
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Thibault Lafosse
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jaber Al Khaili
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Antoine Baldacci
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France; Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Guillaume Lonjon
- Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Sébastien Moreau
- Spine surgery and General Orthopaedics Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Laurent Lantieri
- Department of Plastic and Reconstructive Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jean-Marc Alsac
- Department of Vascular Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jean-Baptiste Dufourcq
- Department of Anaesthesiology, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jean Mantz
- Department of Anaesthesiology, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Philippe Juvin
- Department of Emergency Medicine, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Philippe Halimi
- Department of Imaging, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Richard Douard
- Department of Visceral Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Olivier Mir
- MOVEO Institute, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Emmanuel Masmejean
- Upper limb and Peripheral nerve Unit, Department of Traumatology and Orthopaedic Surgery, Teaching European Hospital Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes, Sorbonne Paris Cité, Paris, France
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Retour d’expérience des attentats du 13 novembre 2015. Rôle spécifique des hôpitaux de proximité. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0606-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hirsch M, Carli P, Nizard R, Riou B, Baroudjian B, Baubet T, Chhor V, Chollet-Xemard C, Dantchev N, Fleury N, Fontaine JP, Yordanov Y, Raphael M, Burtz CP, Lafont A. The medical response to multisite terrorist attacks in Paris. Lancet 2015; 386:2535-8. [PMID: 26628327 DOI: 10.1016/s0140-6736(15)01063-6] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Martin Hirsch
- Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Carli
- SAMU de Paris, Hôpital Necker-Enfants Malades, University Paris-Descartes Paris, France
| | - Rémy Nizard
- Hôpital Lariboisière, University Paris-Diderot, Paris, France
| | - Bruno Riou
- Hôpital de la Pitié Salpétrière, University Pierre & Marie Curie, Paris, France
| | | | | | - Vibol Chhor
- Hôpital Européen Georges Pompidou, Paris, France
| | | | | | | | | | | | | | | | - Antoine Lafont
- Hôpital Européen Georges Pompidou, University Paris-Descartes, Paris, France.
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Tympanic membrane perforation impact on severity of injury and resource use in victims of explosion. Eur J Trauma Emerg Surg 2015; 43:623-626. [PMID: 26660473 DOI: 10.1007/s00068-015-0609-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/18/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE Though tympanic membrane perforation (TMP) is a marker of barotrauma, relation to severity of injury has been contested based on previous observations that following an explosion many victims with significant injuries do not suffer from TMP while many victims with TMP do not suffer from significant injuries. The objective of this study was to reassess the relationship of TMP to severity of injury and resource demand in patients treated in multiple casualty incidents following terrorist bombings treated in one medical center. METHODS Retrospective review. RESULTS Most of the patients with TMP were mildly injured. Nevertheless, TMP was more prevalent in patients with moderate and severe injuries, 53.3 % compared to 13.6 % in mildly injured patients (p = 0.0009). Patients with TMP suffered from more body areas injured (p < 0.0001). They more often needed surgery (30.6 vs. 5.5 %; p < 0.0001), ICU hospitalization (16.1 vs. 1.3 %; p < 0.0001) and secondary transfer to a level I trauma center (12.9 vs. 1.0 %; p < 0.0001). They were hospitalized longer (p < 0.0001). Fifty-three (12.6 %) patients included in this study were not examined by the ENT service. Most of those not examined were either moderately or severely injured. CONCLUSIONS Patients with TMP were more severely injured and more often needed surgery, ICU hospitalization and need for transfer to a level I trauma center. The observation that all those who died in hospital and most of those who were unstable were not examined by the ENT services suggests that impact of TMP as an indicator of severity may be underestimated.
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Miyawaki H, Saitoh D, Hagisawa K, Noguchi M, Sato S, Kinoshita M, Miyazaki H, Satoh Y, Harada N, Sakamoto T. Noradrenalin effectively rescues mice from blast lung injury caused by laser-induced shock waves. Intensive Care Med Exp 2015; 3:32. [PMID: 26662813 PMCID: PMC4675774 DOI: 10.1186/s40635-015-0069-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/06/2015] [Indexed: 01/08/2023] Open
Abstract
Background Blast lung injuries (BLI) caused by blast waves are extremely critical in the prehospital setting, and hypotension is thought to be the main cause of death in such cases. The present study aimed to elucidate the pathophysiology of severe BLI using laser-induced shock wave (LISW) and identify the initial treatment. Methods The current investigation comprised two parts. For the validation study, mice were randomly allocated to groups that received a single shot of 1.2, 1.3, or 1.4 J/cm2 LISW to both lungs. The survival rates, systolic blood pressure (sBP), heart rate (HR), peripheral oxyhemoglobin saturation (SpO2), and shock index were monitored for 60 min, and lung tissues were analyzed histopathologically. The study evaluated the effects of catecholamines as follows. Randomly assigned mice received 1.4 J/cm2 LISW followed by the immediate intraperitoneal administration of dobutamine, noradrenalin, or normal saline. The primary outcome was the survival rate. Additionally, sBP, HR, SpO2, and the shock index were measured before and 5 and 10 min after LISW, and the cardiac output, left ventricular ejection fraction, and systemic vascular resistance (SVR) were determined before and 1 min after LISW. Results The triad of BLI (hypotension, bradycardia, and hypoxemia) was evident immediately after LISW. The survival rates worsened with increasing doses of LISW (100 % in 1.2 J/cm2 vs. 60 % in 1.3 J/cm2, 10 % in 1.4 J/cm2). The histopathological findings were compatible with those of human BLI. The survival rate in LISW high group (1.4 J/cm2) was highest in the group that received noradrenalin (100 %), with significantly elevated SVR values (from 565 to 1451 dyn s/min5). In contrast, the survival rates in the dobutamine and normal saline groups were 40 and 10 %, respectively, and the SVR values did not change significantly after LISW in either group. Conclusions The main cause of death during the initial phase of severe BLI is hypotension due to the absence of peripheral vasoconstriction. Therefore, the immediate administration of noradrenalin may be an effective treatment during the initial phase of severe BLI.
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Affiliation(s)
- Hiroki Miyawaki
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan.
| | - Kohsuke Hagisawa
- Division of Physiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Midori Noguchi
- Division of Traumatology, Research Institute, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Shunichi Sato
- Division of Biomedical Information Sciences, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Hiromi Miyazaki
- Division of Traumatology, Research Institute, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Yasushi Satoh
- Department of Anesthesiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Nahoko Harada
- Division of Nursing, School of Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, 359-8513, Japan
| | - Toshihisa Sakamoto
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, 3-2 Namiki, Tokorozawa, 359-8513, Japan
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Lunze FI, Lunze K, Tsorieva ZM, Esenov CT, Reutov A, Eichhorn T, Offergeld C. Global surgery in a postconflict setting--5-year results of implementation in the Russian North Caucasus. Glob Health Action 2015; 8:29227. [PMID: 26498745 PMCID: PMC4620685 DOI: 10.3402/gha.v8.29227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 11/20/2022] Open
Abstract
Background Collaborations for global surgery face many challenges to achieve fair and safe patient care and to build sustainable capacity. The 2004 terrorist attack on a school in Beslan in North Ossetia in the Russian North Caucasus left many victims with complex otologic barotrauma. In response, we implemented a global surgery partnership between the Vladikavkaz Children's Hospital, international surgical teams, the North Ossetian Health Ministry, and civil society organizations. This study's aim was to describe the implementation and 5-year results of capacity building for complex surgery in a postconflict, mid-income setting. Design We conducted an observational study at the Children's Hospital in Vladikavkaz in the autonomous Republic of North Ossetia-Alania, part of the Russian Federation. We assessed the outcomes of 15 initial patients who received otologic surgeries for complex barotrauma resulting from the Beslan terrorism attack and for other indications, and report the incidence of intra- and postoperative complications. Results Patients were treated for trauma related to terrorism (53%) and for indications not related to violence (47%). None of the patients developed peri- or postoperative complications. Three patients (two victims of terrorism) who underwent repair of tympanic perforations presented with re-perforations. Four junior and senior surgeons were trained on-site and in Germany to perform and teach similar procedures autonomously. Conclusions In mid-income, postconflict settings, complex surgery can be safely implemented and achieve patient outcomes comparable to global standards. Capacity building can build on existing resources, such as operation room management, nursing, and anesthesia services. In postconflict environments, substantial surgical burden is not directly attributable to conflict-related injury and disease, but to health systems weakened by conflicts. Extending training and safe surgical care to include specialized interventions such as microsurgery are integral components to strengthen local capacity and ownership. Our experience identified strategies for fair patient selection and might provide a model for potentially sustainable surgical system building in postconflict environments.
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Affiliation(s)
- Fatima I Lunze
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Health for the Caucasus e.V., Cottbus, Germany
| | - Karsten Lunze
- Health for the Caucasus e.V., Cottbus, Germany.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA;
| | - Zemfira M Tsorieva
- Department of Surgery, Vladikavkaz Children's Hospital, Vladikavkaz, Russian Federation
| | - Constantin T Esenov
- Department of Surgery, Vladikavkaz Children's Hospital, Vladikavkaz, Russian Federation
| | - Alexandr Reutov
- Ministry of Health North Ossetia, Vladikavkaz, Russian Federation.,Federal Hospital Beslan, Beslan, Russian Federation
| | - Thomas Eichhorn
- Health for the Caucasus e.V., Cottbus, Germany.,ENT Department, Carl Thiem Hospital Cottbus, Cottbus, Germany
| | - Christian Offergeld
- Health for the Caucasus e.V., Cottbus, Germany.,ENT Department, Freiburg University, Freiburg im Breisgau, Germany
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Adams HA, Flemming A, Krettek C, Koppert W. [The hospital emergency plan]. Med Klin Intensivmed Notfmed 2015; 110:37-48. [PMID: 25589006 DOI: 10.1007/s00063-014-0414-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/07/2014] [Indexed: 10/24/2022]
Abstract
STRUCTURE The hospital emergency plan consists of a basic plan and an appendix. The basic plan deals with the general aspects of emergency operation and the special aspects of external and internal emergencies. The appendix contains special instructions, e.g., emergency action orders, staff alert lists, material lists, and situation plans. CONTENT AND IMPLEMENTATION External emergencies (e.g., mass casualty incidents) and internal emergencies (e.g., fire and other environmental threats) should be regarded. Once a defined experienced physician decides to activate the emergency plan, the hospital changes from routine to emergency service. Due to its security significance, the emergency plan should be regarded as confidential. MANDATORY REQUIREMENTS A two-tier chain of command is implemented: the hospital staff deals with administrational and organizational aspects, whereas the subsequent medical staff is in charge of immediate patient care. Repeated updating and exercises are necessary. Furthermore, a basic logistic autonomy of the hospital is essential.
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Affiliation(s)
- H A Adams
- Stabsstelle für Interdisziplinäre Notfall- und Katastrophenmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland,
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Adams HA, Flemming A, Lange C, Koppert W, Krettek C. [Care concepts in mass casualty incidents and disasters. Concept for primary care clinic]. Med Klin Intensivmed Notfmed 2015; 110:27-36. [PMID: 25585652 DOI: 10.1007/s00063-014-0413-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patient care in mass casualty incidents and disaster strongly demand a joint approach of all preclinical and clinical forces. OBJECTIVE Special emphasis must be placed on immediate triage, establishment and preservation of transportability of high-risk patients and their clinical treatment as soon as possible. During limited mass casualties, the preclinical rescue station additionally serves as a buffer for patients, whereby in case of disaster, the focus on transportation of high-risk patients is imperative. DISCUSSION AND CONCLUSION Primary care hospitals are a decisive part in the chain of medical supply and are confronted with great challenges, which demand detailed emergency plans and also repeated exercises. In planning and exercises, special attention should be given to the cooperation with the fire department and other medical services.
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Affiliation(s)
- H A Adams
- Stabsstelle für Interdisziplinäre Notfall- und Katastrophenmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland,
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Einav S, Hick JL, Hanfling D, Erstad BL, Toner ES, Branson RD, Kanter RK, Kissoon N, Dichter JR, Devereaux AV, Christian MD. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e17S-43S. [PMID: 25144407 DOI: 10.1378/chest.14-0734] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care. METHODS The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process. RESULTS This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response. CONCLUSIONS Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.
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Alfa-Wali M, Sritharan K, Mehes M, Abdullah F, Rasheed S. Terrorism-related trauma in Africa, an increasing problem. J Epidemiol Glob Health 2014; 5:201-3. [PMID: 25922330 PMCID: PMC7320487 DOI: 10.1016/j.jegh.2014.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/23/2014] [Accepted: 05/26/2014] [Indexed: 11/24/2022] Open
Abstract
Global terrorist activities have increased significantly over the past decade. The impact of terrorism-related trauma on the health of individuals in low- and middle-income countries is under-reported. Trauma management in African countries in particular is uncoordinated, with little or no infrastructure to cater for emergency surgical needs. This article highlights the need for education, training and research to mitigate the problems related to terrorism and surgical public health.
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Affiliation(s)
- Maryam Alfa-Wali
- Chelsea and Westminster NHS Foundation Trust, Department of Academic Surgery, Third Floor, 369 Fulham Road, London SW10 9NH, UK.
| | - Kaji Sritharan
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Academic Department of Vascular Surgery, Praed Street, London W2 1NY, UK
| | - Mira Mehes
- John Hopkins University School of Medicine, Division of Paediatric Surgery, 1800 Orleans Street, Baltimore, MD 21287-0005, USA
| | - Fizan Abdullah
- John Hopkins University School of Medicine & Bloomberg School of Public Health, Division of Paediatric Surgery, 1800 Orleans Street, Baltimore, MD 21287-0005, USA
| | - Shahnawaz Rasheed
- The Royal Marsden Hospital, Department of Colorectal Surgery, Fulham Road, London SW3 6JJ, UK; Humanity First, Red Lion Road, Surrey KT6 7QD, UK
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Ashkenazi I, Turégano-Fuentes F, Einav S, Kessel B, Alfici R, Olsha O. Pitfalls to avoid in the medical management of mass casualty incidents following terrorist bombings: the hospital perspective. Eur J Trauma Emerg Surg 2014; 40:445-50. [PMID: 26816239 DOI: 10.1007/s00068-014-0403-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 04/08/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The unique patterns of injury following explosions together with the involvement of numerous physicians, most of whom are not experienced in trauma, may create problems in the medical management of mass casualty incidents. METHODS Four hundred patient files admitted in 19 mass casualty events following bombing incidents were reviewed and possible areas which could impact survival were defined. RESULTS Forty-nine (9.3 %) patients had an Injury Severity Score ≥16. Of 205 patients in whom triage decisions were available, 5 of 25 severely injured patients were undertriaged by the triage officers at the door of the hospital. Following primary evaluation inside the emergency department critical injuries in two patients were missed due to distracting, less serious injuries. Of 68 (16.1 %) patients who were operated, 28 were in need of either immediate, urgent or high-priority operations. Except for neurosurgical cases which needed to be transferred to other hospitals, there was no delay in surgery. One patient underwent negative laparotomy. There were 15 in-hospital deaths, 6 of which were deemed as either anticipated or unanticipated mortality with possibility for improvement. CONCLUSION Medical management should be evaluated following MCIs as this may illustrate possible problems which many need to be addressed in contingency planning.
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Affiliation(s)
- I Ashkenazi
- Surgery Department, Hillel Yaffe Medical Center, P.O.Box 169, 38100, Hadera, Israel.
| | - F Turégano-Fuentes
- Emergency Surgery Department, Gregorio Marañon Medical Center, Madrid, Spain
| | - S Einav
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - B Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - R Alfici
- Surgery Department, Hillel Yaffe Medical Center, P.O.Box 169, 38100, Hadera, Israel
| | - O Olsha
- Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
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Turégano-Fuentes F, Pérez-Diaz D, Sanz-Sánchez M, Alfici R, Ashkenazi I. Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury. Eur J Trauma Emerg Surg 2014; 40:451-60. [PMID: 26816240 DOI: 10.1007/s00068-014-0397-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 03/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury. METHODS A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS. RESULTS Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties. CONCLUSIONS The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.
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Affiliation(s)
- F Turégano-Fuentes
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - D Pérez-Diaz
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - M Sanz-Sánchez
- General and Emergency Surgery Service, University General Hospital Gregorio Marañón, Madrid, Spain.
| | - R Alfici
- General Surgery B Service, Hillel Yaffe Medical Centre, Hadera, Israel.
| | - I Ashkenazi
- General Surgery B Service, Hillel Yaffe Medical Centre, Hadera, Israel
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Hamele M, Poss WB, Sweney J. Disaster preparedness, pediatric considerations in primary blast injury, chemical, and biological terrorism. World J Crit Care Med 2014; 3:15-23. [PMID: 24834398 PMCID: PMC4021150 DOI: 10.5492/wjccm.v3.i1.15] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 11/21/2013] [Accepted: 12/09/2013] [Indexed: 02/06/2023] Open
Abstract
Both domestic and foreign terror incidents are an unfortunate outgrowth of our modern times from the Oklahoma City bombings, Sarin gas attacks in Japan, the Madrid train bombing, anthrax spores in the mail, to the World Trade Center on September 11(th), 2001. The modalities used to perpetrate these terrorist acts range from conventional weapons to high explosives, chemical weapons, and biological weapons all of which have been used in the recent past. While these weapons platforms can cause significant injury requiring critical care the mechanism of injury, pathophysiology and treatment of these injuries are unfamiliar to many critical care providers. Additionally the pediatric population is particularly vulnerable to these types of attacks. In the event of a mass casualty incident both adult and pediatric critical care practitioners will likely be called upon to care for children and adults alike. We will review the presentation, pathophysiology, and treatment of victims of blast injury, chemical weapons, and biological weapons. The focus will be on those injuries not commonly encountered in critical care practice, primary blast injuries, category A pathogens likely to be used in terrorist incidents, and chemical weapons including nerve agents, vesicants, pulmonary agents, cyanide, and riot control agents with special attention paid to pediatric specific considerations.
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Abstract
OBJECTIVES Inappropriate distribution of casualties in mass-casualty incidents (MCIs) may overwhelm hospitals. This study aimed to review the consequences of evacuating casualties from a bus accident to a single peripheral hospital and lessons learned regarding policy of casualty evacuation. METHODS Medical records of all casualties relating to evacuation times, injury severity, diagnoses, treatments, resources utilized and outcomes were independently reviewed by two senior trauma surgeons. In addition, four senior trauma surgeons reviewed impact of treatment provided on patient outcomes. They reviewed the times for the primary and secondary evacuation, injury severity, diagnoses, surgical treatments, resources utilized, and the final outcomes of the patients at the point of discharge from the tertiary care hospital. RESULTS Thirty-one survivors were transferred to the closest local hospital; four died en route to hospital or within 30 minutes of arrival. Twenty-seven casualties were evacuated by air from the local hospital within 2.5 to 6.15 hours to Level I and II hospitals. Undertriage of 15% and overtriage of seven percent were noted. Four casualties did not receive treatment that might have improved their condition at the local hospital. CONCLUSIONS In MCIs occurring in remote areas, policy makers should consider revising the current evacuation plan so that only immediate unstable casualties should be transferred to the closest primary hospital. On site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.
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