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Al-Hajj S, Farran SH, Dekmak B, Hneiny L, Abou Abbas H, Hassoun A, Youness N, Ghalayini S, Abou Khalil N, Lecky F, Shahjouieh S, Ghamlouche L, Nasrallah Z, Kobeissy F. Pediatric Traumatic Brain Injury in the Middle East and North Africa Region: A Systematic Review and Meta-Analysis to Assess Characteristics, Mechanisms, and Risk Factors. Neurotrauma Rep 2023; 4:693-714. [PMID: 37908319 PMCID: PMC10615069 DOI: 10.1089/neur.2023.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Pediatric traumatic brain injury (pTBI) represents a major cause of child injuries in the Middle East and North Africa (MENA) region. This review aims to assess pTBIs in the MENA region and reports their clinical severity and outcomes. A search was conducted using major electronic databases, including Medline/Ovid, PubMed, EMBASE, Web of Science, and SCOPUS. Abstracts were screened independently and in duplicate to detect original research. The objective and study findings for each article were recorded, along with the mechanism of pTBI, patient age and sex, injury assessment tool(s) used, and outcome. A total of 1345 articles were retrieved, of which 152 met the criteria for full-text review, and 32 were included in this review. Males predominantly suffered from pTBIs (78%). Motor vehicle accidents, followed by child abuse, were the leading causes of pTBI. Overall, 0.39% of cases were mild, 0.58% moderate, 16.25% severe, and 82.27% unclassified. The mortality rate was 13.11%. Most studies used the computed tomography scan, Glasgow Coma Scale, Abbreviated Injury Scale, and Injury Severity Score as investigation methods. This review reports on the alarming rate of child-abuse-related pTBI and offers further understanding of pTBI-associated risk factors and insight into the development of strategies to reduce their occurrence, as well as policies to promote child well-being.
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Affiliation(s)
- Samar Al-Hajj
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sarah H. Farran
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Batoul Dekmak
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Layal Hneiny
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Hussein Abou Abbas
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Aya Hassoun
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nadine Youness
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Sarah Ghalayini
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nour Abou Khalil
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, University of Sheffield, Sheffield, United Kingdom
| | - Shima Shahjouieh
- Department of Neurosurgery, University of New Mexico, New Mexico
| | - Layal Ghamlouche
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Zainab Nasrallah
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Biology Faculty of Medicine, American University of Beirut, Beirut, Lebanon
- Department of Neurobiology, Center for Neurotrauma, Multiomics & Biomarkers (CNMB), Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
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Aguirre AS, Rojas K, Torres AR. Pediatric traumatic brain injuries in war zones: a systematic literature review. Front Neurol 2023; 14:1253515. [PMID: 37745670 PMCID: PMC10511749 DOI: 10.3389/fneur.2023.1253515] [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] [Received: 07/05/2023] [Accepted: 08/11/2023] [Indexed: 09/26/2023] Open
Abstract
Background Pediatric casualties in war zones are a devastating consequence of armed conflicts, causing significant challenges for affected children, especially in the context of poor access to care. This study aimed to understand traumatic brain injuries (TBIs) in this high-risk population and to identify and provide information for the stakeholders, as well as to recognize severe long-term consequences and develop strategies to prevent them, thus minimizing their burden while aiding in the management of these cases. Methods We carried out a systematic literature review following PRISMA guidelines to identify publications discussing traumatic brain injuries in children in the context of war zones, and we analyzed all the collected data. Results Our study showed that head injuries were the most common casualty in war zones; male and female children were affected, and the mean age was 8-10 years. Most children were reported to be from Afghanistan, and blasts were the most common mechanism of injury. The mortality fluctuated from 3 to 47%. Conclusion There is a lack of evidence-based information regarding the characterization, approach, and management of children with TBI in conflict zones. While the world finds ways to live in peace, there is an urgency to research, train, and deploy enough specialists to these areas, if governments are serious about improving outcomes for this population.
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Affiliation(s)
| | | | - Alcy R. Torres
- Division of Pediatric Neurology, Department of Pediatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
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Wild H, Reavley P, Mayhew E, Ameh EA, Celikkaya ME, Stewart B. Strengthening the emergency health response to children wounded by explosive weapons in conflict. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000443. [DOI: 10.1136/wjps-2022-000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/07/2022] [Indexed: 11/04/2022] Open
Abstract
The 2022 war in Ukraine has highlighted the unacceptable consequences wrought on civilians and health infrastructure by conflict. Children are among the most vulnerable of those affected and constitute an increasing percentage of non-combatants injured in conflicts globally. A disproportionate number of these injuries are caused by blast mechanisms from munitions including ‘conventional’ landmines and indiscriminate explosive weapons such as barrel bombs and improvised explosive devices. In 21st century conflict, children are no longer only accidental casualties of war, but are increasingly targeted by parties through acts such as bombing of school buses and playgrounds, conscription as child soldiers, and use as human shields. In the present viewpoint article, we review the state of pediatric blast injury studies, synthesizing current understandings of injury epidemiology and identifying gaps in research to advance the field towards a concrete agenda to improve care for this vulnerable population.
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Bickel A, Akinichev K, Weiss M, Ganam S, Biswas S, Waksman I, Kakiashvilli E. Challenges in abdominal re-exploration for war casualties following on-site abdominal trauma surgery and subsequent delayed arrival to definitive medical care abroad - an unusual scenario. BMC Emerg Med 2022; 22:132. [PMID: 35850737 PMCID: PMC9295351 DOI: 10.1186/s12873-022-00687-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background During the Syrian civil war, patients were initially treated on-site in Syria and later transferred to medical centers in Israel. Relevant details concerning the exact nature of injury and medical/surgical care received in Syria were unavailable to clinicians in Israel. Many of these patients required abdominal re-exploration for obvious or suspected problems related to their injury. Our aim is to present our approach to abdominal trauma patients who survived initial on-site surgery and needed subsequent abdominal re-exploration abroad, in our medical center. Methods Clinical data from all medical records were retrospectively analyzed. Each patient underwent total body computerized tomography on arrival, revealing diverse multi-organ trauma. We divided the patient population who had abdominal trauma into 4 sub-groups according to the location in which abdominal surgical intervention was performed (abdominal surgery performed only in Syria, surgery in Syria and subsequent re-laparotomy in Israel, abdominal surgery only in Israel, and management of patients without abdominal surgical intervention). We focused on missed injuries and post-operative complications in the re-laparotomy sub-group. Results By July 2018, 1331 trauma patients had been admitted to our hospital, of whom 236 had suffered abdominal trauma. Life-saving abdominal intervention was performed in 138 patients in Syria before arrival to our medical center. A total of 79 patients underwent abdominal surgery in Israel, of whom 46 (33%) required re-laparotomy. The absence of any communication between the surgical teams across the border markedly affected our medical approach. Indications for re-exploration included severe peritoneal inflammation, neglected or overlooked abdominal foreign bodies, hemodynamic instability and intestinal fistula. Mortality occurred in 37/236 patients, with severe abdominal trauma as the main cause of fatality in 10 of them (4.2%), usually following urgent re-laparotomy. Conclusions Lack of information about the circumstances of injury in an environment of catastrophe in Syria at the time and the absence of professional communication between the surgical teams across the border markedly dictated our medical approach. Our concerns were that some patients looked deceptively stable while others had potentially hidden injuries. We had no information on who had had definitive versus damage control surgery in Syria. The fact that re-operation was not performed by the same team responsible for initial abdominal intervention also posed major diagnostic challenges and warranted increased clinical suspicion and a change in our standard medical approach.
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Affiliation(s)
- Amitai Bickel
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel. .,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.
| | | | - Michael Weiss
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Samer Ganam
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel
| | - Seema Biswas
- Department of Surgery B, Galilee Medical Center, Nahariya, Israel
| | - Igor Waksman
- The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,Department of Surgery B, Galilee Medical Center, Nahariya, Israel
| | - Eli Kakiashvilli
- Department of Surgery A, Galilee Medical Center, Nahariya, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
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Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Pediatric casualties in contemporary armed conflict: A systematic review to inform standardized reporting. Injury 2021; 52:1748-1756. [PMID: 34006405 DOI: 10.1016/j.injury.2021.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Children represent a significant percentage of casualties in modern conflict. Yet, the epidemiology of conflict-related injury among children is poorly understood. A comprehensive analysis of injuries sustained by children in 21st-century armed conflict is necessary to inform planning of local, military, and humanitarian health responses. METHODS We conducted a systematic search of databases including PubMed, Embase, Web of Science, World Health Organization Catalog, and Google Scholar to identify records that described conflict-related injuries sustained by children since 2001. RESULTS The search returned 5,264 records. 9 eligible reports without potentially duplicative data were included in analysis, representing 5,100 pediatric patients injured in 5 conflicts. Blast injury was the most frequent mechanism (57%), compared to 24.8% in adults. Mortality was only slightly higher among children (11.0% compared to 9.8% among adults; p <0.05). Non-uniform reporting prevented pooled analysis and limited the conclusions that could be drawn. CONCLUSIONS Children sustain a higher proportion of blast injury than adults in conflict. Existing data do support the conclusion that child casualties have higher mortality than adults overall; however, this difference is slighter than has been previously reported. Specific subpopulations of children appear to have worse outcomes. Overall, non-uniform reporting renders currently available data insufficient to understand the needs of children injured in modern conflict.
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Affiliation(s)
- Hannah Wild
- Department of Surgery, University of Washington, Seattle, WA USA.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA USA; Global Injury Control Section, Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | | | - Christopher D Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, CA, USA
| | - Sherry M Wren
- Stanford University School of Medicine, Stanford, CA, USA
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Traumatic Brain Injury-Related Pediatric Mortality and Morbidity in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2021; 153:109-130.e23. [PMID: 34166832 DOI: 10.1016/j.wneu.2021.06.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The burden of pediatric traumatic brain injury (pTBI) in low- and middle-income countries (LMICs) is unknown. To fill this gap, we conducted a review that aimed to characterize the causes of pTBI in LMICs, and their reported associated mortality and morbidity. METHODS A systematic review was conducted. MEDLINE, Embase, Global Health, and Global Index Medicus were searched from January 2000 to May 2020. Observational or experimental studies on pTBI of individuals aged between 0 and 16 years in LMICs were included. The causes of pTBI and morbidity data were descriptively analyzed, and case fatality rates were calculated. PROSPERO ID CRD42020171276. RESULTS A total of 136 studies were included. Fifty-seven studies were at high risk of bias. Of the remaining studies, 170,224 cases of pTBI were reported in 32 LMICs. The odds of having a pTBI were 1.8 times higher (95% confidence interval, 1.6-2.0) in males. The odds of a pTBI being mild were 4.4 times higher (95% confidence interval, 1.9-6.8) than a pTBI being moderate or severe. Road traffic accidents were the most common cause (n = 16,275/41,979; 39%) of pTBIs. On discharge, 24% of patients (n = 4385/17,930) had a reduction in their normal mental or physical function. The median case fatality rate was 7.3 (interquartile range, 2.1-7.7). CONCLUSIONS Less than a quarter (n = 32) of all LMICs have published high-quality data on the volume and burden of pTBI. From the limited data available, young male children are at a high risk of pTBIs in LMICs, particularly after road traffic accidents.
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Rolle M, Duhaime AC. Pediatric Gunshot Wound to Visual Cortex with Retained Bullet: Case Report and Review of the Literature. Pediatr Neurosurg 2021; 56:94-98. [PMID: 33517340 DOI: 10.1159/000513100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pediatric gunshot wounds (GSWs) to the head are not well studied in the literature, especially in civilians. With a dearth of case-based and clinically relevant information, pediatric neurosurgeons may be challenged when considering the risks and benefits of removing retained bullet fragments in different intracranial locations. We explore the literature and highlight the key factors in the surgical decision-making case of a 16-year-old girl with GSW to the visual cortex. CASE REPORT A 16-year-old girl was shot in the head in a parieto-occipital trajectory with the bullet crossing midline, lodging in the occipital lobe into the straight sinus. Her initial Glasgow Coma Scale was 7, and she was urgently stabilized with intracranial pressure monitoring and external ventricular drainage. She underwent craniectomy, debridement, and irrigation and then a reoperation for further debridement and culture 2 weeks later for persistent fevers; cultures remained negative. The retained bullet was not removed. At 18 months post-injury, she had normal speech and motor function, moderate memory dysfunction, and 3-quadrant field loss with retained macular vision. DISCUSSION/CONCLUSION Pediatric penetrating GSWs to the head may be challenging to manage since literature is sparse. In this case, the primary focus of management was to maintain normal intracranial pressure, reduce risk of infection, and preserve potentially viable visual cortex. In the civilian context of available antibiotics and serial imaging, it may be possible to manage retained bullets conservatively without delayed complications.
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Affiliation(s)
- Myron Rolle
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA,
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.
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Syria civil war pediatric casualties treated at a single medical center. J Pediatr Surg 2020; 55:523-529. [PMID: 30902455 DOI: 10.1016/j.jpedsurg.2019.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/07/2019] [Accepted: 02/18/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE We describe the medical and surgical treatment outcomes of Syrian civil war pediatric casualties admitted to our tertiary medical center in northern Israel and compare them to reports of pediatric war victims in Iraq and Afghanistan. METHODS 117 pediatric casualties up to age 18 (median age: 12 years, 91 males) were admitted from 2013 to 2016. We measured demographics, injury mechanism, wound type, injury severity, surgical interventions, morbidity, and mortality. RESULTS Injury mechanisms were penetrating injuries (n = 87, 74%), blunt (n = 34, 29%) and blast (n = 13, 11%) injuries, caused by fragments (56, 48%), blasts (51, 44%), and gunshot wounds (24, 21%). Most common injuries were head trauma (n = 66, 56%) and lower extremities injury (n = 45, 38%). 51 children (44%) had Injury Severity Score > 25. Surgical procedures, most commonly orthopedic (n = 35) and neurosurgical (n = 27), were performed on 81 children (69%). Average number of procedures per patient was 2 ± 2.5; average hospitalization time was 25.8 days. Mortality rate was 3.4% (four children). Injury characteristics were different from those reported for pediatric war casualties in Iraq and Afghanistan. CONCLUSIONS Head trauma was associated with serious injury and mortality; most injuries were penetrating and complex. Collaboration of various hospital departments was often necessary for efficient and successful treatment. LEVEL OF EVIDENCE III Retrospective comparison study.
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Tounsi LL, Daebes HL, Gerdin Wärnberg M, Nerlander M, Jaweed M, Mamozai BA, Nasim M, Drevin G, Trelles M, von Schreeb J. Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan. World J Surg 2019; 43:2123-2130. [PMID: 31065777 DOI: 10.1007/s00268-019-05015-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
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Affiliation(s)
- Linnea Latifa Tounsi
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Hadjer Latif Daebes
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | | | - Maximilian Nerlander
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Momer Jaweed
- Kunduz Trauma Centre, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Kabul Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Gustaf Drevin
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Miguel Trelles
- Medical Department - Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Kadir A, Shenoda S, Goldhagen J. Effects of armed conflict on child health and development: A systematic review. PLoS One 2019; 14:e0210071. [PMID: 30650095 PMCID: PMC6334973 DOI: 10.1371/journal.pone.0210071] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/17/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development. METHODS A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425. FINDINGS Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce. INTERPRETATION The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.
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Affiliation(s)
- Ayesha Kadir
- Malmö Institute for Studies of Migration, Diversity and Welfare, Malmö University, Malmö, Sweden
- Médecins Sans Frontières, Geneva, Switzerland
| | - Sherry Shenoda
- Division of Community and Societal Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States of America
| | - Jeffrey Goldhagen
- Division of Community and Societal Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, Florida, United States of America
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Oravec CS, Motiwala M, Reed K, Jones TL, Klimo P. Big Data Research in Pediatric Neurosurgery: Content, Statistical Output, and Bibliometric Analysis. Pediatr Neurosurg 2019; 54:85-97. [PMID: 30799390 DOI: 10.1159/000495790] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS We sought to describe pediatric "big data" publications since 2000, their statistical output, and clinical implications. METHODS We searched 4 major North American neurosurgical journals for articles utilizing non-neurosurgery-specific databases for clinical pediatric neurosurgery research. Articles were analyzed for descriptive and statistical information. We analyzed effect sizes (ESs), confidence intervals (CIs), and p values for clinical relevance. A bibliometric analysis was performed using several key citation metrics. RESULTS We identified 74 articles, which constituted 1.7% of all pediatric articles (n = 4,436) published, with an exponential increase after 2013 (53/74, 72%). The Healthcare Cost and Utilization Project (HCUP) databases were most frequently utilized (n = 33); hydrocephalus (n = 19) was the most common study topic. The statistical output (n = 49 studies with 464 ESs, 456 CIs, and 389 p values) demonstrated that the majority of the ESs (253/464, 55%) were categorized as small; half or more of the CI spread (CIS) values and p values were high (274/456, 60%) and very strong (195/389, 50%), respectively. Associations with a combination of medium-to-large ESs (i.e., magnitude of difference), medium-to-high CISs (i.e., precision), and strong-to-very strong p values comprised only 20% (75/381) of the reported ESs. The total number of citations for the 74 articles was 1,115 (range per article, 0-129), with the median number of citations per article being 8.5. Four studies had > 50 citations, and 2 of them had > 100 citations. The calculated h-index was 16, h-core citations were 718, the e-index was 21.5, and the Google i10-index was 34. CONCLUSIONS There has been a dramatic increase in the use of "big data" in the pediatric neurosurgical literature. Reported associations that may, as a group, be of greatest interest to practitioners represented only 20% of the total output from these publications. Citations were weighted towards a few highly cited publications.
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Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tamekia L Jones
- Departments of Pediatrics and Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA, .,Semmes Murphey, Memphis, Tennessee, USA, .,Le Bonheur Children's Hospital, Memphis, Tennessee, USA,
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13
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Kadir A, Shenoda S, Goldhagen J, Pitterman S, Suchdev PS, Chan KJ, Howard CR, McGann P, St Clair NE, Yun K, Arnold LD. The Effects of Armed Conflict on Children. Pediatrics 2018; 142:peds.2018-2586. [PMID: 30397168 DOI: 10.1542/peds.2018-2586] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
More than 1 in 10 children worldwide are affected by armed conflict. The effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, environmental hazards, caregiver mental health, separation from family, displacement-related health risks, and the destruction of health, public health, education, and economic infrastructure. Children and health workers are targeted by combatants during attacks, and children are recruited or forced to take part in combat in a variety of ways. Armed conflict is both a toxic stress and a significant social determinant of child health. In this Technical Report, we review the available knowledge on the effects of armed conflict on children and support the recommendations in the accompanying Policy Statement on children and armed conflict.
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Affiliation(s)
- Ayesha Kadir
- Centre for Social Paediatrics, Herlev Hospital, Herlev, Denmark
| | - Sherry Shenoda
- Division of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida; and
| | - Jeffrey Goldhagen
- Division of Community and Societal Pediatrics, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida; and
| | - Shelly Pitterman
- United Nations High Commissioner for Refugees Regional Representative for the United States and the Caribbean, Washington, District of Columbia
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14
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Mikhael M, Frost E, Cristancho M. Perioperative Care for Pediatric Patients With Penetrating Brain Injury: A Review. J Neurosurg Anesthesiol 2018; 30:290-298. [DOI: 10.1097/ana.0000000000000441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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15
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Babl FE, Lyttle MD, Bressan S, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Donath S, Hearps S, Arpone M, Crowe L, Dalziel SR, Barker R, Oakley E. Penetrating head injuries in children presenting to the emergency department in Australia and New Zealand: A PREDICT prospective study. J Paediatr Child Health 2018; 54:861-865. [PMID: 29579354 DOI: 10.1111/jpc.13903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 11/27/2022]
Abstract
AIM Penetrating head injuries (pHIs) are associated with high morbidity and mortality. Data on pHIs in children outside North America are limited. We describe the mechanism of injuries, neuroimaging findings, neurosurgery and mortality for pHIs in Australia and New Zealand. METHODS This was a planned secondary analysis of a prospective observational study of children <18 years who presented with a head injury of any severity at any of 10 predominantly paediatric Australian/New Zealand emergency departments (EDs) between 2011 and 2014. We reviewed all cases where clinicians had clinically suspected pHI as well as all cases of clinically important traumatic brain injuries (death, neurosurgery, intubation >24 h, admission >2 days and abnormal computed tomography). RESULTS Of 20 137 evaluable patients with a head injury, 21 (0.1%) were identified to have sustained a pHI. All injuries were of non-intentional nature, and there were no gunshot wounds. The mechanisms of injuries varied from falls, animal attack, motor vehicle crashes and impact with objects. Mean Glasgow Coma Scale on ED arrival was 10; 10 (48%) had a history of loss of consciousness, and 7 (33%) children were intubated pre-hospital or in the ED. Fourteen (67%) children underwent neurosurgery, two (10%) craniofacial surgery, and five (24%) were treated conservatively; four (19%) patients died. CONCLUSIONS Paediatric pHIs are very rare in EDs in Australia and New Zealand but are associated with high morbidity and mortality. The absence of firearm-related injuries compared to North America is striking and may reflect Australian and New Zealand firearm regulations.
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Affiliation(s)
- Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark D Lyttle
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Children's Hospital, Bristol, United Kingdom.,Academic Department of Emergency Care, University of the West of England, Bristol, United Kingdom
| | - Silvia Bressan
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Yuri Gilhotra
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jeremy Furyk
- Emergency Department, Townsville Hospital, Townsville, Queensland, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
| | - Susan Donath
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Hearps
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Marta Arpone
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise Crowe
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Ruth Barker
- Queensland Injury Surveillance Unit, Brisbane, Queensland, Australia
| | - Ed Oakley
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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16
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Mehmood A, Zia N, Hoe C, Kobusingye O, Ssenyojo H, Hyder AA. Traumatic brain injury in Uganda: exploring the use of a hospital based registry for measuring burden and outcomes. BMC Res Notes 2018; 11:299. [PMID: 29764476 PMCID: PMC5952367 DOI: 10.1186/s13104-018-3419-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/09/2018] [Indexed: 12/03/2022] Open
Abstract
Objective Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system. Results The electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries. Electronic supplementary material The online version of this article (10.1186/s13104-018-3419-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amber Mehmood
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nukhba Zia
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Connie Hoe
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Adnan A Hyder
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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17
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Keneally RJ, Shields CH, Hsu A, Prior HI, Creamer KM. Pediatric Thoracic Trauma in Iraq and Afghanistan. Mil Med 2018; 183:e596-e602. [DOI: 10.1093/milmed/usy044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Ryan J Keneally
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Cynthia H Shields
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Albert Hsu
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Howard I Prior
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD
| | - Kevin M Creamer
- Department of Pediatrics, George Washington University School of Medicine, 2300 I St NW, Washington, DC
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18
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El-Menyar A, Consunji R, Al-Thani H, Mekkodathil A, Jabbour G, Alyafei KA. Pediatric Traumatic Brain Injury: a 5-year descriptive study from the National Trauma Center in Qatar. World J Emerg Surg 2017; 12:48. [PMID: 29151847 PMCID: PMC5678808 DOI: 10.1186/s13017-017-0159-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/26/2017] [Indexed: 11/10/2022] Open
Abstract
Background The epidemiologic characteristics and outcomes of pediatric traumatic brain injury (pTBI) have not been adequately documented from the rapidly developing countries in the Arab Middle East. We aimed to describe the hospital-based epidemiologic characteristics, injury mechanisms, clinical presentation, and outcomes of pTBI and analyze key characteristics and determinant of pTBI that could help to make recommendations for policies to improve their care. Methods We conducted a retrospective observational study in a level 1 trauma center (2010-2014) for all pTBI patients. Data were analyzed and compared according to different patient age groups. Results Out of 945 traumatic brain injury patients, 167 (17.7%) were ≤ 18 years old with a mean age of 10.6 ± 5.9 and 81% were males. The rate of pTBI varied from 5 to 14 cases per 100,000 children per year. The most affected group was teenagers (15-18 years; 40%) followed by infants/toddlers (≤ 4 years; 23%). Motor vehicle crash (MVC; 47.3%) was the most frequent mechanism of injury followed by falls (21.6%). MVC accounted for a high proportion of pTBI among teenagers (77.3%) and adolescents (10-14 years; 48.3%). Fall was a common cause of pTBI for infants/toddlers (51.3%) and 5-9 years old group (30.3%). The proportion of brain contusion was significantly higher in adolescents (61.5%) and teenagers (58.6%). Teenagers had higher mean Injury Severity Scoring of 24.2 ± 9.8 and lower median (range) Glasgow Coma Scale of 3 (3-15) (P = 0.001 for all). The median ventilatory days and intensive care unit and hospital length of stay were significantly prolonged in the teenage group. Also, pTBI in teenage group showed higher association with pneumonia (46.4%) and sepsis (17.3%) than other age groups (P = 0.01). The overall mortality rate was 13% (n = 22); 11 died within the first 24 h, 7 died between the second and seventh day and 4 died one week post-admission. Among MVC victims, a decreasing trend of case fatality rate (CFR) was observed with age; teenagers had the highest CFR (85.7) followed by adolescents (75.0), young children (33.3), and infants/toddlers (12.5). Conclusions This local experience to describe the burden of pTBI could be a basis to adopt and form an efficient, tailored strategy for safety in the pediatric population.
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Affiliation(s)
- Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Rafael Consunji
- Hamad Injury Prevention Program, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | | | | | - Gaby Jabbour
- Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Khalid A Alyafei
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
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19
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Incidence, Demographics, and Outcome of Traumatic Brain Injury in The Middle East: A Systematic Review. World Neurosurg 2017; 107:6-21. [DOI: 10.1016/j.wneu.2017.07.070] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 11/21/2022]
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20
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Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG, Michael LM, Klimo P. Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design. Neurosurgery 2017; 82:728-746. [DOI: 10.1093/neuros/nyx328] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
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21
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Alix-Séguin L, Lodé N, Orliaguet G, Chamorro E, Kerroué F, Lorge C, Moreira A. [And if it happened to children? Adapting medical care during terrorist attacks with multiple pediatric victims]. Arch Pediatr 2017; 24:280-287. [PMID: 28159434 DOI: 10.1016/j.arcped.2016.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/05/2016] [Accepted: 12/16/2016] [Indexed: 01/22/2023]
Abstract
In light of the recent terrorist attacks in Europe, we need to reconsider the organization of rescue and medical management and plan for an attack involving multiple pediatric victims. To ensure quick surgical management, but also to minimize risk for on-site teams (direct threats from secondary terrorist attacks targeting deployed emergency services), it is crucial to evacuate patients in a swift but orderly fashion. Children are vulnerable targets in terrorist attacks. Their anatomical and physiological characteristics make it likely that pediatric victims will suffer more brain injuries and require more, often advanced, airway management. Care of multiple pediatric victims would also prove to be a difficult emotional challenge. Civilian medical teams have adapted the military-medicine principles of damage control in their medical practice using the MARCHE algorithm (Massive hemorrhage, Airway, Respiration [breathing], Circulation, Head/Hypothermia, Evacuation). They have also learned to adapt the level of care to the level of safety at the scene. Prehospital damage control principles should now be tailored to the treatment of pediatric patients in extraordinary circumstances. Priorities are given to hemorrhage control and preventing the lethal triad (coagulopathy, hypothermia, and acidosis). Managing hemorrhagic shock involves quickly controlling external bleeding (tourniquets, hemostatic dressing), using small volumes for fluid resuscitation (10-20ml/kg of normal saline), quickly introducing a vasopressor (noradrenaline 0.1μg/kg/min then titrate) after one or two fluid boluses, and using tranexamic acid (15mg/kg over 10min for loading dose, maximum 1g over 10min). Prehospital resources specifically dedicated to children are limited, and it is therefore important that everyone be trained and prepared for a scene with multiple pediatric patients.
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Affiliation(s)
- L Alix-Séguin
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France; Service d'urgence pédiatrique, CHU Sainte-Justine, 3175, chemin de la Côte-Sainte-Catherine, H3T 1C5 Montréal, Canada.
| | - N Lodé
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - G Orliaguet
- Département d'anesthésie-réanimation, université Paris-Descartes, hôpital universitaire Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - E Chamorro
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - F Kerroué
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - C Lorge
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
| | - A Moreira
- SMUR pédiatrique Robert-Debré (SAMU 75), hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
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