Afghan civilian casualties: a grim reality

Using the Red Cross wound classification to predict treatment needs in children with conflict-related limb injuries: a retrospective database study

Background

The International Committee of the Red Cross (ICRC) implemented the Red Cross wound classification (RCWC) to quickly assess the severity of a wound in conflict settings. A subdivision into wound grades derived from the RCWC consists of grades 1, 2, and 3, and represents low, major, and massive energy transfer, respectively, to the injured tissue. The aim of this observational study is to assess whether the Red Cross wound grade of a pediatric patient’s wound correlates with patient outcomes.

Methods

All pediatric patients (age < 15 years) treated in an ICRC hospital between 1988 and 2014 for conflict-related penetrating extremity injuries were retroactively included. Correlations were assessed between wound grades and number of surgeries, blood transfusions, days hospitalized, and mortality. Stratification analyses were performed to evaluate potential effect modifiers.

Results

The study included 2463 pediatric patients. Pediatric patients with a higher wound grade received significantly more surgeries (grade 1 median 2; grade 3 median 3), more blood transfusions (grades 1 and 3 received 33.9 and 72.2 units per 100 patients, respectively), and were hospitalized longer (grade 1 median 15; grade 3 median 40 days). Mortality rates did not significantly differ. Stratification analyses did not reveal effect modifiers for the association between wound grades and patient outcomes.

Conclusion

The Red Cross wound grade of a pediatric patient’s extremity wound correlates independently with treatment needs. This simple wound grading system could support clinical decision-making and should be integrated into the clinical assessment of weapon-wounded pediatric patients in conflict settings.

Global surgery for paediatric casualties in armed conflict

Background

Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones.

Methods

Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years).

Results

Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6–12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1–3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates.

Conclusions

Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts.

The pattern of paediatric blast injury in Afghanistan

Introduction

Between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within Afghanistan. Improvised explosive devices (IEDs) and explosive remnants of war accounted for 29% of child casualties in 2015. The aim of this study was to review the burden of paediatric blast injuries admitted to Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more head injuries than adults.

Method

A retrospective analysis was undertaken of prospectively collected data derived from the UK Joint Theatre Trauma Registry of ambulant paediatric (aged 2–15 years) admissions with blast injuries at the Role 3 Field Hospital, Camp Bastion from June 2006 to March 2013. The data set included demographic information, injury profile and severity (New Injury Severity Score) and operative findings. The pattern of injuries were investigated by looking at trends in the number and severity of injuries sustained by each body region.

Results

During this period, 295 admissions were identified, 76% of whom were male, with an overall mortality rate of 18.5%. The most common blast mechanism was an IED (68%) causing 80% of fatalities. The lower extremities were the most commonly injured body region, accounting for 31% of total injuries and occurring in 62% of cases. 24.3% of children between 2 and 7 years suffered severe head or neck injuries compared with 19.8% of children aged between 8 and 15 years. 34% of head injuries were rated unsurvivable and accounted for 88% of fatalities. 77% of cases required an operation with a mean operating time of 125 min. The most common first operations were debridement of soft tissues (50%), laparotomy (16%) and lower limb amputation (11%).

Conclusion

Although paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility, the pattern of injuries seen suggests that children are more likely to sustain severe head, face and neck injuries than adults.

Pediatric Surgical Care in a Dutch Military Hospital in Afghanistan

Background

From August 2006–August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civilians, including many children. Humanitarian aid accounted for a substantial part of the workload, necessitating medical, infrastructural, and logistical adaptations. Particularly pediatric care demanded specific expertise and equipment. In our pre-deployment preparations this aspect had been undervalued. Because these experiences could be influential in future mission planning, we analyzed our data and compared them with international reports.

Methods

This is a retrospective, descriptive study. Using the hospital’s electronic database, all pediatric cases, defined as patients <17 years of age, who were admitted between August 2006 and August 2010 to the Dutch R2E-MTF at Multinational Base Tarin Kowt (MBTK), Urzugan, Afghanistan were analyzed.

Results

Of the 2736 admissions, 415 (15.2 %) were pediatric. The majority (80.9 %, 336/415) of these admissions were for surgical, often trauma-related, pathology and required 610 surgical procedures, being 26 % of all procedures. Mean length of stay was 3.1 days. The male to female ratio was 70:30. Girls were significantly younger of age than boys. In-hospital mortality was 5.3 %.

Conclusion

Pediatric patients made up a considerable part of the workload at the Dutch R2E-MTF in Uruzgan, Afghanistan. This is in line with other reports from the recent conflicts in Iraq and Afghanistan, but used definitions in reported series are inconsistent, making comparisons difficult. Our findings stress the need for a comprehensive, prospective, and coalition-wide patient registry with uniformly applied criteria. Civilian disaster and military operational planners should incorporate reported patient statistics in manning documents, future courses, training manuals, logistic planning, and doctrines, because pediatric care is a reality that cannot be ignored.