Surgical outcomes of a civil war in a neighbouring country

Better be prepared: the spectrum of neuropsychiatric impairment among Libyan war victims transferred to Germany for trauma rehabilitation

Background

The current Libyan civil war has originated many casualties, imposing medical challenges. War injuries are complex, requiring specialized knowledge and interdisciplinary assessment for adequate patient and intercultural management.

Methods

This retrospective study analyzed records of 78 Libyan patients admitted from July 2016 to November 2017 to neurological and trauma surgical departments of Krankenhaus Nordwest, Frankfurt, Germany. Issues of system preparation of the hospital, demographics, injury patterns and therapies were analyzed. The chi-squared test was used to analyze differences in injury patterns in explosion and gunshot injuries.

Results

Seventy-seven of seventy-eight patients were male (mean age 30.6 years). The patients received primary and secondary treatment in Tunisia (n = 39), Libya (n = 36) and Turkey (n = 23). Forty-eight patients had gunshot injuries, 37 explosion injuries, 11 both. Preparation for management of injuries included hygienic and isolation protocols, organization of interpreters and intercultural training. Patients presented with a broad variety of neurological, psychiatric and trauma surgical injuries. Fifty-six patients had sensory, 47 motor deficits. Nine reported headache, 5 vertigo, 13 visual impairment, 28 psychiatric symptoms. Eighteen patients had central nervous damage, 50 peripheral nervous damage. Central nervous damage was significantly more common in gunshot than explosion injuries (p = 0.015). Peripheral nervous damage was more common in explosion than gunshot injuries (p < 0.1). Fifty-one patients had polytrauma and 49 suffered from fractures. Therapy included surgical interventions (n = 56) and physiotherapy. Structured rehabilitation programs were often indicated.

Conclusion

Specialized knowledge about war injuries and their management including hospital preparation and planning regarding infrastructure may be required anytime. Injuries include a broad variety of neurological, psychiatric and trauma surgical injuries. Therefore, an interdisciplinary approach is crucial.

Treatment of secondary hip arthritis from shell fragment and gunshot injury in the Syrian civil war

Background

In gunshot and shell fragment injuries to the hip joint, orthopedic intervention includes wound assessment and care, osteosynthesis of fractures, and avoiding of infection and osteoarthritis. Individuals injured in the Syrian civil war were frequently transferred to the authors’ institution in neighboring city. Orthopedic trauma exposures were determined in approximately 30% of these patients. The aim of this study was to evaluate the outcomes of the patients with secondary hip arthritis due to prior gunshot and shell fragment (shrapnel) injuries who underwent primary total hip arthroplasty.

Methods

This retrospective study reviewed 26 patients (24 males, 2 females) who underwent hip arthroplasty due to prior gunshot and shell fragment injuries from November 2013 to January 2019. For all patients, the Harris Hip Score (HHS) was evaluated preoperatively and after surgery.

Results

Mean age was 31.5 (range, 19–48) years. The mean preoperative HHS was 52.95 points, and the mean postoperative HHS was 79.92 points at the final follow-up after surgery. Patients with shell fragment injuries to the hip joint had higher infection rates, but it is not statistically significant.

Conclusions

An anatomic reduction of the fracture may not be possible in these cases as a result of significant bone and/or cartilage loss. Total hip arthroplasty can be done after gunshot- and shell fragment-related posttraumatic arthritis. It is an effective treatment choice to reduce pain and improve function, but the surgeon must be very careful because of high rate of infection.

Management of orthopaedic injuries in Libyan civil war: experiences of a distant hospital

AIM OF THE STUDY

In this study, we aimed to evaluate the musculoskeletal injury types, infections, and treatments of the patients injured in Libyan civil war.

METHODS

A total of 291 patients (288 male, 3 female) treated in our clinic, between November 2011 and April 2020, were included in our retrospective study. Patients' age, injury severity score (ISS), injury type, mechanism, location, accompanying traumas, infection, and operations in Libya and in our clinic were evaluated.

RESULTS

Injuries were caused by gunshots in 172 patients, by explosives in 56, by missiles in eight, and by different mechanisms in the remaining 55 patients. Injuries were located mostly in lower extremities, followed by upper extremities and by both extremities. The most common fracture was tibial fractures, followed with femur and humerus. Plate-screw fixation was performed for 82 cases, intramedullary nailing for 42, external fixator for 41, K-wire fixation for 27, foreign body excisions for 26, arthrodesis for 15, amputation for , arthroplasty for 11, and soft tissue operations for 78. Infection was present among 50 (% 17.2) patients. Complications were seen in five patients. Three patients needed implant removal due to infection, one patient had a plate fracture, and one patient died because of sepsis.

DISCUSSION

Difficulties in the treatment of war injuries begin in the battlefield. Patients' transfers and treatments may not be provided properly due to unsuitable conditions. Hospitals in neighbouring and distant countries can be helpful for supporting the treatment of increased numbers of injured patients.

CONCLUSION

Wars cause excessive numbers of injuries. In this study, we want to show that hospitals far from war zones can be considered as alternatives for treatment of these injuries.

Undeclared civil war? Urban violence in major city in Brazil

PURPOSE

Civil violence is responsible for 2.5% of deaths worldwide; it killed more people in the 21st century than the sum of all wars. This study describes violence victims treated at a trauma reference hospital in Salvador, Brazil and analyzes the impact of different types of interpersonal violence.

METHODS

Interpersonal violence victims admitted between July 2015 and July 2017 were included. The 1,296 patients (mean age: 30.3 years; 90% male) were divided into three groups according to the mechanism of interpersonal violence: 1) beating, 2) firearm injury and 3) stab wound (STW) injury. The groups were compared for the following variables: age, gender, trauma mechanism, Revised Trauma Score (RTS) at admission, need for intensive care unit (ICU) attention, length of hospital stay, need for transfusion of blood products and death.

RESULTS

Gunshot wounds (GSW) were the primary mechanism of injury (59%), followed by beating (24%) and STW (17%). Gunshot wound victims had a lower mean RTS upon admission, increased need for blood products and more Intensive Care Unit (ICU) admissions. Beating victims had the longest mean hospital stay (11.6 ± 19.6 days). The GSW group accounted for 77.4% of all deaths. The in-hospital mortality rate was significantly higher in the GSW group (12.7%) than in the beating group (5.4%) and in the STW group (4.9%).

CONCLUSIONS

Gunshot wound victims are more critical: they require longer ICU stays, more transfusions of blood products and exhibit increased mortality compared with STW and beating victims.

Syrian Civil War: a systematic review of trauma casualty epidemiology

BACKGROUND

The Syrian Civil War has caused over 400 000 traumatic deaths. Understanding the nature of war casualties is crucial to deliver healthcare improvement. Historic regional conflicts and Syrian mortality data have been characterised by blast injuries. The aim of this novel review is to assess the trauma epidemiology of Syrian Civil War casualties from the perspective of healthcare facilities.

METHODS

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Studies addressing Syria, trauma and war were investigated. Eligibility criteria included being conducted from a healthcare facility, published in English and peer reviewed. The outcomes were demography, mechanism of injury and anatomical injury site.

RESULTS

38 papers satisfied the eligibility criteria. 13 842 casualties were reported across the entire data set. Casualties were 88.8% male (n=4035 of 4544). Children contributed to 16.1% of cases (n=398 of 2469). Mortality rate was 8.6% (n=412 of 4774). Gunshot wound was the most common mechanism of injury representing 66.3% (n=7825 of 11799). Head injury was the most common injured site at 26.6% (n=719 of 2701).

CONCLUSIONS

This conflict has a distinct trauma profile compared with regional modern wars. The prevalence of gunshot wounds represents a marked change in mechanism of injury. This may be related to higher mortality rate and proportion of head injuries identified. This review cannot correlate mechanism of injury, demographics or injuries sustained to outcomes. The quality of data from the included studies lacked standardisation; future research and consistent reporting tools are required to enable further analysis.

The blast wounded of Raqqa, Syria: observational results from an MSF-supported district hospital

Background

In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses.

Methods

We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018).

Results

We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p = <.001). The offensive period saw a significantly higher proportion of female patients (32.0%, n = 31 vs. 11.1%, n = 25, p < 0.001) and paediatric patients (42.3%, n = 41 vs 24.9%, n = 56, p = 0.002). Blast-injured patients in the post-offensive period included more cases with multiple traumatic injuries (65.8%, n = 148 vs. 39.2%, n = 38, p < 0.001). The treatment of the blast-injured cases in the post-offensive period was more labor intensive with those patients having a higher median number of interventions (2 vs 1, p = <0.001) and higher median number of days in hospital (7 vs 4, p = < 0.001).

Conclusions

In the wake of the Raqqa offensive, the MSF-supported district hospital received an unpredicted second, larger and more complex wave of blast-wounded cases as the population returned to a city strewn with IEDs and ERWs. These findings indicate the high risk of traumatic injury to the population even after warring factions have vacated conflict zones. Medical humanitarian actors should be prepared for a continued and scaled up response in areas known to be highly contaminated with explosive ordnance.

The Golden Hour After Injury Among Civilians Caught in Conflict Zones

Introduction:

The term “golden hour” describes the first 60 minutes after patients sustain injury. In resource-available settings, rapid transport to trauma centers within this time period is standard-of-care. We compared transport times of injured civilians in modern conflict zones to assess the degree to which injured civilians are transported within the golden hour in these environments.

Methods:

We evaluated PubMed, Ovid, and Web of Science databases for manuscripts describing transport time after trauma among civilian victims of trauma from January 1990 to November 2017.

Results:

The initial database search identified 2704 abstracts. Twenty-nine studies met inclusion and exclusion criteria. Conflicts in Yugoslavia/Bosnia/Herzegovina, Syria, Afghanistan, Iraq, Israel, Cambodia, Somalia, Georgia, Lebanon, Nigeria, Democratic Republic of Congo, and Turkey were represented, describing 47 273 patients. Only 7 (24%) manuscripts described transport times under 1 hour. Transport typically required several hours to days.

Conclusion:

Anticipated transport times have important implications for field triage of injured persons in civilian conflict settings because existing overburdened civilian health care systems may become further overwhelmed if in-hospital health capacity is unable to keep pace with inflow of the severely wounded.

The Libyan civil conflict: selected case series of orthopaedic trauma managed in Malta in 2014

AIM

The purpose of this series of cases was to analyse our management of orthopaedic trauma casualties in the Libyan civil war crisis in the European summer of 2014. We looked at both damage control orthopaedics and for case variety of war trauma at a civilian hospital. Due to our geographical proximity to Libya, Malta was the closest European tertiary referral centre. Having only one Level 1 trauma care hospital in our country, our Trauma and Orthopaedics department played a pivotal role in the management of Libyan battlefield injuries. Our aims were to assess acute outcomes and short term mortality of surgery within the perspective of a damage control orthopaedic strategy whereby aggressive wound management, early fixation using relative stability principles, antibiotic cover with adequate soft tissue cover are paramount. We also aim to describe the variety of war injuries we came across, with a goal for future improvement in regards to service providing.

METHODS

Prospective collection of six interesting cases with severe limb and spinal injuries sustained in Libya during the Libyan civil war between June and November 2014.

CONCLUSIONS

We applied current trends in the treatment of war injuries, specifically in damage control orthopaedic strategy and converting to definitive treatment where permissible. The majority of our cases were classified as most severe (Type IIIB/C) according to the Gustilo-Anderson classification of open fractures. The injuries treated reflected the type of standard and improved weaponry available in modern warfare affecting both militants and civilians alike with increasing severity and extent of damage. Due to this fact, multidisciplinary team approach to patient centred care was utilised with an ultimate aim of swift recovery and early mobilisation. It also highlighted the difficulties and complex issues required on a hospital management level as a neighbouring country to war zone countries in transforming care of civil trauma to military trauma.