Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data

Beirut massive blast explosion: A unique injury pattern of the wounded population

INTRODUCTION

On August 4, 2020, a massive explosion of a warehouse holding 2,700 metric tons of ammonium nitrate took place in the port of Beirut, Lebanon. This incident, which is considered as one of the largest industrial disasters lead to the death of at least 220 people and more than 6000 injuries. Hospitals near the blast were damaged significantly which made it difficult to treat injured patients. The objective of this study is to report the epidemiology and characteristics of the injuries and their initial management that could be useful for healthcare workers and policymakers in case of a similar massive accident in the future.

MATERIALS AND METHODS

A retrospective study was conducted. All charts of patients admitted to the emergency room and outpatient clinics on the day of the blast and during the following 2 weeks were thoroughly reviewed. Due to initial chaos during triage, direct phone contact with patients was utilized in certain situations to confirm their identity or for further information. All acute injuries were recorded based on the region, severity, degree of emergency, initial and later management, type of injured organs, and surgical procedures.

RESULTS

A total of 159 patients presented to our facility. 153 patients presented to the ER on the same day of the blast. The mean age was 47.07 years and around 60% of the patients were males (n = 93). Most of the patients presented either from zone 1 (n = 67, 42%) or zone 3 (n = 68, 43%). The majority of injuries were secondary injuries due to glass (n = 131, 82.3%), with the head (34%) and upper extremities (31.2%) being most commonly affected. A total of 94 patients (62.6%) underwent a type of imaging and 64 patients (40.2%) had at least one surgery performed during their hospitalization in which 71% of the surgeries being related to the limbs.

CONCLUSION

This study demonstrated a unique injury pattern due to this type of blast. Injuries were mostly due to glass shrapnel. Contrary to bomb blasts, most injuries were located in the head and upper extremities rather than on the lower extremities.

Pediatric Blast Trauma: A Systematic Review and Meta-Analysis of Factors Associated with Mortality and Description of Injury Profiles

Introduction:

Blast polytrauma is among the most serious mechanisms of injury confronted by medical providers. There are currently no specific studies or guidelines that define risk factors for mortality in the context of pediatric blast injuries or describe pediatric blast injury profiles.

Objective:

The objectives of this study were to evaluate risk factors for pediatric mortality and to describe differences in injury profiles between explosions related to terrorism versus unrelated to terrorism within the pediatric population.

Methods:

A PRISMA systematic review and meta-analysis was performed where articles published from the years 2000-2021 were extracted from PubMed. Mortality and injury profile data were extracted from articles that met inclusion criteria. A bivariant unadjusted odds ratio (OR) analysis was performed to establish protective and harmful factors associated with mortality and to describe the injury profiles of blasts related to terrorism. Statistical significance was established at P < .05.

Results:

Thirty-eight articles were included and described a total of 222,638 unique injuries. Factors associated with increased mortality included if the explosion was related to terrorism (OR = 32.73; 95% CI, 28.80-37.21; P < .05) and if the explosion involved high-grade explosives utilized in the Global War on Terror ([GWOT] OR = 1.28; 95% CI, 1.04-1.44; P < .05). Factors associated with decreased mortality included if the patient was resuscitated in a North Atlantic Treaty Organization (NATO)-affiliated combat trauma hospital (OR = 0.48; 95% CI, 0.37-0.62; P < .05); if the explosive was fireworks (OR = 3.20×10-5; 95% CI, 2.00×10-6-5.16×10-4; P < .05); and if the explosion occurred in the United States (OR = 2.40×10-5; 95% CI, 1.51×10-6-3.87×10-4; P < .05). On average, victims of explosions related to terrorism were 10.30 years old (SD = 2.73) with 68.96% (SD = 17.58%) of victims reported as male. Comparison of victims of explosions related to terrorism revealed a higher incidence of thoracoabdominal trauma (30.2% versus 8.6%), similar incidence of craniocerebral trauma (39.5% versus 43.1%), and lower incidence of extremity trauma (31.8% versus 48.3%) compared to victims of explosions unrelated to terrorism.

Conclusion:

Explosions related to terrorism are associated with increased mortality and unique injury profiles compared to explosions unrelated to terrorism in the pediatric population. Such findings are important for optimizing disaster medical education of pediatric providers in preparation for and management of acute sequelae of blast injuries—terror-related and otherwise.

A 1-year training program in emergency medicine for physicians in Karachi, Pakistan: Evaluation of learner and program outcomes

BACKGROUND

Pakistan has an underdeveloped and overburdened emergency care system, with most emergency departments (EDs) staffed by physicians not formally trained in emergency medicine (EM). As of January 2020, only nine Pakistani institutions were providing formal EM specialty training; therefore, a training program of shorter duration is needed in the interim.

METHODS

The Certification Program in Emergency Medicine (CPEM) is a 1-year training program in EM consisting of two arms: CPEM-Clinical (CPEM-C), which includes physicians from The Indus Hospital (TIH) ED, and CPEM-Didactic (CPEM-D), including physicians from EDs across Karachi. Both groups participate in weekly conferences, including didactics, small-group discussions, workshops, and journal clubs. CPEM-C learners also receive clinical mentorship from visiting international and TIH EM faculty. Both groups were assessed with preprogram, midterm, and final examinations as well as on clinical skills. Additionally, both groups provided regular feedback on program content and administration.

RESULTS

Twenty-five of the 32 initially enrolled learners completed the program in June 2019. Scores on a matched set of 50 questions administered in the pretest and final examination improved by an average of 15.1% (p < 0.005) for CPEM-C learners and 8.5% (p < 0.0005) for CPEM-D learners, with 93% of learners showing improvement. Clinical evaluations of CPEM-C and CPEM-D learners during the first and fourth quarters showed an average improvement of 1.1 out of 5 (p < 0.05) and 1.2 out of 9 (p < 0.0005) points, respectively. Learner evaluations of the program were overall positive.

CONCLUSIONS

CPEM demonstrated significant improvement in test scores and clinical evaluations in both program arms. Evaluations also suggested that the program was well received. These data, along with CPEM's ability to train physicians from multiple institutions using low-cost, innovative educational strategies, suggest that it may be an effective, transferable mechanism for the expedited development of EM in Pakistan and countries where EM is developing as a specialty.

Epidemiology of Blast Neurotrauma: A Meta-analysis of Blast Injury Patterns in the Military and Civilian Populations

BACKGROUND

Mass casualty incidents (MCIs) due to bombing-related terrorism remain an omnipresent threat to our global society. The aim of this study was to elucidate differences in blast injury patterns between military and civilian victims affected by terrorist bombings.

METHODS

An analysis of the Global Terrorism Database (GTD) and a PubMed literature search of casualty reports of bombing attacks from 2010-2020 was performed (main key words: blast injuries/therapy, terrorism, military personnel) with key epidemiological and injury pattern data extracted and statistically analyzed.

RESULTS

Demographic analysis of casualties revealed that military casualties tend to be younger and predominantly male (P < 0.05) compared with civilians. Military casualties also reported higher amounts of head/neck injury (P < 0.01) compared with civilians. The proportion of instantaneous fatalities along with injuries affecting the thoracoabdominal and extremity regions remained approximately equal across both groups.

CONCLUSIONS

Though the increased number of head/neck injuries was unexpected, we also found that the number of nonlethal head injuries also increased, predicating that more military blast neurotrauma patients survived their injuries. These data can be used to increase blast MCI preparation and education throughout the international neurosurgical community.

Blast injuries in children: a mixed-methods narrative review

BACKGROUND AND SIGNIFICANCE

Blast injuries arising from high explosive weaponry is common in conflict areas. While blast injury characteristics are well recognised in the adults, there is a lack of consensus as to whether these characteristics translate to the paediatric population. Understanding blast injury patterns in this cohort is essential for providing appropriate provision of services and care for this vulnerable cohort.

METHODS

In this mixed-methods review, original papers were screened for data pertaining to paediatric injuries following blasts. Information on demographics, morbidity and mortality, and service requirements were evaluated. The papers were written and published in English from a range of international specialists in the field.

RESULTS

Children affected by blast injuries are predominantly male and their injuries arise from explosive remnants of war, particularly unexploded ordinance. Blasts show increased morbidity and mortality in younger children, while older children have injury patterns similar to adults. Head and burn injuries represent a significant cause of mortality in young children, while lower limb morbidity is reduced compared with adults. Children have a disproportionate requirement for both operative and non-operative service resources, and provisions for this burden are essential.

CONCLUSIONS

Certain characteristics of paediatric injuries arising from blasts are distinct from that of the adult cohort, while the intensive demands on services highlight the importance of understanding the diverse injury patterns in order to optimise future service provisions in caring for this child blast survivor.