Analysis of 983 civilian blast and ballistic casualties and the generation of a template of injury burden: An observational study

BACKGROUND

Terrorism and armed conflict cause blast and ballistic casualties that are unusual in civilian practice. The immediate surgical response to mass casualty events, with civilians injured by these mechanisms, has not been systematically characterised. Standardising an approach to reacting to these events is challenging but is essential to optimise preparation for them. We aimed to quantify and assesses the surgical response to blast and ballistic injuries managed in a world-class trauma unit paradigm.

METHODS

This was an observational study conducted at the UK-led military Medical Treatment Facility, Camp Bastion, Afghanistan from original theatre log-book entries between Nov 5, 2009, and Sept 21, 2014; a total of 10,891 consecutive surgical cases prospectively gathered by surgical teams were catalogued. Patients with combatant status/wearing body-armour to various degrees including interpreters were excluded from the study. Civilian casualties that underwent primary trauma surgery for blast and ballistic injuries were included (n=983). Surgical activity was analysed as a rate per 100 casualties, and patients were grouped according to adult vs. paediatric and ballistic vs. blast injury mechanisms to aid comparison.

FINDINGS

The three most common surgical procedures for civilian blast injuries were debridement, amputation, and laparotomy. For civilian ballistic injuries, these were debridement, laparotomy and vascular procedures. Blast injuries generated more amputations in both adults and children compared to ballistic injuries. Blast injuries generated more removal of fragmentation material compared to ballistics injuries amongst adult casualties. Ballistic injuries lead to more chest drain insertions in adults. As a rate per 100 casualties, adults injured by blast underwent significantly more debridement (63·5); temporary skeletal stabilisation (13·2) and vascular procedures (12·8) compared to children (43·4, z=4·026, p=0·00007; 5·7, z=2·230, p=0·022; 4·9, z=2·468, p=0·014). Adults injured by ballistics underwent significantly more debridement (63·4); chest drain (12·3) and temporary skeletal fixation procedures (11·4) compared to children (50·0, z=2·058, p=0.040, p<0·05; 2·9, z=2·283, p=0.0230; 2·9, z=2·131, p=0.034 respectively). By comparison, children injured by ballistics underwent significantly more removal of fragmentation and ballistic materials (20·6) when compared to adults (7·7, z=-3·234; p=0.001).

INTERPRETATION

This is the first evidence-based, template of the immediate response required to manage civilians injured by blast and ballistic mechanisms. The template presented can be applied to similar conflict zones and to prepare for terror attacks on urban populations.

FUNDING

The work was supported in part by a grant to LM from School of Medicine, University of St Andrews.

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 patient safety practices of emergency medical teams in disaster zones: a systematic analysis

INTRODUCTION

Disaster zone medical relief has been criticised for poor quality care, lack of standardisation and accountability. Traditional patient safety practices of emergency medical teams (EMTs) in disaster zones were not well understood. Improving the quality of healthcare in disaster zones has gained importance within global health policy. Ascertaining patient safety practices of EMTs in disaster zones may identify areas of practice that can be improved.

METHODS

A systematic search of OvidSP, Embase and Medline databases; key journals of interest; key grey literature texts; the databases of the WHO, Médecins Sans Frontieres and the International Committee of the Red Cross; and Google Scholar was performed. Descriptive studies, case reports, case series, prospective trials and opinion pieces were included with no limitation on date or language of publication.

RESULTS

There were 9685 records, evenly distributed between the peer-reviewed and grey literature. Of these, 30 studies and 9 grey literature texts met the inclusion criteria and underwent qualitative synthesis. From these articles, 302 patient safety statements were extracted. Thematic analysis categorised these statements into 84 themes (total frequency 632). The most frequent themes were limb injury (9%), medical records (5.4%), surgery decision-making (4.6%), medicines safety (4.4%) and protocol (4.4%).

CONCLUSION

Patient safety practices of EMTs in disaster zones are weighted toward acute clinical care, particularly surgery. The management of non-communicable disease is under-represented. There is widespread recognition of the need to improve medical record-keeping. High-quality data and institutional level patient safety practices are lacking. There is no consensus on disaster zone-specific performance indicators. These deficiencies represent opportunities to improve patient safety in disaster zones.

Prepared for Mission? A Survey of Medical Personnel Training Needs Within the International Committee of the Red Cross

BACKGROUND

Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel.

METHODS

All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents' personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment.

RESULTS

The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p < 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150).

CONCLUSION

ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.

Getting the best of both worlds--clinical excellence at a peripheral unit

Audit of hospital practice in remote areas and military practice indicates that it is possible to provide a high degree of patient safety with the advantages of care close to home in a small hospital with less than 100 beds. However such an approach requires strict attention to training and retraining, good clinical networking, attention to quality control and a well defined system for identifying those patients who need to be transferred to a specialist centre.

Molecular weight of Hydroxyethyl Starch Molecules influences Coagulation Profile measured by thrombelastography

Background

The consensus about the ideal intravenous fluid in trauma patients remains open. However, hypertonic saline and hydroxyethyl starch (HES) seems to have advantages in terms of immuno-modulatory and haemodynamic effects. Nevertheless clotting abnormalities are frequently reported in association with the use of HES. We investigated the influence of light, medium and heavy molecular weight (MW) hydroxyethyl starch (HES) on coagulation in 29 healthy subjects.

Methods

Ringer’s lactate (RL) served as a control solution. Thrombelastography using Haemoscope’s Thrombelastograph® (TEG®) hemostasis system was used to assess the effect of HES polymers and RL. TEG analysis was performed using recalcified native whole blood both with and without the addition of platelet activating factor IV (PAF IV) before and immediately after infusion of one of the solutions.

Results

Infusion of RL or one of the three HES solutions exerts an anticoagulant effect as demonstrated by a increase in clot formation time (R) and a decrease in maximum amplitude (MA), and the angle. The addition of PAF IV reversed these changes.

Conclusions

This data indicate clear evidence of platelet activity per se or platelet interaction with the plasmatic coagulation system. Key words: Coagulation, thrombelastography, platelets, hydroxyethyl-starch

Molecular weight of hydroxyethyl starch molecules influences coagulation profile measured by thrombelastography

BACKGROUND

The consensus about the ideal intravenous fluid in trauma patients remains open. However, hypertonic saline and hydroxyethyl starch (HES) seems to have advantages in terms of immuno-modulatory and haemodynamic effects. Nevertheless clotting abnormalities are frequently reported in association with the use of HES. We investigated the influence of light, medium and heavy molecular weight (MW) hydroxyethyl starch (HES) on coagulation in 29 healthy subjects.

METHODS

Ringer's lactate (RL) served as a control solution. Thrombelastography using Haemoscope's Thrombelastograph (TEG) hemostasis system was used to assess the effect of HES polymers and RL. TEG analysis was performed using recalcified native whole blood both with and without the addition of platelet activating factor IV (PAF IV) before and immediately after infusion of one of the solutions.

RESULTS

Infusion of RL or one of the three HES solutions exerts an anticoagulant effect as demonstrated by a increase in clot formation time (R) and a decrease in maximum amplitude (MA), and the angle. The addition of PAF IV reversed these changes.

CONCLUSIONS

This data indicate clear evidence of platelet activity per se or platelet interaction with the plasmatic coagulation system.

Ultrastructural localization of silver deposits in the receptacle cells of carnation flowers

Carnations were treated with a silver thiosulphate complex to prevent wilting of the flowers. The ultrastructural localization of silver and sulphur in the receptacle tissue was investigated by electron microscopy. Electron-dense deposits were present in the receptacle tissue. Coarse-grained deposts (diam. 60-100 nm) were predominantly observed at the inner side of the cell wall, whereas fine-grained deposits (diam. 20-60 nm) were predominantly present inside the cell-wall region and in the intercellular spaces. These particles were analyzed for chemical elements by X-ray analytical electron microscopy (Philips EM 400 plus Edax energy dispersive analyzer, type 711). In both types of deposits, the presence of silver and sulphur was verified. Point analysis revealed that in both precipitates the S/Ag ratio was of the same order.

Effects of silver on ethylene synthesis and action in cut carnations

Silver, applied as silverthiosulphate, completely blocked the ethylene surge preceding the wilting of the petals. As a consequence, vase life was extended by nearly 100%. In addition, a pretreatment with silverthiosulphate caused the flowers to become insensitive to an ethylene treatment.

Mobility and ionic form of silver as related to longevity of cut carnations

The mobility of different ionic forms of silver ((110m)Ag) has been studied using semiconductor radiation detectors. Silver, applied as silvernitrate (2mM), moves upward in the stems of cut carnations (Dianthus caryophyllus L.) at about 3 cm day(-1). This transport has the characteristics of a chromatographic exchange transport, but is not promoted by the addition of other cations (K(+) or Ca(2+)). The silverthiosulphate anionic complex is transported at the same speed as [(32)P]phosphate (about 2 m h(-1)); orders of magnitude faster than Ag(+). The antiethylene action of silver is preserved in this complex, as shown by a significant improvement of the longevity of carnation flowers in the presence or absence of ethephon, even after a short treatment with the silverthiosulphate complex. Analysis of the silver content of different flower parts after a silverthiosulphate treatment shows a distinct accumulation in the receptacle, possibly associated with the antiethylene action.

Specificity of phospholipids binding to indole acetic acid and other auxins

Studies in vitro on the binding of phospholipids with IAA, α-NAA and some of their biologically inactive analogues demonstrate that the observed interaction between IA A and lecithin is not related to the primary action of the hormone in plant growth.

Relationship between transport and metabolism of α-naphthaleneacetic acid, β-naphthaleneacetic acid and α-decalylacetic acid in segments of Coleus

Transportand metabolism of α-naphthaleneacetic acid β-naphthaleneacetic acid, and α-decalylacetic acid, all labelled with (14)C in the carboxyl, group, were studied. Only α-naphthaleneacetic acid is transported in a polar way. Most of the radioactivity in the tissue is in a low molecular form, either free or as immobilization products. The immobilization of β-naphthaleneacetic acid is similar to that of α-naphthaleneacetic acid. Immobilization of α-decalylacetic acid is typically different. Bioassays showed α-naphthaleneacetic acid as the sole biologically active component. It is concluded that stereo requirements necessary for biological activity are also required for polar auxin transport. It is further concluded that the observed specificity of the transport system is not related to the formation of immobilization products.

Movement and metabolism of kinetin-C and of adenine-C in coleus petiole segments of increasing age

To see if polar movement was typical of growth-regulators other than auxins, the movement of adenine-8-(14)C and of kinetin-8-(14)C was studied in segments cut from petioles of increasing age. No polarity was found. In time-course experiments lasting 24 hr, kinetin showed a progressive increase of radioactivity in receiver blocks, while adenine showed a maximum at 8 hr with a decline thereafter. More kinetin moved through older segments than through younger ones. There was no difference in net loss as far as the position of the donor block is concerned. However, the loss of radioactivity from adenine donor blocks was much higher than the loss of radioactivity from kinetin donor blocks.The radioactivity in receiver blocks after 24 hr treatment with kinetin-(14)C was still with kinetin, judging by location on chromatograms. By the same criterion, adenine and a smaller amount of some other compound were in receiver blocks after a 6 hr transport with adenine-(14)C in the donors. By contrast, more zones of radioactivity were extracted from petiole segments to which kinetin or adenine had been added. For both purine derivatives the original compound represented no more than 20% of the total radioactivity extracted from the tissue after a transport period of 24 hr.

Transport and metabolism of indole-3-acetic Acid in coleus petiole segments of increasing age

Transport and metabolism of IAA-1-(14)C in Coleus blumei Benth. was studied by means of a combination of liquid scintillation counting, autoradiography and thin-layer chromatography. Transport of IAA in petiole segments of increasing age (No. 2-8) was strictly polar in a basipetal direction. No acropetal movement occurred in either young or old tissues. The greatest amount, expressed as a percentage of the radioactivity lost from the donor block, was found in basal receivers on petiole number 2. There was gradually less transport in older segments. The recovery as a percentage of the radioactivity not accounted for by donor and receiver blocks, measured by counting the radioactivity in an acetonitrile-extract of petiole segments, was low: 25 to 50%. In this acetonitrile-soluble fraction evidence for different radioactive compounds was found, depending on the age of the tissue. A possible relationship between the amounts of auxin transported in the tissue and its corresponding metabolism is discussed.

On the relation between auxin transport and auxin metabolism in explants of Coleus

Transport and metabolism of naphthylacetic acid, labelled with (14)C or with (3)H, were studied by means of the liquid scintillation counting technique in combination with thin layer chromatography.The amounts of radioactivity reaching the receiver blocks as well as the loss from donor blocks greatly depended on the donor concentration. The relative amounts in receiver blocks increased with decreasing auxin concentrations in donor blocks. This phenomenon may be ascribed to the low immobilization capacity of the tissue at very low auxin concentrations.The relative amounts of radioactivity lost from donor blocks increased with decreasing auxin concentrations in donor blocks.Different characteristics of auxin transport can be explained by assuming a movement in symplast or in apoplast. During transport in the symplast the auxin is immobilized. Auxin immobilization governs many characteristics of auxin transport and could have a regulating effect on the free auxin content in plant tissues.

Auxin transport in explants of coleus

alpha-Naphthaleneacetic acid-C(14), labeled in the carboxyl group, was applied in blocks of agar to the distal and to the proximal (either apical or basal) ends of explants of Coleus. The radioactivity in receiver blocks at the opposite ends was measured. Acropetal transport was slight, only 4% of the basipetal transport.Translocation of NAA-C(14) was polar in basipetal direction. Only 1.4% of the radioactivity lost from donor blocks at the apical position reached the receiver blocks; the greatest part remained in the tissue and was immobilized there. All activity found in receiver blocks at the basal end appeared to be still in the form of NAA. There were no differences between petiole tissue and stem tissue, so far as the transport of NAA is concerned.