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Terrorism-Related Thoracic Trauma is Serious, Complex and Costly: Lessons from the Israeli Experience

David Odell, MD, Malcolm M DeCamp, MD, James Hurst, MD, Sidhu Gangadharan, MD, Kobi Peleg, MD, Robert L Berger, MD;
Beth Israel Deaconess Medical Center- Surgery, Boston, MA


PURPOSE OF STUDY
Chest trauma from terrorism inflicts a unique spectrum of injuries in both civilian and military personnel. Analysis of data obtained in a systematic fashion can identify factors responsible for poor outcomes and improve triage, diagnosis and treatment of these complex patients.

METHODS USED:
The INTR is a repository of epidemiologic data on all victims of trauma admitted to emergency departments of all trauma receiving hospitals in Israel between 10/01/00-12/31/05. Using INTR data, we characterize the presentation, management and outcomes of terror-related chest injuries.

SUMMARY OF RESULTS:
Of the 581 patients treated for terror-related injuries during this six-year period, 321 patients (55%) sustained blast injuries, 244(42%) gunshot wounds and a total of 477(82%) penetrating injuries; 93 also suffered from blunt trauma and 49 from burns. Overall, 498(86%) victims sustained multiple organ injuries through different mechanisms. The Injury Severity Score was >25 in 41% of victims (238/581). Endotracheal intubation in the field or ED was performed in 38% of cases (221/581). Tube thoracostomy for hemothorax/pneumothorax was performed in 144(25%) patients and 40(7%) required thoracotomy in the ED. Overall 213 patients (37%) were successfully managed non-operatively. Of the 368 patients requiring surgical intervention 135(37%) required a thoracic procedure and 233(63%) additional non-thoracic operations. Mortality was 16% and 50% of victims (289/581) required >1 week hospitalization.

CONCLUSIONS:
Terror-related thoracic trauma is predominantly penetrating, rarely confined to the chest and frequently involves multiple organ systems. Unlike non-terror related chest trauma, these injuries frequently require surgery. The multiplicity and severity of such injuries produce substantial mortality, and management consumes considerable healthcare resources. The Israeli trauma experience may enlighten the approach to high-energy projectile/blast trauma not readily available within the United States and may help reformulate disaster preparation.

TABLES AND CHARTS:
Table 1: Terror-related Chest Procedures (N = 239 procedures, 135 patients)
Procedure/Location N % Total
Pleura 46 19
Airway 38 16
Diaphragm 33 14
Lung 27 11
Heart 18 8
Chest Wall 10 4
Exploration/Other 67 28

 

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