Maitland Laura, Middleton Lawrence, Veen Harald, Harrison David J, Baden James, Hettiaratchy Shehan
School of Medicine, University of St Andrews, North Haugh, St Andrews KY16 9TF, UK.
Independent Researcher.
EClinicalMedicine. 2022 Sep 29;54:101676. doi: 10.1016/j.eclinm.2022.101676. eCollection 2022 Dec.
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.
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 (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.
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, 4·026, 0·00007; 5·7, 2·230, 0·022; 4·9, 2·468, 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, 2·058, 0.040, <0·05; 2·9, 2·283, 0.0230; 2·9, 2·131, 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, -3·234; 0.001).
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.
The work was supported in part by a grant to LM from School of Medicine, University of St Andrews.
恐怖主义和武装冲突导致爆炸伤和弹道伤，这在平民医疗实践中并不常见。对于因这些机制受伤的平民，针对大规模伤亡事件的即时外科应对措施尚未得到系统描述。规范应对这些事件的方法具有挑战性，但对于优化应对准备至关重要。我们旨在量化并评估在世界级创伤治疗单元模式下对爆炸伤和弹道伤的外科应对情况。
这是一项观察性研究，于2009年11月5日至2014年9月21日期间，在英国主导的阿富汗巴斯蒂安营地军事医疗设施进行；外科团队前瞻性收集的10891例连续外科病例被编入目录。研究排除了具有战斗人员身份/不同程度穿着防弹衣的患者，包括口译人员。纳入接受爆炸伤和弹道伤一期创伤手术的平民伤亡者（983例）。外科手术活动按每100名伤亡者的比率进行分析，患者按成人与儿童以及弹道伤与爆炸伤机制分组以助比较。
平民爆炸伤最常见的三种外科手术是清创术、截肢术和剖腹术。对于平民弹道伤，这些手术是清创术、剖腹术和血管手术。与弹道伤相比，爆炸伤在成人和儿童中导致更多截肢。在成人伤亡者中，与弹道伤相比，爆炸伤导致更多碎片清除。弹道伤导致成人更多插入胸腔引流管。按每100名伤亡者的比率计算，爆炸伤成人接受的清创术（63.5）、临时骨骼固定术（13.2）和血管手术（12.8）显著多于儿童（43.4、4.026、0.00007；5.7、2.230、0.022；4.9、2.468、0.014）。弹道伤成人接受的清创术（63.4）、胸腔引流（12.3）和临时骨骼固定术（11.4）显著多于儿童（50.0、2.058、0.040，<0.05；2.9、2.283、0.0230；2.9、2.131、0.034）。相比之下，弹道伤儿童接受的碎片和弹道材料清除显著多于成人（20.6对7.7，-3.234；0.001）。
这是首个基于证据的应对爆炸和弹道机制致伤平民所需即时反应的模板。所呈现的模板可应用于类似冲突地区，并为针对城市人口的恐怖袭击做准备。
这项工作部分得到了圣安德鲁斯大学医学院授予LM的一笔赠款的支持。
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