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Hemodynamic consequences of extremity injuries following a terrorist bombing attack: retrospective cohort study

European Journal of Trauma and Emergency Surgery volume 45, pages 865–870 (2019)Cite this article

Abstract

Background

Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries.

Methods

Retrospective study based on a cohort of patient records maintained in one hospital’s mass casualty registry.

Results

Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2–22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3–4 were found to be risk factors for HS.

Conclusions

Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.

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References

  1. Weil YA, Peleg K, Givon A, et al. Musculoskeletal injuries in terrorist attacks—a comparison between injuries sustained and those related to motor vehicle accidents, based on a national registry database. Injury Int J Care Injur. 2008;39(12):1359–64.

    Article  Google Scholar 

  2. Weil YA, Petrov K, Liebergall M, et al. Long bone fractures caused byAuthor: Kindly provde the complete details for the reference number 5. penetrating injuries in terrorist attacks. J Trauma. 2007;62(4):909–12.

    Article  Google Scholar 

  3. Aylwin CJ, Konig TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219–25.

    Article  Google Scholar 

  4. Turegano-Fuentes F, Perez-Diaz D. Medical response to the 2005 terrorist bombings in London. Lancet. 2006;368(9554):2188–9.

    Article  Google Scholar 

  5. AAAM (author). Abbreviated Injury Scale (AIS) 2005 Manual. 1st ed.

  6. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Jt Surg Am. 1976;58:453–8.

    CAS  Article  Google Scholar 

  7. Taylor FB, Toh CH, Hoots WK, et al. Towards definition, clinical and a scoring system for disseminated intravascular coagulation. Thromb Haemost. 2001;86(5):1327–30.

    CAS  Article  Google Scholar 

  8. Kluger Y, Peleg K, Daniel-Aharonson L, et al. The special injury pattern in terrorist bombings. J Am Coll Surg. 2004;199(6):875–9.

    Article  Google Scholar 

  9. Covey DC. Combat orphopaedics: a view from the trenches. J Am Acad Orthop Surg. 2006;14(10 Spec:No.):S10-7.

    PubMed  Google Scholar 

  10. Mizra FH, Parhyar HA, Tirmizi SZ. Rising threat of terrorist bomb blasts in Karachi—a 5 year study. J Forensic Leg Med. 2013;20(6):747–51.

    Article  Google Scholar 

  11. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6):431–7.

    Article  Google Scholar 

  12. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):28–37.

    Article  Google Scholar 

  13. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.

    Article  Google Scholar 

  14. Passos E, Dingley B, Smith A, et al. Tourniquet use for peripheral vascular injuries in the civilian setting. Injury. 2014;45(3):573–7.

    Article  Google Scholar 

  15. Inaba K, Siboni S, Resnick S, et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79(2):232–7.

    Article  Google Scholar 

  16. Ode G, Studnek J, Seymour R, et al. Emergency tourniquets for civilians: can military lessons in extremity hemorrhage be translated? J Trauma Acute Care Surg. 2015;79(4):586–91.

    CAS  Article  Google Scholar 

  17. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma. 2005;59(1):217–22.

    CAS  Article  Google Scholar 

  18. King DR, Larentzakis A, Ramly EP, Boston Trauma Collaborative. Tourniquet use at the Boston Marathon bombing: lost in translation. J Trauma Acute Care Surg. 2015;78(3):594–9.

    Article  Google Scholar 

  19. Gates JD, Arabian S, Biddinger P, et al. The initial response to the Boston Marathon bombing. Lessons learned to prepare of the next disaster. Ann Surg. 2014;260(6):960–6.

    Article  Google Scholar 

  20. Biddinger PD, Baggish A, Harrington L, et al. Be prepared—the Boston Marathon and mass casualty events. N Engl J Med. 2013;368(21):1958–60.

    CAS  Article  Google Scholar 

  21. Eikermann M, Velmahos G, Abarra S, et al. Case 11-2014: a man with traumatic injuries after a bomb explosion at the Boston Marathon. N Engl J Med. 2014;370(15):1441–51.

    CAS  Article  Google Scholar 

  22. Pollak AN. Timing of debridement of open fractures. J Am Acad Orthop Surg. 2006;14(10 Spec:No.):S48–51.

    Article  Google Scholar 

  23. Bowyer G. Debridement of extremity war wounds. J Am Acad Orthop Surg. 2006; 14(10 Spec:No.):S52-6.

    PubMed  Google Scholar 

  24. Einav S, Feinberg Z, Weissman C, et al. Evacuation priorities in mass casualty terror-related events: implication for contingency planning. Ann Surg. 2004;239(3):304–10.

    Article  Google Scholar 

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Funding

This study was performed without any funding.

Author information

Affiliations

  1. Hillel Yaffe Medical Center, P.O.B. 169, 38100, Hadera, Israel

    Itamar Ashkenazi & Ricardo Alfici

  2. Orthopedic A Surgery Department, Hillel Yaffe Medical Center, Hadera, Israel

    Roger Sevi

  3. Emergency Surgery Department, Hospital Universitario General Gregorio Marañon, Madrid, Spain

    Fernando Turégano-Fuentes

  4. Surgery Department, School of Medicine at the University of Botswana, Gaborone, Botswana

    Michael S. Walsh

  5. Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel

    Oded Olsha

  6. UCSF Department of Surgery, San Francisco General Hospital, San Francisco, USA

    William P. Schecter

  7. Plot 1836 Princess Marina Hospital, North Ring Road, Gaborone, Botswana

    Michael S. Walsh

Authors
  1. Itamar Ashkenazi
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  2. Roger Sevi
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  3. Fernando Turégano-Fuentes
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  4. Michael S. Walsh
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  5. Oded Olsha
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  6. William P. Schecter
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  7. Ricardo Alfici
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Contributions

IA: substantial contribution to the conception and design of the work; acquisition, analysis and interpretation of data, drafting the manuscript and final approval. RS: substantial contribution to the conception and design of the work, critical revision for important intellectual content and final approval. FT: substantial contribution to the conception and design of the work, critical revision for important intellectual content and final approval. MSW: substantial contribution to the conception and design of the work, critical revision for important intellectual content and final approval. OO: substantial contribution to the conception and design of the work, critical revision for important intellectual content and final approval. WPS: substantial contribution to the conception and design of the work, critical revision for important intellectual content and final approval. RA: substantial contribution to the conception of the work and design, critical revision for important intellectual content and final approval.

Corresponding author

Correspondence to Itamar Ashkenazi.

Ethics declarations

Conflict of interest

Itamar Ashkenazi, Roger Sevi, Fernando Turégano-Fuentes, Michael S. Walsh, Oded Olsha, William P. Schecter, Ricardo Alfici declare no conflict of interest concerning the contents of this manuscript.

Research involving animal and human participants

This study inolved human subjects and was compliant with the 1964 Helsinki Declaration and its later amendments. This study was compliant with the Institutional Review Board of the Hillel Yaffe Medical Center.

Ethical approval

This study was approved by the Institutional Review Board of the Hillel Yaffe Medical Center, Hadera, Israel.

Informed consent

This was a retrospective observational study based on patient files, for which formal consent was not required.

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Supplementary material 1 (DOC 93 KB)

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Cite this article

Ashkenazi, I., Sevi, R., Turégano-Fuentes, F. et al. Hemodynamic consequences of extremity injuries following a terrorist bombing attack: retrospective cohort study. Eur J Trauma Emerg Surg 45, 865–870 (2019). https://doi.org/10.1007/s00068-018-1017-5

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  • DOI: https://doi.org/10.1007/s00068-018-1017-5

Keywords

  • Hemodynamic instability
  • Multiple casualty incidents
  • Blast injuries