Incidence and injury characteristics of traumatic brain injury: Comparison between children, adults and seniors in Israel.

AIM: To assess the incidence and injury characteristics of hospitalized trauma patients diagnosed with TBI. METHODS: A retrospective study of all injured hospitalized patients recorded in the National Trauma Registry at 19 trauma centres in Israel between 2002-2011. Incidence and injury characteristics were examined among children, adults and seniors. RESULTS: The annual incidence rate of hospitalized TBI for the Israeli population in 2011 was 31.8/100,000. Age-specific incidence was highest among seniors with a dramatic decrease in TBI-related mortality rate among them. Adults, in comparison to children and seniors, had higher rates of severe TBI, severe and critical injuries, more admission to the intensive care unit, underwent surgery, were hospitalization for more than 2 weeks and were discharged to rehabilitation. After adjusting for age, gender, ethnicity, mechanism of injury and injury severity score, TBI-related in-hospital mortality was higher among seniors and adults compared to children. CONCLUSION: Seniors are at high risk for TBI-related in-hospital mortality, although adults had more severe and critical injuries and utilized more hospital resources. However, seniors showed the most significant reduction in mortality rate during the study period. Appropriate intervention programmes should be designed and implemented, targeted to reduce TBI among high risk groups.

Transfusion medicine during the summer of 2006: lessons learned in northern Israel.

In July 2006 a Hizballah attack erupted at the Lebanon-Israel border. Reported here is the experience of the Rambam Health Care Campus--a level I trauma center--during 33 days of warfare. Two hundred ninety-five soldiers and 209 civilians were admitted to the emergency department (ED). Forty-eight wounded soldiers (16%) and 12 civilians (6%) had transfusion. Twenty soldiers and 1 civilian had massive transfusions. The ratio between packed red blood cells and fresh frozen plasma (FFP) used for patients who had massive transfusion was 3:2. In these patients, the median prothrombin time international normalized ratio and partial thromboplastin time increased during the first 2 hours after admission from 1.29 to 1.51 and from 33.6 to 39 seconds, respectively. Twenty patients who had massive transfusion survived. Patients with an injury severity score of at least 16 had a higher need for blood products than others, with a lower severity score, with a mean packed red blood cells unit transfusion of 7 vs 4 (P = .03) and FFP transfusion of 13 vs 1.5 (P = .002), respectively. In conclusion, we observed that early transfusion of FFP to casualties with penetrating wounds requiring massive transfusion is needed to overcome the coagulopathy present. The presence of a transfusion service representative on-site in the ED is recommended to ensure proper identification and labeling of blood samples. Real-time consultations provided by a transfusion medicine physician in the operation theater was also found to be essential.

Improving the pattern of work towards emergency medicine at the Emergency Department in Rambam Medical Centre.

BACKGROUND: Rambam Medical Centre is a 950-bed referral hospital, containing 34 beds in the Emergency Department (ED). The arrangement of the ED was based on two separate units: trauma and medical. Patient evaluation lasted many hours, with an abuse of consultants, laboratory and imaging services. OBJECTIVE: To describe the improvement of patient management in our ED by changing working patterns according to emergency medicine guidelines. METHODS: The trauma and medical units were combined into a one-unit ED, managed by one director and two specialists in emergency medicine. The goal of the ED was defined as the treatment and triage of patients towards discharge or admission in the minimal time needed. New protocols for clinical evaluation, blood and imaging tests, consultation facilities and pain management were implemented according to emergency medicine practice. Once a decision for admission is made, a computerized program assigns the patient to the appropriate ward. RESULTS: There was a dramatic reduction (44%) in the time needed for patient evaluation. The number of patients waiting more than 4 h and 8 h for admission was reduced significantly (11 versus 38% and 1 versus 24%, respectively). The total number of blood tests was reduced by 45%, and the number of blood and urine cultures by 81 and 87%, respectively. Two years after the change, the ED won first place in patient satisfaction screening. CONCLUSIONS: By changing work methods according to emergency medicine guidelines, and by using protocols written for emergency medicine, a significant improvement in our duties as an ED was achieved. The backing of the hospital management helped to implement the changes, which led to the functional improvement.

Medical consequences of terrorist bombs containing spherical metal pellets: analysis of a suicide terrorism event.

OBJECTIVE: Various metal objects added to explosives increase and diversify the wounding from bombing; especially favoured are spherical missiles for their special injuring characteristics. Our objective was to study the medical consequences and ballistic effects on human tissue of spherical metal pellets used in terrorist bombings. METHODS: The clinical and forensic data of all bodily injured casualties of a suicide terrorist bombing in a crowded hotel dining room were analysed retrospectively. RESULTS: Of the 250 people at the scene, 164 were injured, with 91 (55.5%) suffering bodily injuries; 30 of them died. The immediately deceased had disseminated tissue damage and their bodies were saturated with steel spheres. Thirty-two immediate survivors sustained severe injuries (Injury Severity Score > or =16), and all suffered tissue penetration by the pellets. Twenty-three (32%) underwent surgery and 15 (21%) required intensive care. CONCLUSIONS: Metal pellets propelled by the explosion enhanced the secondary pattern of injury and injured even patients remote from the origin. Tissue destruction and specific organ injuries among survivors were limited. To evaluate and manage victims of terrorist bombings properly, medical teams should become familiar with these severe injuries.

Evaluation of isoproterenol in patients undergoing resuscitation for out-of-hospital asystolic cardiac arrest (the Israel Resuscitation with Isoproterenol Study Prospective Randomized Clinical Trial).

The Israel Resuscitation with Isoproterenol Study included 79 consecutive patients with witnessed out-of-hospital asystolic cardiac arrest who were resuscitated with epinephrine and atropine and randomized to receive additional isoproterenol or no isoproterenol. The rate of return of spontaneous circulation and survival to hospital admission did not differ in patients receiving standard therapy and those receiving additional isoproterenol.

Increased survival among severe trauma patients: the impact of a national trauma system.

HYPOTHESIS: The survival of severe trauma patients is affected by the implementation of a national trauma system, which brought about developments both at the hospital and prehospital levels during the past decade. DESIGN: A retrospective cohort study of all severely injured patients (Injury Severity Score >16) recorded in the Israeli National Trauma Registry at all level I trauma centers in Israel from January 1, 1997, to December 31, 2001. Inpatient death rates were examined overall and by subgroups. SETTING: The National Trauma Registry includes trauma (International Statistical Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes 800-959) hospitalizations, patients who were transferred to or from other hospitals, and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients who do not fall into the definition of trauma. Main Outcome Measure Inpatient death. RESULTS: Seven thousand four hundred twenty-three severe trauma patients were recorded. Inpatient death rates decreased significantly from 21.6% in 1997 to 14.7% in 2001. The odds ratios of mortality in 1998 through 2001 vs 1997, adjusted for year, age, sex, penetrating injury, and severity of injury (Injury Severity Score >25), were 0.92, 0.89, 0.70, and 0.65, respectively, confirming the downward trend. CONCLUSIONS: A steady significant reduction in the inpatient death rate of severe trauma patients hospitalized at all level I trauma centers in Israel between 1997 and 2001 was observed. Although a single factor that explains the reduction was not identified, it is evident that the establishment of the trauma system brought about a significant decrease in mortality. We believe that integrated cooperation of various components of the national trauma system in Israel across the years may explain the reduction.

National strategy for mass casualty situations and its effects on the hospital.

A mass-casualty situation (MCS) usually is short in duration and resolves itself. To minimize the risks to patients during MCS, planning is essential. This article summarizes the preparations needed at the hospital level, for a local MCS involving numerous trauma victims arriving to the Emergency Department at a short notice. Experiences and conclusions related to the implementation of the Israeli strategy in one hospital that combines the responsibilities of both the military and civilians are summarized. The Ministry of Health distributes the master MCS plan to each hospital where a local committee adapts it to the specific situation in a format of standing orders. After its approval by the Ministry of Health, an annual inspection is conducted to check the ability of the staff to manage a MCS. A full-scale drill is conducted every second year during which each site's readiness level and the continuity of the flow of care are tested. In building the strategy for treating trauma victims during a MCS, a few assumptions were taken into account. The goal of treatment in a MCS is to deliver an acceptable quality of care while preserving as many lives as is possible. In theory, the capacity of the hospital is its ability to manage a load of patients in the range of 20% of the hospital bed capacity. Planning and drilling are the ways to minimize deviations from the guidelines and to avoid management mistakes. Special attention should be paid to problems related to the initial phase of receiving the first message, outside communication, inside hospital communication, and staff recruitment. Other issues include: free access to the hospital; opening a public information center; and dealing with the media and very important persons (VIPs). A new method for creating the needed MCS plan in the hospital is suggested. It is based upon knowledge of management techniques that used multi-level documents, which are spread via Intranet between the different key figures. Using this method, it is possible to keep the strategy, the source documentation, and reasons for choosing it, as well as immediate release of checklists for each functions. This detailed, time consuming work is worthwhile in the long run, when the benefits of easy updating and better preparedness are apparent.

A comparison of two mechanisms of severe paediatric injury in northern Israel.

BACKGROUND: An increased incidence of severe injury due to falls from buildings (FFB) is reported in the rural area of northern Israel. This makes FFB, and motor vehicle collision (MVC) the two leading causes of severe paediatric trauma. METHODS: A single-centre, age-sex matched comparison analysis of the two mechanisms of injury was conducted. Children involved in MVC (study subjects) or FFB (controls), who were brought by the Emergency Medical System Mobile-Intensive-Care-Unit from the field to the trauma bay of the Emergency Department (ED) were enrolled on the basis of a convenience sample. Immediately following ED admission, heart rate (HR), systolic blood pressure (SBP), and base deficit (BD) were recorded. Types of injuries, Glasgow Coma Score (GCS) on scene, and Injury Severity Score (ISS) were also obtained. RESULTS: Eleven study subjects and 22 controls were enrolled during a 1-year period. The mean ISS for the study subjects group and for the controls was 23.4 and 19.5, respectively. No difference was found in comparing the ISS, BD, SBP and HR of the two groups (p=0.261, p=0.421, p=0.314, and p=0.824, respectively). Controls had a lower GCS (p<0.031) and were more likely to have a skull fracture (p<0.0082). Study subjects were more likely to have limb injuries (p<0.0001) and thoracoabdominal injuries (p<0.0059). CONCLUSIONS: This study suggests that the Injury Severity Score of the two mechanisms of paediatric injury is high. The haemodynamic characteristics on ED admission were comparable between the two groups of patients but the likelihood of specific type of injury was different.

An academic medical center under prolonged rocket attack--organizational, medical, and financial considerations.

The Rambam Medical Center, the major academic health center in northern Israel, serving a population of two million and providing specialized tertiary care, was exposed to an unprecedented experience during the Second Lebanon War in the summer of 2006. For more than one month, it was subjected to continuous rocket attacks, but it continued to provide emergency and routine medical services to the civilian population and also served the military personnel who were evacuated from the battlefront. To accomplish the goals of serving the population while itself being under fire, the Rambam Medical Center had to undertake major organizational decisions, which included maximizing safety within the hospital by shifting patients and departments, ensuring that the hospital was properly fortified, managing the health professional teams' work schedules, and providing needed services for the families of employees. The Rambam Medical Center's Level I trauma center expertise included multidisciplinary teams and extensive collaborations; modern imaging modalities usually reserved for peacetime medical practice were frequently used. The function of the hospital teams during the war was efficient and smooth, based on the long-term actions taken to prepare for disasters and wartime conditions. Routine hospital services continued, although at 60% of normal occupancy. Financial losses incurred were primarily due to the decrease in revenue-generating activity. The two most important components of managing the hospital under these conditions are (1) the ability to arrive at prompt and meaningful decisions with respect to the organizational and medical hospital operations and (2) the leadership and management of the professional staff and teams.

Terrorist suicide bombings: lessons learned in Metropolitan Haifa from September 2000 to January 2006.

BACKGROUND: The threat of suicide bombing attacks has become a worldwide problem. This special type of multiple casualty incidents (MCI) seriously challenges the most experienced medical facilities. METHODS: The authors concluded a retrospective analysis of the medical management of victims from the six suicide bombing attacks that occurred in Metropolitan Haifa from 2000 to 2006. RESULTS: The six terrorist suicide bombing attacks resulted in 411 victims with 69 dead (16.8 percent) and 342 injured. Of the 342 injured, there were 31 (9.1 percent) severely injured, seven (2.4 percent) moderately severely injured, and 304 (88.9 percent) mildly injured patients. Twenty four (77 percent) of the 31 severely injured victims were evacuated to the level I trauma center at Rambam Medical Center (RMC). Of the seven severely injured victims who were evacuated to the level II trauma centers (Bnai-Zion Medical Center and Carmel Medical Center) because of proximity to the detonation site, three were secondarily transferred to RMC after initial resuscitation. Eight of the 24 severely injured casualties, admitted to RMC, eventually died of their wounds. There was no in-hospital mortality in the level II trauma centers. CONCLUSIONS: A predetermined metropolitan triage system which directs trauma victims of a MCI to the appropriate medical center and prevents overcrowding of the level I facility with less severe injured patients will assure that critically injured patients of a suicide bombing attack will receive a level of care that is comparable with the care given to similar patients under normal circumstances. Severe blast injury victims without penetrating injuries but with significant pulmonary damage can be effectively managed in ICUs of level II trauma centers.

The utility of focused assessment with sonography for trauma as a triage tool in multiple-casualty incidents during the second Lebanon war.

OBJECTIVE: The purpose of this study was to evaluate the role of focused assessment with sonography for trauma (FAST) as a triage tool in multiple-casualty incidents (MCIs) for a single international conflict. METHODS: The charts of 849 casualties that arrived at our level 1 trauma referral center were reviewed. Casualties were initially triaged according to the Injury Severity Score at the emergency department gate. Two-hundred eighty-one physically injured patients, 215 soldiers (76.5%) and 66 civilians (23.5%), were admitted. Focused assessment with sonography for trauma was performed in 102 casualties suspected to have an abdominal injury. Sixty-eight underwent computed tomography (CT); 12 underwent laparotomy; and 28 were kept under clinical observation alone. We compared FAST results against CT, laparotomy, and clinical observation records. RESULTS: Focused assessment with sonography for trauma results were positive in 17 casualties and negative in 85. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FAST were 75%, 97.6%, 88.2%, 94.1%, and 93.1%, respectively. A strong correlation between FAST and CT results, laparotomy, and clinical observation was obtained (P < .05). CONCLUSIONS: In a setting of a war conflict-related MCI, FAST enabled immediate triage of casualties to laparotomy, CT, or clinical observation. Because of its moderate sensitivity, a negative FAST result with strong clinical suspicion demands further evaluation, especially in an MCI.

Managing mass casualties.

PURPOSE OF REVIEW: The issue of mass casualty associated with terrorism has gained tremendous public interest, but only modest medical interest, in the past 2 years. This review examines recent medical literature and outlines a practical approach to managing the mass casualty situation on the basis of a doctrine developed and extensively practised in Israeli hospitals. RECENT FINDINGS: A large portion of recently published articles deal with the preparedness for 'conventional', biological or chemical mass casualty situations. Accounts of past events reveal serious discrepancies between well-designed contingency plans and the disappointing management of actual mass casualty situations. The 'Israeli doctrine' is a general 'master plan' for managing mass casualty situations that is adjusted by every hospital to its specific characteristics. Its major principles and features, as well as practical 'tips' are described. SUMMARY: The world medical community, being in the forefront of any natural or man-made disaster, should prepare itself for its effective management. Contingency plans should be comprehensive, and should follow certain general guidelines, but should be specific for different causes of mass casualty situations and be adjusted to each medical system or hospital. Medical personnel should become familiar with these plans through repeated drills. Experience gained in actual mass casualty events should be analysed and published to improve contingency plans and their implementation.

Principles of emergency management in disasters.

The organizational and medical conduct in disaster situations is complex and presents a challenge to every manager in the prehospital setting. The handling of such situations is characterized by the need to make decisions under uncertainty in real time, with deficient medical and support forces. The approach used in mass casualty incident situations is cycles of treatment, commonly known as the "butterfly system." There are serious logistic problems involved, both industrial and structural, physical obstacles that may interfere with rescue treatment and evacuation, disruption in communications, and many other difficulties. On top of these, there are other obstacles such as interruption with the cooperation and coordination of different force, enforcement and rescue teams, the press, inquisitive people, and others. However, the most serious problem of all is the tendency in complex situations to attempt to work with fixed preformed guidelines or protocols for operation. One disaster differs from another, regarding location, number of casualties, distribution, severity, type of injury and the nature of injury, size of available rescue teams, time and equipment needs, damage to roads, distance from hospital, and other variables. One of the most important lessons learned from the management of such incidents is do not set fixed protocols but rather principles only. By applying principles adapted to the situation, managers will be able to perform better.

Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study.

BACKGROUND: Low-velocity rubber bullets were used by Israeli police to control riots by Israeli-Arabs in early October, 2000. We aimed to establish the factors that contribute to severity of blunt and penetrating injuries caused by these missiles. METHODS: We analysed medical records of 595 casualties admitted. We assessed relation of severity of injury to type of bullet, anatomical region of injury, and final outcome. Severity of injury was established by the abbreviated injury scale, and we calculated injury severity score. FINDINGS: 151 males and one female (age range 11-59 years) were included in the study, in whom 201 proven injuries by rubber bullets were detected. Injuries were distributed randomly over the body surface and were mostly located in the limbs (n=73), but those to the head, neck, and face (61), chest (39), back (16), and abdomen (12) were also frequently noted. 93 (61%) patients had blunt injuries and 59 (39%) penetrating ones. Severity of injury was dependent on ballistic features of the bullet, firing range, and anatomic site of impact. Two casualties died after a penetrating ocular injury into the brain and one died as a result of postoperative aspiration after a knee injury. INTERPRETATION: Resistance of the body surface at the site of impact (elastic limit) is the important factor that ascertains whether a blunt or penetrating injury is inflicted and its severity. Inaccuracy of rubber bullets and improper aiming and range of use resulted in severe injury and death in a substantial number of people. This ammunition should therefore not be considered a safe method of crowd control.

Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients.

PURPOSE: The use of focused abdominal sonography for trauma (FAST), which detects free fluid in the abdomen and pelvis, for the assessment of blunt abdominal trauma is gaining acceptance worldwide and has been described extensively in the general medical literature. The precise application of this technique in pediatric patients, however, has yet to be established. The aim of this study was to assess the utility of FAST in pediatric trauma patients by comparing the results of this technique with those of CT and explorative laparotomy (ELAP). METHODS: We retrospectively reviewed the medical records and sonographic examinations of pediatric patients who had sustained multiple traumatic injuries for which they were treated at our hospital during a 20-month period. For all patients, FAST had been the initial screening examination for blunt abdominal trauma. We compared the FAST findings, which had been recorded as positive or negative, with the findings on CT or ELAP, which were considered definitive. RESULTS: A total of 313 patients (204 boys and 109 girls) with a mean age of 7.1 years were included in the study. The FAST finding had been negative in 274 patients, of whom 201 had had no clinical signs of abdominal injury and had been managed conservatively without complications. CT had been performed in 109 patients and ELAP in 11. FAST had yielded 3 false-negative and 2 false-positive results. The sensitivity, specificity, and accuracy of FAST were 92.5%, 97.2%, and 95.5%, respectively. CONCLUSIONS: FAST is an effective tool in screening pediatric trauma patients for blunt abdominal trauma.

Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel.

CONTEXT: An increase of terror-related activities may necessitate treatment of mass casualty incidents, requiring a broadening of existing skills and knowledge of various injury mechanisms. OBJECTIVE: To characterize and compare injuries from gunshot and explosion caused by terrorist acts. METHODS: A retrospective cohort study of patients recorded in the Israeli National Trauma Registry (ITR), all due to terror-related injuries, between October 1, 2000, to June 30, 2002. The ITR records all casualty admissions to hospitals, in-hospital deaths, and transfers at 9 of the 23 trauma centers in Israel. All 6 level I trauma centers and 3 of the largest regional trauma centers in the country are included. The registry includes the majority of severe terror-related injuries. Injury diagnoses, severity scores, hospital resource utilization parameters, length of stay (LOS), survival, and disposition. RESULTS: A total of 1155 terror-related injuries: 54% by explosion, 36% gunshot wounds (GSW), and 10% by other means. This paper focused on the 2 larger patient subsets: 1033 patients injured by terror-related explosion or GSW. Seventy-one percent of the patients were male, 84% in the GSW group and 63% in the explosion group. More than half (53%) of the patients were 15 to 29 years old, 59% in the GSW group and 48% in the explosion group. GSW patients suffered higher proportions of open wounds (63% versus 53%) and fractures (42% versus 31%). Multiple body-regions injured in a single patient occurred in 62% of explosion victims versus 47% in GSW patients. GSW patients had double the proportion of moderate injuries than explosion victims. Explosion victims have a larger proportion of minor injuries on one hand and critical to fatal injuries on the other. LOS was longer than 2 weeks for 20% (22% in explosion, 18% in GSW). Fifty-one percent of the patients underwent a surgical procedure, 58% in the GSW group and 46% in explosion group. Inpatient death rate was 6.3% (65 patients), 7.8% in the GSW group compared with 5.3% in the explosion group. A larger proportion of gunshot victims died during the first day (97% versus 58%). CONCLUSIONS: GSW and injuries from explosions differ in the body region of injury, distribution of severity, LOS, intensive care unit (ICU) stay, and time of inpatient death. These findings have implications for treatment and for preparedness of hospital resources to treat patients after a terrorist attack in any region of the world. Tailored protocol for patient evaluation and initial treatment should differ between GSW and explosion victims. Hospital organization toward treating and admitting these patients should take into account the different arrival and injury patterns.