Inadequate mass-casualty knowledge base adversely affects treatment decisions by trauma care providers: Survey on hospital response following a terrorist bombing.

Healthcare professionals require a unique knowledge base to function effectively during a hospital's response to a mass-casualty incident (MCI). A survey of 128 physicians, nurses, and emergency medical technicians involved in trauma care was conducted to assess their knowledge base and how it affected their decision-making in response to a MCI following a terrorist bombing. Three-quarters of the study group responded that = or >20% of the surviving victims were critically injured. Only half of the responders indicated that the main objective of medical management is identifying and treating patients with critical injuries. Forty percent of responders indicated that they would not triage a critically injured victim to immediate care. This survey indicates that further education in the principles of MCI management should be based on critical evaluation of the literature.

Defining the problem, main objective, and strategies of medical management in mass-casualty incidents caused by terrorist events.

Based on the experience of managing > 20 such events during the last decade, the authors' understanding of a mass-casualty incident is that it is an event in which there may be many victims, but only a few that actually suffer from life-threatening injuries. To make an impact on survival, one must identify those who are severely wounded as quickly as possible and offer those patients optimal care. Experienced trauma physicians are the most important resource available to achieve this objective, and they should be allocated to the treatment of seriously injured victims instead of more traditional management roles such as triage and incident manager.

Abdominal stab wounds in Israel, 1997-2004: significant increase in overall incidence and prevalence of severe injury.

BACKGROUND: Non-operative management following abdominal stab wounds is possible in selected patients who are both hemodynamically stable and do not have signs of peritonitis. However, the rate of failure of non-operative management is higher in Israel than in western countries. OBJECTIVES: To assess the patterns of injury following abdominal stabbing. METHODS: Data from the Israeli Trauma Registry were used to identify all patients with abdominal stab injury admitted to eight different trauma centers between 1997 and 2004. RESULTS: The number of patients admitted per year more than doubled between 1997 and 2004, from 257 to 599. The percentage of patients with severe injury (Index Severity Score > or = 16) increased from 9.4% to 19.0%. The incidence of multiple stab injuries almost doubled, from 37% to 62%. CONCLUSIONS: Review of the data in the Israeli Trauma Registry indicates an increase in both absolute rate and relative incidence of serious stab injuries. This indicates that patterns of injury following stab wounds are not necessarily similar, not even within the same geographical area over time.

Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre.

OBJECTIVE: To assess the effect of teleradiology upon the need for transfer of head injured victims requiring hospitalisation but referred initially to a rural level 2 trauma centre without neurosurgical capacity. METHODS: Head injured patients requiring hospitalisation, admitted to a rural level 2 trauma centre between August 2003 and August 2005, were identified. A digitalised copy of the computed tomographic (CT) scan was transferred to the neurosurgical referral centre via teleradiology and was available for review by the neurosurgeon on-call, who then, together with the trauma surgeon in the rural level 2 trauma centre, decided whether to transfer the patient to the neurosurgical referral centre. RESULTS: Of 209 trauma victims with neurosurgical pathology in need of hospitalisation, 126 (60.2%) were immediately transferred while 83 (39.7%) of the patients were hospitalised in the rural level 2 trauma centre for observation. Two (2.4%) failed the intent to treat locally. One patient, suffering from multi-trauma, was stabilised after damage control laparotomy only to succumb to an enlarging epidural haematoma. Another patient was transferred 2 days after admission because of difficulty in clinical evaluation due to a previously existing neurological disorder, but no active treatment was necessary. All other 81 patients recovered uneventfully. CONCLUSIONS: Selective head injured patients with pathological CT scan may be safely managed in level 2 trauma centres. A committed trauma team in the rural trauma centre, neurosurgical consultation and availability of a teleradiology system are requisites. Currently existing transfer criteria should be carefully re-evaluated.

Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era?

INTRODUCTION: According to the Advanced Trauma Life Support, portable pelvis radiography (PXR) is mandatory in multiple trauma patients, and is performed following initial clinical evaluation. The purpose of an early PXR is to identify pelvic fractures that may have haemodynamic consequences. Today, ultrafast multi-detector CT scanners (MDCT) are readily available and widely used in the evaluation of stable trauma patients. The objective of this study was to determine the impact of PXR in stable blunt multiple trauma patients, who required CT scan for full evaluation of the abdomen and pelvis. METHODS: A retrospective review of all stable blunt trauma patients, suffering from pelvic fractures was performed from January 2001 until December 2004 at two high volume Trauma Centres. Patients' demographics and Injury Severity Scores (ISS) were abstracted from our trauma registry. Two certified radiologists and two certified orthopaedic surgeons retrospectively evaluated and compared PXR films and CT angiographies (CTA) of the abdomen and pelvis. We recorded each case when the management policy was altered due to the results of imaging and compared the clinical impact of both modalities. RESULTS: One hundred and twenty-nine stable blunt multiple trauma patients with pelvic fractures underwent CTA of the abdomen and pelvis during their initial evaluation. Mean ISS was 16.5. Average Glasgow Coma Scale on arrival was 13.2 (range 3-15). Compared to CTA, sensitivity and specificity of the PXR was 64.4 and 90.0%, respectively. CTA diagnosed 35.6% more pelvic fractures than PXR (p<0.05). No changes in the therapeutic policy were observed following PXR results. In 19 (14.7%) patients, CTA findings led to pelvic angiography. CONCLUSIONS: PXR in stable blunt multiple trauma patients did not change the therapeutic policy in our patients. CTA of the abdomen and pelvis is the imaging modality of choice in blunt multiple trauma, regardless of the findings of PXR. Benefit of routine PXR is questionable in hospitals where MDCT is available. Based on our results, we suggest re-evaluating the current practice of routine mandatory portable pelvis radiography.

Precision of in-hospital triage in mass-casualty incidents after terror attacks.

INTRODUCTION: Proper management of mass-casualty incidents (MCIs) relies on triage as a critical component of the disaster plan. OBJECTIVE: [corrected] The objective of this study was to assess the precision of triage in mass-casualty incidents. METHODS: The precision of decisions made by two experienced triage officers was examined in two large MCIs. These decisions were compared to the real severity of injury as defined by the Israeli Defence Forces (IDF) classification of severity of injuries and the Injury Severity Score (ISS). RESULTS: Two experienced trauma physicians triaged a total of 94 casualties into 77 mild, seven moderate, and 10 severe casualties. Based on the IDF criteria, there were 74 mild, five moderate, and 15 severe casualties. Based on ISS scoring, there were 78 mild (ISS <9), five moderate (9 < or = ISS < 16), and 11 severe (ISS <16) casualties. Of 15 severely injured victims defined by the IDF classification of injury severity, the triage officers identified only seven (47%). CONCLUSION: Primary triage, even when carried out by experienced trauma physicians, can be unreliable in a MCI.