The Prevalence of Trauma Injuries From Neighboring Countries Transferred to Iran

Trauma is among the main causes of death in developing countries. Annually, about 5 million people die as the result of intentional or unintentional trauma worldwide. In recent years, due to an increase in the number of attacks, the incidence of this type of injury has risen and become a threat to global healthcare. The term “attack” is defined as an aggressive and violent action against a person for various reasons injuring or killing one or more people.1-3 Bombs are the most common source of injury.4 Explosives are usually placed alongside the road. Previous studies have shown that bomb injuries differ from other forms. They are more complex, more severe, dependent upon the type of weapon,3,5-7 and require more medical intervention and rehabilitation. However, most emergency units are not prepared to provide healthcare to bomb victims. The medical team must be acquainted with the physics of these injuries. Although several articles have been published regarding attacks,3,4,6-11 few studies on civilian attacks transferred to Iran were found. The current study sought to assess the cause, type, and severity of injuries, diagnostic and therapeutic interventions, and outcomes of civilian victims of terrorist attacks from countries neighboring Iran who were transferred to hospitals in Iran.


Introduction
Trauma is among the main causes of death in developing countries.Annually, about 5 million people die as the result of intentional or unintentional trauma worldwide.In recent years, due to an increase in the number of attacks, the incidence of this type of injury has risen and become a threat to global healthcare.2][3] Bombs are the most common source of injury. 4xplosives are usually placed alongside the road.Previous studies have shown that bomb injuries differ from other forms.They are more complex, more severe, dependent upon the type of weapon, 3,[5][6][7] and require more medical intervention and rehabilitation.However, most emergency units are not prepared to provide healthcare to bomb victims.The medical team must be acquainted with the physics of these injuries.Although several articles have been published regarding attacks, 3,4,[6][7][8][9][10][11] few studies on civilian attacks transferred to Iran were found.The current study sought to assess the cause, type, and severity of injuries, diagnostic and therapeutic interventions, and outcomes of civilian victims of terrorist attacks from countries neighboring Iran who were transferred to hospitals in Iran.

Methods
Two hundred fourteen injured civilians were transferred to 3 Level 1 trauma centers in Iran and treated there during the time period 2005-2007.Data relative to demographic information, incident location, injury type, severity, No data was available regarding the diagnostic or therapeutic interventions performed before the arrival of these patients in Tehran hospitals.Of the 140 patients who had complete medical records, cardiopulmonary resuscitation and tracheal intubation were performed in 2 and 6 cases (2.8%), respectively, before hospital admission in Tehran.The following procedures were performed in hospital emergency units: cardiopulmonary resuscitation in 2 (1%) cases, tracheal intubation in 8 (3%) cases, and prevention of bleeding in 90 (42%) cases.The mean ISS was 5.91±4.54(range = 1 to 34).The median ISS was 4. ISS classification was as follows: 109 cases (51%) had an ISS between 1 and 8, 73 cases (34%) had an ISS between 9 and 14, 15 (7%) had an ISS between 16 and 24, and 17 (8%) had an ISS ≥25 (Table 1).
The top 6 most commonly injured organs were skin in 160, limbs and skeletal pelvis in 131, face in 49, head and neck in 33, abdomen and visceral pelvis in 36, and chest in 18 victims (Figure 1).The number of organs injured per victim was 1 in 42 (20%), 2 in 124 (58%), 3 in 36 (17%), and 4 or more in 12 (5%) patients (Table 2).The following data regarding medical procedures performed in the patients' home country was available: 18 cases had received a general surgical procedure, 17 cases had received orthopedic procedures, 3 cases had undergone neurosurgery, 4 cases had undergone ENT surgery, 1 case received ophthalmic surgery, and 1 case had undergone urological surgery.In Iran, 86 of these patients received orthopedic surgery (40.2%), 25 (11.7%) received general surgical procedures, 21 (9.8%) underwent ENT surgical procedures, 18 cases (8.4%) underwent plastic surgery, 15 cases (7%) received neurosurgery, and 10 cases (4.7%) underwent ophthalmic surgery (Figure 2).Moreover, 25 (11.7%)patients received psychiatric counseling.Only 2 cases of mortality were reported, and they occurred in emergency rooms.Only 7 cases were hospitalized in the Intensive care unit (ICU).The mean hospital stay was 13.43 ± 19.76 days (range = 1-230 days).Sepsis was present in 4 cases at the time of admission.Of 185 hospitalized cases with adequate information, 37 had infected wounds.This rate was 35 out of 208 at the time of admission.Deep vein thrombosis (DVT) at the time of admission was observed in 4 cases.In 13 out of 208 examined cases, limb amputation was carried out.

Discussion
The rate of morbidity and mortality associated with explosion depends on the injured organs. 12Injury to the central nervous system is fatal.4][15][16] About 1% to 5% of civilian bombing victims die immediately after head trauma.Most patients treated in emergency departments are not badly injured, suffering only lacerations, scratches, and bruising. 9,17bout 12% to 50% of victims are examined and only a small number of them (1% to 15%) suffer abdominal or chest trauma.The high rates of hospitalization and more severe injuries are mainly observed in confined-space explosions  compared to open-air blasts. 17The prevalence of chest and abdominal injuries is low (2.8% of admitted patients), but the risk of morbidity and mortality is higher among them.Hospital morbidity and mortality in patients with blast chest trauma is 15%.This rate is 19% among those with abdominal injuries. 12Victims can be classified into the following groups: those who die immediately, survivors with significant injuries (ISS >15), and overall morbidity and mortality among those who are transferred to hospitals.4][15] In a review of 29 terrorist bombings with 8346 victims and 903 immediate deaths, the casualty rate was 25% at the time of building collapse, 8% at the time of confined-space explosion without building collapse, and 4% in open-air blasts. 17Frykberg and Tepas reviewed 200 terrorist bombings with 3357 victims and found that the rate of immediate death was 13%. 20The mean number of victims in each bombing attack was 15, out of which 87% immediately survived; 30% were transferred to a hospital, and 18.7% had significant injuries.The rate of mortality among immediate survivors was 2.3% and included those with severe injuries.Thus, the rate of morbidity and mortality was 12.4%.Head trauma was the most common injury responsible for both early and delayed deaths (71% and 52%, respectively). 20onfined-space explosions and fire secondary to explosion may cause severe burns and death.Smoke inhalation injuries are not prevalent in bombings (except for confined-space bombings). 21The prevalence of burn injuries in the current study was not high either.Pulmonary blast injury (PBI) is very common in terrorist bombings, but most of these victims die at the scene due to the severity of their injuries. 22PBI was observed in the lungs of only 0.6% of survivors among 2934 bombing victims. 20The autopsies of 495 victims who died in 5600 different bombing attacks in a 12-year period revealed that 66% of them suffered brain injuries, 51% had skull fractures, 47% had severe pulmonary injuries revealed by autopsy, 45% suffered tympanic membrane perforation, and 34% had liver perforation. 23Confined-space explosions cause more severe PBIs, 17 and the survivors have higher ISSs and greater morbidity and mortality. 23Of 104 victims of 2 bus explosions, 7 died immediately, 51 were transferred to hospitals, 16 suffered pulmonary injuries, and 7 complained of abdominal pain (4 of these victims suffered intestinal perforations). 12Tympanic membrane perforation was observed in all those with severe injuries.At least 42 out of 80 Americans (53%) in 1986 were injured in the LaBelle Disco bombing in Berlin, and many victims suffered tympanic membrane perforation. 24In this study, similar to other studies, explosion was the most common cause of trauma.Prevalence of gunshot injury was also high, which indicates the geographical difference of the mechanism of trauma.In the current study, the mean rate of injury was lower than the rate reported by studies evaluating terrorist attack victims at the scene.However, the number of severely injured victims was higher in this study; about 50% of victims had moderate to severe injuries, and 8% suffered extremely severe injuries.Considering the fact that 80% of patients in this study had 2 or more injured organs, it may be concluded that the usual indexes used to assess the severity of trauma are inefficient.The mean (±SD) duration of hospital stay in this study was 13.43 (±19.76)days, which is a higher rate than reported in other studies (5 ± 8 days). 25This difference may be attributed to the referral of patients to the hospitals studied here or to a different pattern of trauma.

Conclusion
Patterns of attack trauma are specific and different from other trauma patterns.Blast injuries in civilians with no protective gear are more complex and severe.Clinicians and medical staff should have adequate knowledge in this respect to better manage terrorist attack victims.Special equipment and trained human resources are required for proper management.Further investigations in this respect can better elucidate this subject.

Figure 2 .
Figure 2. Number and Type of Performed

Table 2 .
Number of Injured Organs