Injury Patterns in Conflict Settings

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Introduction

Depending on the situation the type of casualties expected by EMTs can vary. Understanding the situation on the ground and the burden of disease it creates is crucial to the planning of any intervention. Large waves of patients can be created both by disasters(earthquakes) or by conflicts (short term focused military interventions or terrorist attacks). In contrast some situations such as enduring conflicts (a long running civil war) or disasters (drought leading to famine) can create a steady long term flow of patients. A primary goal of the WHO's EMT Initiative isto aid governments and EMTs in delivering the appropriate type of medical surge capacity that a situation requires. This can best be understood by thinking about burden of disease in waves.

Injury Types in Sudden Onset Disasters

Implications for Rehabilitation

Earthquakes

Earthquakes are some of the highest profile situations that EMTs can respond to. Their relative unpredictability, combined with the obvious destruction of buildings and infrastructure make these events widely reported and often widely responded to. It is crucial for EMTs to understand the needs and limitations of earthquakes when deciding whether to respond to these events. » The patient load and demand on EMTs can differ widely depending on the degree of preparation of the society prior to the event. » Earthquakes carry a low death-to-injury ratio with approximately 1 death for every 3 injuries, meaning that surgical response can result in decreased morbidity and mortality by treating wounds and fractures. » Earthquake victims frequently present with crush type injuries that can progress to crush syndrome. This clinical scenario can present some difficult management challenges, particularly for those inexperienced in dealing with these types of injuries. Management may require ICU care or even dialysis. » The collapse of structures brought on by earthquakes changes the nature of the demands for EMTs. If healthcare facilities are destroyed then the demand for more advanced, totally selfsufficient type 2 and 3 EMTs becomes greater.

TSUNAMIS » Tsunamis create a much different context compared to earthquakes. They carry a much higher mortality ratio of approximately 9 deaths for every 1 injury. » The relatively small number of injured patients means that fewer surgical teams are needed. However, they may demand other types of EMTs such as medical or public health teams. » The surgical need that does exist following a tsunami tends to center around soft tissue injuries and infections sustained during the event or the immediate aftermath. These wounds are made worse by continuous exposure to wet, contaminated conditions. » There may be some role for bolstering local surgical capacity by EMTs that can deploy temporary structures while local structures are being rehabilitated, as the aftermath of Tsunamis can involve significant structural damage due to either the tsunami itself or the inciting earthquake. However, this need should not be assumed to be present unless the host government issues a specific request. FLOODS » The need for a surgical response and the factors affecting what types of EMTs would be of greatest value are highly dependent on the cause of the flood, the state of health-care facilities and the rapidity of the flooding.

Injury Types in Conflict

injuries inflicted in conflict settings are very different to those encountered in the civilian population but currently there is no international humanitarian trauma registry and data describing the needs of those injured during conflict are inadequate to support the development of humanitarian trauma systems. A key challenge specific to conflict is that they can deliver a steady tide of patients that ebbs and flows based on the situation on the ground.

A recent systematic review analysed 49 reports describing injuries sustained by civilians and local combatants in twenty-first century armed conflict representing 18 conflicts, and 58,578 patients including the Middle East (Afghanistan, Iraq, Israel, Palestine, Kuwait, Pakistan, Syria), North Africa (Libya, Egypt), and Sub-Saharan Africa (Nigeria, Central African Republic). These injuries were treated in a wide range of facilities including Military Facilities (30.6%), local academic health centre (20.4%), government or public hospitals (16.3%) and humanitarian organisations (12.2%). The majority of patients were male (79.3%) with a median age of 26 years, and 34.7% under 18 years.

Figure.1 Mechanisms and Anatomic Regions of Injury; a Comparison between US military Personnel and b Comparison between Conflict Settings

Blast injuries, including those from bombs, missiles, grenades, mortars, landmines, improvised explosive devices, unexploded ordnance or explosive remnants of war were more common in rural settings (70%) and accounted for 70.1% of overall injuries, followed by gun shot wounds with 22%, which were more common in urban (42.2%) and semi-urban (26.7%) areas. Other mechanisms of injury included blunt trauma (4.1%), assault (3.9%), unspecified penetrating trauma (3.4%) and burns (3.3%) with the largest number of injuries occurring to the extremities (33.5%). Overall the data also highlights that civilians bear a significant burden of morbidity and mortality in conflict zones. Moreover, paediatric patients sustain a substantial proportion of conflict-related injuries, with children accounting for 34.7% of injured patients. The number of children injured is in line with other international research, which shows that children constitute 30% of seriously injured patients requiring surgical intervention in humanitarian hospitals in conflict zones. Between 2011 and 2016, more than a quarter of Syrian barrel bomb victims were children, while 40% of patients treated at an MSF Hospital in Syria during a 2017 offensive were under the age of 18 years . The implications of this further highlight the need for rehabilitation services to be adequately resourced with paediatric equipment and for rehabilitation professionals to have some paediatric expertise including some understanding of these types of injuries on children.

Implications for Rehabilitation

Injuries sustained in conflict and terrorist attacks present unique challenges, which differ from those seen in disasters, and are also rarely experienced in day-to-day practice away from the conflict zones. Working in situations of conflict, it is important to understand what weaponry is commonly used and the typical injury patterns and surgical and rehabilitation implications.

The concept of ballistics and energy transfer plays an important role in understanding tissue damage in conflict zones, with the level of tissue damage depends on the efficiency of the energy transfer of the missile – whether this be a bullet or blast fragment. You can read more about ballistics and energy transfer in the ICRC and AO Foundation Field Guide ‘Management of Limb Injuries during Disasters and Conflicts.

Knifes / Machete

A machete is a long knife with a sharp edge, a broad blade and a thick back that may be either curved or straight. Like a knife they are readily available in many homes and is used as multipurpose tools used in the farm, home and construction sites are and can be used as a close range weapon within conflict settings. The types of injuries from knives and machetes vary depending on the mode in which they are used (stabbing or cutting), the part of the blade that is used (sharp of dull edge) and whether the injury was accidental or intentional.

Knives and machetes generally cause multiple injuries, which can include streak-like bruises, lacerations, transection of nerves, vessels and tendons, puncture wounds including organs with long knives and machetes able to cause a through-and-through perforating wound and can be capable of slicing through bone resulting in open fractures, subtotal decapitation and traumatic amputations. Given the multipurpose use of knives and machetes, they also carry a night risk for infections following injury, and a possible source of gangrene and tetanus. Lacerations were the most common injury from a machete (51.35%), with the head the most common site (46%), followed closely by the upper extremity (44%) with 19.2% of those tendon injuries in the hand and worst, most commonly seen in someone trying to protect the head from being hit.

Rehabilitation professionals should be aware of the high risk for wound infection, and be aware of the psychological trauma that is commonly associated with this type of injury. Given the high incidence of lacerations to the head, traumatic brain injury should also be considered.

Bullet Wounds

The capability of the gun to cause injury is directly related to its kinetic energy, and the efficiency of the energy transfer from the projective to the tissues. Gunshot wounds (GSWs) can cause medium or high energy injuries with the level and extent of penetration and degree of cavitation based on the type of weapon used, the type of ammunition / projectile used and on the proximity of the person to the weapon and the path the projectile takes. Gunshots can have entry and exit wounds that are large, small, or absent and in conflict settings tend to result in poly-trauma with extensive soft tissue, muscle, nerve and bony injury, with comminuted fractures common. Chest and abdominal injuries are also common and can damage pleura, lungs, great vessels, heart, mediastinum, diaphragm and abdominal-contents and are associated with a high incidence of internal injury often resulting in extensive blood loss.

Rehabilitation professionals should be aware that wide excision or fasciotomy may be required to clear foreign material and dead tissue with frequently delays seen in wound closure for high-velocity injuries, with grafting and suture at 3-5 days, thus impacting on early rehabilitation. Gunshot wounds, like knife wounds are particularly prone to anaerobic infection, especially tetanus and gas gangrene.

Explosive Weapons

Explosive weapons from bombs, missiles, grenades, mortars, landmines, improvised explosive devices, unexploded ordnance or explosive remnants of war cause blast injuries due to multiple effects of the explosive weapon itself and the overpressure created. Blast injuries are divided into four categories:

1. Primary Blast Injuries
   • Caused by the blast wave and tend to have the most effect on gas filled structures within the body including lungs, GI Tract, Middle Ear. Survival and injury from primary blast are contingent on a number of factors, including energy of the blast, confined versus open space, and distance from the explosive source. Casualties who survive may have tympanic membrane rupture (common), pulmonary barotrauma (uncommon), and bowel contusion and perforation. Primary brain injury may also occurs
2. Secondary Blast Injuries
   • Caused by flying fragments from the casing, shrapnel and contents of the explosive device and secondary debris (eg, dirt, rocks, body parts, etc). Types of injuries include penetrating fragments, and blunt injuries with the eyes very susceptible.
3. Tertiary Blast Injuries
   • Caused by physical displacement of the victim, effectively the body being thrown, resulting in blunt force trauma including fractures, traumatic amputation, closed and open brain injury, solid organ injuries, etc.
4. Quaternary Blast Injuries
   • Caused by thermal, chemical, and/or radiation effects. Types of injuries include burns (superficial, partial thickness and full thickness), inhalation injuries including asthma, COPD or other breathing difficulties from dust, smoke or toxic fumes, etc.

Rehabilitation professionals should be aware that explosive devices and blast injuries typically cause poly-trauma including soft tissue, orthopaedic and neurological injury, and lead to high patient numbers, which makes rehabilitation much more complex. Injuries can sometimes be missed or overlooked and infection risks can be high depending on the type of explosive device used and the types of injuries involved with significant associated psychological trauma further complicating early rehabilitation.

Children tend to be more severely injured compared to adults from blast injuries due to their proximity to the ground, curious nature, inability to effectively flee danger, increased head to body size, and decreased physiologic reserve. The Paediatric Blast Injury Manual is an excellent resource for those with medical training but limited experience in treating injured children, enabling the user to adapt their knowledge to the treatment of severely injured children.

Chemical, Biological, Nuclear, Radiological

Chemical, Biological, Nuclear, Radiological incidents can occur as a result of industrial disaster, occupational exposure, natural catastrophe, warfare, or acts of terrorism, necessitating a need for rapid decontamination and treatment of a significant numbers of casualties while taking critical measures to ensure the well-being of the personnel managing the incident. Use in armed conflict or terrorism attacks is becoming more common, and can have a significant impact on patients not only at the time of initial injury but in many cases leave significant lasting complications requiring extensive follow up care and rehabilitation.

These types of agents can cause both small and mass casualty situations with the impact on health are based on the actual agent used, the concentration of the agent, the rate of exposure and the transmissibility / potential for spread of the agent or contamination of others. Exposure routes include inhalation, ingestion, irradiation, dermal exposure through intact or non-intact skin or injection.

Rehabilitation professionals who are going to work in an area where there is a risk for Chemical, Biological, Nuclear, Radiological incidents should ensure adequate training in the use of Personal Protective Equipment (PPE), decontamination and triage mechanisms and recognise that there can be significant challenges for early rehabilitation.

Resources

Management of Limb Injuries during Disasters and Conflicts.

References 

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