Article

Analyses of demographical and injury characteristics of adult and pediatric patients injured in Syrian civil war

a b s t r a c t

Purpose: Aimed to analyze demographical data and Injury characteristics of patients who were injured in the Syrian Civil War (SCW) and to define differences in injury characteristics between adult and pediatric patients. Methodology: Patients who were injured in the SCW and transferred to our emergency department were retro- spectively analyzed in this study during the 15-month period between July 2013 and October 2014.

Results: During the study period, 1591 patients who were the victims of the SCW and admitted to our emergency department due to war injury enrolled in the study. Of these patients, 285 were children (18%). The median of the injury severity score was 16 (interquartile range [IQR]: 9-25) in all patients. The most frequent mechanism of in- jury was blunt trauma (899 cases, 55%), and the most frequently-injured region of the body was the head (676 cases, 42.5%). Head injury rates among the children’s group were higher than those of the adult group (P b

.001). In contrast, injury rates for the abdomen and extremities in the children’s group were lower than those in the adult group (P b .001, P b .001).

Conclusion: The majority of patients were adults, and the most frequent mechanism of injury was blunt trauma. Similarly, the children were substantially affected by war. Although the injury severity score values and mortality rates of the child and adult groups were similar, it was determined that the number of head injuries was higher, but the number of abdomen and extremity injuries was lower in the children’s group than in the adult group.

(C) 2016

Introduction

Although there is limited and conflicting objective information about civilian deaths and injuries in wars, previous studies have suggested that 35% to 60% of all deaths and injuries are civilian [1]. Furthermore, contemporary warfare has shifted dramatically from clas- sical, battlefield war to civil war in civilian areas, which injures more ci- vilians, including children, women, and the elderly [2,3]. In the most- recent ongoing civil war, the Syrian Civil War (SCW), nearly 250 000 persons have died since 2011. Approximately 4.8% (N = 12 000) of these were children, and nearly 3.2% (N = 8000) were females over the age of 18 [4].

? This paper is written in US English.

* Corresponding author at: Kecioren Training and Research Hospital, Emergency Medi- cine Department, Ankara, Turkey. Tel.: +90 543 7656176.

E-mail address: [email protected] (S.K. Corbacioglu).

Differences in the injuries experienced by pediatric and adult pa- tients are well defined in the literature for several trauma mechanisms, including motor vehicle accidents, falls from heights, and pedestrians struck by vehicles. However, in the case of civil wars, data are lacking about how injuries differ between children and adults.

The majority of patients injured during the SCW have been trans- ferred from the Syrian border to hospitals in neighboring Turkish prov- inces for treatment. This study aimed to analyze the demographic data and injury statistics of patients injured in the SCW to identify differ- ences in the types of injuries suffered by adults and pediatric patients.

Materials and methods

Study design

This retrospective study was conducted at the emergency depart- ment (ED) of Antakya State Hospital, in Turkey’s Hatay province, which is 60 kilometers from the Syrian border. The study period was

http://dx.doi.org/10.1016/j.ajem.2016.10.008

0735-6757/(C) 2016

16 months, from July 2013 to October 2014. The local ethics committee approved the study.

Study population and data collection

This study evaluated data from patients admitted to the ED who had been injured in the SCW, first identifying patients’ electronic data (in- cluding radiological views) and file records in the hospital data- registration system and then analyzing them retrospectively. Since all Syrian patients injured in the SCW and transferred by ambulance or other means to our ED are classified using a specific code number upon admission to the ED, they are identifiable. Before the study period, three researchers were trained to collect data from the hospital data- registration system. All of the three researchers were emergency medi- cine physicians and they were all well experienced on trauma due to having been working by the Syrian border of Turkey. Then, each was re- sponsible for identifying data regarding SCW victims during certain por- tions of the study period.

The study included patients who were classified in the hospital data- registration system using the SCW-specific code and who did not meet any of the exclusion criteria, which were being admitted to a hospital department other than the ED, having no electronic data available, and having file records from which data were missing.

The three researchers reviewed the electronic data, including radiological views and reports, and the file records of the included pa- tients for age, sex, injury severity score (ISS), mechanism of injury, body region injured, specific organs injured, and ED outcomes (died, ad- mitted, or transferred). ISS scores were calculated retrospectively using patient files.

In this study, 5 categories were defined as mechanism of injury;

blunt trauma, shrapnel, bullet/gunshot injury, burn, and unknown injuries. Patients who did not have any penetrating injury and injured as a result of direct blast effect, building collapse or falling from heights due to bombing and explosive were included in blunt trauma category. Shrapnel category was defined as Penetrating injuries with any foreign

Table 1

Baseline characteristics of the 1591 patients – median (IQR 25%-75%) or n (%).

Table 2

ISS of patients according to mechanism of injury, median (IQR 25-75%).

Injury mechanism

  • Blunt trauma due to blast during bombing

16 (9-25)

P b .001

  • Shrapnel

18 (9-32)

  • Bullet/Gunshot

20 (16-75)

  • Burn

4 (4-9)

  • Other (Unknown)

9 (4-9)

objects or bomb fragments. Bullet/gunshot category was defined as penetrating injuries with bullets of several weapons. Finally, burn category was defined as burn injuries without severe blunt or penetrat- ing injuries.

Statistical analysis

All statistical calculations were performed using SPSS for Windows version 15.0. The Kolmogorov-Smirnov test was used to evaluate whether patients’ demographic data, injury characteristics, and ISS values were normally distributed. Nonparametric data were reported as median values and inter-quartile-range (IQR) 25% to 75%. A P b .05 was considered statistically significant.

Results

The study included 1591 victims of the SCW, 147 of whom were fe- male (9.2%) and 1444 of whom were male (90.8%). The median age was 25 (IQR: 19-32) for all patients, 24 (IQR: 8-36) for females, and 25 (IQR: 20-31) for males (P = .17). The median ISS was 16 (IQR: 9-25) for all patients. The most common mechanism of injury was blunt trauma (899 cases, 55%), which included blast effects (682 cases), building col- lapses (260 cases), and falls from heights (120 cases) during bombing (Some cases had more than one Blunt mechanisms of injury). The most commonly injured part of the body was the head (676 cases, 42.5%). In 1121 patients (70%), multiple body parts were injured. Table 1 shows the baseline characteristics of all patients. There were sig- nificant differences (P b .001) in ISS depending on the mechanism of in-

  • Blunt trauma due to blast effect and etc. during bombing 899 (55.9)

Age Female

25 (19-32)

147 (9.2)

jury. The highest ISS values were found in the bullet/gunshot injury

group (Table 2). Due to insufficient hospital capacity, many patients

Male

1444 (90.8)

(595 cases, 37.4%) were transferred to other hospitals after initial eval-

Child 285 (18)

Injury mechanism

? ?

  • Direct blast effect 682

uation and intervention. Of the remaining patients, 442 (27.8%) were admitted to the hospital, 313 (19.6%) were admitted to the intensive

care unit (ICU), 101 (6.4%) required Urgent surgery, and 75 (4.7%)

    • Building collapse 260
    • Falling from height 120
  • Shrapnel 547 (34.4)
  • Bullet/gunshot 114 (7.2)
  • Burn 37 (2.3)
  • Other (Unknown) 3 (0.2)

ISS 16 (9-25)

Cardio-pulmonary arrested on admission 59 (3.7) Distribution of injured body parts

  • Head

676 (42.5)

  • Thorax

591 (37.1)

  • Abdomen

295 (18.5)

  • Extremities

370 (23.3)

  • Vertebral column

122 (7.7)

  • Vascular

29 (1.8)

  • Maxilla-facial

234 (14.7)

  • Skin

172 (10.8)

died in the ED.

Of the 1591 patients, 285 were children (18%) and 1306 were adults (82%). Rates of head injury were higher among the children than the adults (P b .001). In contrast, rates of injury to the abdomen and extrem- ities were higher in adults (P b .001). Other injury rates were similar in both groups, as shown in Table 3. Table 4 shows organ-specific injury data. The rates of lung contusion (51% and 34.5% in children and adults, respectively) and eye-globe perforation (28% and 14%, respectively) were higher in children. However, the rates of hemothorax (21% and

Table 3

Distribution of injured body parts according to child and adult groups, n (%).

Child (n = 285) Adult (n = 1306) Total (1591) P

Outcome of ED

Head

156 (54)

520 (39.8)

676 (42.5)

b.001

  • Hospital admission

442 (27.8)

Thorax

97 (34)

494 (37.8)

591 (37.1)

.2

  • Intensive care unit admission

313 (19.6)

Abdomen

34 (12)

261 (20)

295 (18.5)

b.001

  • Transferred other center

595 (37.4)

Extremities

45 (15.8)

325 (25)

370 (23.3)

b.001

  • Urgent operation

101 (6.4)

Vertebral column

17 (6)

105 (8)

122 (7.7)

.2

  • Death in ED

75 (4.7)

Vascular

3 (1.1)

26 (2)

29 (1.8)

.2

  • Discharge to ED

65 (4.1)

Maxilla-facial

32 (11.2)

202 (15.5)

234 (14.7)

.06

* Since some cases have more than one blunt mechanisms of injury, the total of number of cases in subgroups are higher than number of cases in blunt trauma group.

Skin 24 (8.4) 148 (11.3) 172 (10.8) .1

In 1121 of all patients (70%), injuries of multiple body parts were detected.

Table 4

Injuries details and numbers of adult and child patients N (%).

injury type

Child

Adult

Total

Brain injuries

  • Subarachnoid hemorrhage

26 (9.5)

119 (13)

145

  • Subdural hemorrhage

23 (8)

87(9)

110

  • Intra-parenchymal hemorrhage

15 (5)

93 (10)

108

  • Epidural hemorrhage

15(5)

53 (5.5)

68

  • Linear fracture

68 (24.5)

177 (19)

245

  • Depressed fracture

20 (7)

72 (7.5)

92

  • Shrapnel or foreign body

25 (8.5)

74 (8)

99

  • Contusion

49 (17.3)

188 (20)

237

  • Pneumocephalus

20 (7)

50 (5)

70

1 (0.3)

6 (0.5)

7

  • Prolapse brain tissue

1 (0.3)

2 (0.2)

3

1 (0.3)

2 (0.2)

3

1 (0.3)

0 (0)

1

7 (2.5)

10 (1)

17

Total

272 (100)

933 (100)

1205

Chest injuries

  • Lung contusion

61 (51)

249 (34.5)

310

  • Rib fracture

14 (12)

89 (13)

103

  • Hemothorax

25 (21)

227 (32)

252

  • Pneumothorax

15 (13)

107 (15)

122

  • Pneumomediastinum

0 (0)

10 (1)

10

  • Myocardial injury

0 (0)

2 (0.3)

2

  • Tracheal injury

0 (0)

1 (0.2)

1

  • Shrapnel or foreign body

4 (3)

18 (3)

22

Total

119 (100)

703 (100)

822

Abdominal injuries

  • Hollow viscous injuries

5 (10)

39 (15)

44

  • Hepatic injuries

11 (22)

56 (20.5)

67

  • Splenic injuries

6 (12)

32 (12)

38

1 (2)

11 (4)

12

  • Free fluid without SOI

7 (14)

46 (17)

53

  • Shrapnel or foreign body

11 (22)

75 (28)

86

  • Diaphragm abnormality

0 (0)

3 (1)

3

0 (0)

1 (0.2)

1

  • Bladder injuries

0 (0)

1 (0.2)

1

Total

41 (100)

265 (100)

306

Skin injuries

  • Burn with life-threatening

3 (12)

3 (3)

6

  • Burn without life-threatening

11 (44)

23 (26)

34

  • Deep wound needing OR

7 (28)

25 (28)

32

  • Wound with tissue loss

4 (16)

37 (42)

41

Total

25 (100)

88 (100)

113

Extremity and pelvic injuries

5 (10)

42 (10)

47

  • Femur fracture

12 (23)

83 (19)

95

  • Tibia/fibula fracture

12 (23)

99 (23)

111

  • Humeral fracture

8 (15)

50 (12)

58

  • Radius/ulna fracture

6 (12)

64 (15)

70

  • Clavicle

2 (4)

15 (4)

17

  • Other small bone fractures

3 (6)

22(5)

25

  • Hand amputation

1 (2)

6 (1)

7

  • Foot amputation

0 (0)

4 (0.6)

4

  • Lower extremity amputation

0 (0)

8 (2)

8

  • Upper extremity amputation

0 (0)

2 (0.4)

2

1 (2)

6 (1)

7

  • Isolated shrapnel or foreign body

2 (4)

25 (6)

27

Total

52(100)

426(100)

478

Maxilla-facial injuries

  • Glob (Eye) perforation

10 (28)

38 (14)

48

  • Maxillary fracture

5 (14)

111 (40)

116

  • Orbital fracture

3 (8)

9 (3)

12

  • Zygomatic fracture

2 (6)

26 (9)

28

  • Mandibular fracture

6 (17)

45 (16)

51

  • Ethmoid fracture

0 (0)

5 (2)

5

  • Mastoid fracture

0 (0)

4 (1)

4

  • Frontal bone fracture

0 (0)

7 (2)

7

  • Nasal fracture

2 (6)

14

16

  • Dental fracture

1 (3)

65

7

  • Shrapnel or foreign body

5 (14)

12 (4)

17

  • Deep wound needing OR

2 (6)

4 (1)

6

Total

vascular injuries

36 (100)

281 (100)

317

  • Axillar artery

0 (0)

3 (13)

3

1 (25)

3 (13)

4

Table 4 (continued)

Injury type

Child

Adult

Total

0 (0)

3 (13)

3

  • Femoral artery

1 (25)

5 (22)

6

  • Popliteal artery

1 (25)

6 (26)

7

  • Large venous injury

1 (25)

3 (13)

4

Total

4 (100)

23 (100)

27

Vertebral colon injuries

  • Cervical fracture

4 (21)

23 (20)

27

  • Cervical dislocation

1 (5)

4 (3)

5

  • Thoracic vertebra fracture

2 (11)

29 (25)

31

  • Thoracic vertebra dislocation

0 (0)

1 (1)

1

  • Lumbar vertebra fracture

5 (26)

37 (32)

42

  • Lumbar vertebra dislocation

1 (5)

0 (0)

1

  • Sacral fracture

0 (0)

2 (2)

2

  • Shrapnel in vertebral canal

6 (32)

19 (17)

25

Total

19 (100)

115 (100)

134

SOI, solid Organ injuries; OR, operating room.

32% for children and adults, respectively) and maxillary fracture (14% and 40%, respectively) were higher in adults. Both groups had similar median ISS values (16 IQR: 9-25). Finally, 7 children (2.5%) and 68 adults (5.2%) died in the ED, a difference that was not statistically signif- icant (P = .06). In both groups, the most common cause of death was head injury, and the most common mechanism of death was shrapnel injury. Table 5 shows the causes and mechanisms of death.

Discussion

Unfortunately, civil wars and terrorist attacks against civilians are in- creasing in modern warfare, especially in the East Mediterranean re- gion, and wars are the 10th leading cause of death among Young people [5]. However, the literature contains limited analyses of injury characteristics, including type and mechanism. The present study ana- lyzed data regarding patients injured in the SCW during a 16-month pe- riod. Results showed that the majority of patients injured in the SCW were men, but a considerable number were children. In addition, al- though wars bring firearms to mind, the most frequent mechanism of injury was blunt trauma. Finally, one of the most important findings was that the rate of head injury was higher in children than in adults. The study also found that rates of injury to the abdomen and extremities were higher in adults.

A study conducted by Karakus et al. [6] involving 482 patients injured in the SCW reported that the majority of patients were men (88.8%) and the mean age was 30.4 +- 14.9 years (1-79 years). It also reported that the most commonly injured body part was the extremities (31.7%) and the most common mechanism of injury was gunshots [6]. In a study analyz- ing data from 962 patients, Helweg-Larsen et al [7] also found that the majority of patients were men (90%) and the most commonly injured body part was the extremities (33.3%). However, in young patients (under age 15), that study found that head injury was the most common. In addition, it found that the most common mechanism of injury was fire- arms and explosives (65%) [7]. In contrast, although the present the pres- ent study also found that the majority of patients were men, it found that the most common mechanism of injury was blunt trauma.

The reason for this difference may be that the authors of both previ- ous studies cited included blast effects and gunshot injuries in the same

Table 5

Cause of deaths of the patients who died in ED (n = 75) in child and adult groups, n (%).

Child deaths’ causes (n = 7) Adult deaths’ causes (n = 68)

  • Isolated brain injury 4 (57) o Isolated brain injury 47 (70)
  • Burns 2 (28) o Abdominal and thorax injury 18 (25)
  • Brain and abdominal injuries 1 (15) o Burns 2 (3)

mechanism. In contrast, the present study considered the blast effects of bombing to be blunt trauma rather than gunshot injury. Like both pre- vious studies, the present study found a high ratio of extremity injuries (23.3%). However, unlike those studies, the present one found the head to be the most commonly injured body part (42.5%), especially in chil- dren. Although several studies have reported that musculoskeletal inju- ries represent approximately 70%of all war wounds, such injuries have low mortality rates when isolated [8]. Therefore, the lower rates of ex- tremity injuries identified by the present study may be because patients who had Isolated extremity injuries were not transferred to Turkey but instead treated in local hospitals in Syria.

Hakimoglu et al studied 364 patients injured in the SCW who underwent surgery, finding that head injuries were the most likely to be fatal [9]. Similarly, two separate studies by Celikel et al. analyzed causes of death for patients injured in the SCW [10,11]. The second of these two studies included only children. Both studies found the major cause of death to be head injuries (first study: 37.6%, second study: 30%). In addition, previous studies have reported that most deaths were caused by bombing and shrapnel injuries. Likewise, the present study found head injuries to be the most common cause of death and shrapnel injuries the major mechanism of death in both adults and children who died in the ED. However, the present study analyzed only ED mortality, not long-term outcomes and mortality. This was because the majority of patients were transferred directly from the ED or hospital to other hos- pitals, due to their overwhelming numbers. As discussed later, this was

the major limitation of the present study.

To our knowledge, no study has directly analyzed differences in inju- ries between adults and children. In the present study, for both groups, the most commonly injured body part was the head, but the rate of head injury in children was higher than in adults. However, the distribu- tions of specific head injuries were similar in both, with the most com- mon types of injury being linear fracture, contusion, subarachnoid hemorrhage, and subdural hemorrhage. The distribution ratios for specif- ic head injuries were similar to those in previous studies [11,12]. In addi- tion, in the present study, rates of injury to the abdomen and extremities were lower in children than in adults. However, the distributions of spe- cific abdomen and/or extremity injuries were similar, with the most com- mon types of injury to the abdomen being intra-abdominal shrapnel or foreign bodies, hepatic injuries, free fluid without solid organ injury, and hollow viscous injury and the most common types of injury to the ex- tremities being tibia/fibula fracture, femur fracture, radius/ulna fracture, and Humerus fracture. A similar study by Schoenfeld et al. analyzed pel- vic, spinal, and extremity wounds in the Iraq and Afghanistan wars, find- ing that injury types included tibia/fibula fractures (15%), radius/ulna fractures (8%), femur fractures (6%), and humerus fractures (5%) [13].

Ivey et al studied thoracic injuries in the Iraq war, finding that lung contusion and pneumothorax were the most common injury

types [14]. No study has investigated differences in thoracic injury between adults and children due to war. However, Skinner et al. examined thoracic-injury differences between adults and children due to severe blunt trauma [15], finding that children had significantly fewer rib fractures (20.2% vs 42.0%), flail chests (2.4% vs 26.3%), and blunt Cardiac injuries (9.5% vs 23.6%) but sustained more lung contu- sions (79.8% vs 65.6%) [15]. The present study also found lung contusion to be one of the most common injuries, especially in children. In addi- tion, whereas eye-globe perforations were more common in children, hemothorax and maxilla fractures were less common in children than in adults.

Limitations

Antakya State Hospital is very close to the Syrian border and there- fore is the main center to which all injured Syrian civilians are trans- ferred. Due to the excessive number of admissions, the hospital often must practice disaster triage procedures. Some patients are transferred from the ED to other hospitals immediately after stabilization, and some are transferred from the hospital wards to free up Hospital beds for new admissions. Therefore, the present study could not analyze patients’ long-term outcomes and mortality, which is its major limitation.

Conclusions

The results of this large study showed that the majority of patients injured in the SCW were adults and that the most common mechanism of injury was blunt trauma. However, children were substantially affect- ed by the SCW. Although the ISS values and mortality rates of children and adults were similar, head injuries were more common and abdom- inal and extremity injuries less common in children. Although any other wars in the areas at different levels of development might have different results, we believe that results of the present study can be used to pre- dict the medical effects of future wars.

Declaration of interest“>Declaration of Interest

The authors report no conflicts of interest.

References

  1. Meddings DR. Civilians and war: a review and historical overview of the involve- ment of non-combatant populations in conflict situations. Med Confl Surviv 2001; 17:6-16.
  2. Coupland RM, Meddings DR. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ 1999;319(7207):407-10.
  3. Levy B, Sidel V. War and public health. New York: Oxford University Press; 1997.
  4. Syrian Observatory for Human Rights. Syrian observatory for human rights official website. http://www.syriahr.com/en/2015/10/about-20-millions-and-half- killed-and-wounded-since-the-beginning-of-the-syrian-revolution/. [retrieved 22.11.2015].
  5. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: systematic analysis of population health data. Lancet 12 2009;374(9693), 881e92.
  6. Karakus A, Yengil E, Akkucuk S, Cevik C, Zeren C, Uruc V. The reflection of the Syrian civil war on the emergency department and assessment of hospital costs. Ulus Travma Acil Cerrahi Derg 2013;19(5):429-33. http://dx.doi.org/10.5505/tjtes.2013. 78910.
  7. Helweg-Larsen K, Abdel-Jabbar Al-Qadi AH, Al-Jabriri J, Bronnum-Hansen H. Systematic medical data collection of intentional injuries during armed conflicts: a pilot study conducted in West Bank, Palestine. Scand J Public Health 2004;32(1): 17-23.
  8. Gosselin RA. War injuries, trauma, and disaster relief. Tech Orthop 2005;20:97-108.
  9. Hakimoglu S, Karcioglu M, Tuzcu K, Davarci I, Koyuncu O, Dikey I, et al. Assessment of the perioperative period in civilians injured in the Syrian civil war. Braz J Anesthesiol 2015;65(6):445-9. http://dx.doi.org/10.1016/j.bjane. 2014.03.003

    [Epub 2014 Apr 3].

    Celikel A, Karaarslan B, Demirkiran DS, Zeren C, Arslan MM. A series of civilian fatal- ities during the war in Syria. Ulus Travma Acil Cerrahi Derg 2014;20(5):338-42. http://dx.doi.org/10.5505/tjtes. 2014.71173.

  10. Celikel A, Karbeyaz K, Kararslan B, Arslan MM, Zeren C. Childhood casualties during civil war: Syrian experience. J Forensic Leg Med 2015;34:1-4. http://dx.doi.org/10. 1016/j.jflm.2015.04.021 [Epub 2015 May 12].
  11. Barhoum M, Tobias S, Elron M, Sharon A, Heija T, Soustiel JF. Syria civil war: out- comes of humanitarian neurosurgical care provided to Syrian wounded refugees in Israel. Brain Inj 2015;29(11):1370-5. http://dx.doi.org/10.3109/02699052.2015. 1043346 [Epub 2015 Jul 23].
  12. Schoenfeld AJ, Dunn JC, Belmont PJ. Pelvic, spinal and extremity wounds among combat-specific personnel serving in Iraq and Afghanistan (2003-2011): a new par- adigm in military musculoskeletal medicine. Injury 2013;44(12):1866-70. http:// dx.doi.org/10.1016/j.injury.2013.08.001 [Epub 2013 Aug 11].
  13. Ivey KM, White CE, Wallum TE, Aden JK, Cannon JW, Chung KK, et al. Thoracic injuries in US combat casualties: a 10-year review of operation enduring freedom and Iraqi freedom. J Trauma Acute Care Surg 2012;73:514-9 [doi: TA.0b013e3182754654].
  14. Skinner DL, den Hollander D, Laing GL, Rodseth RN, Muckart DJ. Severe blunt thorac- ic trauma: differences between adults and children in a level I trauma centre. S Afr Med J 2015;105(1):47-51.

Leave a Reply

Your email address will not be published. Required fields are marked *