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Gunshot and Explosion Injuries: Characteristics, Outcomes, and Implications for Care of Terror-Related Injuries in Israel

Peleg, Kobi PhD*; Aharonson-Daniel, Limor PhD*; Stein, Michael MD†; Michaelson, Moshe MD‡; Kluger, Yoram MD, FACS§; Simon, Daniel MD**; Israeli Trauma Group (ITG); Noji, Eric K. MD††


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.

Terror-related injuries have become a threat for populations all over the world. With the increase of terror-related activities, physicians will be increasingly required to treat victims of mass casualty incidents, requiring a broadening of their existing skills and itemed knowledge of various mechanism of injuries.1–3

In Israel, terrorist acts have been an unfortunate reality for many years. The most recent uprising has been particularly devastating, causing extensive loss of life and injuries to young civilians.

Medical care for victims of earlier periods of terror was predominantly for stabbings,4 being hit by objects such as rocks and stones and explosions due to explosives concealed and detonated by remote control. The recent eruption of terror activity comprises of 2 major forms – suicide bomber explosions and gunshots. These attacks resulted in victims sustaining injuries that are more complex and severe than earlier periods of terror activity.5,6 The need to understand the effects and implications of these 2 terror mechanisms led to this study. Gunshot and explosion wounds, which vary in injury profile, hospital services utilization, patient characteristics, and outcome are described and compared. The comparison serves to stress the differences in injury patterns and help produce specific protocols for each of the 2 injury mechanisms. The purpose of this study is: (1) to characterize and compare the effects of gunshot and explosion injuries caused by terrorist acts; and (2) to see how these findings contribute to the severity and outcome of terror-related injuries and the implications for care.

Terror related injuries were characterized through retrospective analysis of trauma registry data: 1155 patients, 71% male, 53% aged 15 to 29 years. Gunshot wounds and explosion injuries differed in injured body regions, severity distribution, length of stay, intensive care unit stay, and time of inpatient death. The implications for treatment and for preparedness of hospital resources following a terrorist attack are discussed.

From the *Center for Trauma & Emergency Medicine Research, Gertner Institute, Sheba Medical Center, Tel Hashomer, Israel; †Trauma Services, Department of Surgery, Rabin Medical Center, Petach Tikva, Israel; ‡Trauma Unit, Rambam Medical Center, Haifa, Israel; §Rabin Trauma Center, Department of Surgery, Tel Aviv Medical Center, Israel; **Trauma Unit, Sheba Medical Center, Tel Hashomer, Israel; and the ††Centers for Disease Control and Prevention, Atlanta, Georgia.

Reprints: Kobi Peleg, PhD, MPH, Center for Trauma and Emergency Medicine Research, Gertner Institute, Sheba Medical Center, Tel Hashomer, Israel 52621. E-mail:

© 2004 Lippincott Williams & Wilkins, Inc.