Medical Management of Terrorist Related Injuries

Terrorist acts frequently generate mass casualty events that overwhelm the regional health care system and cause a temporary imbalance between the sudden urgent demand for large-scale resources and expertise at a specific location and the availability of such resources (Shemer and Shapira 2001). The inundation of the medical system with hundreds of victims presents two types of challenge: a medical challenge, i.e., proper medical management with accurate triage, and a logistical challenge (Hirshberg 2004; Shemer and Shapira 2001). While the management of the single patient should initially follow the guidelines of Advanced Trauma Life Support (ATLS) (Shaloner 2005), the medical team should be aware of the unique multidimensional nature of terrorist-related injuries and take this into consideration during triage, diagnosis, treatment, and hospital organization (Peleg and Aharonson-Daniel 2005). As the individual victim is often treated as part of a mass casualty scenario, prompt triage is crucial in order to utilize the hospital resources effectively, sorting the patients into urgent versus nonurgent categories and directing the efforts to a maximal number of salvageable patients (Kluger et al. 2004; Peleg et al. 2004; Stein and Hirshberg 1999; Sutphen 2005). In accordance, Israeli studies have demonstrated that only 20%-23% of the casualties present with critical injuries and require urgent care (Almogy et al. 2004; Einav et al. 2004; Frykberg 2004; Peleg et al. 2004); therefore every effort should be made to prevent treatment of un-salvageable patients and victims who do not really require immediate medical care (overtriage) from delaying the recognition and treatment of the small number of patients with urgent and salvageable life-threatening injuries (undertriage) (Frykberg 2004; Kluger 2003; Stein and Hirshberg 1999). In these circumstances, prioritization of treatment regimens is mandatory and definitive therapy should be delayed until the patient is hemodynamically stabilized: damage control principles should be applied. However, identifying those critically injured patients who are candidates for damage control maneuvers, which aims to achieve hemostasis and prevent uncontrolled spillage of bowel contents and urine, is undoubtedly a challenge. Throughout the management of the event, coordination between the primary on-scene teams responsible for the primary triage and evacuation is obligatory, followed by similar close interaction between the in-hospital teams conducting the triage, the initial treatment, the surgical interventions and the intensive care, as well as between neighboring hospitals, in order to optimize utilization of the hospitals' personnel and resources (Almogy et al. 2004; Einav et al. 2004; Hirshberg 2004). Special consideration should be given to the fact that shrapnel containing human remains might transfect hepatitis B virus (HBV) or human immunodeficiency virus (HIV); thus immunization is recommended in appropriate scenarios (Singer et al. 2005; Sutphen 2005). The psychological effects on victims and family members should not be overlooked, hence the immediate role of specialized psychological teams is critical (Kluger 2003; Rusch et al. 2002). Subsequently, during the long course of rehabilitation, one should not forget the emotional and psychological support for the trauma victims who might present posttraumatic stress disorder, depressive disorder, panic disorder, phobias, and substance abuse (Rusch et al. 2002). Similarly, the medical personnel involved should not be ignored and special sessions should be scheduled for the teams in order to minimize the individual psychological burden and alleviate the reactions (Kluger 2003).

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