Israel Medical Association Journal

Background: Chest trauma is among the most common types of trauma, corresponding to 10% of trauma patients admitted to hospitals. In the military setting, thoracic trauma was reported as a significant cause of death. With well-timed treatment, chest trauma is regarded as survivable. Emergency thoracotomy (ET) is considered when the patient with trauma to the chest needs immediate resuscitation. Survival rate is reported as low as 1% in some reports and 20% in others. The survival rate depends on injury mechanism, protocols for intervention, and other decompressive procedures.

Objectives: To determine parameters that may impact survival of ET.

Methods: We conducted a retrospective cohort study to compare prehospital and in-hospital data regarding ET in the emergency department (ED) versus the operating room (OR).

Results: Between 2009 and 2017, 6532 casualties presented to the ED; 1125 with trauma to the chest. Fifty-four of those with chest trauma underwent ET in the hospital (4.8%), 22 (41%) in the ED, and 32 (59%) in the OR. The overall mortality of the ET subgroup was 48%. With regard to thoracotomies, 19/22 of patients (86%) who underwent ET in the ED died compared to 2/28 in the OR (13%).

Conclusions: Utilizing ET after chest trauma with appropriate clinical indications, well-trained personnel, and prompt transportation poses a significant challenge, but may be associated with better survival than that reported previously with military casualties. Adoption of indications and timed allocation to the OR may improve outcomes with chest trauma casualties.

Background: Traumatic brain injury (TBI) is a significant cause of death in the battlefield. TBI can be challenging to diagnose in the combat setting and remains a substantial challenge for advanced life support (ALS) providers.

Objectives: To compare prehospital and hospitalization characteristics between isolated and non-isolated TBI. To examine the effects of TBI with coexisting injuries on patient evaluation and outcomes based on the Israeli Defense Forces Trauma Registry and the Israeli National Trauma Registry of soldiers hospitalized for TBI between the years 2006–2017.

Methods: A total of 885 casualties were eligible for our study, of whom 271 (30%) had isolated TBI. Only 35% of hospitalized patients with isolated TBI were defined as urgent by the ALS providers versus 67% in the non-isolated TBI group (P < 0.001).

Results: Overall, 29% of the TBIs in the non-isolated group were missed by the ALS providers vs. 11% in the isolated group.

Conclusions: Concomitant injuries may delay the diagnosis of TBI by ALS providers. These findings should be considered in the prehospital evaluation to potentially improve the care and outcome of head injury patients.

Background: Vehicle-ramming attacks have become a common tactic for terror organizations worldwide. However, the medical implications of vehicle-ramming attacks remain unknown.

Objectives: To investigate the characteristics of vehicle-ramming attack incidents and casualties in order to assist in guiding the policy of medical organizations. 

Methods: In this study we included all vehicle-ramming attacks recorded in the Israel Defense Forces-Trauma Registry between 2015 and 2019. Records were screened using text mining of incident, casualty, and injury descriptions. The selected records were examined manually to ensure that they were vehicle-ramming attacks. Incident and casualty data were retrieved from the trauma registry.

Results: During the years 2015–2019, a total of 36 vehicle-ramming attacks with 113 casualties were documented in the trauma registry. The median number of casualties, urgent casualties, and fatalities per incident was 3 (interquartile range [IQR] 2–5), 1 (IQR 1–2), and 1 (IQR 1–1), respectively. Of the incidents, 15 (42%) had three or more casualties. The most prevelant day of the week was Friday with 9 incidents (25%). Within the day, 21 incidents (58%) occurred between the hours of 12:00 and 18:00. Commonly injured body regions were lower extremities (55%), head (28%), and upper extremities. Ten victims (9%) died before arriving at a hospital.

Conclusions: Vehicle-ramming attacks tend to have multiple casualties, be deadly, occur more often on Fridays and in the afternoon, and result mostly in injuries to the extremities and the head. These findings could guide policymaking to improve medical response to vehicle-ramming attacks.

Background: Pain control in trauma is an integral part of treatment in combat casualty care. More soldiers injured on the battlefield need analgesics for pain than life-saving interventions (LSIs). Early treatment of pain improves outcomes after injury, while inadequate treatment leads to higher rates of post-traumatic stress disorder (PTSD).

Objective: To describe the experience of the Israel Defense Forces (IDF) Medical Corps with prehospital use of analgesia.

Methods: All cases documented in the IDF-Trauma Registry between January 1997 and December 2019 were examined. Data collection included analgesia administered, mechanism of injury, wound distribution, and life-saving interventions performed.

Results: Of 16,117 patients, 1807 (11.2%) had at least one documented analgesia. Demographics included 91.2% male; median age 21 years. Leading mechanism of injury was penetrating (52.9%). Of injured body regions reported, 46.2% were lower extremity wounds. Most common types of analgesics were morphine (57.2%) and fentanyl (27%). Over the two decades of the study period, types of analgesics given by providers at point of injury (POI) had changed. Fentanyl was introduced in 2013, and by 2019 was given to 39% of patients. Another change was an increase of casualties receiving analgesia from 5–10% until 2010 to 34% by 2019. A total of 824 LSIs were performed on 556 patients (30.8%) receiving analgesia and no adverse events were found in any of the casualties.

Conclusions: Most casualties at POI did not receive any analgesics. The most common analgesics administered were opioids. Over time analgesic administration has gained acceptance and become more commonplace on the battlefield.

Background: Pain management is fundamental in the treatment of a trauma casualty. Adequate pain management is associated with decreased long-term morbidity and chronic pain. Nonetheless, pain is frequently not documented nor adequately treated in the prehospital setting, a phenomenon described as oligoanalgesia. Gender bias has been suggested as a risk factor for oligoanalgesia.

Objectives: To examine the association between casualty gender and pain management in the prehospital trauma setting.

Methods: We conducted a retrospective cohort study of the Israel Defense Forces Trauma Registry between 2015 and 2020. Univariable analysis followed by multivariable logistic regression was used to assess the association between casualty gender and pain management. For adult patients for whom gender was known, pain scores were documented.

Results: A total of 1044 casualties were included in the study; 894 (85.6%) were male. Females and males differed in several demographic and injury characteristics, including age in years (mean 36 vs. 27.6, P value < 0.001) and injury mechanism (16%% vs. 34.5% penetrating injury, P value < 0.001). Female casualties were less likely to be treated for pain (odds ratio [OR] 0.708, 95% confidence interval [95%CI] 0.5–1, P = 0.05). However, after adjustment for various factors, including pain severity, this association was insignificant (OR 0.748, 95%CI 0.46–1.23, P = 0.25).

Conclusions: In this prehospital study, gender bias in pain management was not apparent. As women’s role on the battlefield continues to increase, further studies regarding the role of

Background: Medical organizations worldwide aim for equity and diversity in the medical profession to improve care quality. Data on whether the caregiver gender affects outcomes in the prehospital setting are essential but scarce compared to available in-hospital studies.

Objective: To analyze the rates of missed injuries in the prehospital setting and determine whether these rates were associated with the gender of the on-field physician or paramedic.

Methods: A retrospective record review was conducted, which included trauma records documented in two trauma registries, the prehospital Israel Defense Forces-Trauma Registry (IDF-TR), and the in-hospital Israeli National Trauma Registry (INTR). Missed injuries were defined as injuries documented in the INTR but not in the IDF-TR. A multivariable regression analysis was performed to assess the association between provider’s gender and missed injuries.

Results: Of 490 casualties, 369 (75.3%) were treated by teams that included only male paramedics or physicians. In 386 (78.8%) cases, a physician was a part of the prehospital team. In all, 94 (19.2%) casualties sustained injuries that were missed by the prehospital medical team. Missed injuries were not associated with the gender of the paramedic or physician (odds ratio 1.242, 95% confidence interval 0.69–2.193).

Conclusions: No association was found between the gender of the medical provider in the prehospital setting and the rate of missed injuries. These results should encourage prehospital emergency medical systems to aim for a balanced and diverse caregiver population.

Background: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert.

Objectives: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress.

Methods: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial.

Results: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress.

Conclusions: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Background: The Israeli Defense Forces-Medical Corps (IDF-MC) focuses on reducing preventable death by improving prehospital trauma care. High quality documentation of care can serve casualty care and to improve future care. Currently, paper casualty cards are used for documentation. Incomplete data acquisition and inadequate data handover are common. To resolve these deficits, the IDF-MC launched the BladeShield 101 project.

Objectives: To assess the quality of casualty care data acquired by comparing standard paper casualty cards with the BladeShield 101.

Methods: The BladeShield 101 system consists of three components: a patient unit that records vital signs and medical care provided, a medical sensor that transmits to the patient unit, and a ruggedized mobile device that allows providers to access and document information. We compared all trauma registries of casualties treated between September 2019 and June 2020.

Results: The system was applied during the study period on 24 patients. All data were transferred to the military trauma registry within one day, compared to 72% (141/194) with a paper casualty card (P < 0.01). Information regarding treatment time was available in 100% vs. 43% (P < 0.01) of cases and 98% vs. 67% (P < 0.01) of treatments provided were documented comparing BladeShield 101 with paper cards, respectively.

Conclusions: Using an autonomous system to record, view, deliver, and store casualty information may resolve most current information flow deficits. This solution will ultimately significantly improve individual patient care and systematic learning and development processes.

Background: Eye trauma is an unfortunate and often preventable cause of vision loss. Confetti cannons are common causes of injury. Awareness of ocular hazards of confetti cannons remains low because of limited reports describing ophthalmic injuries following their use.

Objectives: To describe outcomes of ocular trauma caused by confetti cannons and to increase recognition of their ocular risks.

Methods: A retrospective analysis was conducted of eye injuries caused by confetti cannons presenting to a single medical center between 2016 and 2020. Data collected included age, gender, eye injured, ocular damage, visual outcome, and details of surgeries performed.

Results: Overall, six consecutive patients (2 males, mean age 19.5 ± 9.74 years) were identified and studied. In all patients only one eye was injured (3 right eyes) during a private celebration, most commonly (n=5) to a bystander while in the vicinity of a cannon operated by someone else. Most common eye injuries included corneal erosion (n=4), traumatic hyphema (n=4), and retinal edema (n=3). Mean initial logMAR visual acuity in the injured eye was 0.73 ± 0.18, improving to 0.25 ± 0.16 at the final visit (P = 0.125). Two patients underwent eye surgery due to their trauma: one to repair globe penetration and another to undergo intravitreal injection of tissue plasminogen activator and C3F8 for submacular hemorrhage, followed 8 months later by intravitreal bevacizumab injection for choroidal neovascularization.

Conclusions: Confetti cannons pose hazards that can cause severe ocular trauma resulting in permanent vision loss. Increasing awareness of device hazards is necessary to prevent eye injuries

Background: Patients with severe coronavirus disease-2019 (COVID-19) are susceptible to superimposed infections.

Objectives: To describe COVID-19 patients who presented with complications due to Candida bloodstream co-infection (candidemia) and their outcome in a single center in northern Israel (Emek Medical Center) during the second outbreak of COVID-19 in Israel (15 June 2020 to 20 September 2020).

Methods: A retrospective study of COVID-19 patients presenting with candidemia was conducted, including clinical and laboratory data. The incidence of candidemia among hospitalized COVID-19 patients was compared to a historical cohort of non-COVID-19 controls.

Results: Three COVID-19 patients complicated with candidemia were documented. All three patients died shortly after the detection of candidemia. Three different Candida sp. were isolated from the blood cultures: C. albicans, C. parapsilosis, and C. glabrata. The incidence of candidemia among COVID-19 patients was 0.679 episodes per 1000 hospital days.

Conclusions: Our small sample suggests a much higher incidence of candidemia among COVID-19 patients compared to a historical cohort of non-COVID-19 controls. All clinicians treating COVID-19 patients in GICU should be aware of this complication

Background: Acute extremity compartment syndrome is a surgical emergency for which timely diagnosis is essential.

Objectives: To assess whether the time from the initial insult to the fasciotomy of compartment syndrome of the upper extremity affects outcomes and to examine the differences between compartment syndrome secondary to fractures and that resulting from a non-fracture etiology with regard to the time from insult to fasciotomy and the long-term patient outcomes.

Methods: Patients presented with documented fasciotomy treatment following acute upper extremity compartment syndrome and a minimum of 6 months follow-up. Patient information included demographics, cause of compartment syndrome, method of diagnosis, and outcome on follow-up.

Results: Our study was comprised of 25 patients. Fasciotomies were performed for compartment syndrome caused by fracture in 11 patients (44%), and due to insults other than fractures in 14 patients (56%). The average time to fasciotomy in patients without a fracture was 10.21 hours and 16.55 hours with a fracture. Fasciotomy performed more than 24 hours from the initial insult was not found to significantly affect long-term sequelae compared to fasciotomy performed earlier than 24 hours from the initial insult. The non-fracture group had more long-term sequelae than the fracture group (13/15 patients and 5/11 patients, respectively).

Conclusions: Most injuries treated for fasciotomy of compartment syndrome were non-fracture related, with more complications found in patients with non-fracture related injuries. Time interval from insult to fasciotomy did not affect outcome and was longer in the fracture group, suggesting longer monitoring in this group and supporting fasciotomy even with late presentation.

Background: Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant.

Objectives: To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma

Methods: In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy.

Results: Fourteen patients presented with ICH (6.8%, 3.8–11.1%) and three (1.5%, 0.3–4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0–2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8–98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7–88.3) of the cohort.

Conclusions: None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.

Background: The collapse of the Syrian healthcare system during the civil war led numerous citizens to cross the Syrian–Israeli border to seek medical care.

Objectives: To describe the epidemiology of peripheral nerve injuries (PNIs) sustained in war, their management, and short-term outcomes.

Methods: A retrospective case series study was conducted on 45 consecutive patients aged 25.7 ± 9.3 years. These patients were referred to the hand surgery unit of the department of orthopedic surgery and traumatology at Galilee Medical Center between December 2014 and June 2018. Median time between injury and presentation was 60 days. Injury pattern, additional injuries, surgical findings and management, complications, and length of hospital stay were extracted from medical records.

Results: Most injuries were blast (55.6%) followed by gunshot injuries (37.8%). There were 9 brachial plexus injuries, 9 sciatic nerve injuries, and 38 PNIs distal to the plexus: specifically 20 ulnar, 11 median, and 7 radial nerve injuries. In the latter group, neurotmesis or axonotmesis was found in 29 nerves. Coaptation was possible in 21 nerves necessitating cable grafting in 19. A tendon transfer was performed for 13 peripheral nerves, occasionally supplementing the nerve repair. The patients returned to their country after discharge, average follow-up was 53.6 ± 49.6 days.

Conclusions: For nerve injuries sustained in war, early surgical treatment and providing adequate soft tissue conditions is recommended. Tendon transfers are useful to regain early function.

Background: Consent rates for organ donation remain one of the most important factors determining the number of organs available for transplantation. Trauma casualties constitute a substantial part of the deceased organ donor pool and have unique characteristics that distinguish them from the general donor population. However, this group has not been extensively studied.

Objectives: To identify donor factors associated with positive familial consent for solid organ donation among trauma casualties.

Methods: This retrospective study included all trauma casualties who were admitted to the Rabin Medical Center, Beilinson hospital, during the period from January 2008 to December 2017, who were potential organ donors. Data collected included demographic features, the nature of the injury, surgical interventions, and which organs were donated. Data was collected from the Rabin Medical Center Trauma Registry.

Results: During the study period 24,504 trauma patients were admitted and 556 died over their hospital course. Of these 76 were potential donors, of whom 32 became actual donors and donated their organs. Two factors showed a statistically significant correlation to donation, namely female gender (P = 0.018) and Jewish religion of the deceased (P = 0.032).

Conclusions: Only a small group of in hospital trauma deaths were potential solid organ donors (13.7%) and less than half of these became actual donors. Consent rates were higher when the deceased was female or Jewish

Background: Pancreatic trauma is uncommon in pediatric patients and presents diagnostic and therapeutic challenges. While non-operative management (NOM) of minor pancreatic injuries is well accepted, the management of major pancreatic injuries remains controversial.

Objectives: To evaluate management strategies for major blunt pancreatic injury in children.

Methods: Data were retrospectively collected for all children treated for grade III or higher pancreatic injury due to blunt abdominal trauma from 1992 to 2015 at two medical centers. Data included demographics, mechanism of injury, laboratory and imaging studies, management strategy, clinical course, operative findings, and outcome.

Results: The cohort included seven boys and four girls aged 4–15 years old (median 9). Six patients had associated abdominal (mainly liver, n=3) injuries. The main mechanism of injury was bicycle (handlebar) trauma (n=6). Five patients had grade III injury and six had grade IV. The highest mean amylase level was recorded at 48 hours after injury (1418 U/L). Management strategies included conservative (n=5) and operative treatment (n=6): distal (n=3) and central (n=1) pancreatectomy, drainage only (n=2) based on the computed tomography findings and patient hemodynamic stability. Pseudocyst developed in all NOM patients (n=5) and two OM cases, and one patient developed a pancreatic fistula. There were no differences in average length of hospital stay.

Conclusions: NOM of high-grade blunt pancreatic injury in children may pose a higher risk of pseudocyst formation than OM, with a similar hospitalization time. However, pseudocyst is a relatively benign complication with a high rate of spontaneous resolution with no need for surgical intervention.