Terrorist suicide bombings: Lessons learned in Metropolitan Haifa from September 2000 to January 2006

Background: The threat of suicide bombing attacks has become a worldwide problem. This special type of multiple casualty incidents (MCI) seriously challenges the most experienced medical facilities.Methods: The authors concluded a retrospective analysis of the medical management of victims from the six suicide bombing attacks that occurred in Metropolitan Haifa from 2000 to 2006.Results: The six terrorist suicide bombing attacks resulted in 411 victims with 69 dead (16.8 percent) and 342 injured. Of the 342 injured, there were 31 (9.1 percent) severely injured, seven (2.4 percent) moderately severely injured, and 304 (88.9 percent) mildly injured patients.Twenty four (77 percent) of the 31 severely injured victims were evacuated to the level I trauma center at Rambam Medical Center (RMC). Of the seven severely injured victims who were evacuated to the level II trauma centers (Bnai-Zion Medical Center and Carmel Medical Center) because of proximity to the detonation site, three were secondarily transferred to RMC after initial resuscitation. Eight of the 24 severely injured casualties, admitted to RMC, eventually died of their wounds.There was no in-hospital mortality in the level II trauma centers.Conclusions: A predetermined metropolitan triage system which directs trauma victims of a MCI to the appropriate medical center and prevents overcrowding of the level I facility with less severe injured patients will assure that critically injured patients of a suicide bombing attack will receive a level of care that is comparable with the care given to similar patients under normal circumstances. Severe blast injury victims without penetrating injuries but with significant pulmonary damage can be effectively managed in ICUs of level II trauma centers.

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Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients – Results of a Survey of Level I and II Trauma Centers in Germany

RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren ◽

10.1055/a-1682-7377 ◽

2021 ◽

Author(s):

Antonio Ernstberger ◽

Stefan Ulrich Reske ◽

Alexandra Brandl ◽

Martin Kulla ◽

Stefan Huber-Wagner ◽

...

Keyword(s):

Personal Contact ◽

Severely Injured ◽

Trauma Centers ◽

Process Data ◽

Severely Injured Patients ◽

Trauma Room ◽

Process Characteristics ◽

Level Ii ◽

Level I ◽

Injured Patients

Purpose Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. Materials and Methods Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. Results With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). Conclusion Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. Key Points: Citation Format

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Initial Approach to the Management of Multisystem Trauma

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0062 ◽

2019 ◽

pp. 397-401

Author(s):

David S. Morris

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Hospital Admissions ◽

The United States ◽

Emergency Department Visits ◽

Severely Injured ◽

Level Ii ◽

Level I ◽

Nonfatal Injuries ◽

Injured Patients

Nearly 200,000 people die of injury-related causes in the United States each year, and injury is the leading cause of death for all patients aged 1 to 44 years. Approximately 30 million people sustain nonfatal injuries each year, which results in about 29 million emergency department visits and 3 million hospital admissions. Management of severely injured patients, typically defined as having an Injury Severity Score greater than 15 is best managed in a level I or level II trauma center. Any physician who provides care for critically ill patients should have a basic familiarity with the fundamentals of trauma care.

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Mortality Benefit of Transfer to Level I versus Level II Trauma Centers for Head-Injured Patients

Health Services Research ◽

10.1111/j.1475-6773.2005.0u367.x ◽

2005 ◽

Vol 40 (2) ◽

pp. 435-458 ◽

Cited By ~ 82

Author(s):

K. John McConnell ◽

Craig D. Newgard ◽

Richard J. Mullins ◽

Melanie Arthur ◽

Jerris R. Hedges

Keyword(s):

Trauma Centers ◽

Mortality Benefit ◽

Level Ii ◽

Head Injured ◽

Versus Level ◽

Level I ◽

Injured Patients

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Variations Between Level I Trauma Centers in 24-Hour Mortality in Severely Injured Patients Requiring a Massive Transfusion

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0b013e318227f307 ◽

2011 ◽

Vol 71 ◽

pp. S389-S393 ◽

Cited By ~ 10

Author(s):

Charles E. Wade ◽

Deborah J. del Junco ◽

John B. Holcomb

Keyword(s):

Massive Transfusion ◽

Severely Injured ◽

Trauma Centers ◽

Severely Injured Patients ◽

Level I ◽

Injured Patients

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A Contemporary Analysis of the Effect of Trauma Center Verification Level on Mortality in Severe Injury

The American Surgeon ◽

10.1177/00031348211023437 ◽

2021 ◽

pp. 000313482110234

Author(s):

David S. Plurad ◽

Glenn Geesman ◽

Nicholas W. Sheets ◽

Bhani Chawla-Kondal ◽

Napatakamon Ayutyanont ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Severely Injured ◽

Adult Age ◽

Program Participant ◽

Level Ii ◽

Level I ◽

Verification Process ◽

Injured Patients ◽

The Impact

Background Literature demonstrates increased mortality for the severely injured at a Level II vs. Level I center. Our objective is to reevaluate the impact of trauma center verification level on mortality for patients with an Injury Severity Score (ISS) > 15 utilizing more contemporary data. We hypothesize that there would be no mortality discrepancy. Study Design Utilizing the ACS Trauma Quality Program Participant Use File admission year 2017, we identified severely injured (ISS >15) adult (age >15 years) patients treated at an ACS-verified Level I or Level II center. We excluded patients who underwent interfacility transfer. Logistic regression was performed to determine adjusted associations with mortality. Results There were 63 518 patients included, where 43 680 (68.8%) were treated at a Level I center and 19 838 (31.2%) at a Level II. Male gender (70.1%) and blunt injuries (92.0%) predominated. Level I admissions had a higher mean ISS [23.8 (±8.5) vs. 22.9 (±7.8), <.001], while Level II patients were older [mean age (y) 52.3 (±21.6) vs. 48.6 (±21.0), <.001] with multiple comorbidities (37.7% vs. 34.9%, <.001). Adjusted mortality between Level I and II centers was similar (12.0% vs. 11.8%, .570). Conclusions Despite previous findings, mortality outcomes are similar for severely injured patients treated at a Level I vs. Level II center. We theorize that this relates to mandated Level II resourcing as defined by an updated American College of Surgeons verification process.

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Outcomes after Severe Head Injury: A National Trauma Data Bank-Based Comparison of Level I and Level II Trauma Centers

The American Surgeon ◽

10.1177/000313481107700313 ◽

2011 ◽

Vol 77 (3) ◽

pp. 277-280 ◽

Cited By ~ 5

Author(s):

Fuad Alkhoury ◽

John Courtney

Keyword(s):

Head Injury ◽

Complication Rate ◽

Data Bank ◽

Trauma Centers ◽

National Trauma ◽

Level Ii ◽

Head Injured ◽

National Trauma Data Bank ◽

Level I ◽

Injured Patients

Severely head-injured patients require significant resources across the continuum of care. The objective of this study is to analyze the impact of the level of trauma center designation on the outcome of the severely head-injured patient. The National Trauma Data Bank between 2001 and 2006 (NTDB 6.2) was queried for all patients with isolated traumatic head injury and Glasgow Coma Score (GCS) less than 9. Comparisons between Level I and Level II trauma centers were made reviewing hospital length of stay (LOS), intensive care unit LOS, ventilator days, major complication rate (pulmonary embolism, pneumonia, lower extremity deep vein thrombosis), mortality, and discharge status. Chi-square and Student t tests were used to determine statistical significance defined as P < 0.05. There were 31,736 patients from 258 facilities who met the inclusion criteria during the study period. Level I trauma centers had approximately twice as many patients admissions as Level II centers. However, the severity of injuries and patients’ characteristics identified by the emergency department GCS as well as the probability of survival score showed no difference between Level I and Level II centers. The comparisons between Level I and Level II trauma centers shows that Level II centers are not inferior to Level I in terms of outcomes and complication rate. Level II trauma centers encounter patients with isolated complex head injury less often but with outcomes and complication rates comparable to that of Level I centers. The transport of head-injured patients should not bypass Level II in favor of Level I.

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An Overview of Trauma Center Levels and Disparities in Rural Trauma Care

Reconstructive Review ◽

10.15438/rr.10.1.234 ◽

2020 ◽

Vol 10 ◽

Author(s):

Udit Dave ◽

Brandon Gosine ◽

Ashwin Palaniappan

Keyword(s):

United States ◽

Trauma Care ◽

Rural Areas ◽

The United States ◽

Trauma Centers ◽

Traumatic Injuries ◽

Level Ii ◽

Level I ◽

Injured Patients

Trauma centers in the United States focus on providing care to patients who have suffered injuries and may require critical care. These trauma centers are classified into five different levels: Level I to Level V. Level V trauma centers are the least comprehensive, providing minimal 24-hour care and resuscitation, and Level I trauma centers are the most comprehensive, accepting the most severely injured patients and always delivering care through the use of an attending surgeon. However, there is a major inequity in access to trauma centers across the United States, especially amongst rural residents. Level III to Level V trauma centers tend to be dominantly situated in rural and underserved areas. Furthermore, trauma centers tend to be widely dispersed with respect to rural areas. Therefore, these areas tend to have a greater mortality rate in relation to traumatic injuries. Improvements in access to high-tier traumatic care must occur in order to reduce mortality due to traumatic injuries in underserved rural areas. Possible improvements to rural trauma care include bolstering the quality of care in Level III trauma centers, increasing Level II center efficiency through the involvement of orthopedic traumatologists, placing medical helicopter bases in more strategic locations that enable transport teams to reach other trauma centers faster, building more Level I and Level II trauma centers, and converting Level III centers into either Level I or Level II centers.

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The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01615-1 ◽

2021 ◽

Author(s):

Suzan Dijkink ◽

Erik W. van Zwet ◽

Pieta Krijnen ◽

Luke P. H. Leenen ◽

Frank W. Bloemers ◽

...

Keyword(s):

The Netherlands ◽

Trauma Care ◽

Trauma System ◽

Future Research ◽

Severely Injured ◽

Trauma Centers ◽

Severely Injured Patients ◽

The Right ◽

Injured Patients ◽

The Impact

Abstract Background Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. Methods All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. Results The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. Conclusion Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

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