03-Analysis of 983 civilian blast and ballistic casualties and the generation of a template of injury burden- An observational study

Articles<img src="/media/202408//1724856284.308201.png" />Analysis of 983 civilian blast and ballistic casualtiesand the generation of a template of injury burden: An observational studyLaura Maitland,<a href="#bookmark1">a*</a> Lawrence Middleton,<a href="#bookmark1">b</a> <a href="#bookmark1">Harald Veen,c</a> David J. Harrison,<a href="#bookmark1">a,#</a> James Baden,<a href="#bookmark1">d</a> and Shehan Hettiaratchy <a href="#bookmark1">e</a>a School of Medicine, University of St Andrews, North Haugh, St Andrews KY16 9TF, UK bIndependent ResearchercConsultant, Netherlands Red Cross, Anna Van Saksenlaan 50, HT Den HAAG 2593, Netherlandsd University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2GW, UK e Major Trauma Centre, St Mary’s Hospital, Imperial College Healthcare Trust, London W2 1NY, UKSummaryBackground Terrorism and armed conﬂict cause blast and ballistic casualties that are unusual in civilian practice. The immediate surgical response to mass casualty events, with civilians injured by these mechanisms, has not been systematically characterised. Standardising an approach to reacting to these events is challenging but is essential to optimise preparation for them. We aimed to quantify and assesses the surgical response to blast and ballistic injuries managed in a world-class trauma unit paradigm.Methods This was an observational study conducted at the UK-led military Medical Treatment Facility, Camp Bas- tion, Afghanistan from original theatre log-book entries between Nov 5, 2009, and Sept 21, 2014; a total of 10,891 consecutive surgical cases prospectively gathered by surgical teams were catalogued. Patients with combatant sta- tus/wearing body-armour to various degrees including interpreters were excluded from the study. Civilian casualties that underwent primary trauma surgery for blast and ballistic injuries were included (n=983). Surgical activity was analysed as a rate per 100 casualties, and patients were grouped according to adult vs. paediatric and ballistic vs. blast injury mechanisms to aid comparison.Findings The three most common surgical procedures for civilian blast injuries were debridement, amputation, and laparotomy. For civilian ballistic injuries, these were debridement, laparotomy and vascular procedures. Blast inju- ries generated more amputations in both adults and children compared to ballistic injuries. Blast injuries generated more removal of fragmentation material compared to ballistics injuries amongst adult casualties. Ballistic injuries lead to more chest drain insertions in adults. As a rate per 100 casualties, adults injured by blast underwent signiﬁ- cantly more debridement (63.5); temporary skeletal stabilisation (13.2) and vascular procedures (12.8) compared to children (43.4, z=4.026, p=0.00007; 5.7, z=2.230, p=0.022; 4.9, z=2.468, p=0.014). Adults injured by ballistics underwent signiﬁcantly more debridement (63.4); chest drain (12.3) and temporary skeletal ﬁxation procedures (11.4) compared to children (50.0, z=2.058, p=0.040, p&lt;0.05; 2.9, z=2.283, p=0.0230; 2.9, z=2.131, p=0.034 respec- tively). By comparison, children injured by ballistics underwent signiﬁcantly more removal of fragmentation and bal- listic materials (20.6) when compared to adults (7.7, z=-3.234; p=0.001).Interpretation This is the ﬁrst evidence-based, template of the immediate response required to manage civilians injured by blast and ballistic mechanisms. The template presented can be applied to similar conﬂict zones and to prepare for terror attacks on urban populations.Funding The work was supported in part by a grant to LM from School of Medicine, University of St Andrews.Copyright ® 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (<a href="http://creativecommons.org/licenses/by-nc-nd/4.0/">http://creativecommons.org/licenses/by-nc-nd/4.0/</a>)<img src="/media/202408//1724856285.2582989.jpeg" />Keywords: Civilian; Blast; Ballistic; Trauma; Surgery; Explosion; Treatment; War; Terror attacks; Template; Injury<img src="/media/202408//1724856285.262688.png" /><img src="/media/202408//1724856285.270754.png" /><a href="http://crossmark.crossref.org/dialog/?doi=10.1016/j.eclinm.2022.101676&amp;domain=pdf">check for updates</a><img src="/media/202408//1724856285.274465.png" />eClinicalMedicine2022;54: 101676Published online 29 September 2022<a href="https://doi.org/10.1016/j.eclinm.2022.101676">https://doi.org/10.1016/j.</a> <a href="https://doi.org/10.1016/j.eclinm.2022.101676">eclinm.2022.101676</a>*Corresponding author.E-mail address: <a href="mailto:l.maitland@nhs.net">l.maitland@nhs.net</a> (L. Maitland). # Senior authorwww.thelancet.com Vol 54 December, 2022 1Articles<img src="/media/202408//1724856285.288644.png" /><table><tr><td>Research in contextEvidence before this studyA comprehensive review of the available literature was performed (scope search) to identify similar studies, and any additional surgical databases relevant to this study. The following search terms were used: “surgery OR sur- gical OR surgical training” AND “procedure OR proce- dures OR skill set OR intervention OR interventions” AND “Afghanistan” AND “role 3” AND “ paediatric OR civilian” . The database MEDLINE was continuously searched from Jan 1996 up until July 9, 2022 using the Ovid interface. This was combined with a thorough search, using direct terminology of PubMed and The Cochrane Database of Systematic Reviews.Added value of this studyThis paper represents the ﬁrst quantiﬁcation of the immediate surgical response to civilians injured by blast and ballistic weapons and the surgical ramiﬁcations of these on surgical interventions. The database created for the purposes of this study represents the largest complete consecutive dataset of surgical interventions from any contemporary conﬂict. Through analysis, a way of anticipating the number of surgical procedures (e.g. amputations, laparotomies etc.) necessary to be performed in future mass casualty blast/ballistic events, per 100 casualties is described.Implications of all the available evidenceThis paper presents the best available evidence-based template of injury burden and the surgical response required to attend these types of mass casualty events (MCE). In this way, these data can be used to better understand the immediate surgical response, to allocate resources, theatres and staff in major trauma events. These stratiﬁed frequency tables enable Emergency Pre- paredness, Resilience and Response (EPRR) planning for future acts of terror, industrial events and comparable conﬂicts using these wounding mechanisms.</td></tr></table>IntroductionThe rise in terror attacks directed at civilians has pre- sented a unique challenge for healthcare professionals globally.<a href="#bookmark1">1</a> The future of armed conﬂicts is likely to be typiﬁed by prolonged evacuation chains, fewer sur- geons, more austere environments and exaggerated timelines for casualty evacuation as we see in the Ukraine.<a href="#bookmark1">2</a> Civilian trauma surgeons do not see blast injuries routinely and may have limited experience with ballistic injuries.<a href="#bookmark1">3−7</a> Though blast and ballistic injuries are uncommon in times of peace, they are common in warzones, including the use of cluster bombs in the Ukraine.<a href="#bookmark1">8</a> Urban hospitals experience new kinds of injuries in war since blast injuries are typiﬁed by the polytrauma nature of injury, affecting multiple bodyregions with devastating effect, especially mangled extremities, whilst ballistic injuries produce cavities in tissue depending on the velocity and rate of energy they enter the tissue from the projectile source.<a href="#bookmark1">9</a>,<a href="#bookmark1">10</a>The ballistic and blast wounds experienced in war are very different to traditional Gun Shot Wounds (GSW). The wounds are caused by projectiles and frag- ments from exploding munitions which send energized fragments into bodies causing catastrophic damage. Porta et al., (2013) report that 30% of US surgeons deployed to Iraq and Afghanistan performed procedures they hadn’tdone before. It is clear that there is a paucity of data to help address this important issue.<a href="#bookmark1">9,11</a> In accor- dance with Geneva conventions, civilian casualties were brought to Camp Bastion, Afghanistan. This non-body- armour wearing cohort included casualties with poten- tial co-morbid conditions and presented a unique chal- lenge to the surgeon and are generalisable to civilians injured by these mechanisms across the world. The immediate surgery carried out on the local population affected by conﬂict and its impact on the surgical provi- sion has not yet been fully analysed. This study we hope provides potential surgeons with a heads-up list of the multiple surgical skills that a single surgeon or surgical team should possess when faced with a single blast or ballistic casualty in the context of a similar war zone or act of terror.Unfortunately, due to the stochastic nature of ter- ror attacks and limitations within conﬂicts, collecting coherent datasets has been challenging. In addition, translating ﬁndings from a resource limited warzone to resource rich peace-time healthcare systems can be difﬁcult.The dataset described here is the largest record of primary surgical interventions carried out on civilian casualties injured from blast and ballistics during an armed conﬂict, in a paradigm of effectively a peace-time major trauma centre setting. The surgery carried out on civilians affected by conﬂict and how this need may con- tribute to,or change, the surgical skills required has not been fully analysed.<a href="#bookmark1">2,6</a>,<a href="#bookmark1">12</a> Previous attempts have been made, however these primarily focus on the description of injury patterns, as opposed to the surgical ramiﬁca- tions of these on surgical interventions.There is a paucity in comparable studies available since few available datasets include the latter half of the conﬂict in Afghanistan, as studied in this cohort. Previ- ous attempts have been made to outline the surgical impact of civilian casualties on surgical provision. Such studies, however, primarily focus on the description of injury patterns, mechanisms of injury, and numbers of casualties. Ramasamy et al., (2010) classiﬁed the surgi- cal procedures carried out in a two-year period (n=1668) by surgical speciality, and Schwab (2015) commented that it matched the American experience.<a href="#bookmark1">2,5</a>,<a href="#bookmark1">6</a> However, surgery on civilians was not delineated from combatants in describing suggested surgical skills sets and since2 www.thelancet.com Vol 54 December, 2022Articles<img src="/media/202408//1724856285.333219.png" />analysis and data was centred around admissions, it was Emergency Medicine focused as well as limited by the number of data-points and narrow time periods ana- lysed. Secondary take-back operations were not excluded from other studies (Jacobset al 2012 n=299; Mckechnie et al 2014, n=766).<a href="#bookmark1">5,12</a> In addition, such studies described the civilian experience but also included non- combat related surgeries e.g. RTA and follow-up proce- dures. They are therefore limited in their scope and abil- ity to characterise the surgical interventions performed, or the continuum of care required for future conﬂicts, or terror attacks caused by blast/ballistic mechanisms.Since the present study focuses only on primary emergent trauma surgery, we present the ﬁrst evidence- based surgical requirement for civilians injured by blast and ballistics. When we combine this with failings in the organisation of trauma care in England which are well described in the NCEPOD 2007 report “Trauma, who cares? we feel this study provides a tool to ensure both training and EPRR planning are informed as well as possible.<a href="#bookmark1">13</a>The scenario in Afghanistan represented a unique situation where a state-of-the-art trauma hospital was deployed to an active warzone. During the conﬂict, some blast and ballistics civilian casualties were man- aged from the point of wounding to discharge by coali- tion forces in a state-of-the-art healthcare paradigm. This unique situation has allowed analysis of injury pat- terns, surgical skillsets required, types of surgery, num- bers of operations and outcomes to be collected. Casualty nationality data were used as a proxy to exam- ine the surgical activity for a population not wearing protective body armour (civilians). Compared to other civilian nations, those in our cohort may have had worse pre-morbid status perhaps given the limitations and accessibility of primary care within Afghanistan at the time of the conﬂict. However, this would not inﬂuence the injuries and or surgical provision sustained which is the focus of the present study. Our ﬁndings are there- fore translatable to the civilian context of future conﬂicts and Mass Casualty Events (MCE) globally. As blast inju- ries increasingly occur in peacetime, the surgical tem- plate proposed ﬁrst here is no-longer conﬁned to the military or armed conﬂicts. Through analysis, the most effective surgical response for situations where high numbers of blast and ballistic casualties occur can be better determined.MethodsDatabaseThe database consists of the entirety of surgical cases ofcasualties treated in the UK-led ﬁeld surgical hospital in Afghanistan between November 5, 2009, and the end of formal operations in Afghanistan, September 21, 2014. The database contains data on 10,891 individual surgical cases and 20,266 surgical procedures recordedin electronic format for analysis. Bias was avoided by searching sequentially as follows: 10891 cases, 8388 of which recorded demographics and 2676 were civilian casualties, therefore 2503 surgical cases are missing from the analysis and these would have been made up of civilians and combatants, who can be considered to be missing at random.The present study focused speciﬁcally on the data from 983 individual civilian patients that underwent primary blast/ballistic trauma surgery. Given the mini- mal degree of missing data, a complete case population was used within each analysis.Ethics and Review Board Statement: The Defence Medical Services (DMS) approves this research under the auspices of the Academic Department of Military Surgery and Trauma (ADMST) (MOD Research and Ethics Committee (MODREC) communication dated April 27 2017). Informed consent was waived given the retrospective and anonymised nature of the database.Study design, patient identiﬁcation and mechanism ofinjuryIndividual surgical cases were categorised and analysed by casualty, nationality and mechanism of injury. Cases were selected for analysis based on mechanism of injury [blast and Gun Shot Wound (GSW)]; operation type (immediate vs. secondary), and demographics (civilian casualties, and paediatric casualties age &lt;16 year). Blast or explosions included Improvised Explosive Devices (IED), mortar, and grenade. All other injury mecha- nisms and conditions were excluded. Secondary cases (i.e., surgery consequent to the immediate surgery) were also excluded from analysis. Bias was further addressed as we felt it appropriate to exclude combat- ants and interpreters as they wore varying degrees of body armour, which impacted on injury patterns, surgi- cal need, and case fatality rates (manuscript in prepara- tion).<a href="#bookmark1">14</a> Whilst it would deﬁnitely assist planners to provide the same template for the combatant (body- armour-wearing) cohort of our dataset − we felt that including this analysis (manuscript in preparation) would detract from the focus of the present work which focuses on the humanitarian surgical provision, since civilians are predominantly the ﬁrst casualties of con- ﬂicts or terror related attacks, as an example, 2/3 of Ukrainian civilians remain in Ukraine.Statistical analysisThe study size was determined by the number of eligi- ble patients included in the database. First we character- ised the wounding patterns by analysing body regions operated on. We then itemised the most common surgi- cal procedures performed depending on the wounding mechanism to develop a template for anticipatingthe surgical response and lastly carried out comparative sta- tistical analysis to deﬁne the differences between surgi- cal interventions caused by different mechanisms ofwww.thelancet.com Vol 54 December, 2022 3Articles<img src="/media/202408//1724856285.3790662.png" /><img src="/media/202408//1724856285.511534.png" /><table><tr><td>83%79%</td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr></table>pae diat ric 19% <img src="/media/202408//1724856285.6222148.jpeg" /> Ballistic 40%<img src="/media/202408//1724856285.6955898.png" />50% 40% 30% 20%% population:Adults81%<img src="/media/202408//1724856285.743145.png" />80% 70%<img src="/media/202408//1724856285.780659.png" /><img src="/media/202408//1724856285.787035.png" />21%<img src="/media/202408//1724856285.7944021.png" />17%<img src="/media/202408//1724856285.8108642.png" />Figure 1. Patient groupings by Injury.Proportion of total casualties (n=983) per mechanism of wounding. Of immediate surgery on civilian casualties, Blast and Ballis- tics accounted for 60% and 40% of wounding respectively [BLAST n=590; GSW n=393]. As a percentage of population, Adults accounted for 81% and Paediatric 19% of casualties [Adults: BLAST n=468; GSW 325; Paediatric: BLAST n=122; GSW n=68].injury and performed on adults compared to paediatric casualties. All the data were entered into the Excel spreadsheet and analysed to determine the signiﬁcance of various parameters. Statistical signiﬁcance was expressed as a two-sided p value of &lt;0.05, calculated using the two proportion z-test. Based on guidance pro- vided in Newcombe 1998 we estimate conﬁdence inter- vals for the difference in proportions using a method based on Wilson’s score (method 10 of [Newcombe 1998]). Reported conﬁdence intervals relate to the dif- ference in two proportions. Intervals that include 0 are deemed non-signiﬁcantat the 95% level.<a href="#bookmark1">15</a>Role of the funding sourceThe funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all of the data in the study, compiled the data- base for analysis, and had ﬁnal responsibility for the decision to submit for publication.ResultsPatient characteristicsBetween November 5, 2009, and the end of formal Brit- ish operations in Helmand province, September 21, 2014, we screened 10891 cases. The study included 983 civilian blast and ballistic casualties that received imme- diate surgery for their injuries (983/8388, 12%). For blast injuries, 468 were adult (79%) and 122 were paedi- atric (21%) (see <a href="#bookmark1">Figure 1</a>). For ballistic injuries, 325 were adult (83%) and 68 were paediatric (17%) (see <a href="#bookmark1">Figure 1</a>). As a percentage by population 81% were adults (n=793) and 19% were paediatric (n=190) (<a href="#bookmark1">Figure 1</a>) and as a per- centage by mechanism 60% were blast (n=590) and 40% were ballistic (n=393) (<a href="#bookmark1">Figure 1</a>). None of thetrauma casualties were female; just 12 female civilian casualties were recorded in our dataset (n=10,891),all of which were not trauma related, but rather emergency surgeries such as appendectomy or caesarean section. (8 adult, 4 paediatric).Wounding characteristicsWe show injury patterns for blast, ballistic trauma and the differences between childs and adult casualties in <a href="#bookmark1">Tables 1a</a> −<a href="#bookmark1">4a</a>.Adult blast casualties suffered signiﬁcantly more head (26.5%), abdomen (43.6%) and upper (42.9%) and lower extremity (51.1%) trauma compared to adult ballistic casualties (<a href="#bookmark1">Table 1a</a> Body Map: 8.0%, z=6.542, p=0.0000; 31.7%, z=3.383; p=0.0008; 28.9%, z=4.012, p=0.00007 and 40.0%, z=3.082, p=0.002). Civilian adults wounded by ballistics suffered signiﬁcantly more chest trauma compared to blast (28.0%) (<a href="#bookmark1">Table 1a</a> Body map: 18.2%, z=-3.265; p=0.002).Paediatric casualties injured by blast suffered signiﬁ- cantly more upper (33.6%) and lower (54.1%) extremity trauma when compared to ballistic wounding (<a href="#bookmark1">Table 2a</a> Body map: 11.8%, z=3.292, p=0.001; 38.2%, z=2.202, p=0.038).Paediatric blast casualties suffered signiﬁcantly more head (36.9%) trauma compared to adults <a href="#bookmark1">Table 3a</a> Body map: 26.5%,z-2.263; p=0.024).We compared the wounding patterns between adult and paediatric casualties wounded by ballistics and found that adults suffered signiﬁcantly more upper extremity trauma (28.9%) but children suf- fered more head (29.4%) and abdominal trauma (60.3%) (<a href="#bookmark1">Table 4a</a> Body map: 11.8%, z=2.926, p=0.004; 8%, z=-4.992; p=0.0000; 31.7%, z=-4.451, p=0.00001).4 www.thelancet.com Vol 54 December, 2022Articles<img src="/media/202408//1724856285.846296.png" /><img src="/media/202408//1724856285.854768.png" /><table><tr><td>Regions affected</td><td>commonly Percentage body regionsinjured by blast % n=468</td><td>Percentage body regions injured by ballistics n=325</td><td>CI of difference in proportions</td><td>z-value and p-value</td></tr><tr><td colspan="3">Head 26.5 8.0</td><td>0.01−0.06</td><td>z=6.542; p=0.0000 p&lt;0.001</td></tr><tr><td colspan="3">Neck 3.8 6.2</td><td>-0.03−0.01</td><td>z=-1.557p=0.120; p&gt;0.05</td></tr><tr><td colspan="3">Chest 18.2 28.0</td><td>-0.09−0.01</td><td>z=-3.265; p=0.002 p&lt;0.01</td></tr><tr><td colspan="3">Abdomen 43.6 31.7</td><td>-0.05−0.04</td><td>z=3.383; p=0.0008 p&lt;0.001</td></tr><tr><td colspan="3">Perineum 3.6 1.8</td><td>-0.01−0.02</td><td>z=1.495; p=0.136 p&gt;0.05</td></tr><tr><td colspan="3">Junctional 7.9 4.6</td><td>-0.02−0.02</td><td>z=1.848; p=0.065 p&gt;0.05</td></tr><tr><td colspan="3">Lower extremity 51.1 40.0</td><td>-0.06−0.03</td><td>z= 3.082; p=0.002 p&lt;0.05</td></tr><tr><td colspan="3" rowspan="2">Upper extremity 42.9 28.9Table 1a: Body map Blast and Ballistic Adult Wounding Patterns.Adult wounding patterns for adults injured by blast and ballistic weapons (n=793).</td><td>-0.04−0.04</td><td rowspan="2">z=4.012; 0.00007 p&lt;0.001</td></tr><tr><td></td></tr></table><table><tr><td>BLAST n=468Rate per 100blast casualties</td><td>GSW n=325Rate per 100GSW casualties</td><td>CI in</td><td>of difference proportions</td><td>z-value and p-value</td></tr><tr><td colspan="5"><table><tr><td>Debridement</td><td>63.5</td><td>63.4</td><td>-0.11−0.01</td><td>z=0.029; p=0.977 p&gt;0.05</td></tr><tr><td>Amputation</td><td>28.2</td><td>4.6</td><td>0.02−0.07</td><td>z=8.407; p=0.0000 p&lt;0.001</td></tr><tr><td>Laparotomy</td><td>22.2</td><td>24.0</td><td>-0.07−0.01</td><td>z=-0.593; p=0.554 p&gt;0.05</td></tr><tr><td>Removal of fragmentation or ballistic materials</td><td>17.6</td><td>7.7</td><td>-0.01−0.04</td><td>z=4.007; p=0.00007 p&lt;0.001</td></tr><tr><td>Temporary skeletal stabilisation</td><td>13.2</td><td>11.4</td><td>-0.04−0.02</td><td>z=0.755; p=0.451 p&gt;0.05</td></tr><tr><td>Vascular procedures</td><td>12.8</td><td>11.7</td><td>-0.04−0.02</td><td>z=0.463; p=0.643 p&gt;0.05</td></tr><tr><td>Chest drain</td><td>7.7</td><td>12.3</td><td>-0.05−0.00</td><td>z=-2.164; p=0.030 p&lt;0.05</td></tr><tr><td>Fasciotomy</td><td>6.0</td><td>6.5</td><td>-0.03−0.01</td><td>z=-0.287; p=0.774 p&gt;0.05</td></tr><tr><td>Thoracotomy</td><td>2.4</td><td>3.9</td><td>-0.03−0.04</td><td>z=-1.215; p=0.225 p&gt;0.05</td></tr><tr><td>Flaps/skin graft/reconstruction</td><td>1.3</td><td>0.8</td><td>-0.01−0.04</td><td>z=0.665; p=0.506 p&gt;0.05</td></tr><tr><td>Burns</td><td>0.9</td><td>0.0</td><td>-0.01−0.04</td><td>z=1.715; p=0.087 p&gt;0.05</td></tr><tr><td>Sternotomy</td><td>0.9</td><td>1.2</td><td>-0.02−0.03</td><td>z=-0.413; p=0.680 p&gt;0.05</td></tr><tr><td>Airway procedures</td><td>0.2</td><td>0.3</td><td>-0.02−0.03</td><td>z=-0.282; p=0.778 p&gt;0.05</td></tr></table></td></tr><tr><td colspan="5">Table 1b: Standardised surgical response to adult trauma casualties.Rate of surgical procedures per 100 adult blast and ballistic injured casualties. Adult blast and ballistic jcasualties n=793 (<a href="#bookmark1">Figure 1</a>).</td></tr></table><img src="/media/202408//1724856285.886851.png" /><table><tr><td rowspan="2">Regions commonly affectedHead</td><td>Percentage body regions injured by blast n=122</td><td>Percentage body regions injured by ballistics n=68</td><td>CI difference in proportions</td><td>z-value and p-value</td></tr><tr><td colspan="3">36.9 29.4 -0.32−0.00</td><td>z=1.045, p=0.298 p&gt;0.05</td></tr><tr><td>Neck</td><td colspan="3">2.5 1.5 -0.08−0.05</td><td>z=0.456, p=0.649 p&gt;0.05</td></tr><tr><td>Chest</td><td colspan="3">23.8 19.1 -0.26−0.03</td><td>z=0.748, p=0.456 p&gt;0.05</td></tr><tr><td>Abdomen</td><td colspan="3">52.5 60.3 -0.63−0.33</td><td>z=-1.037, p=0.302 p&gt;0.05</td></tr><tr><td>Perineum</td><td colspan="3">4.1 2.9 -0.10−0.05</td><td>z=0.422, p=0.674 p&gt;0.05</td></tr><tr><td>Junctional</td><td colspan="3">9.0 4.4 -0.1−0.09</td><td>z=1.165, p=0.247 p&gt;0.05</td></tr><tr><td>Lower extremity</td><td colspan="3">54.1 38.2 -0.32−0.02</td><td>z=2.102, p=0.038 p&lt;0.05</td></tr><tr><td rowspan="2">Upper extremityTable 2a: Body Map Blast</td><td colspan="3">33.6 11.8 -0.05−0.23</td><td rowspan="2">z=3.292, p=0.001 p&lt;0.01</td></tr><tr><td colspan="3">and Ballistic Paediatric Wounding Patterns.</td></tr><tr><td>Body MapTable 2: Paediatric</td><td colspan="3">wounding patterns for children injured by blast and ballistic weapons (n=190).</td><td></td></tr></table>Surgical characteristicsThe ﬁve surgeries most frequently performed on adult blast casualties were: debridement, amputation, laparot- omy, removal of fragmentation or ballistic materials,and temporary skeletal stabilization (<a href="#bookmark1">Figure 2</a>) and for ballistics: debridement, laparotomy, chest drain inser- tion, vascular procedures, and temporary skeletal stabili- sation (<a href="#bookmark1">Figure 2</a>).www.thelancet.com Vol 54 December, 2022 5Articles<img src="/media/202408//1724856285.9163818.png" /><table><tr><td>BLAST n=122Rate per 100blast casualties</td><td>GSW n=68Rate per 100GSW casualties</td><td>CI in</td><td>difference proportions</td><td>z-value and p-value</td></tr><tr><td colspan="5"><table><tr><td>Debridement</td><td>43.4</td><td>50.0</td><td>-0.58−0.26</td><td>z=-0.875; p=0.383 p&gt;0.05</td></tr><tr><td>Amputation</td><td>27.9</td><td>1.5</td><td>0.11−0.31</td><td>z=4.497; p=0.00002 p&lt;0.001</td></tr><tr><td>Laparotomy</td><td>26.2</td><td>35.3</td><td>-0.50−0.18</td><td>z=-1.319; p=0.189 p&gt;0.05</td></tr><tr><td>Removal of fragmentation or ballistic materials</td><td>16.4</td><td>20.6</td><td>-0.34−0.06</td><td>z=-0.724; p=0.471 p&gt;0.05</td></tr><tr><td>Chest drain</td><td>8.2</td><td>2.9</td><td>-0.07−0.10</td><td>z=1.441 p=0.152 p&gt;0.05</td></tr><tr><td>Temporary skeletal stabilisation</td><td>5.7</td><td>2.9</td><td>-0.09−0.07</td><td>z=0.874; p=0.383 p&gt;0.05</td></tr><tr><td>Vascular procedures</td><td>4.9</td><td>10.3</td><td>-0.25−0.3</td><td>z=-1.414; p=0.160 p&gt;0.05</td></tr><tr><td>Thoracotomy</td><td>3.3</td><td>4.4</td><td>-0.14−0.2</td><td>z=0.385; p=0.700 p&gt;0.05</td></tr><tr><td>Fasciotomy</td><td>2.5</td><td>2.9</td><td>-0.11−0.03</td><td>z=-0.024; p=0.869 p&gt;0.05</td></tr><tr><td>Sternotomy</td><td>1.6</td><td>1.5</td><td>-0.09−0.04</td><td>z=0.053; p=0.958 p&gt;0.05</td></tr><tr><td>Burns</td><td>0.8</td><td>0</td><td></td><td><a href="#bookmark1">a</a></td></tr><tr><td>Flaps/skin graft/reconstruction</td><td>0.8</td><td>0</td><td></td><td><a href="#bookmark1">a</a></td></tr><tr><td>Airway procedures</td><td>0</td><td>0</td><td></td><td>NA</td></tr></table></td></tr><tr><td colspan="5">Table 2b: Standardised surgical response to paediatric trauma casualties.Rate of surgical procedures per 100 paediatric blast and ballistic injured casualties. Paediatric blast and ballistic casualties n=190. a proportions too small for analysis.</td></tr></table><img src="/media/202408//1724856285.939195.png" /><table><tr><td>Regions commonly affected Percentage body regions injured by blast % n=468Head 26.5</td><td>Percentage body regions injured by blast n=12236.9</td><td>CI differencein proportions-0.30−0.18</td><td>z-value and p-valuez-2.263; p=0.024 p&lt;0.05</td></tr><tr><td colspan="3">Neck 3.8 2.5 -0.06−0.01</td><td>z=0.693, p=0.488 p&gt;0.05</td></tr><tr><td colspan="3">Chest 18.2 23.8 -0.25−0.10</td><td>z=-1.394, p=0.164 p&gt;0.05</td></tr><tr><td colspan="3">Abdomen 43.6 52.5 -0.46−0.27</td><td>z=-1.758, p=0.080 p&gt;0.05</td></tr><tr><td colspan="3">Perineum 3.6 4.1 -0.08−0.01</td><td>z=-0.260, p=0.795 p&gt;0.05</td></tr><tr><td colspan="3">Junctional 7.9 9.0 -0.13−0.02</td><td>z=-0.396,p=0.692 p&gt;0.05</td></tr><tr><td colspan="3">Lower extremity 51.1 54.1 -0.46−0.26</td><td>z=-0.591, p=0.555 p&gt;0.05</td></tr><tr><td colspan="3">Upper extremity 42.9 33.6 -0.29−0.12Table 3a: Body Map Adult vs. Paediatric Blast Wounding Patterns.Body MapTable 3: Wounding patterns for adults compared topaediatric casualties injured by blast (n=590).</td><td>z=1.860, p=0.063 p&gt;0.05</td></tr></table><table><tr><td>BLAST n=468Rate per 100 blast casualties</td><td>BLAST n=122Rate per 100blast casualties</td><td>CI difference in proportions</td><td>z-value and p-value</td></tr><tr><td colspan="4"><table><tr><td>Debridement</td><td>63.5</td><td>43.4</td><td>-0.34−0.15</td><td>4.026; p=0.00007 p&lt;0.001</td></tr><tr><td>Amputation</td><td>28.2</td><td>27.9</td><td>-0.27−0.11</td><td>0.046; p=0.948 p&gt;0.05</td></tr><tr><td>Laparotomy</td><td>22.2</td><td>26.2</td><td>-0.27−0.11</td><td>-0.0935; p=0.350 p&gt;0.05</td></tr><tr><td>Removal of fragmentation or ballistic materials</td><td>17.6</td><td>16.4</td><td>-0.18−0.05</td><td>0.312; p=0.755 p&gt;0.05</td></tr><tr><td>Temporary skeletal stabilisation</td><td>13.2</td><td>5.7</td><td>-0.08−0.01</td><td>2.230; p=0.022 p&lt;0.05</td></tr><tr><td>Vascular procedures</td><td>12.8</td><td>4.9</td><td>-0.07−0.02</td><td>2.468; p=0.014 p&lt;0.05</td></tr><tr><td>Chest drain</td><td>7.7</td><td>8.2</td><td>-0.12−0.02</td><td>-0.183; p=0.855 p&gt;0.05</td></tr><tr><td>Fasciotomy</td><td>6.0</td><td>2.5</td><td>-0.06 -0.01</td><td>1.540; p=0.124 p&gt;0.05</td></tr><tr><td>Thoracotomy</td><td>2.4</td><td>3.3</td><td>-0.07−0.00</td><td>-0.558; p=0.577 p&gt;0.05</td></tr><tr><td>Flaps/skin graft/reconstruction</td><td>1.3</td><td>0.8</td><td>-0.04−0.01</td><td>0.452; p=0.651 p&gt;0.05</td></tr><tr><td>Burns</td><td>0.9</td><td>0.8</td><td><a href="#bookmark1">a</a></td><td><a href="#bookmark1">a</a></td></tr><tr><td>Sternotomy</td><td>0.9</td><td>1.6</td><td><a href="#bookmark1">a</a></td><td><a href="#bookmark1">a</a></td></tr><tr><td>Airway procedures</td><td>0.2</td><td>0</td><td><a href="#bookmark1">a</a></td><td><a href="#bookmark1">a</a></td></tr></table>Table 3b: Standardised Surgical response to adult vs paediatric blast casualties.Rate of surgical procedures per 100 adult blast casualties compared to paediatric blast casualties. Civilians underwent primary emergent trauma surgery for blast (n=590) (<a href="#bookmark1">Figure 2</a>; <a href="#bookmark1">Figure 3</a>).a Proportions are not signiﬁcantly different.</td></tr></table>6 www.thelancet.com Vol 54 December, 2022Articles<img src="/media/202408//1724856285.968819.png" /><table><tr><td>Regions commonly affected Percentage body regions injured by ballistics n=325</td><td>Percentage body regions injured by ballistics n=68</td><td>CI difference in proportions</td><td>z-value and p-value</td></tr><tr><td colspan="2">Head 8.0 29.4</td><td>-0.59−0.33</td><td>z=-4.992; p=0.000; p&lt;0.001</td></tr><tr><td colspan="2">Neck 6.2 1.5</td><td>-0.08−0.02</td><td>z=1.561, p=0.119; p&gt;0.05</td></tr><tr><td colspan="2">Chest 28.0 19.1</td><td>-0.36−0.11</td><td>z=1.513, p=0.131; p&gt;0.05</td></tr><tr><td colspan="2">Abdomen 31.7 60.3</td><td>-0.96−0.75</td><td>z=-4.451, p=0.00001; p&lt;0.001</td></tr><tr><td colspan="2">Perineum 1.8 2.9</td><td>-0.13−0.01</td><td>z=-0.591; p=0.555, p&gt;0.05</td></tr><tr><td colspan="2">Junctional 4.6 4.4</td><td>-0.15−0.01</td><td>z=0.072; p=0.943, p&gt;0.05</td></tr><tr><td colspan="2">Lower extremity 40.0 38.2</td><td>-0.63−0.36</td><td>z=0.276; p=0.783, p&gt;0.05</td></tr><tr><td colspan="2" rowspan="2">Upper extremity 28.9 11.8Table 4a: Body Map Adult vs. Paediatric Ballistic Wounding Patterns.Body Map: Wounding patterns for adults compared topaediatric casualties injured by ballistics (n=393)</td><td>-0.23−0.01</td><td rowspan="2">z=2.926, p=0.004; p&lt;0.01</td></tr><tr><td>.</td></tr></table><table><tr><td><table><tr><td>GSW n=325</td><td>GSW n=68</td><td></td><td></td><td></td></tr><tr><td>Rate per 100 adult GSW casualties</td><td>Rate per 100 paediatric GSW casualties</td><td>CI difference in proportion</td><td>z-value and</td><td>p-value</td></tr></table><table><tr><td>Debridement</td><td>63.4</td><td>50.0</td><td>-0.73−0.47</td><td>z=2.058; p=0.040 p&lt;0.05</td></tr><tr><td>Laparotomy</td><td>24.0</td><td>35.3</td><td>-0.63−0.37</td><td>z=-1.971; p=0.054</td></tr><tr><td>Chest drain</td><td>12.3</td><td>2.9</td><td>-0.10−0.03</td><td>z=2.283; p=0.0230 p&lt;0.05</td></tr><tr><td>Vascular procedures</td><td>11.7</td><td>10.3</td><td>-0.25−0.05</td><td>z=0.330; p=0.741</td></tr><tr><td>Temporary skeletal stabilisation</td><td>11.4</td><td>2.9</td><td>-0.10−0.03</td><td>z=2.131; p=0.034 p&lt;0.05</td></tr><tr><td>Removal of fragmentation or ballistic materials</td><td>7.7</td><td>20.6</td><td>-0.45−0.20</td><td>z=-3.234; p=0.001 p&lt;0.01</td></tr><tr><td>Fasciotomy</td><td>6.5</td><td>2.9</td><td>-0.11−0.01</td><td>z=1.148; p=0.252</td></tr><tr><td>Amputation</td><td>4.6</td><td>1.5</td><td>-0.09 -0.02</td><td>z=1.177; p=0.240</td></tr><tr><td>Thoracotomy</td><td>3.9</td><td>4.4</td><td>-0.16−0.01</td><td>z=-0.192; p=0.848</td></tr><tr><td>Sternotomy</td><td>1.2</td><td>1.5</td><td>-0.10−0.00</td><td>z=-0.202; p=0.840</td></tr><tr><td>Airway procedures</td><td>0.3</td><td>0</td><td>*</td><td>z=0.452; p=0.651</td></tr><tr><td>Flaps/skin graft/reconstruction</td><td>0.8</td><td>0</td><td>*</td><td>z=0.740; p=0.460</td></tr><tr><td>Burns</td><td>0</td><td>0</td><td>NA</td><td>NA</td></tr></table>Table 4b: Standardised Surgical response to adult vs. paediatric ballistic casualties.Rate of surgical procedures per 100 adult ballistic casualties compared to paediatric ballistic casualties. Civilian casualties underwent immediate surgery for ballistic injuries (n=393) (<a href="#bookmark1">Figures 2</a> and <a href="#bookmark1">3</a>).</td></tr></table>The ﬁve paediatric surgical interventions most com- monly performed for blast were, in decreasing order of frequency: debridement, amputation, laparotomy, removal of fragmentation or ballistic material, chest drain insertion (<a href="#bookmark1">Figure 3</a>) and for ballistics: debride- ment, laparotomy, removal of fragmentation or ballistic materials, vascular procedures, and thoracotomy proce- dures (<a href="#bookmark1">Figure 3</a>).Surgical characteristics blast vs. ballistics<a href="#bookmark1">Tables 1b</a> and <a href="#bookmark1">2b</a> show the standardised surgical response to adult and paediatric trauma casualties shown as a rate per 100 civilian casualties that suffered blast and ballistic injuries. All these data were used to design a standardised injury template to anticipate the numbers of surgical procedures required to manage any given mass casualty blast or ballistic event.Adult blast casualties were associated with signiﬁ- cantly more amputations (28.2) and removal of frag- mentation materials (17.6) but signiﬁcantly fewer chestdrain insertions (7.7) compared to ballistic injuries <a href="#bookmark1">(Figure 2</a>; <a href="#bookmark1">Table 1b</a>: 4.6, z=8.407; p=0.0000; z=4.007; p=0.00007; 12.3, z=-2.164; p=0.030).In paediatric casualties, those with blast injuries underwent signiﬁcantly more amputation procedures (27.9) compared to ballistic injuries (1.5) (<a href="#bookmark1">Figure 3</a>; <a href="#bookmark1">Table 2b</a>: z=4.497; p=0.00002).Comparative analysis adults vs. paediatric casualties<a href="#bookmark1">Tables 3b</a> and <a href="#bookmark1">4b</a> respectively compare the surgical response between adults and paediatric casualties injured by blast (<a href="#bookmark1">Figure 4</a>; <a href="#bookmark1">Table 3b</a>) and ballistics <a href="#bookmark1">(Figure 5</a>; <a href="#bookmark1">Table 4b</a>).Adults injured by blast underwent signiﬁcantly more debridement (63.5); temporary skeletal stabilisation (13. 2) and vascular procedures (12.8) compared to children <a href="#bookmark1">(Figure 4</a>; <a href="#bookmark1">Table 3b</a>: 43.4, z=4.026, p=0.00007; 5.7, z=2.230, p=0.022; 4.9, z=2.468, p=0.014).Adults injured by ballistics signiﬁcantly more under- went debridement (63.4); chest drain (12.3) andwww.thelancet.com Vol 54 December, 2022 7Articles<img src="/media/202408//1724856286.071178.png" /><table><tr><td colspan="12"><img src="/media/202408//1724856286.105244.png" /><img src="/media/202408//1724856286.379445.png" /></td><td rowspan="2"><img src="/media/202408//1724856286.79866.png" /> <img src="/media/202408//1724856287.042416.png" /><img src="/media/202408//1724856287.067998.png" /> <img src="/media/202408//1724856287.122292.png" /></td></tr><tr><td><img src="/media/202408//1724856287.166232.png" /></td><td><img src="/media/202408//1724856287.172404.png" /></td><td><img src="/media/202408//1724856287.1864572.png" /></td><td><img src="/media/202408//1724856287.205968.png" /></td><td><img src="/media/202408//1724856287.2205162.png" /></td><td><img src="/media/202408//1724856287.231019.png" /></td><td><img src="/media/202408//1724856287.253576.png" /></td><td><img src="/media/202408//1724856287.287803.png" /></td><td><img src="/media/202408//1724856287.326795.png" /></td><td><img src="/media/202408//1724856287.343619.png" /></td><td><img src="/media/202408//1724856287.3519812.png" /></td><td><img src="/media/202408//1724856287.499456.png" /></td></tr></table>Figure 2. Surgical procedures on adult blast vs. ballistic casualties.Surgical procedures most frequently performed on adult casualties injured by blast vs. ballistic (see <a href="#bookmark1">Table 1b</a> for data. No nota- tion represents non-signifcance, notation *p&lt;0.05; ** p&lt;0.01, *** p&lt;0.001 accordingly).temporary skeletal ﬁxation procedures (11.4) compared to children (<a href="#bookmark1">Figure 5</a>; <a href="#bookmark1">Table 4b</a>: 50.0, z=2.058, p=0.040; 2.9, z=2.283, p=0.023, p&lt;0.05; 2.9, z=2.131, p=0.034 respectively).Children injured by ballistics underwent signiﬁ- cantly more removal of fragmentation or ballistic mate- rials (20.6) when compared to adults (<a href="#bookmark1">Figure 5</a>; <a href="#bookmark1">Table 4b</a>: 7.692, z=-3.234, p=0.001).DiscussionThis study was designed to provide urgent and much needed evidence on the effect of blast and ballistic weap- onson surgical procedures in civilian patients. Our data shows through analysis of 10,891 surgical cases, the largest surgical database caused by violence available in the world, for the ﬁrst time the type of injuries sus- tained and the immediate surgical response required. The key ﬁndings are that the immediate surgical response is similar for adult versus paediatric popula- tions and that though there are some variations in the surgical response between blast and ballistic injuries, the most common four surgical procedures for both mechanisms are the same. The primary aim of this study was to provide evidence to support clinicians tomake decisions about the appropriate allocation of sur- gical resources for civilians injured in other armed con- ﬂictse.g. Ukraine, as well as MCE, where applicable.This study provides a baseline/starter dataset and if we collect more data from other scenarios then we can understand how the battle space environment e.g. weap- ons and geography inﬂuences the data. This study ena- bles the best template of the most likely injuries civilians may suffer in war/terror-acts from blast and ballistic wounding mechanisms, and the most probable consequent surgical interventions. We caveat that with this having the greatest application to future conﬂicts which are predominantly rural, asymmetric, and fought with total air superiority, and with access to a well-estab- lished trauma facility within an hour or so of injury. We are collaborating with Ukrainian colleagues to see if an equivalent dataset can be generated there.This study further characterizes the different injury patterns produced by blast and ballistic weapons.<a href="#bookmark1">10</a> It demonstrates the different effects of these wounding mechanisms on adult versus paediatric casualties. The results can be translated and used to standardise the type of surgical response needed and allow the develop- ment of more informed decision making when design- ing systems to respond to these types of casualties.8 www.thelancet.com Vol 54 December, 2022Articles<img src="/media/202408//1724856287.560641.png" /><table><tr><td colspan="12"><img src="/media/202408//1724856287.5837429.png" /><img src="/media/202408//1724856287.714992.png" /></td><td rowspan="2"><img src="/media/202408//1724856287.751064.png" /> <img src="/media/202408//1724856287.817905.png" /><img src="/media/202408//1724856287.848694.jpeg" /> <img src="/media/202408//1724856287.953099.png" /></td></tr><tr><td><img src="/media/202408//1724856287.994187.png" /></td><td><img src="/media/202408//1724856288.013323.png" /></td><td><img src="/media/202408//1724856288.051353.png" /></td><td><img src="/media/202408//1724856288.0864708.png" /></td><td><img src="/media/202408//1724856288.141953.png" /></td><td><img src="/media/202408//1724856288.174211.png" /></td><td><img src="/media/202408//1724856288.326777.png" /></td><td><img src="/media/202408//1724856288.3668249.png" /></td><td><img src="/media/202408//1724856288.41589.png" /></td><td><img src="/media/202408//1724856288.434201.png" /></td><td><img src="/media/202408//1724856288.497059.png" /></td><td><img src="/media/202408//1724856288.531084.png" /></td></tr></table>Figure 3. Surgical procedures on paediatric blast vs. ballistic casualties.Surgical procedures most frequently performed on paediatric casualties injured by blast vs. ballistic (see <a href="#bookmark1">Table 2b</a> for data. No notation represents non-signiﬁcance, notation *p&lt;0.05; ** p&lt;0.01, *** p&lt;0.001 accordingly).Wounding patterns show how head and abdominal region trauma predominates for both blast and ballistic injuries in children (Body Map <a href="#bookmark1">Tables 1a</a> −<a href="#bookmark1">4a</a>). Perhaps this relates to the disproportionately large head in rela- tion to the rest of their body, and perhaps or over-cau- tious surgeries where abdomens were opened as a precaution.<a href="#bookmark1">14</a> Adult wounding patterns showed vulner- abilities of the extremities predominantly for blast and ballistic trauma (<a href="#bookmark1">Tables 1a</a> −<a href="#bookmark1">4a</a>).These data conﬁrm the well documented biomechani- cal differences between blast and ballistic injury, but the translation of this into what is required surgically to man- age such injuries is less well described.<a href="#bookmark1">16,17</a> According to <a href="#bookmark1">Table 1b</a>, the main difference between the surgical man- agement of blast and ballistic injuries in adults include signiﬁcantly more amputations and removal of fragmen- tation materials compared to those injured by ballistics <a href="#bookmark1">(Table 1b</a>) and signiﬁcantly more chest drain insertions to manage ballistic injuries compared to blast injuries <a href="#bookmark1">(Table 1b</a>). In paediatric casualties, there were more simi- larities in the surgical procedures required to manage blast and ballistic injuries with just signiﬁcantly moreamputations performed for blast injuries compared to bal- listic (<a href="#bookmark1">Table 2b</a>); a ﬁnding which is consistent with Arulet al., (2012) who found that extremities were the most com- monly affected paediatric region.<a href="#bookmark1">18</a> Their ﬁndings are simi- lar to ours and practically, <a href="#bookmark1">Tables 1b</a> and <a href="#bookmark1">2b</a> can be used to quantify the surgical response in future mass casualty blast or ballistic events, terror-related or otherwise.In order to prepare the medical response to MCEs , our analysis highlights important differences in the sur- gical care provision for adult compared to paediatric casualties. Adults injured from blast undergo signiﬁ- cantly more debridement; temporary skeletal stabilisa- tion, and vascular procedures compared to paediatric casualties (<a href="#bookmark1">Table 3b</a>). Adult ballistic casualties undergo signiﬁcantly more debridement, chest drain and tempo- rary skeletal stablisation compared to children <a href="#bookmark1">(Table 4b</a>). Ballistic trauma in children lead to signiﬁ- cantly more removal of ballistic materials compared to adults (<a href="#bookmark1">Table 4b</a>). Few reports on paediatric care in Afghanistan are available for comparison to the present study due to small cases numbers (for example Coppola et al, 2006, n=85; Arul et al, 2012, n=82).<a href="#bookmark1">18,19</a>www.thelancet.com Vol 54 December, 2022 9Articles<img src="/media/202408//1724856288.631747.png" /><table><tr><td><img src="/media/202408//1724856288.846875.png" /><img src="/media/202408//1724856288.91975.png" /><img src="/media/202408//1724856288.9586198.png" /><img src="/media/202408//1724856289.041793.png" /><img src="/media/202408//1724856289.141827.png" /><img src="/media/202408//1724856289.1978781.png" /><img src="/media/202408//1724856289.233801.png" /><img src="/media/202408//1724856289.476543.png" /><img src="/media/202408//1724856289.503537.png" /><img src="/media/202408//1724856289.5620968.png" /><img src="/media/202408//1724856289.584946.png" /><img src="/media/202408//1724856289.669953.png" /><img src="/media/202408//1724856289.737077.png" /><img src="/media/202408//1724856289.816236.png" /><img src="/media/202408//1724856289.934981.png" /><img src="/media/202408//1724856290.253547.png" /><img src="/media/202408//1724856290.359499.png" /><table><tr><td></td></tr><tr><td>** *</td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td>**</td></tr><tr><td><img src="/media/202408//1724856290.441814.png" /></td></tr></table><img src="/media/202408//1724856290.5164301.png" /></td></tr><tr><td><img src="/media/202408//1724856290.635254.png" /> <img src="/media/202408//1724856290.693816.png" /> <img src="/media/202408//1724856290.7622652.png" /> <img src="/media/202408//1724856291.008241.png" /></td></tr></table>Figure 4. Surgical procedures on adult and paediatric blast casualties.<img src="/media/202408//1724856291.08652.png" /><img src="/media/202408//1724856291.192101.png" /><img src="/media/202408//1724856291.205085.png" /><img src="/media/202408//1724856291.21668.png" /><img src="/media/202408//1724856291.227984.png" /><img src="/media/202408//1724856291.243509.png" />Surgical procedures most frequently performed on adult vs paediatric casualties injured by Blast (see <a href="#bookmark1">Table 3b</a> for data. No nota- tion represents non-signiﬁcance, notation *p&lt;0.05; ** p&lt;0.01, *** p&lt;0.001 accordingly).<table><tr><td>*</td><td colspan="5"></td></tr><tr><td></td><td colspan="5"></td></tr><tr><td></td><td colspan="5"></td></tr><tr><td></td><td colspan="5"></td></tr><tr><td></td><td colspan="5"><img src="/media/202408//1724856291.275993.png" /></td></tr><tr><td></td><td colspan="5">**</td></tr><tr><td></td><td><img src="/media/202408//1724856291.335934.png" /></td><td></td><td></td><td><img src="/media/202408//1724856291.403656.png" /></td><td><img src="/media/202408//1724856291.412695.png" /></td></tr></table><table><tr><td><img src="/media/202408//1724856291.4156952.png" /></td><td><img src="/media/202408//1724856291.418934.png" /></td><td><img src="/media/202408//1724856291.42188.png" /></td><td><img src="/media/202408//1724856291.425018.png" /></td><td><img src="/media/202408//1724856291.430646.png" /></td><td><img src="/media/202408//1724856291.434489.png" /></td><td><img src="/media/202408//1724856291.440484.png" /></td><td><img src="/media/202408//1724856291.448077.png" /></td><td><img src="/media/202408//1724856291.4549031.png" /></td><td><img src="/media/202408//1724856291.461782.png" /></td><td><img src="/media/202408//1724856291.469735.png" /></td><td><img src="/media/202408//1724856291.480478.png" /></td><td><img src="/media/202408//1724856291.511704.png" /></td></tr><tr><td colspan="13"><img src="/media/202408//1724856291.521889.png" /> <img src="/media/202408//1724856291.5322292.png" /> <img src="/media/202408//1724856291.551164.png" /> <img src="/media/202408//1724856291.5674691.png" /></td></tr></table>Figure 5. Surgical procedures on adult and paediatric ballistic casualties.Surgical procedures most frequently performed on civilian adult vs paediatric casualties injured by Ballistics (see <a href="#bookmark1">Table 4b</a> for data. No notation represents non-signiﬁcance, notation *p&lt;0.05; ** p&lt;0.01, *** p&lt;0.001 accordingly).10 www.thelancet.com Vol 54 December, 2022Articles<img src="/media/202408//1724856291.575805.png" />Debridement and washout procedures remained the most common surgical procedure in paediatric casual- ties (<a href="#bookmark1">Figures 2</a> and <a href="#bookmark1">3</a>).<a href="#bookmark1">4</a>,<a href="#bookmark1">20</a>,<a href="#bookmark1">21</a> The present study enables us to understand the surgical burden for blast and bal- listic wounding mechanisms in paediatric casualties.Compared to larger studies on the paediatric cohort, we show that 19% (n=511) of operations were carried out on paediatric casualties. This compared to 14.7% (n=245) reported by Ramasamy and colleagues and 5.1% (n=85; n=99) reported in Iraq [Coppola et al., 2006 and McGuigan 2006] and 6% (n=299) reported by Jacobset al., (2012).<a href="#bookmark1">5</a>,<a href="#bookmark1">6,19</a>,<a href="#bookmark1">22</a> Some larger studies like Borgman (2012) (n=7505) found that paediatric trauma accounted for 5.8% of admissions, however, this study and other larger comparable studies report data from Iraq and Afghanistan and data from hospital teams that were placed close to the point of injury with limited resources and so their results cannot be translated to resource rich setting e.g. Creamer 2009, (n=2060) and Edwards et al, (2014) (n=982).<a href="#bookmark1">20,23</a>,<a href="#bookmark1">24</a> Although these studies have large admission numbers, it is not clear how many of those required primary damage control surgery, nor the procedures they required.The effect of the cultural and or religious unacceptabil- ity of serious physical injury like amputation requires addi- tional considerations on surgical care provision for civilians (present study; Coupland 1991).<a href="#bookmark1">25</a> There were clear gender differences in our ﬁndings. There were no female trauma casualties, and 12 female civilian casualties recorded in our dataset, all of which were not trauma related,but rather emergency surgeries such as appendec- tomy or caesarean section etc. (8 adult, 4 paediatric) (i.e. 0.004% of the dataset). Creamer and colleagues (2009) reported girls accounting for 21% of paediatric admis- sions, and a signiﬁcantly higher mortality rate in girls.<a href="#bookmark1">24</a> This suggests a male dominance for trauma, and, also probable cultural issues whereby female trauma patients did not receive the same care as male patients, suggesting an inequality of access to trauma care for females within the native population.<a href="#bookmark1">26</a>It is possible that inaccuracies might have occurred during data collection; however, records were prospec- tively recorded by surgical teams involved in the case and were experienced in collecting surgical data. It is likely more operations were civilian casualties but did not have civilian status recorded in the handwritten operative logbooks. Since all casualties operated on were included in the database, regardless of injury type, selection bias was minimised.A further limitation of this study, is that civilians treated in military hospitals in Afghanistan experienced survival bias, since it was assumed the most severely injured died during transfer or did not make it to the hospital.<a href="#bookmark1">27−30</a> However, in the present study cohort, the civilians were brought by the same pre-hospital provision as military casualties, which were on an equal if not superior footing, to what is available outside of a conﬂict zone.In light of the evidence, as blast injuries become more prevalent in peacetime, the surgical skills outlined in this study are sadly no longer conﬁned to the mili- tary, or overseas armed conﬂicts.<a href="#bookmark1">7</a> With the increase in terror-related attacks in cities at home, there is a recog- nised need to improve readiness for terror attacks in addition to armed conﬂicts, in order to manage the major trauma, which inevitably occurs.<a href="#bookmark1">1</a>,<a href="#bookmark1">7</a>,<a href="#bookmark1">30</a>Since the end of combat operations in Afghanistan (2014), the rise in terror attacks has presented a unique challenge for the doctors and surgeons practicing in our local cities.<a href="#bookmark1">1</a> Major trauma training is, however, not pri- oritised in the UK despite four separate terror attacks having occurred in 2017 alone: Westminster Bridge (22 March); Manchester Arena bombing (22 May),the Lon- don Bridge attack (3 June) Parsons Green underground station (15 Sept).<a href="#bookmark1">1</a>,<a href="#bookmark1">7</a> These events involved mass casual- ties that resulted in 37 deaths and more than 265 people injured.<a href="#bookmark1">30</a> The need for trauma training remains an issue for all medical professionals.<a href="#bookmark1">7</a> Whilst the surgical procedures to manage these events remain uncommon day to day in the civilian world, it could be concluded that the training needs are also highlighted from the present study. The template presented helps to high- light raw numbers and provision at the system level (to allocate resources, theatres and staff and movement of casualties), but also brings focus to any training needs this may show for the individual surgeon and wider team.This study was designed to assess the effect of blast and ballistic wounding patterns on surgical procedures in civilian casualties, thereby creating a template of immediate treatment, needs to help countries to enable Emergency Preparedness, Resilience and Response (EPRR) planning. Overall these ﬁndings support the use of this template for planning for armed conﬂicts and mass casualty events, which, given the likely contin- uance of terror attacks, has been recognised by NHS England as important.<a href="#bookmark1">1</a> The ﬁndings show the impor- tance of a standardised surgical template, based on evi- dence, tooptimise the immediate medical response and improve patient outcomes. This is particularly impor- tant since there is a magic number for the management of blast casualties, with surgeons with &gt;50 blast surgical cases having a reduced case fatality rate (manuscript in preparation).<a href="#bookmark1">14</a>A comprehensive evidence-based surgical require- ment for the management of blast and ballistic wounds has yet to be deﬁned, and there remains no current international agreement.<a href="#bookmark1">2</a> This study aims to support policy makers in making informed decisions about pre- cisely what the medical needs are by providing stratiﬁed frequency tables to enable decision-makers to better determine the type and scale of the immediate surgical response required in armed conﬂicts, or in the immedi- ate aftermath of a MCE, in order to deliver the right sur- gical procedures to save lives.www.thelancet.com Vol 54 December, 2022 11Articles<img src="/media/202408//1724856291.615604.png" />ContributorsLM designed the study, carried out the data collection,database creation, data analysis and interpretation as well as writing of the manuscript. SH conceived the analytical design, and with LM wrote the ﬁrst draft of the manu- script. L.Middleton and LM carried out the statistical analy- sis. SH and DH veriﬁed the underlying data. All authors were involved in each stage of the planning, interpretation of the results and write up of the work. All authors approved the ﬁnal version, had access to the data, contrib- uted to writing and editing the manuscript and accept responsibility to submit the ﬁnal version for publication.Data sharing statementAll data sharing and collaboration requests should be directed to the corresponding author.Declaration of interestsWe declare no competing interests. L.Middleton is anemployee of AstraZenica.AcknowledgementsLM was funded in part by a grant from the School ofMedicine, University of St Andrew.References1 <a href="http://refhub.elsevier.com/S2589-5370(22)00406-0/sbref0001">Moran CG, Webb C, Brohi K, Smith M, Willett K. 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