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Maitland et al’s analysis of 983 civilian casualties generates the first template of immediate surgical response for civilian blast injuries

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

Laura Maitland, Lawrence Middleton, Harald Veen, David J. Harrison, James Baden, and Shehan Hettiaratchy

The Lancet, Vol 54, December, 2022

Published in the Lancet, this first-of-its-kind study is an indispensable response to the increasing prevalence of blast injuries in peacetime. In an era which is seeing unprecedented terror-related attacks in towns and cities around the world, the surgical skills necessary to respond to blast and ballistic injuries are no longer confined to the military or overseas armed conflicts.

Over the past decade, from 2013 to November 2022, AOAV recorded 31,832 incidents of explosive weapon use or detonation as reported in English-language news sources, and 250,054 civilian casualties. 67% (159,452) of those civilians were recorded as injured. 61% (19,535) of recorded incidents took place in towns and cities, where 91% (227,495) of all recorded civilian casualties occurred. More specifically, 92% (146,831) of civilian blast injuries happened when explosive weapons were detonated in towns and cities. 

Furthermore, based on an analysis of AOAV data collected over that time, the use of explosive weapons in populated areas has been generally increasing over the past decade. 2022 has so far seen an 83% increase in incidents of explosive weapons in populated areas compared to 2013, and a 14% increase compared to the previous highest levels recorded in 2017.

The most harmful explosive weapons in towns and cities in that time have been improvised explosive devices (IEDS), which caused 104,730 civilian casualties, or 46% of all civilian casualties of explosive weapons in populated areas. Non-specific IEDs and car bombs were the most injurious weapons, having caused 53,435 (38,439 injuries) and 41,685 (30,172 injuries) respectively.

Air-launched weapons caused 57,064 civilian casualties in towns and cities, especially air-strikes, which caused 80% (45,850) of those civilian casualties, and ground-launched weapons caused 51,705 civilian casualties in populated areas, particularly shelling (16,920 civilian casualties) and mortars (10,516). 

Responding to the evolving nature of civilian surgical response amidst the continuing urbanisation of warfare and explosive weapon use, the authors carried out an observational study from original log-book entries, between 2009 and 2014, of civilian casualties that underwent primary trauma surgery for blast and ballistic injuries at the UK-led military Medical Treatment Facility, Camp Bastion, Afghanistan. This is the first evidence-based template of the immediate response required to manage civilians injured by blast and ballistic mechanisms. The study aims to inform a standardised approach to blast and ballistic injuries in civilian practice, providing a framework to improve the immediate surgical response to mass casualty events (MCE). 

Based on the study, adult blast casualties suffered significantly more head, abdomen, and upper and lower extremity trauma compared to adult ballistic casualties. Civilian adults wounded by ballistics suffered significantly more chest trauma compared to blast casualties. 

Paediatric casualties injured by blast suffered significantly more upper and lower extremity trauma when compared to ballistic wounding.

The findings indicate that the four most common surgical procedures for civilian blast injuries were debridement (cleaning a skin wound), amputation, laparotomy (open surgery of the abdomen to examine the abdominal organs), and temporary skeletal stabilisation. The immediate surgical response was similar for adult versus paediatric populations, and though there were some variations in the surgical response between blast and ballistic injuries, the most common four surgical procedures for both mechanisms were the same. The main difference between the surgical management of blast and ballistic injuries lay in the greater prevalence of amputations and removal of fragmentation materials in the response to blast injuries, compared to ballistic injuries. 

The research underscores the highly destructive and long-term impacts of explosive weapons. If they do not deprive victims of their lives, they are shown to be more likely to result in the amputation of limbs and internal damage by fragmentation materials, which in turn can result in the loss of, or difficulty in maintaining, a livelihood, and generate mental and emotional strain for which civilian trauma-response is ill-prepared.

The authors hope the template presented here can be applied to similar conflict zones and to prepare for attacks on urban populations. Their research accords well with the work done by the International Blast Injury Research Network (IBRN), which was launched in 2019 to address the civilian gap in blast research. Their research found that, in the last two decades, more than 80% of funding for blast injury-related research came from the US Department of Defense, focusing on military, not civilian, situations and perspectives. 

The IBRN drives research into the interaction of blast shockwaves within urbanised environments, and the specific injuries which result from that interaction. In this way, the work of the IBRN and Maitland et al. contributes to an evolving framework for civilian preparedness – a key principle in mitigating civilian harm from explosive weapons – by ​​helping to inform urban planning, risk assessments, prevention or mitigation strategies, and emergency response.