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The pattern of paediatric blast injury in Afghanistan
  1. Daniel C Thompson1,2,
  2. R J Crooks3,
  3. J C Clasper4,5,
  4. A Lupu6,
  5. S A Stapley1,7 and
  6. D J Cloke3
  1. 1 Defence Medical Group South, Queen Alexandra Hospital, Portsmouth, UK
  2. 2 Army Medical Service, Royal Military Academy Sandhurst, UK
  3. 3 201 (Northern) Field Hospital, Newcastle upon Tyne, UK
  4. 4 The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
  5. 5 Defence Medical Group South East, Frimley Park Hospital, UK
  6. 6 SpR Trauma and Orthopaedics, Northern Deanery, UK
  7. 7 Royal Centre for Defence Medicine, Queen Elizabeth Hospital, BIrmingham, UK
  1. Correspondence to Dr Daniel C ThompsonArmy Medical Services and Queen Alexandra Hospital, Portsmouth PO6 3LY, UK; dcthompson101{at}gmail.com

Abstract

Introduction Between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within Afghanistan. Improvised explosive devices (IEDs) and explosive remnants of war accounted for 29% of child casualties in 2015. The aim of this study was to review the burden of paediatric blast injuries admitted to Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more head injuries than adults.

Method A retrospective analysis was undertaken of prospectively collected data derived from the UK Joint Theatre Trauma Registry of ambulant paediatric (aged 2–15 years) admissions with blast injuries at the Role 3 Field Hospital, Camp Bastion from June 2006 to March 2013. The data set included demographic information, injury profile and severity (New Injury Severity Score) and operative findings. The pattern of injuries were investigated by looking at trends in the number and severity of injuries sustained by each body region.

Results During this period, 295 admissions were identified, 76% of whom were male, with an overall mortality rate of 18.5%. The most common blast mechanism was an IED (68%) causing 80% of fatalities. The lower extremities were the most commonly injured body region, accounting for 31% of total injuries and occurring in 62% of cases. 24.3% of children between 2 and 7 years suffered severe head or neck injuries compared with 19.8% of children aged between 8 and 15 years. 34% of head injuries were rated unsurvivable and accounted for 88% of fatalities. 77% of cases required an operation with a mean operating time of 125 min. The most common first operations were debridement of soft tissues (50%), laparotomy (16%) and lower limb amputation (11%).

Conclusion Although paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility, the pattern of injuries seen suggests that children are more likely to sustain severe head, face and neck injuries than adults.

  • blast
  • paediatrics
  • Afghanistan
  • IED
  • trauma
  • orthopedics

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Key messages

  • Paediatric casualties represented a significant workload on recent operations in Afghanistan.

  • Children suffer a greater proportion of thorax, head and neck injuries compared with adults following a blast mechanism.

  • There should be a high degree of suspicion of a head or thorax injury in a child with blast injuries.

  • Lower limb injuries are the most commonly injured body region.

  • Future deployments should ensure sufficient paediatric training, and equipment is available for the likely injuries sustained.

Introduction

It is estimated that over 2 million children have been killed as a result of war in the past decade with over 6 million injured or permanently disabled.1 Civilian casualties, including children, have been a tragic consequence of the war in Afghanistan with more than half being victims of improvised explosive devices (IEDs), suicide bombings and complex attacks.2 According to the United Nations Assistance Mission in Afghanistan between 2009 and 2015, 3746 children died, and 7904 were injured as a result of armed conflict within the country. IEDs and explosive remnants of war accounted for 29% of child casualties in 2015.3 International Security Assistance Force Field Hospitals are bound by the Geneva Convention to treat all casualties of war, therefore during combat operations in Afghanistan, British medical facilities encountered high numbers of children.4

Papers reporting casualty data from Afghanistan have shown that explosive blasts were the most common mechanism of injury sustained across all age groups, among both combatant and civilian populations.1 5 6 They also reported that a typical pattern of blast injury in children involves complex trauma to multiple body regions. The extremities, especially the lower extremities, most commonly sustain injury, largely mirroring the pattern of injury in adults.5 6 However, some studies have shown that children as a group are more likely to sustain head and facial trauma than adults.7 8 It can be speculated this is due to the proportionally larger skull in children and closer proximity to ground blast than in adults. A study using data from US Medical Treatment facilities in Afghanistan and Iraq suggested a negative correlation between age and head injury, suggesting that the height of the child may be relevant.8 Literature consistently suggests that paediatric blast injuries are more common in males with social and cultural factors being cited as explanations.6

It has also been recognised in previous literature that civilians who are injured by a blast (both adult and child) do not have the protection of personal armour unlike personnel of International Security Assistance Forces. As a result of this, civilians received comparatively more torso injuries than soldiers protected by body armour.5 To our knowledge, no data regarding the patterns of paediatric blast injury seen in Afghanistan alone has been presented. The aim of this study was to evaluate the workload of the paediatric burden at Camp Bastion, Afghanistan, and to investigate the hypothesis that children suffer proportionally more severe head injuries than adults.

Method

This study was registered with the Royal Centre for Defence Medicine Research Directorate (RCDM/Res/Audit/1036/12/0170). The Joint Theatre Trauma Registry (JTTR) in Camp Bastion prospectively collected data on all trauma admissions at the UK led Role 3 Field Hospital. The data on paediatric admissions to Camp Bastion Field Hospital with a registered blast mechanism from June 2006 to March 2013 was obtained. This period encompassed the deployment of UK troops to Helmand Province to a decline in admissions due to the drawdown of the hospital at Camp Bastion.

For the purpose of this study, only ambulant children were included, who were between the ages 2 and 15 years. The data set included demographic information, injury profile and severity and operative findings. Injuries were grouped into body regions by their Abbreviated Injury Scale (AIS) code into: lower extremity, abdomen, upper extremity, thorax, face, head, neck, spine, external and other.

The pattern of injury was investigated by looking at trends in the number and severity of injuries sustained by each body region. The severity of injuries was assessed by using the most severely injured body region recorded in an individual case as scored by the AIS and using the New Injury Severity Score (NISS) for the overall severity of the trauma.9 10 AIS assigns an injury a score from 1 (minor) to 6 (unsurvivable). A severe body region injury was defined as an injury of AIS ≥3.8 NISS is calculated using the following equation: NISS = A2 + B2 + C2, where A, B and C are the AIS scores of the three most severe injuries regardless of body regions. A critically injured casualty was defined as an NISS ≥25.4

Results

During the study period, there were 295 paediatric admissions to the Role 3 Medical Facility in Camp Bastion, including 54 deaths (18.5% mortality). Of the admissions, 225 (76%) were male, and 70 (24%) female with a male to female ratio of 3.21:1. Figure 1 demonstrates the distribution of admissions by age and gender. The median ages for males and females to be admitted were 12 and 8 years, respectively. The year 2011 saw the most paediatric admissions with 78 cases being admitted. As shown in Table 1, the most common mechanism of blast was IED (68%), which accounted for 80% (n=43) of fatalities.

Figure 1

Distribution of admissions by age and gender.

Table 1

Number of admissions per mechanism of injury

In total, there were 1572 recorded injuries across 295 cases. Table 2 shows that 62% of admissions sustained an injury to the lower extremities and accounted for 31% of all injuries. The ‘other’ category was used in data collection for whole body injuries, for example, ‘whole body injury massive; multiple organ injury to thorax and/or abdomen with loss of one or more limbs and/or decapitation’. The median number of body regions injured in an individual case was 2 (range 1–8).

Table 2

Breakdown of injuries per body region

Table 3 shows that injuries to the lower extremities were most commonly recorded as the most severe injury for an individual, with this being the case in 31% of individuals. Although the lower extremities were the most common site for the most severe injury, head injuries accounted for the highest average AIS of 4.72 with 34% of head injuries rated unsurvivable (AIS 6). A total of 24.3% of children between 2 and 7 years sustained a severe head or neck injury compared with 19.8% of older children aged between 8 and 15 years. The distribution of cases within different NISS bands can be seen in Figure 2. A total of 32 cases scored the maximum NISS of 75, all of which were achieved by sustaining an unsurvivable injury, of these 28 (88%) died from a head injury. A total of 121 (41%) patients were critically injured, and the average NISS for fatalities was 52 compared with 22 for survivors.

Table 3

The most severely injured body region per admission

Figure 2

Distribution of admissions within New Injury Severity Score (NISS) bands.

A total of 228 cases (77%) received at least one operation during their admission to Camp Bastion Role 3 Facility. The most common first procedure was debridement of soft tissues (114 cases) followed by laparotomy (37 cases) and lower limb amputation (25 cases). The distribution of operation durations can be seen in Figure 3. The mean duration for the first operation was 125 min.

Figure 3

Distribution of operations by duration.

Discussion

This study has demonstrated that IEDs were responsible for the majority of paediatric blast injuries in Afghanistan. In terms of pattern of injuries, the most commonly and severely injured body region seen in paediatric blast trauma was the lower extremities. However, in terms of mortality, a head injury was more likely to be fatal, and younger children were more likely to have a severe head injury than an older child.

When comparing our results with US JTTR data using a comparable timeline from Iraq and Afghanistan, there is a similar trend in blast injuries incidence, with severe head injury incidence decreasing with the increasing age of a child.8 A direct comparison between this study and ours for severe head, face and neck injuries in adults (>15 years) compared with children aged 2–15 years shows the incidence to be 18.9% versus 21.4%, respectively. Although the difference is small, the hypothesis that children suffer proportionally more severe head injuries than adults is supported. This trend has previously been noted in another study, which noted a higher incidence of head injuries in children aged 0–3 years compared with older children and young adults.11 It appears that the difference between older and younger children is actually greater than broadly speaking about children and adults. Various reasons might be speculated regarding the different injury patterns seen in child casualties. Children do not wear body armour and helmets, leading to a greater number of head and torso injuries than combatants, in conjunction with a greater proportional head surface area. The lower limbs were the most commonly and severely injured body region, similar to research on paediatric casualties in Iraq and Afghanistan.4 12 This most likely reflects that the lower limbs are the closest body region to the epicentre of the blast.

In terms of the burden of paediatric blast injuries on the UK Role 3 Facility at Camp Bastion, there were 298 admissions, including non-ambulant children, across the 7-year study period. There were a total of 19 933 admissions to Camp Bastion Role 3 Facility between 1 April 2006 to 31 July 2013.13 As an estimate, paediatric blast injuries accounted for 1.5% of all admissions to Camp Bastion. This is only an estimate as the time period for the total admissions’ data is slightly different to the time frame used in our study.

Our study showed that 41% of casualties were critically injured and had an 18.5% mortality rate, which is higher when compared with another paper looking at Camp Bastion paediatric data. That study showed a critical injury rate of 30% and a mortality rate of 9%, but this figure included medical admissions, which inevitably carry a lower mortality rate to blast.4 Another paper looking at traumatic paediatric admissions to US Medical facilities in Afghanistan found a mortality rate of 10%. The authors of this paper describe how from 2001 to 2005 the mortality rate had increased over time and that the predominant mechanism of injury was gunshot wound.6 The discrepancies in mortality rate are possibly due to the focus of our study, as blast injuries can inflict more widespread damage compared with a gunshot wound and therefore pose a greater risk to life. In addition, our study period included a time when insurgent tactics moved towards the use of IEDs.

In terms of the demographics of the casualties in our study, the findings were in keeping with many previous studies of paediatric casualties from Afghanistan, Iraq and Croatia.4–6 12 14–16 In particular, casualties seen were predominantly male and a median age around 9 years. It has previously been suggested that this may be due to the more outgoing and adventurous role played by boys in certain societies.16

Previous research from US and UK Field Hospitals has shown that explosive blast was a common mechanism of injury sustained across all age groups in Afghanistan, among both combatant and civilian populations, with IEDs being the most common mechanism.1 4–6 This trend of children admitted with blast injuries corresponds with the number of coalition fatalities caused by IED, with 2010–2011 being the period with the most fatalities.17

Head injuries were the most common cause of death seen in our cohort, as similarly found in other literature.6 15 The majority of fatalities were admitted with catastrophic head injuries, for which no treatment could be offered.

A total of 228 cases (77%) required an operation with a mean operating time of 125 min, therefore placing a high demand on surgical services in particular. The operative rate is very similar to the previous Camp Bastion paediatric study which showed an operative rate of 76%.4 Likewise, there were very similar operations performed with the most common being soft tissue debridement followed by laparotomy. Our study showed a similar amputation rate (12%) to another study focusing on blast injuries (13%).11

The findings are of clinical significance as there should be a greater index of suspicion of a head or neck injury in a child, and in particular, a younger, smaller child compared with an adult. There should also be appropriate training in the management of paediatric head injuries as this was the greatest cause of death in our cohort.

As with most similar studies, this is a retrospective analysis, although of a prospectively collected trauma database. While generalisations can be made about the susceptibility to head injuries due to the smaller size of paediatric casualties, we also accept that the use of mean AIS could be questioned as it is a categorical scale, and therefore decimals may not necessarily represent an increased severity within a category. However, the highest average AIS for the head injuries is likely to be a true reflection that these are the most severe injuries that paediatric casualties sustain. Another limitation of this study is that a comparison was made with results from another paper in order to compare paediatric and adult blast injuries. Although the paper used for comparison was similar in terms of study design, the data included blast injuries sustained in Iraq as well as Afghanistan. Therefore, future work could look at JTTR adult blast injury data from Camp Bastion, which would enable a more detailed and reliable analysis of the differences in the pattern of injuries in blast trauma between children and adults. It may also be of value to compare the mortality rates of casualties from non-blast trauma versus blast.

Conclusions

In this specific study of those children injured by a blast mechanism in Afghanistan, we have noted the lower extremities to be the most commonly affected. However, there is a higher mortality rate in children who sustain a head injury compared with other body regions and a higher proportion of severe head and neck injuries in younger children compared with older children. Review of adult blast injury data from published literature supported the hypothesis that children sustain a higher rate of severe head injuries compared with adults.

Paediatric blast casualties represented a small percentage of the overall workload at Camp Bastion Role 3 Medical Facility. Clinicians deploying on future operations in a similar environment must be prepared with regard to training and equipment to deal with paediatric casualties, and should in particular be proficient in the management of head injuries.

References

Footnotes

  • Contributors All authors have made substantial contributions to the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article or revising it critically for important intellectual content and final approval of the version to be submitted.

  • Competing interests None declared.

  • Ethics approval This study was registered and approved by the Royal Centre for Defence Medicine Research Directorate (RCDM/Res/Audit/1036/12/0170) and has been granted permission to seek publication. Ethical approval was not sought as the paper uses retrospective analysis of anonymous patient data.

  • Provenance and peer review Not commissioned; externally peer reviewed.