Surgical management of penetrating thoracic injuries ...

ORIGINAL ARTICLE

European Journal of Cardio-Thoracic Surgery 51 (2017) 1195–1202 doi:10.1093/ejcts/ezx036 Advance Access publication 27 March 2017

Cite this article as: Boddaert G, Mordant P, Le Pimpec-Barthes F, Martinod E, Aguir S, Leprince P et al. Surgical management of penetrating thoracic injuries during the Paris attacks on 13 November 2015. Eur J Cardiothorac Surg 2017;51:1195–202.

Surgical management of penetrating thoracic injuries during the Paris attacks on 13 November 2015 Guillaume Boddaerta,*, Pierre Mordantb, Françoise Le Pimpec-Barthesc, Emmanuel Martinodd, €tilg, Antonio Fioreg, Thomas Lescoth, Sonia Aguira, Pascal Leprincee, Mathieu Rauxf, Jean-Paul Coue Brice Malgrasi, François Ponsj and Yves Castierb a b c d

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Division of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France Division of Thoracic and Vascular Surgery, Bichat Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris Diderot University, Paris, France Division of Thoracic Surgery, Georges Pompidou European Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris Descartes University, Paris, France Assistance Publique-Hoˆpitaux de Paris, Hoˆpitaux Universitaires Paris Seine-Saint-Denis, Avicenne Hospital, Department of Thoracic and Vascular Surgery. Sorbonne Paris Cite´, Paris 13 University, Faculty of Medicine SMBH, Bobigny, France Division of Cardiac surgery, Pitie´ Salpêtrie`re Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris Curie University, Paris, France Department of Anaesthesiology and Intensive Care, Pitie´ Salpêtrie`re Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris Curie University, Paris, France Division of Cardiac Surgery, Henri Mondor Hospital, Assistance Publique-Hoˆpitaux de Paris, Paris Est University, Cre´teil, France Department of Anaesthesiology and Intensive Care, Saint-Antoine Hospital, Assistance Publique-Hoˆpitaux de Paris and Sorbonne Universite´s, UPMC Univ Paris 06, France Division of Visceral and General Surgery, Be´gin Military Teaching Hospital, Saint-Mande´, France French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France

* Corresponding author. Division of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, 101 avenue Henri Barbusse, BP 406, 92141 Clamart, France. Tel: +33-1-41466627; fax: +33-1-41466169; e-mail: [email protected] (G. Boddaert). Received 20 November 2016; received in revised form 31 December 2016; accepted 17 January 2017

Abstract OBJECTIVES: The Paris terrorist attacks on 13 November 2015 caused 482 casualties, including 130 deaths and 352 wounded. Facing these multisite terrorist attacks, Parisian public and military hospitals simultaneously managed numerous patients with penetrating thoracic injuries. The aim of this study was to analyse this cohort, the injury patterns, and assess the results of this mobilization.

RESULTS: The study group included 25 patients (7% of the casualties) with a mean age of 34 ± 8 years and a majority of gunshot wounds (n = 20, 80%). Most patients presented with severe thoracic injury (Abbreviated Injury Score Thorax 3.3 ± 1.2), and also associated nonthoracic injuries in 21 cases (84%). The mean Injury Severity Score was 26.8 ± 9.4. Eight patients (32%) were managed with chest tube insertion and 17 (68%) required thoracic surgery. Lung resection, diaphragmatic repair, and lung suture were performed in 6 (36%), 6 (35%), and 5 cases (29%), respectively. Extra-thoracic surgical procedures were performed in 16 patients, mostly for injuries to the extremities. Postoperative mortality was 12% (n = 3) and postoperative morbidity was 60% (n = 15), CONCLUSIONS: The coordination of Parisian military and civilian hospitals allowed the surgical management of 25 patients. The mortality is high but consistent with what has been reported in previous series. The current times expose us to the threat of new terrorist attacks and require that the medical community be prepared. Keywords: Penetrating thoracic injury • Terrorist attack • Gunshot wound • Suicide-bombing attack

INTRODUCTION Most large series of penetrating thoracic injuries have been reported by the military services [1–3] and North American trauma centres [4]. These institutions have dedicated trauma teams, technical facilities, emergency protocols, and surgical training, to deliver the fastest and the most efficient management to these kinds of patients [5]. The context is very different in France, where

penetrating thoracic injuries are infrequent and mostly managed by organ-based surgical specialists in non-military hospitals. The management of these patients therefore represents a particular challenge. Facing multisite terrorist attacks on 13 November 2015, Parisian public and military hospitals managed numerous patients with multiple injuries following the protocol of a hospital mobilization plan called the ‘White Plan’ (Plan Blanc) [5].

C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. V

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METHODS: The clinical records of all patients admitted to Parisian public and military hospitals with a penetrating thoracic injury related to the Paris 13 November terrorist attacks were reviewed.

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The White Plan allows the mobilization of all hospitals within the Paris area, the recall of caregivers, and the release of beds to cope with a large influx of wounded people. The Paris 13 November terrorist attacks have justified the activation of the White Plan for the first time in the last 20 years. The aim of this study was to assess the results of this mobilization in the management of penetrating thoracic injury.

hall–hundreds of people were then held hostage until 00:23 am. The terrorists were armed with explosive belts and firearms as reported above. Overall, these multisite terrorist attacks have been responsible for 482 casualties, including 130 deaths and 352 wounded.

PATIENTS AND METHODS

The clinical records of all patients presenting with a penetrating thoracic injury related to the Paris 11/13 terrorist attacks were reviewed. Accrual completeness was ensured by direct contact with medical and surgical directors of hospitals involved in the management of the Paris 11/13 victims. Pre-hospital admittance categorization was reported as absolute emergency (AE) or relative emergency (RE) according to the pre-hospital admittance rescue organization plan called the ‘Red Plan’ (Plan Rouge). AE may require surgery or embolization without delay whereas RE may be managed secondarily [5]. In-hospital categorization was reported as immediate, delayed, minimal and expectant according to French and NATO Military Health Service recommendations [6]. In the immediate group are casualties who require attention within minutes to 2 h on arrival to avoid death or major disability. The delayed group included those wounded who are in need of surgery, but whose general condition permits delay in

Attacks Three groups of 3 terrorists attacked the Paris area on 13 November 2015 (Fig. 1). From 9:17 pm to 9:53 pm, 3 explosions occurred at the Stade de France, a stadium located in the north of Paris. These explosions were the result of 3 suicide bombing attacks (SBA) using explosive belts that included triacetone triperoxyde (TATP) and metallic pieces, mostly bolts. At 9:41 pm, another SBA took place in a bar in the 11th district of Paris. At the same time, from 9:25 pm to 9:43 pm, 3 shooting incidents occurred at the terrace of several bars and restaurants in the 10th and 11th districts of Paris. The terrorists were moving by car using military grade firearms, Kalashnikov AK47 and Zastava M70. At 9:40 pm, a massacre took place in the Bataclan concert

Study design

Figure 1: Map of Paris attacks. Map of Paris showing the terrorist attacks, location of the hospitals and distribution of patients with thoracic wounds. Red figures are the location of terrorist attacks, (A) explosion at Stade de France, 1 person and 3 terrorists dead, (B) shooting on rue Bichat, 15 people dead, (C) shooting on rue de la Fontaine au Roi, 5 people dead, (D) Hostage-taking in Le Bataclan concert hall, 89 people and 3 terrorists dead, (E) explosion in the Comptoir Voltaire Cafe´, 1 terrorist dead, (F) shooting on rue Charonne, 19 people dead. Red arrows are the primary orientations of patients with thoracic wounds. Circles are the hospitals, which received patients with thoracic wounds and their names. Green circles are those with thoracic surgery capabilities and orange ones those without. Yellow arrows are the secondary orientations of the patients. Figures correspond to the numbers of patients concerned.


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Figure 2: Trunk impacts. (A) Patients wounded by gunshot. Figures are the number attributed to each of the patients, each circle is one impact, and each colour is for the same patient. (B) Patients wounded by explosions. Figures are the number attributed to each of the patients, each hexagon is one impact, and each colour is for the same patient. Coloured areas are lesional areas as defined on the figure.

treatment without unduly endangering life, limb, or eyesight. The minimal group consists of those patients who have relatively minor injuries and can effectively care for themselves or be treated with minimal medical care. Patients in the expectant group are casualties that overwhelm current medical resources at the expense of treating salvageable patients. Severity was reported using the Glasgow Coma Scale (GCS), Abbreviated Injury Scale (AIS), Injury Severity Scale (ISS), New Injury Severity Score


(NISS), Revised Trauma Score (RTS) and TRauma and Injury Severity Score (TRISS). An AIS >_ 3 in a body region indicated a severe injury, an ISS greater than 15 indicated a severe trauma, RTS is inversely proportional to mortality, a TRISS of 50% or less was considered an unexpected survivor [7, 8]. Outcomes were defined as postoperative deaths and complications that included events occurring within 90 days after surgery or during the same hospital stay if longer.

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Table 1: Patients demographics, pre-hospital care, ED status and procedures (n = 25) Age (years) Male Mechanism of injury GSW Number of impacts SBA Number of impacts Pre-hospital care Cardiac arrest Mean time (min) Catecholamine Chest tube Seal chest Pre-hospital triage categorization Absolute emergency Relative emergency Patient status upon arrival in ED Systolic blood pressure (mmHg) Heart rate (n = 21) Respiratory rate (n = 20) GCS 8 15 ED triage categorization Immediate Delayed Minimal Expectant ED imaging CXR Abnormal CXR (e-)FAST Pericardium positive Abdomen positive Pleura positive CT scan

34 ± 8 [22–56] 16 (64%) 20 (80%) 2.1 ± 1 [1–5] 5 (20%) 10.2 ± 3.83 [6–15] 2 (8%) 5 ± 0 [5–5] 6 (24%) 0 3 (12%) 24 (96%) 1 (4%) 103 ± 43 [0–176] 95 ± 35 [0–135] 18 ± 7 (0–26) 12.5 ± 4.5 [3–15] 4 (16%) 15 (60%) 7 (28%) 17 (68%) 1 (4%) 0 8 (32%) 7/8 (88%) 12 (48%) 0 4/12 (30%) 4/7 (57%) 15 (60%)

The data are presented as the n (%) and the mean ± the SDs [ranges] for continuous variables. ED: emergency department; GSW: gunshot wound; SBA: suicide bombing attack; GCS: Glasgow coma score; CXR: chest X-ray; (e-)FAST: (extended-)focused assessment with sonography for trauma; CT: computed tomography.

Patient management All patients were managed according to the protocol of the White Plan as already reported [5, 9, 10]. Most of patients had pre-hospital care by the fire brigade or emergency medical services’ teams before being referred to an appropriate trauma centre or emergency department (ED). Some patients made their own way or were carried by relatives or witnesses to the closest hospitals [5, 9]. All patients were managed by the Greater Paris Public Hospitals network (Assistance Publique - Hoˆpitaux de Paris - AP-HP, a network of 40 civilian hospitals in Paris Area) or the French Military Health Service (Hoˆpitaux d’Instruction des Armeés - HIA, including 2 military hospitals in the Paris Area).

Table 2: Injury pattern and severity (n = 25) Injury pattern Thoracic injuries Haemothorax Lung contusion Pneumothorax Lung laceration Rib fractures Diaphragm injury Scapula fracture Open chest wound Pericardial effusion Heart laceration Phrenic nerve injury Non-thoracic injuries Extremities Intra-abdominal injury Retro-peritoneal injury Spine Spinal chord Skull Brain Injury severity AIS thorax AIS abdomen AIS spine AIS upper limb AIS external AIS head AIS lower limb AIS neck ISS ISS >15 NISS RTS (n = 20) TRISS (n = 20)

20 (80%) 20 (80%) 15 (60%) 14 (56%) 10 (40%) 6 (24%) 3 (12%) 1 (4%) 2 (8%) 1 (4%) 1 (4%) 12 (48%) 10 (40%) 7 (28%) 7 (28%) 5 (20%) 3 (12%) 2 (8%) 3.3 ± 1.2 [0–5] 1.8 ± 1.7 [0–4] 1 ± 1.8 [0–5] 1 ± 1.3 [0–3] 1 ± 0 [0–0] 0.5 ± 1.4 [0–5] 0.5 ± 1.1 [0–3] 0.1 ± 0.3 [0–1] 26.8 ± 9.4 [14-43] 21 (84%) 35.3 ± 9.7 [22–59] 6.55 ± 2.58 [0–7.841] 80.7 ± 31.6 [51.4–98.7]

The data are presented as the n (%) and the mean ± the SD [ranges] for continuous variables. AIS: abbreviated injury score; ISS: injury severity score; NISS: new injury severity score; RTS: revised trauma score; TRISS: trauma and injury severity score.

P-value less than 0.05 was considered significant. The database creation was approved by the French Committee for Informatics and Liberty (Commission Nationale Informatique et Liberte´ – CNIL, number 1977746 v 0). The study protocol was approved by the Institutional Review Board of the French Society of Thoracic and Cardiovascular Surgery (Socie´te´ Française de Chirurgie Thoracique et Cardio Vasculaire – SFCTCV, number 2016-7-19-11-21-11-MoPi). All statistical analyses were performed using the statistical software StatA version 12.0 (StataCorp LP, Houston, TX, USA).

RESULTS Demographic characteristics, pre-hospital management, emergency department status and procedures

Statistical analysis Categorical variables were described as count and proportion. Continuous variables were described as mean and standard deviation, and compared using Student’s t-test. For all comparisons, a


Twenty-five patients were admitted for penetrating thoracic injury related to the Paris November 13 terrorist attacks, and make up the study group. Attack locations and patient distribution are shown in Fig. 1. The majority of patients were male (n = 16, 64%),


Chest tube only Thoracic surgery Time to thoracic surgery Immediate 12 h Exposure Antero-lateral thoracotomy Sternotomy Videothoracoscopy Postero-lateral thoracotomy Elective basi-thoracic thoracotomy Clamshell thoracotomy Wound debridement Procedure Lung resection Wedge resection Formal lobectomy Diaphragmatic repair Pericardiotomy Formal lobectomy Lung foreign body remove Chest wall haemostasis Pleural foreign body removal Open chest resuscitation Cardiac repair Packing Other surgical procedure Timing of the other surgical procedure Before thoracic surgery Concomitant After thoracic surgery Location of the other surgical procedure Extremity Abdomen Spine Head

Table 4: Postoperative outcome (n = 25) 8 (32%) 17 (68%) 4 (24%) 1 (6%) 3 (18%) 4 (24%) 5 (28%) 4 (24%) 3 (18%) 3 (18%) 3 (18%) 2 (12%) 1 (6%) 1 (6%) 6 (35%) 3 (18%) 3 (18%) 6 (35%) 6 (35%) 3 (18%) 3 (18%) 3 (18%) 2 (12%) 1 (6%) 1 (6%) 1 (6%) 16 (64%) 4 (25%) 8 (50%) 6 (32%) 13 (52%) 11 (44%) 5 (20%) 1 (4%)

The data are presented as the n (%).

with a mean age of 34 ± 8 years. Gunshot wounds (GSW, n = 20, 80%) were more frequent than wounds from SBA (n = 5, 20%). The number of impacts was higher in the latter patients (2.1 ± 1 for GSW vs 10.2 ± 3.83 for SBA, P = 0.001). Impact locations are illustrated in Fig. 2. Before being transferred to the ED, 24 patients (96%) were classified as an absolute emergency. After triage upon arrival at the ED, 7 patients (28%) were categorized as immediate, and 5 patients were considered as an extreme emergency and underwent surgery without prior exam (Table 1).

Injury pattern and severity Most patients presented with severe thoracic injury (AIS thorax 3.3 ± 1.2), associated with non-thoracic injuries in 21 cases (84%). In 15 patients (60%) their thoracic injury was the most severe injury. The most frequent extra-thoracic injuries involved the extremities (n = 12, 48%), the abdomen (n = 10, 40%), the retroperitoneum (n = 7, 28%) and the spine (n = 7, 28%). The mean ISS score was 26.8, ranging from 14 to 43, and 21 patients (84%) had an ISS above 15 (Table 2).


Mortality Morbidity Thoracic complications Pneumonia Pulmonary embolism Persistent haemo or pneumothorax Prolonged ventilation (>21 days) Mean time (n = 22) Haemorrhage ARDS Non-thoracic complications Iterative surgery Thoracic Non-thoracic Total blood products use RBC >10 RBC in 24 h FFP or PLYO Platelets ICU LOS (days)a Hospital LOS (days)a Discharge location Home Rehabilitation

3 (12%) 15 (60%) 10 (40%) 5 (20%) 3 (12%) 2 (8%) 2 (8%) 5.3 ± 14.1 [0–52] 1 (4%) 1 (4%) 10 (40%) 16 (64%) 3 (12%) 14 (56%) 6.72 ± 7.5 [0–35] 6 (24%) 4.8 ± 8 [0–37] 0.6 ± 1.5 [0–7] 5 [1–56] 13.5 [4–239] 12 (60%) 8 (40%)

The data are presented as the n (%) and the mean ± the SD [ranges] for continuous variables. ARDS: acute respiratory distress syndrome; RBC: red blood cells; FFP: fresh frozen plasma; PLYO: plasma lyophilized; ICU: intensive care unit; LOS: length of stay. a Median [ranges].

Surgical management Eight patients (32%) were managed with chest tube insertion (32%), 17 (68%) underwent thoracic surgery. Surgery was performed within the first 6 hours in 7 patients (28% of the series, 41% of the patients who underwent surgery). Anterior approaches (anterolateral thoracotomy, sternotomy, clamshell) were the most frequent approaches (n = 8, 47%). Lung resection was performed in 6 cases (36%), including 3 lobectomies and 3 wedge resections, lung suture was performed in 5 cases (29%). One patient required cardiac suture, and one patient required thoracic packing. Six patients (36%) had diaphragmatic repair and 4 required an associated abdominal procedure (66%). Extrathoracic surgical procedures were performed in 16 patients, mostly for injuries to the extremities, and were mostly carried out during the thoracic procedure. Six patients (35%) have had a damage control procedure (thoracic n = 4, abdominal n = 2) according to their physiological status (Table 3).

Postoperative outcome Postoperative mortality was 12% (n = 3) and overall postoperative morbidity was 60% (n = 15). Five patients (20%) presented with thoracic complications, 5 (20%) with extra-thoracic complications and 5 (20%) with both. Iterative surgeries were performed in 16 patients, mostly for non-thoracic injuries (n = 14, 56%). Transfer from primary to specialized centres was required in 6 cases (24%), as shown in Fig. 1. The median ICU and hospital length of stay were 5 [1–56] and 13.5 [4–239] days, respectively. The majority of patients were then discharged home (n = 12, 54% of living patients) (Table 4).

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Table 3: Surgical management (n = 25)

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1200

Table 5: Comparison with the recent published series of terrorist attacks Terrorist attacks

Paris, 2015

Boston, 2013 [9, 10]

Utoya-Oslo, 2011 [11, 12]

Israel, 2010 [13]

Mumbai, 2008 [14]

London, 2005 [15]

Madrid, 2004 [16]

Casualties Died

483 27% (130/483) 352

284 1% (3/284) 281

235 32% (76/235) 159

154

476 36% (175/476) 304

831 7% (56/831) 775

2191 9% (191/2191) 2000

16% (79/483) 84% (404/483) 7% (25/352) 27 ± 9 [14–43] 32% (8/25) 64% (16/25) 12% (3/25)

100%

100%

Mostly combined

100%

100%

0

-

0

0

2.8% (7/243) 12.5% > 15a

45% (106/235) 55% (129/235) 20% (7/35) 23a

18% (29/163) -

-

0

11

-

-

39% (199/512) 29 [11–75]a -

0

1 -

3% (1/29) -

1

0

37% (57/154) 22 [14–34] 45% (25/55) 9% (5/55) 11% (6/55)

Wounded Mechanism Bombing Shooting Thoracic trauma ISS Tube thoracostomy Thoracotomy Thoracic mortality

0

-

1

0.5% (1/199) -

Data are presented as n, % (n) and mean ± SD [ranges]. - : not available. a Overall studied population.

Table 6: Comparison with the recent published series of military and civilian thoracic trauma Terrorist attacks

Paris 2015

Mil., USA 2012 [21]

Mil., UK 2013 [2]

Mil., FR 2016 [3]

Civ., ZAF, 2011 [22]

Civ., USA 2001 [4]

Civ., TUR 1998 [23]

Casualties Thoracic trauma

352 7% (25/352)

23797 9% (2049/23797)

7856 10% (826/7856)

922 10% (89/922)

1186 100%

3049 100%

755 100%

20% (5/25) 80% (20/25)

62% (1268/2049) 19% (782/2049)

58% (477/826) 39% (320/826)

-

-

10% (124/1186) 90% (1062/1186)

56% (1702/3049) 44% (1347/3049)

27 ± 9 [14–43] 32% (8/25) 64% (16/25) 12% (3/25)

23 ± 14

-

37% (34/89) 53% (47/89) 9% (8/89) 39 ± 18

47% (964/2049) 9% (176/2049) 8% (169/2049)

-

54% (48/89) 37% (33/89) 11% (10/89)

-

57% (1752/3049) 15% (453/3049) 3% (86/3049)

3% (21/755) 52% (392/755) 45% (342/755) 20 ± 14 [1–75] 60% (459/755) 8% (61/755) 6% (42/755)

Mechanism Bombing Shooting Stabbing ISS Tube thoracostomy Thoracotomy Thoracic mortality

13% (106/826) 14% (118/826)

9% (108/1186) 0.9% (11/1186)

Data are presented as n, % (n) and mean ± SD [ranges]. Mil.: military; USA: United Sates of America; UK: United Kingdom; FR: France; Civ.: civilian; ZAF: South Africa; TUR: Turkey; - : not available; ISS: injury severity score.

DISCUSSION Main results Facing multisite terrorist attacks which combined assault rifles shots and bomb explosions, the mobilization and the


coordination of Parisian public and military hospitals allowed the emergency surgical management of 25 patients with penetrating thoracic injuries. These dreadful attacks challenged the healthcare system with a large number of patients with war injuries over a short amount of time, with complex and severe thoracic injuries, and resulted in a thoracic mortality of 12%.


In France, the medical response to a mass casualty incident is organised according to the ‘White Plan’ that allows the mobilization of hospitals and caregivers [5]. After previous terrorist attacks that occurred in the Paris area on 7 January 2015, emergency services in and out of Parisian hospitals undertook simulation exercises. The last exercise took place at 10:00 am on the morning of November 13, but nothing could prepare the medical teams for the violence observed that night [11]. Attacks perpetrated with assault rifles, often combined with bombings, are associated with a higher mortality than isolated bombings. For comparison purposes, recent terrorist attacks targeting civilians have been summarized in Table 5 [12–19]. The highest number of casualties was encountered after the Madrid terrorist attacks in 2004. These bomb attacks in trains were associated with the highest proportion of patients with thoracic trauma (39%) but the lowest proportion of patients undergoing thoracotomy (0.5%) [19]. In the same way, there was only one thoracotomy after the London bombings and none after Boston [12, 13, 18]. Reports of terrorist incidents in Israel of 17 SBA have described a large proportion of thoracic trauma (37%) a consequent rate of thoracotomy (9%) and a high rate of mortality (11%) often due to associated injuries [16]. The Utoya-Oslo and Mumbai attacks were characterized by a balance between both bombing and shooting incidents (45% and 55% for the first series) and resulted in an average rate of thoracic trauma of 20% and 18%, respectively, but only one thoracotomy for each series [14, 15, 17, 20]. The Paris attacks with a majority of injuries from GSW (84%) resulted in one of the lowest rates of thoracic trauma (7%) but the highest rate of thoracotomy (64%) and thoracic mortality (12%). Altogether, these data confirm that bomb attacks are often associated with thoracic trauma, blast lung or shrapnel injuries, but these injuries infrequently require thoracotomy nor are they responsible for specific thoracic mortality after hospital admission. Conversely, GSW in unprotected civilians are often associated with severe injuries that require surgical management and are often associated with a heavy burden of complications and mortality. However, this has probably to be weighted by the pre-hospital mortality.

Injury severity For comparison purposes, recent military and civilian penetrating thoracic trauma series have been summarized in Table 6 [2–4, 21– 23]. In the case of penetrating thoracic injury with a haemo/or pneumothorax the AIS is at least 3. The mean thoracic AIS of our series is 3.3 which is considered as severe. This mean thoracic AIS is similar to that reported by Bala et al. after the SBA in Israel which had a median thoracic AIS of 3; in addition to wartime injuries reported by Ivey et al. during Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) with a mean thoracic AIS of 2.9 [16, 21]. The injuries sustained in the Paris attack were also characterized by a high rate of extra-thoracic injuries (84%), the majority involving extremities (48%), followed by abdominal injuries (40%). De Lesquen et al. have reported similar findings during the war in Afghanistan with 78% of extra-thoracic injuries, 56% involving the extremities and 48% involving the abdomen [3]. Furthermore, thoraco-abdominal and multi-cavity injuries are known to be associated with adverse outcome [4]. In our study, the association of severe thoracic injury and frequent extra-thoracic involvement


led to a mean Injury Severity Score (ISS) of 27, a high proportion of patients (84%) with an ISS over 15 and a probability of death above 10% [8]. This is quite similar to the report of Ivey et al. [21] during OEF and OIF. Finally, patients with war thoracic injuries following terrorist attacks probably require a rapid relocation to high-grade trauma centres for a multidisciplinary management.

Surgical management In France, the management of thoracic and associated injuries may vary according to the institution. French military surgeons are mostly general and trauma-surgeons, who have benefitted from a thorough training in the management of trauma, including cardiothoracic and vascular skills, in order to master damage control surgery in the combat environment [3]. Conversely, civilian surgeons are organ-specialized surgeons, who have been partly trained in trauma management and damage control, but mostly used to multidisciplinary collaboration. These approaches are complementary and their pooling appears mutually beneficial since military surgeons may need organ specialization and civilian surgeons need trauma training. Despite these training differences, our results are close to those of recent military series [2, 3, 21]. Compared to other military and civilian series, our study is characterized by a lower rate of tube thoracostomy management (32%) and a higher rate of thoracotomy (64%) [2–4, 21– 23]. This potentially reflects a higher incidence of high velocity GSW among an unprotected civilian population but may also indicate a surgical over-triage. Along the same lines, the thoracic mortality in our series (12%) is quite similar to military series but higher than civilian series [2–4, 21–23]. This may be explained by the mechanism of injury but also by the difficulties in prehospital management related to the extent of the attacks and the security conditions.

Limitations Missing data on the cause of death of people dead on site is a major limitation of our study. Causes of death are still under investigation and further analyses will be of tremendous importance to improve pre-hospital protocols and materials, as recently highlighted after the Boston marathon bombing [13]. Our study has other limitations. The extent of the attacks, the number of hospitals involved and the multiplicity of people involved, might have led to heterogeneous management protocols and ultimately to missing data. However, repeated contacts with all the centres involved in the management of patients with thoracic injuries, together with the creation of a dedicated database that included all casualties attributed to November 13 Paris attacks, and the complete follow-up of all patients included, lead to a reasonable confidence into the completeness of this study.

CONCLUSIONS The mobilization and the coordination of Parisian military and civilian hospitals allowed the surgical management of 25 patients presenting with penetrating thoracic injury due to the Paris 13 November terrorist attacks. The mortality is high but consistent with what has been reported in previous series. The current times expose us to the threat of new terrorist attacks and require that the medical community be prepared.

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Terrorist urban mass casualty incidents

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ACKNOWLEDGEMENTS We salute the strength and the determination of all the healthcare professionals committed to patients’ care during the 13 November Paris attacks, and we pay homage to the patients and their relatives.

Conflict of interest: none declared.

REFERENCES [1] Keneally R, Szpisjak D. Thoracic trauma in Iraq and Afghanistan. J Trauma Acute Care Surg 2013;74:1292–7. [2] Poon H, Morrison JJ, Apodaca AN, Khan MA, Garner JP. The UK military experience of thoracic injury in the wars in Iraq and Afghanistan. Injury 2013;44:1165–70. [3] Lesquen HD, Beranger F, Berbis J, Boddaert G, Poichotte A, Pons F et al. Challenges in war-related thoracic injury faced by French military surgeons in Afghanistan (2009-2013). Injury 2016;47:1939–44. [4] Mandal AK, Sanusi M. Penetrating chest wounds: 24 years experience. World J Surg 2001;25:1145–9. [5] Hirsch M, Carli P, Nizard R, Riou B, Baroudjian B, Baubet T et al. The medical response to multisite terrorist attacks in Paris. Lancet Lond Engl 2015;386:2535–8. [6] Borden Institute (U.S.). Emergency War Surgery. Washington DC: Office of the Surgeon General, U.S. Army, Borden Institute, Walter Reed Army Medical Center, 2004, 29–45. [7] Copes WS, Champion HR, Sacco WJ, Lawnick MM, Gann DS, Gennarelli T et al. Progress in characterizing anatomic injury. J Trauma 1990;30:1200–7. [8] Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987; 27:370–8. [9] Service Me´dical du RAID. Tactical emergency medicine: lessons from Paris marauding terrorist attack. Crit Care Lond Engl 2016;20:37. [10] TRAUMABASE Group. Paris terrorist attack: early lessons from the intensivists. Crit Care Lond Engl 2016;20:88.

[11] Philippe J-M, Brahic O, Carli P, Tourtier J-P, Riou B, Vallet B. French Ministry of Health’s response to Paris attacks of 13 November 2015. Crit Care Lond Engl 2016;20:85. [12] Gates JD, Arabian S, Biddinger P, Blansfield J, Burke P, Chung S et al. The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster. Ann Surg 2014;260:960–6. [13] King DR, Larentzakis A, Ramly EP. Boston Trauma Collaborative. Tourniquet use at the Boston Marathon bombing: lost in translation. J Trauma Acute Care Surg 2015;78:594–9. [14] Gaarder C, Jorgensen J, Kolstadbraaten KM, Isaksen KS, Skattum J, Rimstad R et al. The twin terrorist attacks in Norway on July 22, 2011: the trauma center response. J Trauma Acute Care Surg 2012;73:269–75. [15] Waage S, Poole JC, Thorgersen EB. Rural hospital mass casualty response to a terrorist shooting spree. Br J Surg 2013;100:1198–204. [16] Bala M, Shussman N, Rivkind AI, Izhar U, Almogy G. The pattern of thoracic trauma after suicide terrorist bombing attacks. J Trauma 2010;69:1022–9. [17] Bhandarwar AH, Bakhshi GD, Tayade MB, Borisa AD, Thadeshwar NR, Gandhi SS. Surgical response to the 2008 Mumbai terror attack. Br J Surg 2012;99:368–72. [18] Aylwin CJ, Ko¨nig TC, Brennan NW, Shirley PJ, Davies G, Walsh MS et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet Lond Engl 2006;368:2219–25. [19] Ture´gano-Fuentes F, Caba-Doussoux P, Jover-Naval on JM, Martın-Pe´rez E, Fernandez-Luengas D, Dıez-Valladares L et al. Injury patterns from major urban terrorist bombings in trains: the Madrid experience. World J Surg 2008;32:1168–75. [20] Roy N, Kapil V, Subbarao I, Ashkenazi I. Mass casualty response in the 2008 Mumbai terrorist attacks. Disaster Med Public Health Prep 2011;5:273–9. [21] Ivey KM, White CE, Wallum TE, Aden JK, Cannon JW, Chung KK et al. Thoracic injuries in US combat casualties: a 10-year review of Operation Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 2012;73(6 Suppl 5):S514–9. [22] Clarke DL, Quazi MA, Reddy K, Thomson SR. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg 2011;142:563–8. [23] Inci I, Ozçelik C, Taçyildiz I, Nizam O, Eren N, Ozgen G. Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice. World J Surg 1998;22:438–42.

EDITORIAL COMMENT

European Journal of Cardio-Thoracic Surgery 51 (2017) 1202–1203 doi:10.1093/ejcts/ezx073 Advance Access publication 27 March 2017

Cite this article as: Molnar TF. Thoracic surgeons in multiple/mass casualty scenario: are we ready? Eur J Cardiothorac Surg 2017;51:1202–3.

Thoracic surgeons in multiple/mass casualty scenario: are we ready? Tamas F. Molnara,b,* a b

Department of Operational Medicine, Faculty of Medicine, University of Pećs, Pećs, Hungary Department of Surgery, Petz Hospital, St Sebastian Thoracic Surgery Unit, Gy} or, Hungary

* Corresponding author. Department of Operational Medicine, Faculty of Medicine, University of Pećs, Szigeti u. 12, 7622 Pećs, Hungary. Tel: +36-30-6403362; e-mail: [email protected] (T.F. Molnar)

Keywords: Damage control thoracic surgery • Chest trauma • Education • Mass casualty ‘One who wishes to be a surgeon should go to war’, states Hyppocrates’ aphorism [1]. What should we expect, when the war faces the surgeon: this is the message of the article of G. Boddaert et al. [2]. Global challenges: Thoracic Surgeons, are you prepared? That was a conference title, held in east-southern Europe, Kazan, Russia [http://www.lp.amtec-kazan.com/global/


(10 March 2017, date last accessed)]. The correct answer is a polite yet pale acknowledgement, ‘Well, not really’. All of the mass terror attacks against civilians on European soil from 25 July 1995, Paris Metro bombings to the New Year’s attack, 1 January 2017, in Istambul, left a significant number of the victims with chest injuries [3, 4], many of them polytraumatized. Our