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20/03/2016

Blessés par balle: Civil et guerre, différent !

The profile of wounding in civilian public mass shooting fatalities.
 
Smith ER et Al. J Trauma Acute Care Surg. 2016 Mar 8. [Epub ahead of print]
 
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Des armes différentes, des distances de tir différentes, l'absence de protection balistique expliquent des lésions différentes. Dans cette publication, ce ne sont pas les lésions des membres qui sont les plus fréquentes mais les lésions du torse. A méditer pour la prise en charge des blessés, prise en charge qui semble devoir être différente en contexte civil de ce qui peut être fait dans un contexte de conflits armées, même asymétrique. D'autres expériences ont été rapportées exprimant la grande complexité du problème (1, 2, 3)
 
Ceci est d'autant plus vrai que la chaîne de relève est complètement différente avec notamment un accès aux structures chirurgicales beaucoup plus rapide qu'en contexte militaire. 
 
 
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Background: The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different than in military combat fatalities and thus may require a new management strategy.
 
Methods: A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. CPMS was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if pre-hospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author.
 
Results: A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity
 
Conclusion: The overall and fatal wounding patterns following CPMS are different than those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries.

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