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Yoram Kluger

Publications and source records attributed to Yoram Kluger.

At least 19 recordsLinked to original sources
PubMed2006

Terrorist bombing.

Bombings and explosion incidents directed against innocent civilians are the primary instrument of global terror. In the present review we highlight the major observations and lessons learned from these events. Five mechanisms of blast injury are outlined and the different type of injury that they cause is described. Indeed, the consequences of terror bombings differ from those of non-terrorism trauma in severity and complexity of injury, and constitute a new class of casualties that differ from those of conventional trauma. The clinical implications of terror bombing, in treatment dilemmas in the multidimensional injury, ancillary evaluation and handling of terror bombing mass casualty event are highlighted. All this leads to the conclusion that thorough medical preparedness to cope with this new epidemic is required, and that understanding of detonation and blast dynamics and how they correlate with the injury patterns is pivotal for revision of current mass casualty protocols.

Journal Article↗
PubMed2006

Pharmacokinetics of recombinant activated factor VII in trauma patients with severe bleeding.

INTRODUCTION: Recombinant activated factor VII (rFVIIa) has been used as adjunctive therapy in trauma patients with severe bleeding. However, its pharmacokinetics profile remains unknown. METHODS: In two placebo-controlled studies in patients with blunt and penetrating trauma, the pharmacokinetics of rFVIIa given at an initial dose of 200 microg x kg-1 after transfusion of eight red blood cell units, followed by additional doses of 100 microg x kg-1, one and three hours later, have been studied, based on the FVII coagulant activity assay. Both non-compartment and population pharmacokinetic analyses were performed. A two-compartment, population pharmacokinetic model was used to estimate a population profile for the rFVIIa dosing regimen. Data are population means (percent coefficient of variation (CV)). RESULTS: Based on the two-compartment population model, the estimated pharmacokinetic parameters were: clearance 40 (30% CV) ml x kg-1 x h-1; central volume of distribution 89 (32% CV) ml x kg-1; inter-compartmental clearance 24 ml x kg-1 x h-1; and peripheral compartment volume 31 ml x kg-1. Baseline FVII coagulant activity was estimated at 0.29 (39% CV) U x ml-1, initial half-life was 0.6 (34% CV) hours, and terminal half-life 2.4 (50% CV) hours. High intra- and inter-patient variability was noted in volume of distribution and clearance, which was in part correlated with the transfusion requirements as the single significant covariate. The non-compartmental analysis led to almost identical estimates of key parameters. CONCLUSION: A high intra- and inter-patient variability was noted in the volume of distribution and clearance of rFVIIa in trauma patients with severe bleeding, mainly related with the transfusion requirements and thus blood loss and/or bleeding rate.

Adult↗
PubMed2006

Recombinant activated factor VII as an adjunctive therapy for bleeding control in severe trauma patients with coagulopathy: subgroup analysis from two randomized trials.

INTRODUCTION: We conducted a post-hoc analysis on the effect of recombinant factor VIIa (rFVIIa) on coagulopathic patients from two randomized, placebo-controlled, double-blind trials of rFVIIa as an adjunctive therapy for bleeding in patients with severe trauma. METHODS: Blunt and penetrating trauma patients were randomly assigned to rFVIIa (200 + 100 + 100 microg/kg) at 0, 1, and 3 hours after transfusion of 8 units of red blood cells (RBCs) or to placebo. Subjects were monitored for 48 hours post-dosing and followed for 30 days. Coagulopathy was retrospectively defined as transfusion of fresh frozen plasma (FFP) (>1 unit of FFP per 4 units of RBCs), FFP in addition to whole blood, and transfusion of platelets and/or cryoprecipitate. RESULTS: Sixty rFVIIa-treated and 76 placebo subjects were retrospectively identified as being coagulopathic. No significant differences were noted in baseline characteristics. The rFVIIa-treated coagulopathic subgroup consumed significantly less blood product: RBC transfusion decreased by 2.6 units for the whole study population (P = 0.02) and by 3.5 units among patients surviving more than 48 hours (P < 0.001). Transfusion of FFP (1,400 versus 660 ml, P < 0.01), platelet (300 versus 100 ml, P = 0.01), and massive transfusions (29% versus 6%, P < 0.01) also dropped significantly. rFVIIa reduced multi-organ failure and/or acute respiratory distress syndrome in the coagulopathic patients (3% versus 20%, P = 0.004), whereas thromboembolic events were equally present in both groups (3% versus 4%, P = 1.00). CONCLUSION: Coagulopathic trauma patients appear to derive particular benefit from early adjunctive rFVIIa therapy.

Adult↗
PubMed2005

Embolization of transected vertebral arteries in unstable trauma patients.

The aim of this paper is to report our experience with coil embolization for the treatment of vertebral artery transection in unstable trauma patients. The course of four patients admitted to our units between 1998 and 2003 with traumatic injuries of the upper thorax or neck is described. All had unstable hemodynamic parameters at presentation. Emergent arteriogram revealed vertebral artery transection, which was managed by immediate coil embolization proximal to the injury site. Initial technical success was achieved in all four patients, with hemodynamic improvement. No further treatment or surgery to control the vessel injury was needed. There were no immediate or late complications of the procedure and no neurological sequelae. Emergency coil embolization is an effective endovascular technique for use in unstable patients with angiography findings of a transected vertebral artery.

Adolescent↗
PubMed2005

Medical consequences of terrorist bombs containing spherical metal pellets: analysis of a suicide terrorism event.

OBJECTIVE: Various metal objects added to explosives increase and diversify the wounding from bombing; especially favoured are spherical missiles for their special injuring characteristics. Our objective was to study the medical consequences and ballistic effects on human tissue of spherical metal pellets used in terrorist bombings. METHODS: The clinical and forensic data of all bodily injured casualties of a suicide terrorist bombing in a crowded hotel dining room were analysed retrospectively. RESULTS: Of the 250 people at the scene, 164 were injured, with 91 (55.5%) suffering bodily injuries; 30 of them died. The immediately deceased had disseminated tissue damage and their bodies were saturated with steel spheres. Thirty-two immediate survivors sustained severe injuries (Injury Severity Score > or =16), and all suffered tissue penetration by the pellets. Twenty-three (32%) underwent surgery and 15 (21%) required intensive care. CONCLUSIONS: Metal pellets propelled by the explosion enhanced the secondary pattern of injury and injured even patients remote from the origin. Tissue destruction and specific organ injuries among survivors were limited. To evaluate and manage victims of terrorist bombings properly, medical teams should become familiar with these severe injuries.

Abbreviated Injury Scale↗
PubMed2005

Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials.

BACKGROUND: Uncontrolled bleeding is a leading cause of death in trauma. Two randomized, placebo-controlled, double-blind trials (one in blunt trauma and one in penetrating trauma) were conducted simultaneously to evaluate the efficacy and safety of recombinant factor VIIa (rFVIIa) as adjunctive therapy for control of bleeding in patients with severe blunt or penetrating trauma. METHODS: Severely bleeding trauma patients were randomized to rFVIIa (200, 100, and 100 microg/kg) or placebo in addition to standard treatment. The first dose followed transfusion of the eighth red blood cell (RBC) unit, with additional doses 1 and 3 hours later. The primary endpoint for bleeding control in patients alive at 48 hours was units of RBCs transfused within 48 hours of the first dose. RESULTS: Among 301 patients randomized, 143 blunt trauma patients and 134 penetrating trauma patients were eligible for analysis. In blunt trauma, RBC transfusion was significantly reduced with rFVIIa relative to placebo (estimated reduction of 2.6 RBC units, p = 0.02), and the need for massive transfusion (>20 units of RBCs) was reduced (14% vs. 33% of patients; p = 0.03). In penetrating trauma, similar analyses showed trends toward rFVIIa reducing RBC transfusion (estimated reduction of 1.0 RBC units, p = 0.10) and massive transfusion (7% vs. 19%; p = 0.08). Trends toward a reduction in mortality and critical complications were observed. Adverse events including thromboembolic events were evenly distributed between treatment groups. CONCLUSION: Recombinant FVIIa resulted in a significant reduction in RBC transfusion in severe blunt trauma. Similar trends were observed in penetrating trauma. The safety of rFVIIa was established in these trauma populations within the investigated dose range.

Adult↗
PubMed2005

Brain injuries caused by spherical bolts.

OBJECT: Metallic particles contained in antihuman bombs increase the number of fatalities. The ballistics of these particles depends on the explosive that is used, the distance from the explosion, the shape of the particle projected, and the biomechanics of the injured tissue. The authors present their experience with penetrating spherical bolt injuries to the brain. METHODS: The authors retrospectively reviewed clinical and radiological data obtained in eight patients with penetrating spherical bolt injuries to the cranium: four had Glasgow Coma Scale (GCS) scores less than 8 (three died, one from an unrelated injury) and four had a GCS score of 15 (all survived). Two of the latter patients suffered unique anatomical injuries attributed to the distinctive ballistics of spherical bolts: in one patient the bolt penetrated the cavernous sinus causing minimal cranial nerve injury, and in the other patient the bolt lodged in the fourth ventricle causing acute hydrocephalus without other neurological deficits. CONCLUSIONS: Penetrating spherical bolts to the brain may be lethal. Nevertheless, they have unique ballistics that cause highly delineated anatomical damage and minor neurological deficits.

Adolescent↗
PubMed2005

Risk for motorcyclists in a busy metropolitan city: the example of Tel Aviv.

BACKGROUND: The proportion of motorcyclists injured in road accidents in Israel is larger than their proportion among road users. OBJECTIVES: To identify factors contributing to the risk of injury motorcyclists as compared to drivers of other motor vehicles. METHODS: We retrieved and analyzed National Trauma Registry data on drivers, aged 16 and above, who were involved in traffic accidents and hospitalized between 1 January 1997 and 30 June 2003. RESULTS: The study group comprised 10,967 patients: 3,055 (28%) were motorcyclists and 7,912 (72%) were drivers of other motor vehicles. A multiple logistic regression revealed that Tel Aviv, the busiest metropolitan city in Israel, is a risk for motorcycle injury as compared to other regions; males have an increased risk compared to females; and age is a protecting factor since the risk of injury as a motorcyclist decreases as age increases. Nevertheless, the population of injured motorcyclists in Tel Aviv was significantly older (mean age 32.5 years vs. 28.6 elsewhere; t-test P < 0.0001). Twenty percent (n = 156) of the injured motorcyclists in Tel Aviv were injured while working, compared to 9.5% (n = 217) in other regions (chi-square P < 0.0001). Motorcycle injuries in Tel Aviv were of lower severity (7.7% vs. 16.4% according to the Injury Severity Scale 16+, chi2 P < 0.0001), and had lower inpatient death rates (1.2% vs. 2.5%, chi2 P = 0.001). CONCLUSIONS: Tel Aviv is a risk for motorcycle injury compared to other regions, males have an increased risk compared to females, and age is a protecting factor. The proportion of motorcyclists in Tel Aviv injured while working is double that in other regions.

Accidents, Traffic↗
PubMed2004

Increased survival among severe trauma patients: the impact of a national trauma system.

HYPOTHESIS: The survival of severe trauma patients is affected by the implementation of a national trauma system, which brought about developments both at the hospital and prehospital levels during the past decade. DESIGN: A retrospective cohort study of all severely injured patients (Injury Severity Score >16) recorded in the Israeli National Trauma Registry at all level I trauma centers in Israel from January 1, 1997, to December 31, 2001. Inpatient death rates were examined overall and by subgroups. SETTING: The National Trauma Registry includes trauma (International Statistical Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes 800-959) hospitalizations, patients who were transferred to or from other hospitals, and those who died in the emergency department. It excludes patients who were dead on arrival, discharged following treatment in the emergency department, and patients who do not fall into the definition of trauma. Main Outcome Measure Inpatient death. RESULTS: Seven thousand four hundred twenty-three severe trauma patients were recorded. Inpatient death rates decreased significantly from 21.6% in 1997 to 14.7% in 2001. The odds ratios of mortality in 1998 through 2001 vs 1997, adjusted for year, age, sex, penetrating injury, and severity of injury (Injury Severity Score >25), were 0.92, 0.89, 0.70, and 0.65, respectively, confirming the downward trend. CONCLUSIONS: A steady significant reduction in the inpatient death rate of severe trauma patients hospitalized at all level I trauma centers in Israel between 1997 and 2001 was observed. Although a single factor that explains the reduction was not identified, it is evident that the establishment of the trauma system brought about a significant decrease in mortality. We believe that integrated cooperation of various components of the national trauma system in Israel across the years may explain the reduction.

Adolescent↗
PubMed2004

The special injury pattern in terrorist bombings.

BACKGROUND: The destructive human consequences of terrorist bombing always challenge the medical system in diagnosis, decision making, and patient management. This injury is produced by multiple injury mechanisms, and departs from the conventional description of trauma complexity. Our objective was to characterize and compare terror-bombing victims with casualties of all other kinds of trauma, and to validate the existence of a different, more complex, injury pattern. STUDY DESIGN: A retrospective cohort study was conducted of patient records from October 2000 through June 2003 in the Israeli National Trauma Registry. All were categorized as victims of terrorist bombings or of nonterror-related trauma. Analysis included age, gender, Injury Severity Score, Glasgow Coma Scale, admission blood pressure, injury complexity, surgical interventions, intensive care and hospital lengths of stay, in-hospital mortality, and disposition. This analysis was extended to Injury Severity Score subgroups. RESULTS: Victims of terrorist bombings (n = 906) were compared with 55,033 casualties of nonterror-related trauma. Bombing resulted in significantly different injury complexity, increased severity, and with more body regions involved. Significantly enhanced use of intensive care, prolonged hospital stay, more surgical interventions, and increased hospital mortality are characteristic of these patients. CONCLUSIONS: Terrorist bombings inflict injury of a distinctly different pattern than other means of trauma. The simultaneous combination of different injury mechanisms in explosions results in a multidimensional injury pattern and a complicated clinical course. Hospital preparedness and medical team awareness to the unique nature of the injuries are mandatory for improving the outcomes of these patients.

Adolescent↗
PubMed2004

Functions and principles in the management of bombing mass casualty incidents: lessons learned at the Tel-Aviv Souraski Medical Center.

Mass casualty incidents (MCI) resulting from terrorist bombings pose special problems and may overwhelm even the most experienced trauma centre. Although role assignments for MCI management and control are documented, we would like to share several aspects that we have found to be crucial for the management of terrorist bombing MCI. Twelve topics and possible answers were brought up and discussed extensively in MCI debriefing sessions in our institution. They were of two main categories: assignments and functions of key personnel, and principles and definitions. The first category includes the Triage Officer, the Medical Director, the Administrative Director, the Head Nurse, the Emergency Medical System Coordinator, the Blood Bank Liaison, and the trauma teams. The second category encompasses the concept of triage hospital, the unidirectional patient flow, ancillary evaluation during MCI, the consultancy, and tertiary survey. All were identified as critical for proper event handling. The integration and implementation of the topics discussed throughout the medical system may enable emergency departments to handle MCI resulting from terrorist bombings better.

Blast Injuries↗
PubMed2004

Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel.

CONTEXT: An increase of terror-related activities may necessitate treatment of mass casualty incidents, requiring a broadening of existing skills and knowledge of various injury mechanisms. OBJECTIVE: To characterize and compare injuries from gunshot and explosion caused by terrorist acts. METHODS: A retrospective cohort study of patients recorded in the Israeli National Trauma Registry (ITR), all due to terror-related injuries, between October 1, 2000, to June 30, 2002. The ITR records all casualty admissions to hospitals, in-hospital deaths, and transfers at 9 of the 23 trauma centers in Israel. All 6 level I trauma centers and 3 of the largest regional trauma centers in the country are included. The registry includes the majority of severe terror-related injuries. Injury diagnoses, severity scores, hospital resource utilization parameters, length of stay (LOS), survival, and disposition. RESULTS: A total of 1155 terror-related injuries: 54% by explosion, 36% gunshot wounds (GSW), and 10% by other means. This paper focused on the 2 larger patient subsets: 1033 patients injured by terror-related explosion or GSW. Seventy-one percent of the patients were male, 84% in the GSW group and 63% in the explosion group. More than half (53%) of the patients were 15 to 29 years old, 59% in the GSW group and 48% in the explosion group. GSW patients suffered higher proportions of open wounds (63% versus 53%) and fractures (42% versus 31%). Multiple body-regions injured in a single patient occurred in 62% of explosion victims versus 47% in GSW patients. GSW patients had double the proportion of moderate injuries than explosion victims. Explosion victims have a larger proportion of minor injuries on one hand and critical to fatal injuries on the other. LOS was longer than 2 weeks for 20% (22% in explosion, 18% in GSW). Fifty-one percent of the patients underwent a surgical procedure, 58% in the GSW group and 46% in explosion group. Inpatient death rate was 6.3% (65 patients), 7.8% in the GSW group compared with 5.3% in the explosion group. A larger proportion of gunshot victims died during the first day (97% versus 58%). CONCLUSIONS: GSW and injuries from explosions differ in the body region of injury, distribution of severity, LOS, intensive care unit (ICU) stay, and time of inpatient death. These findings have implications for treatment and for preparedness of hospital resources to treat patients after a terrorist attack in any region of the world. Tailored protocol for patient evaluation and initial treatment should differ between GSW and explosion victims. Hospital organization toward treating and admitting these patients should take into account the different arrival and injury patterns.

Adolescent↗
PubMed2004

[Trauma education of general surgery residents].

Educating residents in surgery, especially in trauma surgery, and the best way to teach it among the other subspecialties of surgery, is a topic heavily debated in recent literature. Several important factors affecting this learning have changed lately. Many educators have expressed concern about the adequacy of the exposure of surgical residents to surgery and of their ability to care for their patients, with the newly imposed legal constraints on the length of shifts and working hours. Since trauma is inherently unpredictable, residents must spend many hours in the emergency department to become exposed to various types of trauma. Some will only see a small number of trauma patients during their residency, depending on the location of hospital and its commitment to trauma. Furthermore, the operative exposure in trauma has decreased dramatically, with the current trend of non-operative management of blunt splenic and hepatic trauma and conservatism in the management of some stable patients injured by penetrating mechanisms. Similar concerns have also been raised about the exposure of attending surgeons to surgical trauma practice. In most centers in Israel, the trauma patient is managed by a general surgery specialist rather than by a trauma-specialized general surgeon. This may lead to dilution of trauma cases among multiple medical providers and furthermore, to inconsistency in the delivery of care. Consequently, this may effect the education of surgical residents. We therefore suggest a structured curriculum for general surgery residents as well as structural changes in the department of surgery to increase the caseload of general surgeons especially those choosing to specialize in trauma.

Humans↗