Specific Trauma Risks

Urban Survival Guide

Urban Survival Secrets for Terrorist Attacks

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It is reasonable to assume that there is greater risk of physical injury to children in developing countries from falls, motor vehicle crashes, and other trauma as there are fewer resources devoted to safety standards and accident prevention (27,28). It is common in many countries to see families of two adults and a child riding on one motorcycle, with only the father wearing a helmet, and bicycle helmets are rarely seen. In south or southeast Asia and the Middle East, seat belts (at least in the rear seat) are rare in our experience, and young children frequently ride on their parents' laps in the front seat.

High population density, poverty, and illiteracy put people at increased risk for burn injury (29). Burn centers tend to be located in major cities and may have inadequate resources even for the local population. Children suffering burns in rural communities may have to travel long distances to receive care. Although most burns are sustained by women aged 16-35 years of age, children are still at significant risk as they may be playing in unsafe kitchen areas where the working area and flame are at floor level. Pressurized kerosene stoves are common, and they are susceptible to explosions or flame bursts, resulting in burn injuries (30). In addition, fireworks are still popular in many communities during festivals, and children are particularly at risk.

Panjeshahin and colleagues (31) found that 51% of admissions to a burn center in southwestern Iran were under 20 years old, and 24% were younger than 10 years. Ahuja and Bhattacharya (32) analyzed 11,196 burn admissions to a burn unit in New Delhi over an 8-year period, identifying approx 50% mortality. Of these patients, 17% (1920) were younger than 16 years old, and 16% of those had greater than 50% body surface area burned. Most pediatric burns were scalds from hot water or other liquid. One-third (65) of the electrical burns in the population were to children. The management of burns in this center was discussed, but, interestingly, there was no mention of pain or analgesia.

2.2.2. Land Mines

Approximately 110 million land mines have been distributed since the 1960s in 70 countries (33). It is estimated that 15,000-25,000 people are killed or injured every year; 80% of these are civilian, and many civilian deaths are of children. The small size, color, and novel appearance of mines and bomblets make them attractive to children, who may either pick them up as toys or may collect them as scrap metal to sell. Death or painful mutilation results. The International Committee of the Red Cross (ICRC) collected data from five ICRC hospitals in Afghanistan, Pakistan, Thailand (at the Cambodian border), and Kenya (at the Sudanese border). They did not specify how many children were injured, but 35% of mine-injured patients (who made it to the hospital) were children, women, or men over 50 years of age (i.e., civilians). The ICRC estimated that mine injuries require an average of 32 days hospitalization and four operations per patient (34).

2.2.3. War, Terrorism, and Civil Disturbances

Little is known about the pain consequences of war, terrorism, or civil disturbance in children. We are all familiar with news reports of children injured or killed in terrorist attacks or war, although a Medline search with the criteria {Pain[MESH] AND Child[MESH] AND (War[MESH] OR Terrorism[MESH])} identified only eight publications, most of which were not relevant.

Lacoux and colleagues (35) published a report on their research in Sierra Leone with a Médecins sans Frontières mission until it was curtailed by deteriorating security conditions. They identified a high incidence of phantom sensations and phantom pain, and 100% incidence of stump pain, in a population of unilateral and bilateral upper limb amputees who had suffered intentional mutilation of healthy limbs by machete, axe, or gunshot. Their sample of 40 subjects included patients as young as 16 years. Even infants as young as 2 months old suffered intentional hand amputation (Lacoux PA, personal communication, 2005).

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