Acta Medica Mediterranea, 2014, 30: 797
EVALUATION OF THE DEATH CASES OCCURRED AS A RESULT OF INJURY DURING WAR
BEKIR KARAARSLAN1, CEM UYSAL2, ADNAN ÇELIKEL3, YUSUF ATAN4, MUSTAFA KENAN ASILDAĞ4, ZEKERIYA TATAROĞLU4,
HIKMET ERGIN DÜLGER4
1
Gaziosmanpaşa University Medical Faculty Department of Forensic Medicine, Tokat - 2Dicle University Medical Faculty
Department of Forensic Medicine, Diyarbakır - 3Mustafa Kemal University Medical Faculty Department of Forensic Medicine, Hatay
- 4Gaziantep University Medical Faculty Department of Forensic Medicine, Gaziantep, Turkey
ABSTRACT
Aim: Injuries appeared on civilian deaths vary according to the weapon characteristics used. This study we aimed to describe
and analyze demographic characteristics of the deceased cases, quantity and qualifications of the injuries, assessment of the autopsy
findings in the light of the latest literature findings.
Material and method: Examination and autopsy records of 352 judicial death cases who have been injured and died during
the civil war in Syria between July 2012 and March 2013 were analyzed retrospectively.
Result: The most injured body parts were determined as head & neck (29%, n:239), abdomen (17%, n:1489, chest (16%,
n:140), respectively. It was detected that 41.1% (n:90) of the cases have died within the first 24 hours following the injury and the
most common cause of death was brain tissue damage and cranial hemorrhage (38.6%, n:136). Abbreviated Injury Scale (AIS) score
was determined as >3 in 96% of the deceased and Injury Severity Scores (ISS) median was 39.62±23.48 (interval 4-75).
Conclusion: In our study it was observed that quantity and qualification of the people injured in the war environment has a
high prevalence. It was detected that death occurred earlier in the injuries by bullet.
Key words: War, fatal injuries, civil deaths, Syria.
Received February 18, 2014; Accepted May 19, 2014
Aim
Civil people are also effected negatively in the
wars which occur worldwide. It is reported that
civil deaths rate is very high as well as soldier
deaths(1, 2).
Traumas appeared in soldiers are different
from those detected in civilians. Furthermore, since
penetration characteristic of the military traumas
has a high prevalence, most of them die during the
war(3, 4). Most of the injuries which appear in civilians are blunt and majority of these people die in
the hospital during the treatment (5). It has been
reported that mortality and morbidity rate in soldiers and civilians during the war is associated with
the weapons used(6-8).
Individuals who were injured during the civil
war in Syria are referred to the hospitals in
Gaziantep and Kilis which are Southeastern neighbor of our country for treatment. However, some of
the cases die in here. In this study we aimed to
describe and analyze demographic characteristics of
the deceased cases, quantity and qualifications of
the injuries, assessment of the autopsy findings in
the light of the latest literature findings.
Material and method
Examination and autopsy records of deceased
cases were analyzed by getting permission from
Gaziantep Chief Prosecution Office. Hospital
records, examination and autopsy records of 352
798
judicial death cases who have been injured and died
during the civil war in Syria within a 9 month period between July, 2012 and March 2013 were analyzed retrospectively. Cases were assessed according to age, gender, injury form and injured area,
treatment period, time between the injury and the
death, examination and autopsy findings and cause
of death. Two forensic science specialists have
searched in company with an autopsy technician if
there was a metallic body image by a radiological
examination before the examination and autopsy
procedures of the deceased. Statements of the relatives were considered for the cases with insufficient
information with the injury.
Mean Abbreviated Injury Scale (AIS) code
and Injury Severity Scores (ISS) were calculated by
two independent physicians according to hospital
records, examination and autopsy records of the
deceased people. Statistical analysis of unequal
variance of the data obtained by simple student ttest through SPSS 13.0 (Statistical Package for
Social Sciences) package program for Windows.
Bekir Karaarslan, Cem Uysal et Al
been detected in 49.1% (n:114) of the cases whereas abdominal injury has been detected in 7.5%
(n:17), chest injury has been detected in 6.1%
(n:14) and multiple injuries have been detected in
51.9% (n:118) of such cases.
It was detected in the cases that injuries
caused by shrapnel pieces were the most common.
This was followed by injuries caused by sharpnel
pieces, firearm bullet, burn, bodies protruded as a
result of an explosion and blunt injuries due to hitting a hard surface after the explosion, respectively.
Injury sites were detected as head-neck by
29% (n=239), abdomen by 17%, chest by 16% and
lower extremities by 15% (Figure 1). Number of
penetrating injury sites on the body of the cases was
854 in total and mean penetrating injury site of each
case was found 2.42. It was detected that number of
injuries have differed according to the weapon type
used. There was a significant difference between
number of penetrating injury caused by bomb
explosion and by firearm bullet. (p<0,01) (Fig. 1)
Results
Between July 2012 and March 2013, 352
death cases due to the civil war in Syria were determined. It was found that 88.4% (n=311) of the
cases were male and 11.6% (n=41) were female;
the mean age of the male and female cases was 27.3
± 12.6 (min:1, max:75) and 25.8 ± 20.7 (min:3,
max:80), respectively. It was also determined that
21% (n:74) of the cases were below 18 years of age
and 3.9% (n:14) were 60 years and above.
Autopsy was performed onto 87.8% (n:309) of
the cases and corpse examination was done on
12.2% (n:43) of the cases. Corpse examination and
autopsy procedures of 97.2% of the cases have been
performed by a forensic science specialist. During
the x-ray scan performed before corpse examination and autopsy, no metallic body has been detected on the body of 65.5% (n:232) of the cases
whereas metallic bodies due to bomb explosion
have been found in 28.7% (n:101) and firearm bullet in 5.4% (n:19 ) of the cases. Nineteen bullets
and 101 shrapnel pieces have been removed from
the head in 73.7% (n:14) and 69.3% (n:70) of the
cases, respectively.
Among 232 cases whom no metallic image
has been detected in the body, injury on one body
site only (at most head-neck; 33.80% (n:70)) has
Figure 1: Distribution of the injuries according to the
body sites.
Prevalence of fatal injuries occurred by bombing (n:101) was more than firearm bullets (n 19)
and therefore treatment period in the hospital was
longer. A statistically significant difference was
detected in the period between firearm injury and
shrapnel injury by bombing and the death (p<0.01).
It was detected that 29.2% of the cases have died
before reaching to the hospital and 11.9% of the
cases have died in the hospital within 24 hours
(Figure 2).
Figure 2: Distribution of the treatment periods between
the injury and the death.
Evaluation of the death cases occurred as a result of injury during war
Cause of death was brain tissue damage and
cranial hemorrhage in 136 (38.6%) cases, visceral
organ damage due to abdominal penetration and
bleeding in 30 (8.5%) cases, visceral organ damage
due to chest penetration and bleeding because of
large vascular damage in 26 (7.4%) cases and visceral organ damage due to multiple injury and
bleeding because of large vascular damage in
45.5% the cases.
Cause of death for the cases who have died
just after the injury was brain tissue damage and
brain hemorrhage (29.2%) and cause of death of
deceased individuals who have died after the treatment in the hospital was multiple organ injuries
(brain, lungs, liver, large vascular damage, infection, burn).
Figure 3: AIS score diagram.
AIS and ISS score calculation was performed
according to the surgery and hospital records in 46%
of the cases and corpse examination and autopsy
findings in 54% of the cases. AIS score was 3 and
more in 96% of all cases. Among the cases, 25% was
assessed as unsurvivable (Figure 3).
Figure 4: Distribution of injury severity of the cases.
Mean ISS of the cases was detected as 39.62 ±
23.48 (interval 4-75). ISS score according to the
period between the injury and death was determined as mean ISS of 66.76±16.60(n=64) for those
who have died just after the injury, as 31.76±17.12
(n=26) for those who have died within the first 24
hours and as 27.33±13.88(n=15) in the group who
have died after 1 day (Figure 4). A significant difference was detected between mean ISS of the
group who have died just after the injury and other
groups p<0.01.
799
Discussion
It is reported that 18.6% of the deaths due to
firearm injury occur during the war. Injuries
appeared on the civilian and soldiers during the war
are different. It was determined that civil traumas
have a blunt characteristics in general whereas war
traumas cause penetrating injuries on the body
because of firearm bullet and explosive materials
(shrapnel etc.). It is also reported that injuries
caused by bomb explosion are more fatal than the
injuries due to firearm bullet(9-12).
In line with the literature, number of injuries
and fatal injuries on the cases were detected more
as a result of the bomb explosion. It was detected
that 84% (101 of 120) of cases whom metallic
images were detected during the x-ray examination
got injured because of bombs and shrapnel.
In a study where injury sites of the deceased
soldiers who have been injured during the war were
searched(13), it has been reported that injuries on the
head, neck, chest and abdomen were more fatal
whereas extremity injuries were less fatal. It has
been specified that most of the cases die within the
first 30 minutes on the conflict zone or after they
were taken to the hospital. It has been reported in a
study conducted on the cases who have been
injured and treated in the hospital and where the
civil mortality was 3.9%(12) that injuries occur on the
muscular and soft tissues and these are followed by
osseous tissue, abdomen and thorax injuries.
In several studies it has been stated that
injuries occurred on the soldiers were penetrating
whereas civilians were blunt ones; the cause for
that was the equipment used. It has been reported
that fatal injuries occurred because of broken rocket
was more than those occurred by firearms(9,10). It
was detected in our study that number and extensity
of the fatal injuries due to bomb parts were more
than those occurred by firearms. However, it should
be noted that our study included cases who have
been brought as injured and died after the treatment. Our cases have been reported as civilians
according to the information provided by the relatives. It is a deficiency of our study that we do not
know how many of these deceased individuals were
personnel in operation or how many of them were
civilians.
In our study, common injuries of the head,
chest and abdomen were higher as already stated by
similar studied conducted in the literature. In parallel with injury sites, the most common cause of
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Bekir Karaarslan, Cem Uysal et Al
death was noted as brain damage and bleeding and
visceral organ damages(13-15).
In line with the studies conducted before
(10,13), when we compare the distribution of severity of the injuries (AIS>3), we detected that they
mainly involve the head, chest, abdomen and lower
extremity. Injuries on the extremities were rarely
fatal. ISS average was found higher in the groups
over 16+. Severity of the wound was higher in the
groups who have died just after the injury and/or
within the first 24 hours. As the treatment period
prolongs, ISS average was detected lower.
The period between the injury and the death
was similar with the previous studies(3,13). Cases who
have died just after the injury without accessing to
the hospital were 29% of all cases and 11.9% of the
cases were those who have died within the first 24
hours. It was determined that approximately 42% of
the cases have died within the first 24 hours following the injury. We believe that timely medical aid
on suitable conditions significantly decrease the
mortality. Especially, if hospitals would be set up
close to the war environment and the personnel
who will work there was trained about trauma
surgery, death cases as a result of injury will
decrease.
Consequently, it was observed that injuries
occurred during the war have a very high prevalence in terms of quantity and qualification by
effect of the developed weapon technology. It was
detected that death occurred earlier in the injuries
by bullet. Cases who could be analyzed within this
study were those who have been injured and could
pass the border and get medical intervention. It is
believed that those who have died in the war zone
have severe injuries. We believe that especially
civilians who do not have the training and protection methods like soldiers are effected more from
high explosive bombs.
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_________
Corresponding Author
CEM UYSAL, M.D.
Dicle University School of Medicine
Department of Forensic Medicine
Diyarbakir
(Turkey)