Analysis of 193,618 trauma patient presentations in war-affected Syria from July 2013 to July 2015

Introduction Since 2011, the Syrian war has produced a mounting toll in terms of deaths and displaced persons. We present an analysis of demographic and temporal patterns of trauma patient presentations to Syrian hospitals in non-governmental, non-Islamic State (NGNI) regions from 2013 – 2015. Methods We analyzed an administrative dataset of patient presentations to 95 NGNI Syrian hospitals in regions outside of Syrian government control from July 2013 – July 2015. Descriptive analysis of this secondary data is reported and logistic regression was performed to assess for factors associated with inpatient mortality. Results 193,618 trauma patients presented to 95 NGNI hospitals from July 2013 – July 2015 (154,225 male, 79.7%; 39,393 female, 20.4%). Age information was complete for 160,237 encounters (82.8%): 0-2y: 8,257 (4.3%), 3-12y: 24,199 (12.5%), 13-18y: 22,482 (11.6%), 19-60y: 100,553 (51.9%), and elders over 60 years: 4,746 (2.5%). 59,387 patients were admitted (Ward 57,625; ICU 1,762) for an average length of stay of 3.80 days. There were 2,694 inpatient deaths (4.5% of admitted) and 4,758 patients (8.0%) required transfer to another facility for definitive care. Shrapnel (81,946; 42.3%) and blunt/crush injuries (71,477; 36.9%) were dominant injury mechanisms with an increasing proportion of these injuries over time. Inpatient mortality was most associated with extremes of age (age less than 2 aOR 2.92; age greater than 60 aOR 2.48), penetrating chest trauma (gunshot-chest aOR 6.03) and neurotrauma (blast-head aOR 13.42; blast-spine aOR 11.31; gunshot-head aOR 10.07; shrapnel-head aOR 6.34). Civilians presentations increased from 20% at start of data collection to a peak of 50% in June 2015. Conclusion The Syrian war has resulted in large volumes of trauma patients and significant mortality at NGNI Syrian hospitals. Mortality was most associated with neurotrauma and penetrating chest trauma. There was an increasing trend over time towards blunt/crush and shrapnel injuries consistent with the transition to the widespread use of aerial bombardment with resultant explosions and building collapse. Civilians including children and the elderly represent high proportions of the injured in NGNI Syrian hospitals. Additional work is needed to improve documentation of clinical service and to assess outcomes of care to improve quality of services provided to Syrian war trauma patients. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The Union of Medical Care and Relief Organizations funded the collection of the underlying administrative dataset. There was no funding for the study itself other than salary support for the lead author HM from Yale University ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The institutional review board of Yale University approved this study I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes The data for this study is available upon request from the authors.