European Journal of Cardio-Thoracic Surgery 0 (2017) 1–8 ORIGINAL ARTICLE

doi:10.1093/ejcts/ezx036

Cite this article as: Boddaert G, Mordant P, Le Pimpec-Barthes F, Martinod E, Aguir S, Leprince P et al. Surgical management of penetrating thoracic injuries during
the Paris attacks on 13 November 2015. Eur J Cardiothorac Surg 2017; doi:10.1093/ejcts/ezx036.

Surgical management of penetrating thoracic injuries during

THORACIC
the Paris attacks on 13 November 2015
Guillaume Boddaerta,*, Pierre Mordantb, Françoise Le Pimpec-Barthesc, Emmanuel Martinodd,
Sonia Aguira, Pascal Leprincee, Mathieu Rauxf, Jean-Paul Coue €tilg, Antonio Fioreg, Thomas Lescoth,
Brice Malgrasi, François Ponsj and Yves Castierb
a
Division of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France
b
Division of Thoracic and Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris Diderot University, Paris, France
c
Division of Thoracic Surgery, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
d
Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris Seine-Saint-Denis, Avicenne Hospital, Department of Thoracic and Vascular Surgery.
Sorbonne Paris Cité, Paris 13 University, Faculty of Medicine SMBH, Bobigny, France
e
Division of Cardiac surgery, Pitié Salp^etrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris Curie University, Paris, France
f
Department of Anaesthesiology and Intensive Care, Pitié Salp^etrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris Curie University, Paris, France
g
Division of Cardiac Surgery, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Paris Est University, Créteil, France
h
Department of Anaesthesiology and Intensive Care, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Universités, UPMC Univ Paris 06,
France
i
Division of Visceral and General Surgery, Bégin Military Teaching Hospital, Saint-Mandé, France
j
French Military Health Service Academy, Ecole du Val-de-Gr^ace, Paris, France

* Corresponding author. Division of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, 101 avenue Henri Barbusse, BP 406, 92141 Clamart, France. Tel:
+33-1-41466627; fax: +33-1-41466169; e-mail: guillaume.boddaert@intradef.gouv.fr (G. Boddaert).

Received 20 November 2016; received in revised form 31 December 2016; accepted 17 January 2017

Abstract
OBJECTIVES: The Paris terrorist attacks on 13 November 2015 caused 482 casualties, including 130 deaths and 352 wounded. Facing these
multisite terrorist attacks, Parisian public and military hospitals simultaneously managed numerous patients with penetrating thoracic inju-
ries. The aim of this study was to analyse this cohort, the injury patterns, and assess the results of this mobilization.
METHODS: The clinical records of all patients admitted to Parisian public and military hospitals with a penetrating thoracic injury related
to the Paris 13 November terrorist attacks were reviewed.
RESULTS: The study group included 25 patients (7% of the casualties) with a mean age of 34 ± 8 years and a majority of gunshot wounds
(n = 20, 80%). Most patients presented with severe thoracic injury (Abbreviated Injury Score Thorax 3.3 ± 1.2), and also associated non-
thoracic injuries in 21 cases (84%). The mean Injury Severity Score was 26.8 ± 9.4. Eight patients (32%) were managed with chest tube inser-
tion and 17 (68%) required thoracic surgery. Lung resection, diaphragmatic repair, and lung suture were performed in 6 (36%), 6 (35%),
and 5 cases (29%), respectively. Extra-thoracic surgical procedures were performed in 16 patients, mostly for injuries to the extremities.
Postoperative mortality was 12% (n = 3) and postoperative morbidity was 60% (n = 15),
CONCLUSIONS: The coordination of Parisian military and civilian hospitals allowed the surgical management of 25 patients. The mortality
is high but consistent with what has been reported in previous series. The current times expose us to the threat of new terrorist attacks and
require that the medical community be prepared.
Keywords: Penetrating thoracic injury • Terrorist attack • Gunshot wound • Suicide-bombing attack

INTRODUCTION penetrating thoracic injuries are infrequent and mostly managed

Most large series of penetrating thoracic injuries have been re-
ported by the military services [1–3] and North American trauma
centres [4]. These institutions have dedicated trauma teams, tech-
nical facilities, emergency protocols, and surgical training, to de-
liver the fastest and the most efficient management to these
kinds of patients [5]. The context is very different in France, where
by organ-based surgical specialists in non-military hospitals. The
management of these patients therefore represents a particular
challenge.
Facing multisite terrorist attacks on 13 November 2015,
Parisian public and military hospitals managed numerous pa-
tients with multiple injuries following the protocol of a hospital
mobilization plan called the ‘White Plan’ (Plan Blanc) [5].

C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
2 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery

The White Plan allows the mobilization of all hospitals within the
Paris area, the recall of caregivers, and the release of beds to
cope with a large influx of wounded people. The Paris 13
November terrorist attacks have justified the activation of the
White Plan for the first time in the last 20 years. The aim of this
study was to assess the results of this mobilization in the manage-
ment of penetrating thoracic injury.
hall–hundreds of people were then held hostage until 00:23 am.
The terrorists were armed with explosive belts and firearms as re-
ported above. Overall, these multisite terrorist attacks have been
responsible for 482 casualties, including 130 deaths and 352
wounded.
Study design

PATIENTS AND METHODS
Attacks
Three groups of 3 terrorists attacked the Paris area on 13
November 2015 (Fig. 1). From 9:17 pm to 9:53 pm, 3 explosions
occurred at the Stade de France, a stadium located in the north
of Paris. These explosions were the result of 3 suicide bombing
attacks (SBA) using explosive belts that included triacetone triper-
oxyde (TATP) and metallic pieces, mostly bolts. At 9:41 pm, an-
other SBA took place in a bar in the 11th district of Paris. At the
same time, from 9:25 pm to 9:43 pm, 3 shooting incidents
occurred at the terrace of several bars and restaurants in the
10th and 11th districts of Paris. The terrorists were moving by car
using military grade firearms, Kalashnikov AK47 and Zastava
M70. At 9:40 pm, a massacre took place in the Bataclan concert
The clinical records of all patients presenting with a penetrating
thoracic injury related to the Paris 11/13 terrorist attacks were re-
viewed. Accrual completeness was ensured by direct contact
with medical and surgical directors of hospitals involved in the
management of the Paris 11/13 victims. Pre-hospital admittance
categorization was reported as absolute emergency (AE) or rela-
tive emergency (RE) according to the pre-hospital admittance
rescue organization plan called the ‘Red Plan’ (Plan Rouge). AE
may require surgery or embolization without delay whereas RE
may be managed secondarily [5]. In-hospital categorization was
reported as immediate, delayed, minimal and expectant accord-
ing to French and NATO Military Health Service recommenda-
tions [6]. In the immediate group are casualties who require
attention within minutes to 2 h on arrival to avoid death or major
disability. The delayed group included those wounded who are
in need of surgery, but whose general condition permits delay in

Figure 1: Map of Paris attacks. Map of Paris showing the terrorist attacks, location of the hospitals and distribution of patients with thoracic wounds. Red figures are
the location of terrorist attacks, (A) explosion at Stade de France, 1 person and 3 terrorists dead, (B) shooting on rue Bichat, 15 people dead, (C) shooting on rue de la
Fontaine au Roi, 5 people dead, (D) Hostage-taking in Le Bataclan concert hall, 89 people and 3 terrorists dead, (E) explosion in the Comptoir Voltaire Café, 1 terrorist
dead, (F) shooting on rue Charonne, 19 people dead. Red arrows are the primary orientations of patients with thoracic wounds. Circles are the hospitals, which
received patients with thoracic wounds and their names. Green circles are those with thoracic surgery capabilities and orange ones those without. Yellow arrows are
the secondary orientations of the patients. Figures correspond to the numbers of patients concerned.
 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery 3

THORACIC

Figure 2: Trunk impacts. (A) Patients wounded by gunshot. Figures are the number attributed to each of the patients, each circle is one impact, and each colour is for
the same patient. (B) Patients wounded by explosions. Figures are the number attributed to each of the patients, each hexagon is one impact, and each colour is for
the same patient. Coloured areas are lesional areas as defined on the figure.

treatment without unduly endangering life, limb, or eyesight. The
minimal group consists of those patients who have relatively
minor injuries and can effectively care for themselves or be
treated with minimal medical care. Patients in the expectant
group are casualties that overwhelm current medical resources at
the expense of treating salvageable patients. Severity was re-
ported using the Glasgow Coma Scale (GCS), Abbreviated Injury
Scale (AIS), Injury Severity Scale (ISS), New Injury Severity Score
(NISS), Revised Trauma Score (RTS) and TRauma and Injury
Severity Score (TRISS). An AIS >_ 3 in a body region indicated a se-
vere injury, an ISS greater than 15 indicated a severe trauma, RTS
is inversely proportional to mortality, a TRISS of 50% or less was
considered an unexpected survivor [7, 8]. Outcomes were defined
as postoperative deaths and complications that included events
occurring within 90 days after surgery or during the same hos-
pital stay if longer.
4 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery

Table 1: Patients demographics, pre-hospital care, ED status Table 2: Injury pattern and severity (n = 25)
and procedures (n = 25)
Injury pattern
Age (years) 34 ± 8 [22–56] Thoracic injuries
Male 16 (64%) Haemothorax 20 (80%)
Mechanism of injury Lung contusion 20 (80%)
GSW 20 (80%) Pneumothorax 15 (60%)
Number of impacts 2.1 ± 1 [1–5] Lung laceration 14 (56%)
SBA 5 (20%) Rib fractures 10 (40%)
Number of impacts 10.2 ± 3.83 [6–15] Diaphragm injury 6 (24%)
Pre-hospital care Scapula fracture 3 (12%)
Cardiac arrest 2 (8%) Open chest wound 1 (4%)
Mean time (min) 5 ± 0 [5–5] Pericardial effusion 2 (8%)
Catecholamine 6 (24%) Heart laceration 1 (4%)
Chest tube 0 Phrenic nerve injury 1 (4%)
Seal chest 3 (12%) Non-thoracic injuries
Pre-hospital triage categorization Extremities 12 (48%)
Absolute emergency 24 (96%) Intra-abdominal injury 10 (40%)
Relative emergency 1 (4%) Retro-peritoneal injury 7 (28%)
Patient status upon arrival in ED Spine 7 (28%)
Systolic blood pressure (mmHg) 103 ± 43 [0–176] Spinal chord 5 (20%)
Heart rate (n = 21) 95 ± 35 [0–135] Skull 3 (12%)
Respiratory rate (n = 20) 18 ± 7 (0–26) Brain 2 (8%)
GCS 12.5 ± 4.5 [3–15] Injury severity
8 4 (16%) AIS thorax 3.3 ± 1.2 [0–5]
15 15 (60%) AIS abdomen 1.8 ± 1.7 [0–4]
ED triage categorization AIS spine 1 ± 1.8 [0–5]
Immediate 7 (28%) AIS upper limb 1 ± 1.3 [0–3]
Delayed 17 (68%) AIS external 1 ± 0 [0–0]
Minimal 1 (4%) AIS head 0.5 ± 1.4 [0–5]
Expectant 0 AIS lower limb 0.5 ± 1.1 [0–3]
ED imaging AIS neck 0.1 ± 0.3 [0–1]
CXR 8 (32%) ISS 26.8 ± 9.4 [14-43]
Abnormal CXR 7/8 (88%) ISS >15 21 (84%)
(e-)FAST 12 (48%) NISS 35.3 ± 9.7 [22–59]
Pericardium positive 0 RTS (n = 20) 6.55 ± 2.58 [0–7.841]
Abdomen positive 4/12 (30%) TRISS (n = 20) 80.7 ± 31.6 [51.4–98.7]
Pleura positive 4/7 (57%)
CT scan 15 (60%) The data are presented as the n (%) and the mean ± the SD [ranges] for
continuous variables.
The data are presented as the n (%) and the mean ± the SDs [ranges] for AIS: abbreviated injury score; ISS: injury severity score; NISS: new in-
continuous variables. jury severity score; RTS: revised trauma score; TRISS: trauma and injury
ED: emergency department; GSW: gunshot wound; SBA: suicide severity score.
bombing attack; GCS: Glasgow coma score; CXR: chest X-ray; (e-)FAST:
(extended-)focused assessment with sonography for trauma; CT:
computed tomography.
P-value less than 0.05 was considered significant. The database
creation was approved by the French Committee for Informatics
and Liberty (Commission Nationale Informatique et Liberté –
Patient management CNIL, number 1977746 v 0). The study protocol was approved
by the Institutional Review Board of the French Society of
All patients were managed according to the protocol of the Thoracic and Cardiovascular Surgery (Société Française de
White Plan as already reported [5, 9, 10]. Most of patients had Chirurgie Thoracique et Cardio Vasculaire – SFCTCV, number
pre-hospital care by the fire brigade or emergency medical ser- 2016-7-19-11-21-11-MoPi). All statistical analyses were per-
vices’ teams before being referred to an appropriate trauma formed using the statistical software StatA version 12.0
centre or emergency department (ED). Some patients made their (StataCorp LP, Houston, TX, USA).
own way or were carried by relatives or witnesses to the closest
hospitals [5, 9]. All patients were managed by the Greater Paris
Public Hospitals network (Assistance Publique - Hôpitaux de RESULTS
Paris - AP-HP, a network of 40 civilian hospitals in Paris Area) or
the French Military Health Service (Hôpitaux d’Instruction des Demographic characteristics, pre-hospital
Armées - HIA, including 2 military hospitals in the Paris Area). management, emergency department status and
procedures
Statistical analysis
Twenty-five patients were admitted for penetrating thoracic in-
Categorical variables were described as count and proportion. jury related to the Paris November 13 terrorist attacks, and make
Continuous variables were described as mean and standard devi- up the study group. Attack locations and patient distribution are
ation, and compared using Student’s t-test. For all comparisons, a shown in Fig. 1. The majority of patients were male (n = 16, 64%),
 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery 5

Table 3: Surgical management (n = 25) Table 4: Postoperative outcome (n = 25)

Chest tube only 8 (32%) Mortality 3 (12%)

Thoracic surgery 17 (68%) Morbidity 15 (60%)
Time to thoracic surgery Thoracic complications 10 (40%)

THORACIC
Immediate 4 (24%) Pneumonia 5 (20%)
<1 h 1 (6%) Pulmonary embolism 3 (12%)
1 to 6 h 3 (18%) Persistent haemo or pneumothorax 2 (8%)
6 to 12 h 4 (24%) Prolonged ventilation (>21 days) 2 (8%)
>12 h 5 (28%) Mean time (n = 22) 5.3 ± 14.1 [0–52]
Exposure Haemorrhage 1 (4%)
Antero-lateral thoracotomy 4 (24%) ARDS 1 (4%)
Sternotomy 3 (18%) Non-thoracic complications 10 (40%)
Videothoracoscopy 3 (18%) Iterative surgery 16 (64%)
Postero-lateral thoracotomy 3 (18%) Thoracic 3 (12%)
Elective basi-thoracic thoracotomy 2 (12%) Non-thoracic 14 (56%)
Clamshell thoracotomy 1 (6%) Total blood products use
Wound debridement 1 (6%) RBC 6.72 ± 7.5 [0–35]
Procedure >10 RBC in 24 h 6 (24%)
Lung resection 6 (35%) FFP or PLYO 4.8 ± 8 [0–37]
Wedge resection 3 (18%) Platelets 0.6 ± 1.5 [0–7]
Formal lobectomy 3 (18%) ICU LOS (days)a 5 [1–56]
Diaphragmatic repair 6 (35%) Hospital LOS (days)a 13.5 [4–239]
Pericardiotomy 6 (35%) Discharge location
Formal lobectomy 3 (18%) Home 12 (60%)
Lung foreign body remove 3 (18%) Rehabilitation 8 (40%)
Chest wall haemostasis 3 (18%)
Pleural foreign body removal 2 (12%)
The data are presented as the n (%) and the mean ± the SD [ranges] for
Open chest resuscitation 1 (6%)
continuous variables.
Cardiac repair 1 (6%)
ARDS: acute respiratory distress syndrome; RBC: red blood cells; FFP:
Packing 1 (6%)
fresh frozen plasma; PLYO: plasma lyophilized; ICU: intensive care unit;
Other surgical procedure 16 (64%)
LOS: length of stay.
Timing of the other surgical procedure a
Before thoracic surgery 4 (25%) Median [ranges].
Concomitant 8 (50%)
After thoracic surgery 6 (32%)
Location of the other surgical procedure Surgical management
Extremity 13 (52%)
Abdomen 11 (44%)
Spine 5 (20%) Eight patients (32%) were managed with chest tube insertion
Head 1 (4%) (32%), 17 (68%) underwent thoracic surgery. Surgery was per-
formed within the first 6 hours in 7 patients (28% of the series,
The data are presented as the n (%). 41% of the patients who underwent surgery). Anterior
approaches (anterolateral thoracotomy, sternotomy, clamshell)
were the most frequent approaches (n = 8, 47%). Lung resection
was performed in 6 cases (36%), including 3 lobectomies and 3
with a mean age of 34 ± 8 years. Gunshot wounds (GSW, n = 20,
wedge resections, lung suture was performed in 5 cases (29%).
80%) were more frequent than wounds from SBA (n = 5, 20%). One patient required cardiac suture, and one patient required
The number of impacts was higher in the latter patients (2.1 ± 1 thoracic packing. Six patients (36%) had diaphragmatic repair
for GSW vs 10.2 ± 3.83 for SBA, P = 0.001). Impact locations are and 4 required an associated abdominal procedure (66%). Extra-
illustrated in Fig. 2. Before being transferred to the ED, 24 pa- thoracic surgical procedures were performed in 16 patients,
tients (96%) were classified as an absolute emergency. After triage mostly for injuries to the extremities, and were mostly carried
upon arrival at the ED, 7 patients (28%) were categorized as im- out during the thoracic procedure. Six patients (35%) have had a
mediate, and 5 patients were considered as an extreme emer- damage control procedure (thoracic n = 4, abdominal n = 2) ac-
gency and underwent surgery without prior exam (Table 1). cording to their physiological status (Table 3).

Injury pattern and severity
Most patients presented with severe thoracic injury (AIS thorax
3.3 ± 1.2), associated with non-thoracic injuries in 21 cases (84%).
In 15 patients (60%) their thoracic injury was the most severe in-
jury. The most frequent extra-thoracic injuries involved the
extremities (n = 12, 48%), the abdomen (n = 10, 40%), the retro-
peritoneum (n = 7, 28%) and the spine (n = 7, 28%). The mean ISS
score was 26.8, ranging from 14 to 43, and 21 patients (84%) had
an ISS above 15 (Table 2).
Postoperative outcome
Postoperative mortality was 12% (n = 3) and overall postoperative
morbidity was 60% (n = 15). Five patients (20%) presented with thor-
acic complications, 5 (20%) with extra-thoracic complications and 5
(20%) with both. Iterative surgeries were performed in 16 patients,
mostly for non-thoracic injuries (n = 14, 56%). Transfer from primary
to specialized centres was required in 6 cases (24%), as shown in
Fig. 1. The median ICU and hospital length of stay were 5 [1–56]
and 13.5 [4–239] days, respectively. The majority of patients were
then discharged home (n = 12, 54% of living patients) (Table 4).
6 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery

Table 5: Comparison with the recent published series of terrorist attacks

Terrorist attacks Paris, Boston, Utoya-Oslo, Israel, Mumbai, London, Madrid,

2015 2013 [9, 10] 2011 [11, 12] 2010 [13] 2008 [14] 2005 [15] 2004 [16]

Casualties 483 284 235 - 476 831 2191

Died 27% 1% 32% - 36% 7% 9%
(130/483) (3/284) (76/235) (175/476) (56/831) (191/2191)
Wounded 352 281 159 154 304 775 2000
Mechanism
Bombing 16% 100% 45% 100% Mostly combined 100% 100%
(79/483) (106/235)
Shooting 84% 0 55% 0 - 0 0
(404/483) (129/235)
Thoracic trauma 7% 2.8% 20% 37% 18% - 39%
(25/352) (7/243) (7/35) (57/154) (29/163) (199/512)
ISS 27 ± 9 12.5% > 15a 23a 22 - - 29
[14–43] [14–34] [11–75]a
Tube thoracostomy 32% 0 11 45% - - -
(8/25) (25/55)
Thoracotomy 64% 0 1 9% 3% 1 0.5%
(16/25) (5/55) (1/29) (1/199)
Thoracic mortality 12% 0 - 11% - 1 -
(3/25) (6/55)

Data are presented as n, % (n) and mean ± SD [ranges].

- : not available.
a
Overall studied population.

Table 6: Comparison with the recent published series of military and civilian thoracic trauma

Terrorist attacks Paris Mil., USA Mil., UK Mil., FR Civ., ZAF, Civ., USA Civ., TUR
2015 2012 [21] 2013 [2] 2016 [3] 2011 [22] 2001 [4] 1998 [23]

Casualties 352 23797 7856 922 1186 3049 755

Thoracic trauma 7% 9% 10% 10% 100% 100% 100%
(25/352) (2049/23797) (826/7856) (89/922)
Mechanism
Bombing 20% 62% 58% 37% - - 3%
(5/25) (1268/2049) (477/826) (34/89) (21/755)
Shooting 80% 19% 39% 53% 10% 56% 52%
(20/25) (782/2049) (320/826) (47/89) (124/1186) (1702/3049) (392/755)
Stabbing 9% 90% 44% 45%
(8/89) (1062/1186) (1347/3049) (342/755)
ISS 27 ± 9 23 ± 14 - 39 ± 18 20 ± 14
[14–43] [1–75]
Tube thoracostomy 32% 47% - 54% - 57% 60%
(8/25) (964/2049) (48/89) (1752/3049) (459/755)
Thoracotomy 64% 9% 13% 37% 9% 15% 8%
(16/25) (176/2049) (106/826) (33/89) (108/1186) (453/3049) (61/755)
Thoracic mortality 12% 8% 14% 11% 0.9% 3% 6%
(3/25) (169/2049) (118/826) (10/89) (11/1186) (86/3049) (42/755)

Data are presented as n, % (n) and mean ± SD [ranges].

Mil.: military; USA: United Sates of America; UK: United Kingdom; FR: France; Civ.: civilian; ZAF: South Africa; TUR: Turkey; - : not available; ISS: injury severity
score.

DISCUSSION coordination of Parisian public and military hospitals allowed the

Main results
Facing multisite terrorist attacks which combined assault rifles
shots and bomb explosions, the mobilization and the
emergency surgical management of 25 patients with penetrating
thoracic injuries. These dreadful attacks challenged the healthcare
system with a large number of patients with war injuries over a
short amount of time, with complex and severe thoracic injuries,
and resulted in a thoracic mortality of 12%.
 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery
Terrorist urban mass casualty incidents
In France, the medical response to a mass casualty incident is
organised according to the ‘White Plan’ that allows the mobiliza-
tion of hospitals and caregivers [5]. After previous terrorist attacks
that occurred in the Paris area on 7 January 2015, emergency
services in and out of Parisian hospitals undertook simulation ex-
ercises. The last exercise took place at 10:00 am on the morning
of November 13, but nothing could prepare the medical teams
for the violence observed that night [11]. Attacks perpetrated
with assault rifles, often combined with bombings, are associated
with a higher mortality than isolated bombings. For comparison
purposes, recent terrorist attacks targeting civilians have been
summarized in Table 5 [12–19]. The highest number of casualties
was encountered after the Madrid terrorist attacks in 2004. These
bomb attacks in trains were associated with the highest propor-
tion of patients with thoracic trauma (39%) but the lowest pro-
portion of patients undergoing thoracotomy (0.5%) [19]. In the
same way, there was only one thoracotomy after the London
bombings and none after Boston [12, 13, 18]. Reports of terrorist
incidents in Israel of 17 SBA have described a large proportion of
thoracic trauma (37%) a consequent rate of thoracotomy (9%)
and a high rate of mortality (11%) often due to associated injuries
[16]. The Utoya-Oslo and Mumbai attacks were characterized by
a balance between both bombing and shooting incidents (45%
and 55% for the first series) and resulted in an average rate of
thoracic trauma of 20% and 18%, respectively, but only one
thoracotomy for each series [14, 15, 17, 20]. The Paris attacks
with a majority of injuries from GSW (84%) resulted in one of the
lowest rates of thoracic trauma (7%) but the highest rate of thora-
cotomy (64%) and thoracic mortality (12%). Altogether, these
data confirm that bomb attacks are often associated with thor-
acic trauma, blast lung or shrapnel injuries, but these injuries in-
frequently require thoracotomy nor are they responsible for
specific thoracic mortality after hospital admission. Conversely,
GSW in unprotected civilians are often associated with severe
injuries that require surgical management and are often associ-
ated with a heavy burden of complications and mortality.
However, this has probably to be weighted by the pre-hospital
mortality.
Injury severity
For comparison purposes, recent military and civilian penetrating
thoracic trauma series have been summarized in Table 6 [2–4, 21–
23]. In the case of penetrating thoracic injury with a haemo/or
pneumothorax the AIS is at least 3. The mean thoracic AIS of our
series is 3.3 which is considered as severe. This mean thoracic AIS
is similar to that reported by Bala et al. after the SBA in Israel
which had a median thoracic AIS of 3; in addition to wartime inju-
ries reported by Ivey et al. during Operations Enduring Freedom
(OEF) and Iraqi Freedom (OIF) with a mean thoracic AIS of 2.9 [16,
21]. The injuries sustained in the Paris attack were also character-
ized by a high rate of extra-thoracic injuries (84%), the majority
involving extremities (48%), followed by abdominal injuries (40%).
De Lesquen et al. have reported similar findings during the war in
Afghanistan with 78% of extra-thoracic injuries, 56% involving the
extremities and 48% involving the abdomen [3]. Furthermore,
thoraco-abdominal and multi-cavity injuries are known to be
associated with adverse outcome [4]. In our study, the association
of severe thoracic injury and frequent extra-thoracic involvement
7
led to a mean Injury Severity Score (ISS) of 27, a high proportion
of patients (84%) with an ISS over 15 and a probability of death
above 10% [8]. This is quite similar to the report of Ivey et al. [21]
during OEF and OIF. Finally, patients with war thoracic injuries fol-
lowing terrorist attacks probably require a rapid relocation to
high-grade trauma centres for a multidisciplinary management.
THORACIC
Surgical management
In France, the management of thoracic and associated injuries
may vary according to the institution. French military surgeons
are mostly general and trauma-surgeons, who have benefitted
from a thorough training in the management of trauma, includ-
ing cardiothoracic and vascular skills, in order to master damage
control surgery in the combat environment [3]. Conversely, civil-
ian surgeons are organ-specialized surgeons, who have been
partly trained in trauma management and damage control, but
mostly used to multidisciplinary collaboration. These approaches
are complementary and their pooling appears mutually benefi-
cial since military surgeons may need organ specialization and ci-
vilian surgeons need trauma training. Despite these training
differences, our results are close to those of recent military series
[2, 3, 21]. Compared to other military and civilian series, our
study is characterized by a lower rate of tube thoracostomy man-
agement (32%) and a higher rate of thoracotomy (64%) [2–4, 21–
23]. This potentially reflects a higher incidence of high velocity
GSW among an unprotected civilian population but may also in-
dicate a surgical over-triage. Along the same lines, the thoracic
mortality in our series (12%) is quite similar to military series but
higher than civilian series [2–4, 21–23]. This may be explained by
the mechanism of injury but also by the difficulties in pre-
hospital management related to the extent of the attacks and the
security conditions.
Limitations
Missing data on the cause of death of people dead on site is a
major limitation of our study. Causes of death are still under in-
vestigation and further analyses will be of tremendous import-
ance to improve pre-hospital protocols and materials, as recently
highlighted after the Boston marathon bombing [13]. Our study
has other limitations. The extent of the attacks, the number of
hospitals involved and the multiplicity of people involved, might
have led to heterogeneous management protocols and ultimately
to missing data. However, repeated contacts with all the centres
involved in the management of patients with thoracic injuries, to-
gether with the creation of a dedicated database that included all
casualties attributed to November 13 Paris attacks, and the com-
plete follow-up of all patients included, lead to a reasonable con-
fidence into the completeness of this study.
CONCLUSIONS
The mobilization and the coordination of Parisian military and ci-
vilian hospitals allowed the surgical management of 25 patients
presenting with penetrating thoracic injury due to the Paris 13
November terrorist attacks. The mortality is high but consistent
with what has been reported in previous series. The current times
expose us to the threat of new terrorist attacks and require that
the medical community be prepared.
8 G. Boddaert et al. / European Journal of Cardio-Thoracic Surgery
ACKNOWLEDGEMENTS
We salute the strength and the determination of all the health-
care professionals committed to patients’ care during the 13
November Paris attacks, and we pay homage to the patients
and their relatives.
Conflict of interest: none declared.
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