Sustained War-Related Emergency Department Presentations and Evolving Civilian Injury Patterns During Recurrent...

Prolonged missile-related conflicts may generate evolving civilian injury patterns and continuing war-related presentations to emergency departments. Although mass casualty incidents receive substantial attention in the disaster medicine literature, less is known regarding how civilian injury profiles and war-related emergency department presentations evolve during recurrent and prolonged conflict conditions. Understanding these changes is important for healthcare preparedness and continuity of emergency services.

We conducted a retrospective observational study of civilian presentations to a large urban emergency department documented as occurring in the context of 2 conflicts involving attacks by the same regional adversary: June 13-25, 2025, and February 28-April 19, 2026. Demographic characteristics, injury severity, patient disposition, and diagnosis categories were analyzed. Because 4 nearby mass casualty incidents occurred during the first conflict period, an adjusted analysis excluding casualties presenting on mass casualty incident dates was performed to evaluate underlying wartime injury patterns. The second conflict period was additionally divided into early and later phases to assess temporal changes during prolonged conflict exposure. Daily presentation rates were calculated to account for differences in conflict duration. The study was approved by the Institutional Review Board of Edith Wolfson Medical Center (approval no. 0084-26-WOMC, 2026). The requirement for informed consent was waived due to the retrospective nature of the study.

A total of 1,018 war-related civilian ED presentations were included. Period 1 included 418 presentations over 13 days, corresponding to 32.2 presentations per day. After excluding the 4 mass casualty incident dates, 127 presentations occurred over 9 days, corresponding to 14.1 presentations per day. Period 2 included 600 presentations over 51 days, corresponding to 11.8 presentations per day. Initial analyses demonstrated lower injury severity during Period 2; however, after exclusion of mass casualty incident-associated casualties, severity distributions were similar, with mild injuries accounting for 96.1% and 97.0% of presentations, respectively. Diagnosis distributions differed significantly between periods (P < .001). Extremity injuries increased from 31.9% to 44.2% and peaked during the early phase of Period 2 at 48.2%, before declining to 34.8% during the later phase. Psychological/anxiety-related presentations decreased from 11.8% to 0.8%, while multiregion trauma reached 9.9% during the later phase of Period 2. War-related presentations continued throughout the prolonged second conflict period despite the absence of nearby missile impacts or formal mass casualty incident activation.

Civilian wartime injury profiles evolved across recurrent missile-related conflicts despite relatively stable injury severity after adjustment for local mass casualty incidents. Preparedness strategies should consider both acute mass casualty events and the continuing occurrence of predominantly low-acuity war-related emergency department presentations during prolonged conflict conditions.