Analysis of 828 servicemen killed or injured by explosion in Northern Ireland 1970-84: the Hostile Action Casualty System

Management of blast injuries and shock lung

PURPOSE OF REVIEW

Blast injuries have always occurred both in civilian life and as acts of war or terrorism. Nowadays, the risk of being involved in an explosion has increased even for those living in countries with no previous experience of such events. It is our intention that this review is of assistance to those providing emergency/critical care to patients who have sustained blast injuries.

RECENT FINDINGS

Exposure to blast may indirectly produce physiological insults such as bradycardia, hypotension, tissue hypoxia and oxidative stress. The use of early goal-directed therapy might be important in minimizing such insults. Explosions in an enclosed environment are associated with increased risk of pulmonary blast injury and also air and fat embolism. Mechanical ventilation after pulmonary blast injury is associated with barotrauma and the use of lung protective strategies previously recommended in acute lung injury may be beneficial.

SUMMARY

The potential for blast to cause injury depends on the nature of the explosive and environment in which the blast occurs. Soft tissue injury with environmental contamination is frequent. Optimal antimicrobial cover and strategies such as selective digestive decontamination may be advantageous. Early surgery should follow the principles of 'damage control'. Blast injury often leads to severe sepsis/systemic inflammatory response, multiple organ dysfunction and prolonged critical illness. In this clinical scenario, recent studies have shown improved outcome with the use of activated protein C, steroid replacement and aggressive control of blood glucose but have been less convincing regarding the use of immuno-nutrition.

Mechanisms of injury by explosive devices

Explosive devices cause injury by four mechanisms, of which primary blast injury is the least familiar to most non-military clinicians. The pathophysiology of the various mechanisms of injury is described, and the implications for translating a knowledge of mechanism of injury to clinical management is discussed.

Terrorist bombing

Bombings and explosion incidents directed against innocent civilians are the primary instrument of global terror. In the present review we highlight the major observations and lessons learned from these events. Five mechanisms of blast injury are outlined and the different type of injury that they cause is described. Indeed, the consequences of terror bombings differ from those of non-terrorism trauma in severity and complexity of injury, and constitute a new class of casualties that differ from those of conventional trauma. The clinical implications of terror bombing, in treatment dilemmas in the multidimensional injury, ancillary evaluation and handling of terror bombing mass casualty event are highlighted. All this leads to the conclusion that thorough medical preparedness to cope with this new epidemic is required, and that understanding of detonation and blast dynamics and how they correlate with the injury patterns is pivotal for revision of current mass casualty protocols.

Fatal explosion injuries in Finland: a twenty-year nationwide survey

BACKGROUND AND AIMS

Expanding violence may necessitate treatment of explosion victims, requiring a broadening of existing medical skills and knowlegde of injury mechanisms. The aim of the study was to assess the number, nature and injury pattern of fatal explosion incidents in Finland.

MATERIAL AND METHODS

Retrospective analysis of explosion-related deaths from January 1985 to December 2004. Death certificates were obtained and reviewed.

RESULTS

Over the 20-year period from 1985 to 2004, only 61 inviduals died in Finland as a result of unintentional or unspecified explosion related events. A homemade bomb assault for unknown motives killed seven people in a suburb in 2002. The incidence was 5.7 cases per 10,000,000 person-years. Suicides using explosives were slightly more common; on average 4 cases per year (6.7 cases per 10,000,000 person-years). A small increase in the fatality trend was noticeable during the last years of the study period.

CONCLUSIONS

The incidence of fatal explosion injuries is a minor problem, but a small increase can be seen during the last few years. Victims of such injuries required only minimal hospital resources, because in most cases they died at the scene. Our results suggest that efforts to prevent fatalities related to explosives or corresponding devices, or to reduce their number, should focus on prevention of intentions.

Blast injuries: from triage to critical care

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries.

The neurological consequences of explosives

Neurological injuries produced by explosive blasts are the result of a cascade of events that begin with the initial explosion and evolve from the secondary, tertiary, and quaternary effects that the explosion engenders [Lavonis EJ. Blast Injuries. EMedicine.htm]. Only the results of the primary blast are predictable, and subsequent actions ripple outward in an increasingly random and chance sequence. This article reviews and explains how the ensuing chain of circumstances injures the nervous system, and what examining physicians should anticipate when they treat these patients.

Terrorist Homicide Bombings: A Primer for Preparation

Contemporary planning for disaster response to terrorist events usually assumes the use of chemical, radiological, or biological weapons. Historically, most victims of terrorist attacks are injured by the use of conventional explosives rather than weapons of mass destruction. Such attacks will likely produce victims who have suffered burn injuries along with conventional trauma. Alternately, the large number of patients sustaining conventional soft-tissue or crush injuries will benefit from burn center expertise. This study summarizes the current state of knowledge related to the management of terrorism mass casualty incidents caused by the use of conventional explosives. A review of pertinent medical, technical, and popular literature relating to terrorism and explosives, along with instruction received at Hadassah Hospital, Jerusalem, Israel on the management of mass casualty terrorism events was undertaken, and the pertinent medical and scientific literature relating to bomb delivery methods, blast mechanics, blast pathophysiology, and medical response to a terrorist bombing is presented here. Although terrorist use of chemical, radiological, or biological weapons is possible, historical analysis consistently demonstrates that the most likely terrorist weapon causing a mass casualty event is a standard explosive device detonated in a crowded area. The medical basis for management of such casualties is herein described.

Suicide Bombing Injuries: The Jerusalem Experience of Exceptional Tissue Damage Posing a New Challenge for the Reconstructive Surgeon

BACKGROUND

Suicide bomb injuries vary in form and magnitude. From the onset of the second Palestinian "intifada" in October of 2000 until January of 2004, 577 victims of suicide bombings were admitted to the Hadassah-Hebrew University Medical Center. A single bomber carrying a handbag or belt containing multiple metal objects and explosives carried out most of the attacks. As a result, many of the victims suffered massive tissue destruction in addition to conventional blast injuries.

METHODS

This article describes the management of this trauma-related "syndrome" of combined primary and high-magnitude secondary blast injury.

RESULTS

The management of the extensive soft-tissue damage is described and two representative cases presented.

CONCLUSION

Suicide bombing-related injuries in their present form are a true challenge for the reconstructive surgeon.

TERRORISM AND BLAST EXPLOSIONS: LESSONS FOR THE AUSTRALIAN SURGICAL COMMUNITY

The prospect of a terrorist attack against Australian interests is currently being debated across our society. The explosive blast attack is most favoured by terrorists. Blast injuries create unique patterns of multisystem injury with contaminated wounds and extensive devitalized tissue. Australian civilian surgeons are increasingly likely to be involved in the management of these injuries, either in response to a terrorist incident in Australia or as part of delayed management of Australian nationals injured overseas. An appreciation of the unique complexities of blast injuries is equally important to both military and civilian surgeons. This paper covers the mechanisms and pathophysiology of blast injuries and discusses issues of surgical management as they would apply to an Australian civilian setting.

War and suicidal deaths by explosives in southwestern Croatia

A total of 853 suicides, from which 29 were committed by explosives, were recorded in the examined region during three distinctly specific intervals-peace time (1986-1990), wartime (1991-1995), and the postwar time (1996-2000). Suicides caused by explosives, without a terrorist background, from 1986-2000 were reviewed. Out of 29 suicides by explosives committed in the examined period, the age and sex of suicide victims and alcohol intoxication at the time of suicide were analyzed. In the prewar period no suicides by explosives were recorded, in distinction from wartime and the postwar period when 20 and 9 such suicides were recorded, respectively. Alcohol testing was performed in 76% of the cases, showing the highest alcohol concentration in suicides' blood in wartime with an average value of 1.58 g/kg of absolute alcohol. As to the suicides' sex, 93% of the victims were male and 7% female. The paper emphasizes the drastically increased number of suicides committed by explosives in wartime.

The Bali burn disaster: implications and lessons learned

In October 2002, a terrorist attack on a nightclub in Bali resulted in an explosion and fire, causing the deaths of more than 200 people, including 88 Australian citizens. After first aid and primary care, the injured were repatriated to Darwin for triage and continued treatment and were then disseminated to various burn units throughout Australia. At the Repatriation General Hospital Concord Sydney, we received 12 patients with burns and a variety of blast injuries. Their treatment was complicated by infection with multiresistant organisms that were previously unseen in our unit and the presence of complex shrapnel wounds. There were no deaths and, with two exceptions, all patients were discharged within 6 weeks. This incident had profound effects on our unit, particularly related to the management of high-velocity shrapnel injuries, serious ongoing septic complications, and the psychological effects on both patients and staff, all of which are detailed and discussed.

“Bomb Explosion On The Nis Express” – Lessons From A Major Incident, Kosovo 16 Feb 2001

On Friday 16 February 2001, terrorists detonated a bomb under a civilian coach travelling from Nis in Serbia to Gracanica in Kosovo. 10 people were killed at the scene. 13 casualties were treated in the British KFOR hospital (Reynolds Hospital) in Pristina. Another 8 casualties were evacuated to the American KFOR hospital at Camp Bondsteel. The incident provided a unique opportunity for co-operation between British, American, Russian, German and French KFOR hospitals, as well as with Serbian clinicians and forensic pathologists. This article analyses the medical management of this major incident, identifies the lessons to be learned from it, and also provides enough detail for teaching scenarios.

[Orthopedic surgery and traumatology]

Terrorist explosions cause destruction of material goods and human injury on such a scale that the provision of healthcare in available centers can be compromised. In the last few years we have witnessed terrible terrorist attacks that affect us increasingly closely. The authors describe the intervention of the Department of Traumatology of a university hospital in response to a terrorist attack that left nearly 2,000 persons wounded and 191 dead. As usually occurs in these attacks, the victims' lesions were characterized by the severity and extension of the tissue damage, including penetrating wounds, blast injuries and burns. Critical analysis of previous disasters described by our colleagues in the medical literature is useful to avoid future errors.

Otorrinolaringología

The terrorist attack on 11 March caused a high percentage of patients with ear injuries. Shock waves provoke alterations to the external ear as well as to the middle and inner ear. The most frequent lesion is tympanic membrane perforation. Initial evaluation with otoscopy, acoumetry, tonal audiometry and vestibular examination was performed and was repeated after 2 and 3 months. In most patients there was a correlation between the grade of middle ear lesion and auditory damage. In most patients with tympanic rupture, the perforation was total or subtotal. Spontaneous closure can occur in some patients but is usually related to the size of the initial lesion. Thus in tympanic perforations of more than 50%, spontaneous closure is unlikely.

Surgical aspects of operation Bali assist: initial wound surgery on the tarmac and in flight

BACKGROUND

The explosion of three bombs on 12 October 2002 in Kuta, Bali resulted in mass casualties akin to those seen in war. The aim of the present report is to describe the sequence of events of Operation Bali Assist including triage, resuscitation and initial wound surgery in Bali at Sanglah Hospital in the aeromedical staging facility (ASF), Denpasar airport and the evacuation to Darwin.

METHODS

A descriptive report is provided of the event and includes; resuscitation, anaesthesia, initial burns surgery management including escharotomy and fasciotomy, head injury management and importance of supplies and medical records with a description of the evacuation to Darwin.

RESULTS

Operation Bali Assist involved five C130 Hercules aircraft and aeromedical evacuation medical and nursing teams managing 66 casualties in the Denpasar area and their evacuation to Royal Darwin Hospital with ketamine the most useful anaesthetic agent and cling film the most useful burns dressing. Twelve procedures were performed at the ASF including seven escharotomies, three fasciotomies and two closed reductions. One escharotomy was performed in flight.

DISCUSSION

The important lessons learnt from the exercise is the inclusion of a surgeon in the aeromedical evacuation team, the importance of debridement and delayed primary closure, the usefulness of cling film as a burns dressing and the importance of continuous assessment. Future disaster planning exercises need to consider a patient age mix that might be expected in a shopping mall, rather than the young adult encountered in Bali, a more familiar age mix for Australian Defence Force medical staff.

Treatment of the mangled lower extremity after a terrorist blast injury

Terrorist bombings, with resultant blast injuries, have been increasing in frequency during the past 30 years. Injury to the musculoskeletal system is common in victims who survive such attacks. Substantial injury to the limbs may occur through several different mechanisms, each of which may affect prognosis and alter the treatment algorithm. An analysis of the available literature on terrorism and blast events revealed that resource use of the treating medical facility is high during the initial hours after a blast attack, but usually is manageable. A resource management protocol was developed to organize the treatment of limb salvage into four phases. This management protocol may improve the medical facility's ability to manage system resources while treating patients with severe blast injuries. The decision of whether to salvage or proceed with limb amputation is one of the most difficult in orthopaedic trauma. A basic education in the mechanisms of blast damage, a methodical approach to resuscitation, and mangled extremity treatment, likely can improve surgical success.

Injuries to the colon from blast effect of penetrating extra-peritoneal thoraco-abdominal trauma

Although rare, blast injury to the intestine can result from penetrating thoraco-abdominal extra-peritoneal gunshot (and shotgun) wounds despite the absence of injury to the diaphragm or to the peritoneum. Injuries of the spleen, small intestine and the mesentery by this mechanism have been previously reported in the world literature. This paper reports the first two cases of non-penetrating ballistic trauma to the colon.

Histologic, immunohistochemical, and ultrastructural findings in human blast lung injury

The objective of this autopsy-based study was to investigate the pathology of human blast lung injury using histology, Fat Red 7B staining, immunohistochemistry, and scanning electron microscopy on lung specimens from eight medicolegal autopsy cases of fatal close-range detonations of chemical explosives. The micromorphologic equivalents of human blast lung injury can be summarized as follows: diffuse alveolar overdistension, circumscribed interstitial hemorrhages showing a cufflike pattern around pulmonary vessels, venous air embolism, bone marrow embolism, and pulmonary fat embolism. Hemorrhages within the lung parenchyma that were present in this study in blast victims without coexisting blunt or penetrating chest trauma must be regarded as potentially life-threatening intrapulmonary bleeding sites in survivors. In addition, the potential clinical importance of the presence of massive pulmonary fat embolism, which has, to the best of our knowledge, not been described previously in human blast lung injury, must be emphasized because pulmonary fat embolism may be a leading cause of the rapid respiratory deterioration with progressive hypoxia and development of acute respiratory distress syndrome in blast victims who survive. Furthermore, this study provides evidence that air embolism presenting in blast victims is not a mere ventilation-induced artifact.

Explosions and blast injuries

Powerful explosions have the potential to inflict many different types of injuries on victims, some of which may be initially occult. Flying debris and high winds commonly cause conventional blunt and penetrating trauma. Injuries caused by blast pressures alone result from complex interactions on living tissues. Interfaces between tissues of different densities or those between tissues and trapped air result in unique patterns of organ damage. These challenge out-of-hospital personnel, emergency physicians, and trauma surgeons to specifically seek evidence of these internal injuries in individuals with multiple trauma, adjust management considerations to avoid exacerbation of life-threatening problems caused by the blast wave itself, and ensure appropriate disposition of these patients in possible mass-casualty situations. Knowledge of the potential mechanisms of injury, early signs and symptoms, and natural courses of these problems will greatly aid the management of blast-injured patients.

Ocular injuries sustained by survivors of the Oklahoma City bombing

OBJECTIVE

The purpose of this study is to provide a review of the ocular injuries sustained by survivors of the April 19, 1995, bombing of the Alfred P. Murrah Federal Building in Oklahoma City.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

The authors retrospectively evaluated data collected on all surviving persons receiving ocular injuries during the bombing and on all at-risk occupants of the federal building and four adjacent buildings.

METHODS

Injury data from survivors were collected from multiple sources to include hospital medical records, a physician survey, emergency medical services run reports, written survivor accounts, building occupant survey, telephone interviews, and mail surveys.

MAIN OUTCOME MEASURES

The types of ocular injuries, the associated systemic injuries, and the location of the injured at the time of the blast were evaluated.

RESULTS

Fifty-five (8%) of the 684 injured bombing survivors sustained an ocular injury. Persons injured in the Murrah building were more than three times more likely to sustain an ocular injury than other injured persons. Seventy-one percent of ocular injuries occurred within 300 feet of the point of detonation. The most common serious ocular injuries included lid/brow lacerations (20 patients, 23 eyes), open globe injuries (12 eyes), orbital fractures (6 eyes), and retinal detachment (5 eyes). A retained intraocular foreign body accounted for only two of the injuries (4%). Glass accounted for nearly two thirds of the ocular injuries.

CONCLUSIONS

Blasts involving explosions inflict severe ocular injury, mostly as a result of secondary blast effects from glass, debris, etc. Eye injuries in bombings can probably be prevented by increasing the distance from and orientation away from windows (i.e., by facing desks away from windows). Use of such products as laminated glass, toughened window glazing, and Mylar curtains may reduce glass projectiles in the blast vicinity.

Imaging in thoracic trauma: the trauma surgeon's perspective

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.

Medical consequences of terrorism. The conventional weapon threat

As long as gunpowder and explosives are used to solve disagreements between nations, ethnic groups, and individuals, victims of blast injury continue to arrive occasionally at trauma centers around the world. Bombs planted in crowded urban locations or suicide bombings continue to stress civilian EMS and urban medical systems. Although the clinical presentation depends on whether the blast occurs in open or confined quarters, open air, or water, the pattern of injury inflicted on the body is relatively consistent. The proximity to the detonating device is probably much more important than the size of the bomb. If not injured by secondary, tertiary, or other miscellaneous mechanisms of most conventional bombs with 1 to 20 kg of TNT, people at distances exceeding 6 m will probably not experience substantial blast-induced injury. Three systems are prone to injury. The first is the auditory system, with damage to the eardrum in milder cases and inner-ear injury in more severe cases. The alimentary tract with contusions, hematoma, and occasional perforation of a hollow viscus is the second system involved. Solid organs are rarely damaged in survivors of blast injury. Close proximity to the blast can impose traumatic amputation of limbs (i.e., arms and legs) and ear lobes. Most of these victims succumb to their injuries in the immediate post-injury phase, but the hallmark of blast injury is the involvement of the respiratory system. With expeditious evacuation performed by efficiently coordinated and highly skilled EMS personnel, more patients with blast injuries arrive with signs of life to the medical facility. At the medical facility, the staff need to triage many victims into urgent and nonurgent groups. Only lifesaving procedures should be performed during the initial phase. Later, medical care is directed at patients moved to ICUs. Prompt evacuation after necessary lifesaving procedures in the field; proper triage and distribution; prudent hospital triage and surgical care; and, last but not least, expert critical care provide the best possible outcome in such circumstances.

Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review

OBJECTIVE

To determine the implications of variation in mortality associated with use of weapons in different contexts.

DESIGN

Literature review.

SETTINGS

Armed conflicts and civilian mass shootings, 1929-96.

MAIN OUTCOME MEASURE

Mortality from wounds.

RESULTS

During the fighting of war the number of people wounded is at least twice the number killed and may be 13 times as high; this ratio of the number wounded to the number killed results from the impact of a weapon system on human beings in the particular context of war. When firearms are used against people who are immobilised, in a confined space, or unable to defend themselves the wounded to killed ratio has been lower than 1 or even 0.

CONCLUSIONS

Mortality from firearms depends not only on the technology of the weapon or its ammunition but also on the context in which it is used. The increased mortality resulting from the use of firearms in situations other than war requires a complex interaction of factors explicable in terms of wound ballistics and the psychology of the user. Understanding these factors has implications for recognition of war crimes. In addition, the lethality of conventional weapons may be increased if combatants are disabled by the new non-lethal weapons beforehand; this possibility requires careful legal examination within the framework of the Geneva Conventions.

Blast injury from explosive munitions

OBJECTIVE

To evaluate the effect of blast in common war injuries.

METHODS

One thousand three hundred and three patients injured by explosive munitions and demonstrating extremity wounds without other penetrating injuries were admitted to the Military Medical Academy in Belgrade between 1991 and 1994. Of these, 665 patients (51%) had symptoms and physical signs that were compatible with the clinical diagnosis of primary blast injury, whereas the remaining 658 patients did not.

RESULTS

Random sampling of 65 patients in the blast group during the early posttraumatic period showed statistically significant elevations in blood thromboxane A2 (TxA2), prostacyclin (PGI2), and sulfidopeptide leukotrienes compared with the random sample of 62 patients in the nonblast group. This difference could not be accounted for by differing injury severity between the groups, because the severity of wounds as measured by both the Injury Severity Score and the Red Cross Wound Classification was similar in both groups. Amongst blast patients, 200 patients (30%) had long-term (1 year) symptoms and signs reflecting central nervous system disorders. These symptoms and signs were only sporadically found in 4% of the nonblast patients. These findings indicate that primary blast injury is more common in war injuries than previously thought and that of those affected by blast, a surprisingly high proportion retain long-term neurologic disability. The elevation in eicosanoids could be used to confirm and monitor blast injury.

CONCLUSION

In relation to the immediate management of patients injured by explosive weapons, it follows that particular attention should be paid to the presence and/or development of blast injury. Our findings indicate that blast is more common in war injuries than previously thought. Eicosanoid changes after blast injury suggest that blast injury causes a major physiologic stress. A variety of effects on the central nervous system suggest that blast injury could be responsible for some aspects of what is now considered to be the posttraumatic stress disorder.

Blast lung injury from an explosion on a civilian bus

OBJECTIVE

To assess clinical signs and management of primary blast lung injury (BLI) from explosions in an enclosed space and to propose a BLI severity scoring system.

DESIGN

Retrospective analysis.

PATIENTS

Fifteen patients with primary BLI resulting from explosions on two civilian buses in 1996.

RESULTS

Ten patients were extremely hypoxemic on admission (PaO2 < 65 mm Hg with oxygen supplementation). Four patients remained severely hypoxemic (PaO2/fraction of inspired oxygen (FIO2) ratio of < 60 mm Hg) after mechanical ventilation was established and pneumothoraces were drained. Initial chest radiographs revealed bilateral lung opacities of various sizes in 12 patients (80%). Seven patients (47%) had bilateral pneumothoraces and two patients had a unilateral pneumothorax. Five (33%) had clinically significant bronchopleural fistulae. After clinical and laboratory data were collected, a BLI severity score was defined based on hypoxemia (PaO2/FIO2 ratio), chest radiographic abnormalities, and barotrauma. Severe BLI was defined as a PaO2/FIO2 ratio of < 60 mm Hg, bilateral lung infiltrates, and bronchopleural fistula; moderate BLI as a PaO2/FIO2 ratio of 60 to 200 mm Hg and diffuse (bilateral/unilateral) lung infiltrates with or without pneumothorax; and mild BLI as a PaO2/FIO2 ratio of > 200, localized lung infiltrates, and no pneumothorax. Five patients developed ARDS with Murray scores > 2.5. Respiratory management included positive pressure ventilation in the majority of the patients and unconventional methods (ie, high-frequency jet ventilation, independent lung ventilation, nitric oxide, and extracorporeal membrane oxygenation) in patients with severe BLI. Of the four patients who had severe BLI, three died. All six patients with moderate BLI survived, and four of five with mild BLI survived (one with head injury died).

CONCLUSIONS

BLI can cause severe hypoxemia, which can be improved significantly with aggressive treatment. The lung damage may be accurately estimated in the early hours after injury. The BLI severity score may be helpful in determining patient management and prediction of final outcome.

Physiologic responses to primary blast

BACKGROUND

Primary blast injuries are produced by the blast shock wave. The critical determinant of survival is pulmonary injury, but acute cardiorespiratory responses to blast exposure are not well understood. The aim of this study was to investigate these changes.

METHODS

Twenty anesthetized rats were exposed to moderate blast overpressure, 10 animals receiving thoracic and 10 receiving abdominal exposure. Another 9 animals acted as controls. Respiration, heart rate, and blood pressure were recorded continuously before, during, and for 6 hours after blast exposure.

RESULTS

All animals exposed to thoracic blast demonstrated apnea, bradycardia, and hypotension after blast exposure, followed by a return to preblast values. No significant cardiovascular or respiratory changes were seen in animals in the other groups.

CONCLUSION

Moderate thoracic blast injury produces a reflex triad of apnea, bradycardia, and hypotension that is not present after abdominal blast. These observations may have important implications for the immediate management of patients with blast injuries.

Victims of the Palestinian uprising (Intifada): a retrospective review of 220 cases

The purpose of this study was to review the cases of the victims of the Palestinian uprising (Intifada) and to describe the clinical presentations, the types of weapons used, and the different sites of injuries. This is a retrospective chart review study of the patients who were injured during the Palestinian uprising in the period April 1993-April 1994 and treated in the emergency department of the Barzilai Medical Center, Ashkelon, Israel. The Barzilai Medical Center is a regional level II trauma referral general hospital. Two hundred and twenty patients were injured during the Palestinian uprising and referred to our emergency department. Forty-one patients were citizens of the Gaza area, 26 patients were Israeli civilians, and 153 were Israeli soldiers. There were 55 patients (25%) injured by firearms, 10 patients (4.5%) by explosives, and 120 (54.5%) by striking stones. Seventy-three patients (33.2%) were hospitalized, and 22 patients needed surgery. The most commonly injured part of the body was the lower limb among the Gaza citizens and the head and neck among the Israeli soldiers and civilians. Striking stones was the most common means of injury used by the Palestinians, and stab wounds by knives and other sharp objects were the most common injuries among Israeli civilians. None of the patients suffered direct blast injuries. The Palestinian uprising resulted in many victims and disabled people in both nations. Terrorism did not cease after the peace treaty. It changed its face and moved from Gaza to the center of Israel. Suicidal terrorist bombing in public spaces and public buses carries more danger and more victims with much more severe injuries. We hope that the future will be brighter, and both nations will eventually be able to live in peace.

Suicide bombers in Israel

Between 1993 and 1995, 14 suicidal terrorist bombings took place in Israel; 86 victims perished in these attacks, which were carried out by militant Palestinian organizations that oppose peace treaties between the state of Israel and the Palestinian people. The modus operandi of the perpetrators was detonating, in a public area, an explosive device carried on or in close proximity to the terrorist's body. We reviewed the postmortem examinations and identification procedures performed by the medical and law enforcement personnel involved in mass disaster management. The types of injuries sustained by the victims and perpetrators include body disruption, explosive injuries, flying missile injuries, and blast injuries. Blunt trauma directly produced by the explosion and flying missile injuries account for 80.1% of the wounds. The number of fatalities was more closely related to the type of the attack rather than to the amount and type of explosives used. Swift identification of all victims and perpetrators was obtained through collaboration between the different professional teams involved: forensic scientists, law enforcement agencies, and secret service investigators. Based on the analysis of the data obtained from the necroscopic examinations, we observed that most of the wounds sustained fall within the realm of blunt force injuries; emergency medical facilities that might be faced with similar situations should prepare accordingly. Collaboration between the various forensic and law enforcement teams results in swift resolution of disaster management. Prompt identification of the perpetrators allows the authorities to apprehend any accomplices and to prevent similar attacks.

Cardiopulmonary effects of high-impulse noise exposure

In high-energy impulse noise environments, the biomechanical coupling process between the external forces and the pathophysiology of cardiopulmonary injury is not well understood. A 12-in-diameter compressed air-driven shock tube with reflector plate was used to induce three levels of pulmonary contusion injury in a large animal model. Twenty-one anesthetized sheep were exposed to the various levels of impulse noise generated by the shock tube, with six additional sheep serving as a control group. Pathologic evaluations, performed 3 hours after exposure, showed pulmonary contusion ranging from minor petechial changes on the surface of the lung parenchyma to diffuse ecchymoses affecting as much as 60% of the lung. The gross pathologic observations of injury produced by exposure to the impulse noise produced by the shock tube were similar to those reported for blunt impact trauma or exposure to chemical or grain-dust explosions. The extent of lung injury (lung injury index) was quantitatively assessed. A semilogarithmic relationship between the lung injury index and the measured peak pressure was demonstrated. A significant linear correlation was demonstrated between lung injury index and lung weight-to-body weight ratio. Significant cardiopulmonary changes were also observed as a result of exposure to high-impulse noise. Although in most cases the degree of change was related to the severity of the injury, significant cardiopulmonary function changes were also observed in the absence of significant grossly observable pulmonary injury. Cardiac injury was indicated by decreased cardiac output and hypotension at all levels of injury and might be the result of myocardial contusion or air emboli. Pulmonary injury was demonstrated by respiratory acidosis, increases in lung resistance, and decreases in lung compliance and lung volume. Arterial PO2 appeared to be the most sensitive parameter of injury and was decreased for all measurement intervals for all exposure groups.

Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions

OBJECTIVES

To compare injury patterns resulting from explosions in the open air versus within confined spaces.

METHODS

Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations.

RESULTS

A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001).

CONCLUSION

Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.

Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation?

Blast injuries are rare, and although blast-induced perforations of the bowel have been described in the past, the entity of a delayed perforation caused by an evolving injury has not been reported. We report three men injured by the explosion of a terrorist bombing in open air. They suffered primary blast injuries, which resulted in isolated perforations of the terminal ileum. They were operated at different times after the blast event. The resected specimens were examined under light microscopy. One patient was operated immediately, and had three perforations in the terminal ileum. In the other two patients, abdominal complaints appeared only 24 and 48 hours later. These two patients were found to have hematomas in the wall of the terminal ileum, and small perforations therein, with almost no contamination of the peritoneal cavity. On histological examination, there were small perforations with disruption of all intestinal layers. In the vicinity of the perforations, the mucosa was necrotic and disorganized. The submucosa showed edema and vascular thrombi, and at several points mucus was shown dissecting through the muscularis propria, thus creating minute microperforations. Because of the findings in these patients, we suggest a mechanism of evolving damage to the bowel wall and delayed perforation rather than delayed diagnosis, after blast injuries. We suggest that patients exposed to a significant blast should be watched carefully for at least 48 hours.

Epidemiological approach to surgical management of the casualties of war

The nature of modern conflicts precludes adequate medical care for most people wounded in wars. The traditional military approach of echeloned care for those wounded on the battlefield has limited relevance. I present an alternative, epidemiological approach whereby some effective care may reach many more. For a surgical facility to have a positive impact by using surgical and anaesthetic competence there must be access to the wounded; security for staff and patients; and a functioning hospital infrastructure. These all depend on respect for the first Geneva convention. Early hospital admission for urgent surgery is not so important if there is adequate first aid beforehand. The hospitals of the International Committee of the Red Cross have provided surgical care for thousands of wounded people by fulfilling these conditions. People wounded in modern conflicts would fare better if these priorities were recognised and less emphasis was placed on the more spectacular aspects of surgical care that benefit only a few.

Tympanic membrane perforation in survivors of a SCUD missile explosion

On February 25, 1990, an Iraqi SCUD missile exploded inside a building housing United States military personnel in Dhahran, Kingdom of Saudi Arabia. One hundred seventy-two individuals who were near the impact site at the time of the blast were interviewed and examined to determine blast injury to the ear. Tympanic membrane (TM) perforation was used as the clinical marker for aural blast injury. Thirty-four personnel had unilateral TM perforation and 28 had bilateral TM perforation. Eighty-six sustained sufficient injury to be hospitalized. Fifty-nine of hospitalized personnel (70%) had TM perforation. Of a total of 90 TM perforations, 39% were estimated to be 25% or less of the tympanic membrane surface area, 36% were 26% to 50%, 16% were 51% to 75%, and 10% were greater than 75%. Morphology of the perforations and estimated proximity to the blast were documented. Personnel distant from the blast, in open doorways or wearing headphones, had relative protection from TM perforation. Historic nuclear blast data were used to estimate the SCUD blast waveform based on measurements of the SCUD impact crater. A mathematical model based on the estimated waveform was validated against the actual field data by comparing the proximity and incidence of TM perforations in the SCUD missile explosion.

Gulf war wounds: application of the Red Cross wound classification

The Red Cross wound classification was applied to 63 casualties requiring surgery in the recent Gulf war. The majority of wounds affect only soft tissue, caused predominantly by antipersonnel fragments. Bullet wounds were fewer but tended to be more severe, often involving a fracture or vascular damage. We recommend minor modification to the classification to include scoring of significant neurological injury. Further, we feel that by recording the distribution of all wounds as well as scoring the casualty's two worst injuries, the incidence and pattern of multiple wounds are ascertained, which is useful in military surgical research. We believe that the Red Cross wound classification is valuable in assessing a wound as part of a secondary survey, but that this wound score has little part to play in triage. It may help to decide management of individual wounds in clinical practice and is useful for recording the nature of wounds for future analysis.