40 years of terrorist bombings - A meta-analysis of the casualty and injury profile

Impact of injury mechanism on early wound closure in patients with acute conflict-related extremity wounds: A prospective cohort analysis from two civilian hospitals in Iraq and Jordan

BACKGROUND

Gunshots and bomb blasts are important causes of extremity injuries in conflict zones, yet little research exists on the characteristics and outcomes of these injuries in civilian populations.

METHODS

We performed a prospective cohort analysis utilizing data from a randomized trial conducted at two civilian hospitals in Jordan and Iraq in 2015-2019. Adults who presented ≤72 h of sustaining an extremity injury were included. We used mechanism of injury (gunshot/bomb blast) as the exposure and wound closure by day 5 as the primary outcome measure.

RESULTS

The population predominantly comprised young men (n = 163, 94% male, and median age 29 years) injured by gunshots (61%) or bomb blasts (39%). Compared with the gunshot group, more participants in the bomb blast group had concomitant injuries (32/63 [51%] vs. 11/100 [11%], p < 0.001) and vascular injuries (9/63 [14%] vs. 4/100 [4%], p = 0.02). The wounds were larger in the bomb blast group compared with the gunshot group (median area 86 cm2 [IQR 24-161] vs. 21 cm2 [IQR 7-57], p < 0.001). Compared with the bomb blast group, significantly more participants in the gunshot group achieved wound closure by day 5 (74/100 [74%] vs. 16/63 [25%], p < 0.001). This difference remained after controlling for confounding factors (odds ratio 4.7, 95% confidence interval 1.6-13.7).

CONCLUSIONS

In civilians with conflict-related extremity injuries, bomb blast wounds had a lower likelihood of achieving closure within 5 days than gunshot wounds, independent of other factors, such as wound size and vascular injuries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02444598. Registered 14-05-2015, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT02444598.

Burn or trauma scoring: experience of the burn unit of the Queen Astrid Military Hospital during the terror attacks on 22 March 2016

PURPOSE

On 22 March 2016, the burn unit (BU) of Queen Astrid Military Hospital assessed a surge in severely injured victims from terror attacks at the national airport and Maalbeek subway station according to the damage control resuscitation (DCR) and damage control surgery (DCS) principles. This study delves into its approach to identify a suitable triage scoring system and to determine if a BU can serve as buffer capacity for mass casualty incidents (MCIs).

METHODS

The study reviewed retrospectively the origin of explosion, demographic data, sustained injuries, performed surgery, and length of stay of all admitted patients. Trauma scores (Injury Severity Score (ISS) and New Injury Severity Score (NISS)) and triage scores (Revised Trauma Score (RTS), New Trauma Score (NTS), and Trauma Score Injury Severity Score (TRISS)), were compared to burn mortality scores (Osler updated Baux Score and Tobiasen's Abbreviated Burn Severity Index (ABSI)).

RESULTS

Of the 23 casualties admitted to the BU, the scores calculated on average 3.5 indications for a level 1 trauma center (ISS 4, NISS 6, RTS 0, T-NTS 4). Nevertheless, no deaths occurred during admission or the 1-year follow-up.

CONCLUSION

MCIs create chaos and a high demand for care. Avoiding bottlenecks and adhering to the DCR/DCS principles are necessary to deliver the best care to the largest number of people. This study indicates that a BU can serve as buffer capacity for MCIs. Nevertheless, its integration into the medical resilience plan depends on accurate scoring, comprehensive care availability, and understanding of the DCR/DCS concept. NTS for triage seems the best fit for scoring polytrauma referrals to a BU during MCIs.

Injury modelling for strategic planning in protecting the national infrastructure from terrorist explosive events

Terrorist events in the form of explosive devices have occurred and remain a threat currently to the population and the infrastructure of many nations worldwide. Injuries occur from a combination of a blast wave, energised fragments, blunt trauma and burns. The relative preponderance of each injury mechanism is dependent on the type of device, distance to targets, population density and the surrounding environment, such as an enclosed space, to name but a few. One method of primary prevention of such injuries is by modification of the environment in which the explosion occurs, such as modifying population density and the design of enclosed spaces. The Human Injury Predictor (HIP) tool is a computational model which was developed to predict the pattern of injuries following an explosion with the goal to inform national injury prevention strategies from terrorist attacks. HIP currently uses algorithms to predict the effects from primary and secondary blast and allows the geometry of buildings to be incorporated. It has been validated using clinical data from the '7/7' terrorist attacks in London and the 2017 Manchester Arena terrorist event. Although the tool can be used readily, it will benefit from further development to refine injury representation, validate injury scoring and enable the prediction of triage states. The tool can assist both in the design of future buildings and methods of transport, as well as the situation of critical emergency services required in the response following a terrorist explosive event. The aim of this paper is to describe the HIP tool in its current version and provide a roadmap for optimising its utility in the future for the protection of national infrastructure and the population.

The risk of fragment penetrating injury to the heart

Injury due to the penetration of fragments into parts of the body has been the major cause of morbidity and mortality after an explosion. Penetrating injuries into the heart present very high mortality, yet the risk associated with such injuries has not been quantified. Quantifying this risk is key in the design of personal protection and the design of infrastructure. This study is the first quantitative assessment of cardiac penetrating injuries from energised fragments. Typical fragments (5-mm sphere, 0.78-g right-circular cylinder and 1.1-g chisel-nosed cylinder) were accelerated to a range of target striking velocities using a bespoke gas-gun system and impacted ventricular and atrial walls of lamb hearts. The severity of injury was shown to not depend on location (ventricular or atrial wall). The striking velocity with 50% probability of critical injury (Abbreviated Injury Scale (AIS) 5 score) ranged between 31 and 36 m/s across all 3 fragments used. These findings can help directly in reducing morbidity and mortality from explosive events as they can be implemented readily into models that aim to predict casualties in an explosive event, inform protocols for first responders, and improve design of infrastructure and personal protective equipment.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia

BACKGROUND

War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities.

METHODS

The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed.

RESULTS

Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014).

CONCLUSION

Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Terrorist Attacks Against Performing Arts Venues: Global Trends and Characteristics Spanning 50 Years

INTRODUCTION

In fostering community and culture through entertainment in shared spaces, performing arts venues have also become targets of terrorism. A greater understanding of these attacks is needed to assess the risk posed to different types of venues, to inform medical disaster preparedness, to anticipate injury patterns, and to reduce preventable deaths.

METHODS

A search of the Global Terrorism Database (GTD) was conducted from the year 1970 through 2019. Using pre-coded variables for target/victim type and target subtype, attacks involving "business" and "entertainment/cultural/stadium/casino" were identified. Attacks targeting performing arts venues were selected using the search terms "theater," "theatre," "auditorium," "center," "hall," "house," "concert," "music," "opera," "cinema," and "movie." Manual review by two authors was performed to confirm appropriateness for inclusion of entries involving venues where the primary focus of the audience was to view a performance. Descriptive statistics were performed using R (version 3.6.1).

RESULTS

A total of 312 terrorist attacks targeting performing arts venues were identified from January 1, 1970 through December 31, 2019. Two-hundred nine (67.0%) attacks involved cinemas or movie theaters, 80 (25.6%) involved unspecified theaters, and 23 (7.4%) specifically targeted live music performance venues. Two-hundred thirty-four (75.0%) attacks involved a bombing or explosion, 50 (16.0%) damaged a facility or infrastructure, and 17 (5.4%) included armed assault. Perpetrators used explosives in 234 (75.0%) attacks, incendiary weapons in 50 (16.0%) attacks, and firearms in 19 (6.1%) attacks. In total, attacks claimed the lives of 1,307 and wounded 4,201 persons. Though fewer in number, attacks against music venues were responsible for 29.4% of fatalities and 35.0% of those wounded, and more frequently involved the use of firearms. Among 95 attacks falling within the highest quartile for victims killed or wounded (>two killed and/or >ten wounded), 83 (87.4%) involved explosives, seven (7.4%) involved firearms, and three (3.2%) involved incendiary methods.

CONCLUSION

While uncommon, terrorist attacks against performing arts venues carry the risk for mass casualties, particularly when explosives and firearms are used.

Physicians' Response and Preparedness of Terrorism-Related Disaster Events in Quetta City, Pakistan: A Qualitative Inquiry

Background

Besides catastrophes, infrastructural damages, and psychosocial distress, terrorism also imposes an unexpected burden on healthcare services. Considerably, adequately-prepared and responsive healthcare professionals affirms effective management of terrorism-related incidences. Accordingly, the present study aimed to evaluate physicians' preparedness and response toward terrorism-related disaster events in Quetta city, Pakistan.

Methods

A qualitative design was adopted. Physicians practicing at the Trauma Center of Sandeman Provincial Hospital (SPH), Quetta, were approached for the study. We conducted in-depth interviews; all interviews were audio-taped, transcribed verbatim, and analyzed for thematic contents by a standard content analysis framework.

Results

Fifteen physicians were interviewed. The saturation was achieved at the 13th interview however we conducted another two to validate the saturation. The thematic content analysis revealed five themes and 11 subthemes. All physicians have experienced, responded to, and managed terrorism-related disaster events. They were prepared professionally and psychologically in dealing with a terrorism-related disaster. Physicians identified lack of disaster-related curricula and training, absence of a standardized protocol, recurrence of the disaster, and hostile behavior of victim's attendants during an emergency as critical barriers to effective terrorism-related disaster management. Among limitations, all respondents mentioned workspace, and resources as a foremost constraint while managing a terrorism-related disaster event.

Conclusion

Although physicians understood the abilities and had the required competencies to mitigate a terrorism-related disaster, lack of workspace and resources were identified as a potential barrier to effective disaster management. Based on the results, we propose reconsideration and integration of the medical curriculum, particularly for terrorism-related disaster management, collaboration, and communication among various stakeholders to manage terrorism-related disaster events competently.

KABUL AIRPORT SUICIDE BOMBING ATTACK: MASS CASUALTY MANAGEMENT AT THE EMERGENCY'NGO HOSPITAL

BACKGROUND

Terrorist attacks with large numbers of civilian victims are not uncommon in war-torn countries, and present a unique challenge for health care facilities with limited resources. However, these events are largely under-reported and little is known about how the mass casualty events (MCE) are handled outside of a military setting.

METHODS

This study is a retrospective analysis of the MCE which ensued the Kabul Airport suicide attack (26th August 2021) at the Kabul EMERGENCY'NGO Hospital (Afghanistan).

RESULTS

Within six hours 93 causalities presented at our hospital. Out of them, 36 severe injured were admitted. Mean age was 30.8 years (SD 10.1). The most common injury mechanism was shell fragments. The most common injury site was head (63%; 23/36), followed by limbs (55.5%; 20/36) and thoracoabdominal region (30.5%; 11/36). Combined injuries occurred in 38.9% of cases. Patients receiving surgery presented more combined injuries in comparison with patients receiving only medical treatment (47.1% vs 31.6%). Thoraco-abdomen (25.0% vs 15.4%) and/or extremity injury (42.9% vs 28.6%) were more prevalent in the surgical group. Thirty major surgical procedures were carried out on 17 patients in the nine hours following the first arrival. The rate of Intensive Care Unit/High Dependency Unit admission was 36.1% and the 30-day in-hospital mortality was 16.6% (6/36). All deaths were recorded in the first 24 hours and none of them received surgery.

CONCLUSIONS

A large number of wounded patients must be anticipated after suicide bombing attacks. The authors report the challenges faced and key aspects of their management of MCEs.

LEVEL OF EVIDENCE

Retrospective analysis/incident management.

Penetration of Energised Metal Fragments to Porcine Thoracic Tissues

Energised fragments from explosive devices have been the most common mechanism of injury to both military personnel and civilians in recent conflicts and terrorist attacks. Fragments that penetrate into the thoracic cavity are strongly associated with death due to the inherent vulnerability of the underlying structures. The aim of this study was to investigate the impact of fragment-simulating projectiles (FSPs) to tissues of the thorax in order to identify the thresholds of impact velocity for perforation through these tissues and the resultant residual velocity of the FSPs. A gas-gun system was used to launch 0.78-g cylindrical and 1.13-g spherical FSPs at intact porcine thoracic tissues from different impact locations. The sternum and rib bones were the most resistant to perforation, followed by the scapula and intercostal muscle. For both FSPs, residual velocity following perforation was linearly proportional to impact velocity. These findings can be used in the development of numerical tools for predicting the medical outcome of explosive events, which in turn can inform the design of public infrastructure, of personal protection, and of medical emergency response.

50 Years of Mass-Fatality Terrorist Attacks: A Retrospective Study of Target Demographics, Modalities, and Injury Patterns to Better Inform Future Counter-Terrorism Medicine Preparedness and Response

BACKGROUND

Terrorism-related deaths have fallen year after year since peaking in 2014, and whilst the coronavirus disease 2019 (COVID-19) pandemic has disrupted terrorist organizations capacity to conduct attacks and limited their potential targets, counter-terrorism experts believe this is a short-term phenomenon with serious concerns of an escalation of violence and events in the near future. This study aims to provide an epidemiological analysis of all terrorism-related mass-fatality events (>100 fatalities) sustained between 1970-2019, including historical attack strategies, modalities used, and target selection, to better inform health care responders on the injury types they are likely to encounter.

METHODS

The Global Terrorism Database (GTD) was searched for all attacks between the years 1970-2019. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD codebook. Ambiguous events were excluded. State-sponsored terrorist events do not meet the codebook's definition, and as such, are excluded from the study. Data analysis and subsequent discussions were focused on events causing 100+ fatal injuries (FI).

RESULTS

In total, 168,003 events were recorded between the years 1970-2019. Of these, 85,225 (50.73%) events recorded no FI; 67,356 (40.10%) events recorded 1-10 FI; 5,791 (3.45%) events recorded 11-50 FI; 405 (0.24%) events recorded 51-100 FI; 149 (0.09%) events recorded over 100 FI; and 9,077 (5.40%) events recorded unknown number of FI.Also, 96,905 events recorded no non-fatal injuries (NFI); 47,425 events recorded 1-10 NFI; 8,313 events recorded 11-50 NFI; 867 events recorded 51-100 NFI; 360 events recorded over 100 NFI; and 14,130 events recorded unknown number of NFI. Private citizens and property were the primary targets in 67 of the 149 high-FI events (100+ FI). Of the 149 events recording 100+ FI, 46 (30.87%) were attributed to bombings/explosions as the primary attack modality, 43 (28.86%) were armed assaults, 23 (15.44%) hostage incidents, two (1.34%) were facility/infrastructure attacks (incendiary), one (0.67%) was an unarmed assault, seven (4.70%) had unknown modalities, and 27 (18.12%) were mixed modality attacks.

CONCLUSIONS

The most common attack modality causing 100+ FI was the use of bombs and explosions (30.87%), followed by armed assaults (28.86%). Private citizens and properties (44.97%) were most commonly targeted, followed by government (6.04%), businesses (5.37%), police (4.70%), and airports and aircrafts (4.70%). These data will be useful for the development of training programs in Counter-Terrorism Medicine (CTM), a rapidly emerging Disaster Medicine sub-specialty.

Explosion-related deaths: An overview on forensic evaluation and implications

Purpose

Explosion-related deaths are uncommon events which require expertise and confidence so that an appropriate death investigation can be performed. The present study aims to provide a detailed forensic analysis of the issues and implications arising in the event of an explosion.

Methods

A retrospective review of casualty data was conducted on electronic literature databases. Cases concerning deadly explosions registered at the Milan Institute of Legal Medicine were examined and analyzed altogether.

Results

Explosions may involve closed or open systems. A security assessment of the site is always necessary. Alterations of the site due to rescue procedures can occur; thus, on-site forensic investigation should be adapted to the environment. Then, a study protocol based on autopsy procedures is presented. Application of the postmortem radiology enforces forensic procedures both for the analysis of blast injuries and skeleton fractures, and for identification purposes. Blast injuries typically cause lacerations of the lungs, intestine and major vessels; moreover, hyoid fractures can be documented. Histopathology may help to define blast injuries effectively. Forensic chemistry, toxicology and ballistics provide useful investigative evidence as well as anthropology and genetics. Different forensic topics regarding explosions are discussed through five possible scenarios that forensic pathologists may come across. Scenarios include self-inflicted explosion deaths, domestic explosions, work-related explosions, terrorist events, and explosions caused by accidents involving heavy vehicles.

Conclusion

The scenarios presented offer a useful instrument to avoid misinterpretations and evaluation errors. Procedural notes and technical aspects are provided to the readers, with an insight on collaboration with other forensic experts.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020

PURPOSE

Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs.

METHODS

This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis.

RESULTS

During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed.

CONCLUSIONS

Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

The Injury Mechanism of Traumatic Amputation

Traumatic amputation has been one of the most defining injuries associated with explosive devices. An understanding of the mechanism of injury is essential in order to reduce its incidence and devastating consequences to the individual and their support network. In this study, traumatic amputation is reproduced using high-velocity environmental debris in an animal cadaveric model. The study findings are combined with previous work to describe fully the mechanism of injury as follows. The shock wave impacts with the casualty, followed by energised projectiles (environmental debris or fragmentation) carried by the blast. These cause skin and soft tissue injury, followed by skeletal trauma which compounds to produce segmental and multifragmental fractures. A critical injury point is reached, whereby the underlying integrity of both skeletal and soft tissues of the limb has been compromised. The blast wind that follows these energised projectiles completes the amputation at the level of the disruption, and traumatic amputation occurs. These findings produce a shift in the understanding of traumatic amputation due to blast from a mechanism predominately thought mediated by primary and tertiary blast, to now include secondary blast mechanisms, and inform change for mitigative strategies.

Simultaneous Casualty Admissions-Do they Affect Treatment in the Receiving Trauma Center?

Background

Simultaneous trauma admissions expose medical professionals to increased workload. The impact of simultaneous trauma admissions on hospital allocation, therapy, and outcome is currently unclear. We hypothesized that multiple admission-scenarios impact the diagnostic pathway and outcome.

Methods

The TraumaRegister DGU® was utilized. Patients admitted between 2002–2015 with an ISS ≥ 9, treated with ATLS®- algorithms were included. Group ´IND´ included individual admissions, two individuals that were admitted within 60 min of each other were selected for group ´MULT´. Patients admitted within 10 min were considered as simultaneous (´SIM´) admissions. We compared patient and trauma characteristics, treatment, and outcomes between both groups.

Results

132,382 admissions were included, and 4,462/3.4% MULTiple admissions were found. The SIM-group contained 1,686/1.3% patients. The overall median injury severity score was 17 and a mean age of 48 years was found. MULT patients were more frequently admitted to level-one trauma centers (68%) than individual trauma admissions were (58%, p < 0.001). Mean time to CT-scanning (24 vs. 26/28 min) was longer in MULT / SIM patients compared to individual admissions. No differences in utilization of damage control principles were seen. Moreover, mortality rates did not differ between the groups (13.1% in regular admissions and 11.4%/10,6% in MULT/SIM patients).

Conclusion

This study demonstrates that simultaneous treatment of injured patients is rare. Individuals treated in parallel with other patients were more often admitted to level-one trauma centers compared with individual patients. Although diagnostics take longer, treatment principles and mortality are equal in individual admissions and simultaneously admitted patients. More studies are required to optimize health care under these conditions.

Bomb blast: imaging findings, treatment and clinical course of extremity traumas

Background

To describe the severity and types of blast-related extremity injuries and the presence of accompanying vascular injuries (VI) and amputation, and to identify the associated factors affecting the treatment management and clinical course.

Methods

The study included 101 patients with extremity injuries caused by a bomb explosion. The radiographs and computed tomography angiographies of the patients were evaluated in terms of injury patterns, presence of penetrating fragments and fractures, and localization (upper or lower extremity) and type (open or closed) of injury. The Gustilo-Anderson classification was used for open fractures. According to their severity, open fractures classified as types 1 and 2 were included in Group 1 and those classified as type 3A, 3B and 3C in Group 2.

Results

As a result of blast exposure, 101 (57.7%) patients had extremity injuries, of which 76 (75.2%) presented with at least one fracture. Of the total of 103 fractures, nine (8.8%) were closed and 94 (91.2%) were open. Thirty-eight (40.4%) of the open fractures were located in the upper extremities, and 56 (59.6%) in the lower extremities and pelvis. Open fractures were most frequently localized in the femur (n = 20; 21.2%), followed by the tibia (n = 18; 19.1%). The majority of patients with open fractures were in Group 1 (71.4%). The duration of hospital stay was longer in Group 2 (12.1 ± 5.8 vs. 6.3 ± 6.7 days, p <  0.0001, respectively). Mortality among patients in Group 2 (45.0%) was significantly higher than in Group 1 (8.0%) (p <  0.0001). Similarly, the injury severity score (ISS) was higher in Group 2 (median 20 vs. 9, p <  0.0001). VI was present in 13 (12.9%) of all patients, and amputation in seven (7.9%).

Conclusion

The presence of severe open fractures, VI, and high ISS score can be considered as important factors that increase morbidity and mortality. In extremity traumas, through the secondary blast mechanism, contaminated-fragmented tissue injuries occur. Therefore, we believe that it will be beneficial to apply damage control surgery in places with low socioeconomic level and poor hygienic conditions.

Pelvic Protection Limiting Lower Limb Flail Reduces Mortality

Pelvic blast injury is one of the most severe patterns of injury to be sustained by casualties of explosions. We have previously identified the mechanism of injury in a shock tube-mediated murine model, linking outward flail of the lower limbs to unstable pelvic fractures and vascular injury. As current military pelvic protection does not protect against lower limb flail, in this study we have utilized the same murine model to investigate the potential of novel pelvic protection to reduce injury severity. Fifty cadaveric mice underwent shock-tube blast testing and subsequent injury analysis. Pelvic protection limiting lower limb flail resulted in a reduction of pelvic fracture incidence from both front-on (relative risk (RR) 0.5, 95% confidence intervals (CIs) 0.3-0.9, p < 0.01) and under-body (RR 0.3, 95% CI 0.1-0.8 p < 0.01) blast, with elimination of vascular injury in both groups (p < 0.001). In contrast, pelvic protection, which did not limit flail, had no effect on fracture incidence compared to the control group and was only associated with a minimal reduction in vascular injury (RR 0.6, 95% CI 0.4-1.0, p < 0.05). This study has utilized a novel strategy to provide proof of concept for the use of pelvic protection, which limits limb flail to mitigate the effects of pelvic blast injury.

Epidemiology of Blast Neurotrauma: A Meta-analysis of Blast Injury Patterns in the Military and Civilian Populations

BACKGROUND

Mass casualty incidents (MCIs) due to bombing-related terrorism remain an omnipresent threat to our global society. The aim of this study was to elucidate differences in blast injury patterns between military and civilian victims affected by terrorist bombings.

METHODS

An analysis of the Global Terrorism Database (GTD) and a PubMed literature search of casualty reports of bombing attacks from 2010-2020 was performed (main key words: blast injuries/therapy, terrorism, military personnel) with key epidemiological and injury pattern data extracted and statistically analyzed.

RESULTS

Demographic analysis of casualties revealed that military casualties tend to be younger and predominantly male (P < 0.05) compared with civilians. Military casualties also reported higher amounts of head/neck injury (P < 0.01) compared with civilians. The proportion of instantaneous fatalities along with injuries affecting the thoracoabdominal and extremity regions remained approximately equal across both groups.

CONCLUSIONS

Though the increased number of head/neck injuries was unexpected, we also found that the number of nonlethal head injuries also increased, predicating that more military blast neurotrauma patients survived their injuries. These data can be used to increase blast MCI preparation and education throughout the international neurosurgical community.

Pelvic injury patterns in blast: Morbidity and mortality

BACKGROUND

Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality.

METHODS

The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded.

RESULTS

One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73).

CONCLUSION

Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden.

LEVEL OF EVIDENCE

Prognostic, level III.

A New Understanding of the Mechanism of Injury to the Pelvis and Lower Limbs in Blast

Dismounted complex blast injury (DCBI) has been one of the most severe forms of trauma sustained in recent conflicts. This injury has been partially attributed to limb flail; however, the full causative mechanism has not yet been fully determined. Soil ejecta has been hypothesized as a significant contributor to the injury but remains untested. In this study, a small-animal model of gas-gun mediated high velocity sand blast was used to investigate this mechanism. The results demonstrated a correlation between increasing sand blast velocity and injury patterns of worsening severity across the trauma range. This study is the first to replicate high velocity sand blast and the first model to reproduce the pattern of injury seen in DCBI. These findings are consistent with clinical and battlefield data. They represent a significant change in the understanding of blast injury, producing a new mechanistic theory of traumatic amputation. This mechanism of traumatic amputation is shown to be high velocity sand blast causing the initial tissue disruption, with the following blast wind and resultant limb flail completing the amputation. These findings implicate high velocity sand blast, in addition to limb flail, as a critical mechanism of injury in the dismounted blast casualty.

Terrorist attacks: common injuries and initial surgical management

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

Indirect impact of violent events on emergency department utilization and disease patterns

Background

The health effects of war and armed conflict on casualties and mental health of those directly exposed has been well described, but few studies have explored the indirect health effects of violent events. This paper assesses the indirect health impact of several violent events that took place in Beirut in 2013–2014 on ED visit utilization and disease patterns.

Methods

As tracked by media reports, there were 9 violent events in Beirut during 2013–2014. We compared visits to the Emergency Department of a major medical center during weeks when violent events happened and weeks without such events (the preceding week and the same week in preceding years). After re-coding de-identified data from the medical records of 23,067 patients, we assessed differences in the volume of visits, severity index, and discharge diagnoses. Individual control charts were used to analyze ED visit trends post-event.

Results

Comparisons of weeks with violent events and weeks without such events indicate that the socio-demographic characteristics of patients who visited the Emergency Department were similar. Patients seen during violent weeks were significantly more likely to be admitted to the hospital, and less likely to present with low acuity complaints, indicating greater complexity of their conditions. The discharge diagnoses that were significantly higher during violent event weeks included anxiety disorders, sprains, and gastritis. Daily ED visits dropped post events by 14.111%, p < 0.0001.

Conclusions

The results indicate that violent events such as bombs, explosions, and terrorist attacks reverberate through the population, impact patterns of ED utilization immediately post-event and are associated with adverse health outcomes, even among those who are not directly affected by the events.

Acute and Chronic Molecular Signatures and Associated Symptoms of Blast Exposure in Military Breachers

Injuries from exposure to explosions rose dramatically during the Iraq and Afghanistan wars, which motivated investigations of blast-related neurotrauma and operational breaching. In this study, military “breachers” were exposed to controlled, low-level blast during a 10-day explosive breaching course. Using an omics approach, we assessed epigenetic, transcriptional, and inflammatory profile changes in blood from operational breaching trainees, with varying levels of lifetime blast exposure, along with daily self-reported symptoms (with tinnitus, headaches, and sleep disturbances as the most frequently reported). Although acute exposure to blast did not confer epigenetic changes, specifically in DNA methylation, differentially methylated regions (DMRs) with coordinated gene expression changes associated with lifetime cumulative blast exposures were identified. The accumulative effect of blast showed increased methylation of PAX8 antisense transcript with coordinated repression of gene expression, which has been associated with sleep disturbance. DNA methylation analyses conducted in conjunction with reported symptoms of tinnitus in the low versus high blast incidents groups identified DMRS in KCNE1 and CYP2E1 genes. KCNE1 and CYP2E1 showed the expected inverse correlation between DNA methylation and gene expression, which have been previously implicated in noise-related hearing loss. Although no significant transcriptional changes were observed in samples obtained at the onset of the training course relative to chronic cumulative blast, we identified a large number of transcriptional perturbations acutely pre- versus post-blast exposure. Acutely, 67 robustly differentially expressed genes (fold change ≥1.5), including UFC1 and YOD1 ubiquitin-related proteins, were identified. Inflammatory analyses of cytokines and chemokines revealed dysregulation of MCP-1, GCSF, HGF, MCSF, and RANTES acutely after blast exposure. These data show the importance of an omics approach, revealing that transcriptional and inflammatory biomarkers capture acute low-level blast overpressure exposure, whereas DNA methylation marks encapsulate chronic long-term symptoms.

Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers

INTRODUCTION

The current terrorist threat challenges nations to train numerous non-trauma care providers with different backgrounds in damage control (DC) strategies. The purpose of this work was to propose a specific DC training program.

METHODS

A Task Force of 16 civilian and military physicians met for a 24-hour session, to propose the construction of a DC training program for non-specialised caregivers.

RESULTS

Existing DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned.

CONCLUSIONS

The DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.

Thoracic Injury in Patients Injured by Explosions on the Battlefield and in Terrorist Incidents

Thoracic injury is common on the battlefield and in terrorist attacks, occurring in 10% to 70% of patients depending on the type of weapons used. Typical injuries seen include bullet, blast, and fragment injuries to the thorax, which are often associated with injuries to other parts of the body. Initial treatment prehospital and in the ED is carried out according to the principles of Tactical Combat Casualty Care or other standard trauma management systems. Immediately life-threatening problems including catastrophic hemorrhage are dealt with rapidly, and early consideration is given to CT scanning or rapid surgical intervention where appropriate. All patients should be given lung-protective ventilation. Treatment of these patients in the critical care unit is complicated by the severity of associated injuries and by features specific to combat trauma including blast lung injury, a high incidence of delirium, unusual infections such as colonization with multidrug-resistant Acinetobacter baumannii complex, and sometimes invasive fungal infections. A minority of patients with blast lung injury in published series have been successfully treated with prolonged respiratory support with high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. The role of newer treatment options such as resuscitative endovascular balloon occlusion of the aorta is not yet known. In this article we review the relatively sparse literature on this group of patients and provide practical advice based on the literature and our institution's extensive experience of managing battlefield casualties.

Systematic review: Do commercial tourniquets have potential to be a life-saving intervention for ambulance services?

Background:

Globally, terrorist attacks have major impact because of high rates of mortality and severe injury. Compression with direct pressure may be time-consuming in limb exsanguination and accelerate onset of haemorrhagic shock. Tourniquet applications have undergone scrutiny over a long period, but recently tourniquets have been developed and modified for effective and efficient use in prehospital settings to mitigate adverse effects.

Objectives:

This systematic review aimed at examining commercial tourniquets that demonstrated efficacy for use in prehospital services.

Methods:

Six search engines (ScienceDirect, Ovid, PubMed, SAGE, SpringerLink, Taylor & Francis) were used and articles of which 14 were selected for data analysis.

Results:

The findings were not sufficiently conclusive to pinpoint whether one tourniquet application was superior overall; however, Combat Application Tourniquet appeared to be better than other commercial tourniquets in terms of occlusion of distal blood flow, easy and quick self-application and fewer complications.

Conclusion:

In prehospital settings, ambulance personnel should not hesitate to apply tourniquets when encountering critical circumstances in which they must choose between saving life and potential complications.

Care of victims of suicide bombing

Summary

Suicide bombers often target crowds. This commentary discusses the additional features required in a medical response beyond conventional mass casualty care, including forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling and postexposure prophylaxis. We propose a pathway for care of victims of a suicide bomb, adapting elements from protocols for child abuse, sexual assault and needle-stick exposure.

[Terrorist attack trauma - an individual entity of polytrauma : A 10-year update]

The incidence of terrorist attacks is increasing worldwide, and they have also become a permanent threat in European cities. Due to its complexity, terrorist attack trauma places high demands on the strategy of surgical treatment. The combination of various mechanisms, explosions and gunshot injuries, with the characteristic pressure (blast) damage and a high proportion of penetrating trauma with simultaneous burns are characteristic features. Unlike in military conflicts, injuries to people of all ages and without ballistic body protection (body armor) are to be expected. The mechanism of the attack and its local conditions are of relevance for the assessment of the situation and the expected injury patterns. Thus, suicide attacks result in several times higher numbers of fatalities and casualties. Explosions on free ground lead to different types of injury than those in closed or semi-enclosed spaces. The treatment principles of the Advanced Trauma Life Support (ATLS®) are based on the intrahospital care of casualties as well as damage control strategies with trigger factors. In order to prepare and educate clinics and surgeons in Germany for such scenarios, various course formats of the professional societies, the German Society for General and Visceral Surgery (DGAV) and the German Society for Trauma Surgery (DGU) have now been established.

Environment at the time of injury determines injury patterns in pelvic blast

The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and loss of life, on a very large scale. The environment at the time of detonation is known to result in different injury patterns in casualties exposed to blast, which is highly relevant to injury mitigation analyses. We describe differences in pelvic injury patterns in relation to different environments, from casualties that presented to the deployed UK military hospitals in Iraq and Afghanistan. A casualty on foot when injured typically sustains an unstable pelvic fracture pattern, which is commonly the cause of death. These casualties die from blood loss, meaning treatment in these should focus on early pelvic haemorrhage control. In contrast, casualties injured in vehicle present a different pattern, possibly caused by direct loading via the seat, which does not result in pelvic instability. Fatalities in this cohort are from injuries to other body regions, in particular the head and the torso and who may require urgent neurosurgery or thoracotomy as life-saving interventions. A different strategy is therefore required for mounted and dismounted casualties in order to increase survivors.

Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

The First Aid and Hospital Treatment of Gunshot and Blast Injuries

BACKGROUND

When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience.

RESULTS

In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment.

CONCLUSION

In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.

Experimental platforms to study blast injury

Injuries sustained due to attacks from explosive weapons are multiple in number, complex in nature, and not well characterised. Blast may cause damage to the human body by the direct effect of overpressure, penetration by highly energised fragments, and blunt trauma by violent displacements of the body. The ability to reproduce the injuries of such insults in a well-controlled fashion is essential in order to understand fully the unique mechanism by which they occur, and design better treatment and protection strategies to alleviate the resulting poor long-term outcomes. This paper reports a range of experimental platforms that have been developed for different blast injury models, their working mechanism, and main applications. These platforms include the shock tube, split-Hopkinson bars, the gas gun, drop towers and bespoke underbody blast simulators.

Developing a Hospital Disaster Preparedness Plan for Mass Casualty Incidents: Lessons Learned From the Downtown Beirut Bombing

Mass casualty incidents (MCIs) are becoming more frequent worldwide, especially in the Middle East where violence in Syria has spilled over to many neighboring countries. Lebanon lacks a coordinated prehospital response system to deal with MCIs; therefore, hospital preparedness plans are essential to deal with the surge of casualties. This report describes our experience in dealing with an MCI involving a car bomb in an urban area of downtown Beirut, Lebanon. It uses general response principles to propose a simplified response model for hospitals to use during MCIs. A summary of the debriefings following the event was developed and an analysis was performed with the aim of modifying our hospital's existing disaster preparedness plan. Casualties' arrival to our emergency department (ED), the performance of our hospital staff during the event, communication, and the coordination of resources, in addition to the response of the different departments, were examined. In dealing with MCIs, hospital plans should focus on triage area, patient registration and tracking, communication, resource coordination, essential staff functions, as well as on security issues and crowd control. Hospitals in other countries that lack a coordinated prehospital disaster response system can use the principles described here to improve their hospital's resilience and response to MCIs. (Disaster Med Public Health Preparedness. 2018; 12: 379-385).

Learning lessons in emergency management: the 4th International Conference on Healthcare System Preparedness and Response to Emergencies and Disasters

Background

The International Preparedness & Response to Emergencies & Disasters (IPRED) conferences are conducted bi-annually in order to share insights and lessons learned from diverse crises. The aim of the article is to bring the IPRED conferences into better professional attention and to share the main insights that were presented in IPRED IV, which was held in January 2016.

Main body

The major lessons learned included: Planning, regional/global collaboration and public–private cooperation should be implemented in developing novel technologies. International humanitarian action necessitates coordination between diverse actors concerning all potential threats. Leadership/coordination and decision-making capacities of emergency response leaders should be enhanced to ensure quality of care. Ethics in disaster management: Triage decisions must not discriminate against terrorists, even when attackers and victims are treated simultaneously. Resilience management: Establishing family and community networks increases resilience of individuals and society. Training programs & exercises must be evaluated considering cost–benefits. Human resources: Teams of experts should be transformed into expert teams. Communication: A common disaster-management language needs to be established. Social media is useful due to bi-directional communication. Civil–military cooperation should be established to facilitate a coordinated response including common terminologies and exercises. Animal sheltering: First responders and pet owners are jeopardized if animals are not included in emergency planning. Re-unification of animals with their owners should be included in response models.

Conclusions

IPRED conferences provide a platform for sharing insights and lessons learned from diverse emergencies and disasters. The conferences offer a unique opportunity to share knowledge aimed at improving emergency preparedness, networking between various parties, and substantiates the knowledge and experience of all professionals who take part in the proceedings.