Ocular injuries sustained by survivors of the Oklahoma City bombing

High risk and low prevalence diseases: Blast injuries

INTRODUCTION

Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries.

OBJECTIVE

This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential.

CONCLUSIONS

An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Analysis of ocular injury 1-year outcome in survivors of Beirut Port ammonium nitrate blast

Purpose

Ascertain the 1-year outcome of patients who sustained open eye injuries from the Beirut Port ammonium nitrate (AN) explosion, one of the most powerful non-nuclear explosions in history.

Methods

Retrospective chart review of the operated eyes in 2 major eye hospitals.

Results

Out of 42 patients with open globe injury that was originally sutured, 29 patients (34 eyes) were followed at the 1-year mark. The initial vision in logMAR (mean ± SD) was 2.93 ± 0.87 (hand motion equivalent) and the final vision was 1.80 ± 1.47 (counting finger 2 m equivalent). No light perception (NLP) vision was noted in 12 eyes on presentation and 10 eyes remained so, while 2 eyes reached light perception (LP) vision. Eight eyes had an intraoperative expulsive choroidal hemorrhage (7 NLP and 1 LP both pre- and postoperatively), and 6 of the 8 developed phthisis. All eyes that developed phthisis had NLP preoperatively and postoperatively. Ocular Trauma Score (OTS) correlated inversely with both initial and final vision (p < 0.001). Zone of injury inversely correlated with initial vision (p = 0.02) and positively with final vision (p < 0.001). Final vision was significantly worse in zone 3 vs. zones 1 and 2 (3.2 ± 0.5) vs. 0.9 ± 1.1) (p < 0.001) injuries, as was the initial vision (3.3 ± 0.5 vs. 2.7 ± 0.8; p = 0.002).

Conclusion

The OTS, which provides prognostic information for serious ocular trauma, also yields valuable prognostic information for AN-associated ocular injuries. Expulsive choroidal hemorrhage and NLP vision at presentation remain very poor prognostic signs.

Creation of a New Explosive Injury Equipment to Induce a Rabbit Animal Model of Closed Globe Blast Injury via Gas Shock

To establish a rabbit animal model of closed globe blast injury with an application of self-developed explosive injury equipment, we tend to explore the anatomic and pathological changes of eyes under different gas pressure. The device comprises of high-pressure air source compression pump, air channel, and gas shock. There were 36 healthy bluish blue rabbits exposed to one of five blast pressures (500, 1,000, 1,500, 2,000, and 5,000 Kpa). Slit lamp microscope, B-mode ultrasonography, fundus photography, optical coherence tomography (OCT), and intraocular pressure (IOP) examination were performed at 0-, 1-, 3-, and 7-days post exposure, while gross histopathology was assessed with H&E stain at 7 days. The contralateral eyes and non-blast exposed rabbits were used as controls. Definitive evidence of closed globe blast injury was obtained. Corneal edema and hyphema were observed in the models under all pressures with no full-thickness globe injury, or lens rupture, as the severity was pressure independent. There was no obvious retinal abnormality on B ultrasound or OCT scan, while light vitreous hemorrhage, commotio retinae, and heavy retinal pigmentation presented on one eye, respectively, in the eyes exposed to 5,000 Kpa. Increased retinal thickness with disorganizations on the retinal ganglion cell (RGC) layer and RGC apoptosis in groups under higher pressure (>500 Kpa). IOP of injured eyes were statistically decreased at day 1 and 7 post injury (p < 0.05). Conclusively, the rabbit animal model induced by self-developed equipment could mimic the clinical features of closed ocular blast injury successfully that was feasible and easy to operate. This will be a new rabbit animal model for investigating mechanisms and new therapeutic interventions of closed globe blast injury in the future.

Characteristics of open eye injuries in the Beirut Port explosion

INTRODUCTION

On the 4^th of August 2020 an ammonium nitrate explosion took place at the Port of Beirut in Lebanon. The aim of this study was to present the open eye injuries caused by the Beirut Port blast, and to describe their characteristics and visual outcomes at 6 months.

METHODS

Patients who suffered from open globe injuries during the Beirut port explosion were recruited. Characteristics of the ocular injuries and best corrected distance visual acuity (BCVA) were recorded at presentation and at 6 months.

RESULTS

All included eyes (23 eyes of 19 patients) suffered from penetrating open globe injuries secondary to glass material and were operated by globe exploration + primary repair. Four of the 19 patients suffered from bilateral injuries none of whom suffered from legal blindness. BCVA at presentation was hand motion or worse in 21 of 23 eyes (91%). Seven of 23 eyes (30%) had expulsive loss of intraocular tissue, 4 of 23 eyes (17%) had retinal detachment and 4 of 23 eyes (17%) had traumatic cataracts. Ocular trama score (OTS) had a mean +/- standard deviation (SD) of 61 +/- 12. Eleven of 23 eyes (48%) had zone 2 ocular injuries and 10 of 23 eyes (43%) had zone 3 ocular injuries. At 6 months follow-up 15 of 23 eyes (65%) had a BCVA of less than 20/200. All patients with Grade 2 OTS, zone 3 injuries, expulsive loss of intraocular tissue and retinal detachment had BCVA of less than 20/200 at 6 months.

CONCLUSION

Open eye injuries secondary to explosions occur most frequently due to glass fragments. Most of the victims were indoors, near windows and less than 500m away of the explosion site at the time of the blast. The majority of victims have very low BCVA, a low OTS and a high ocular ZOI at presentation which reflects the danger of open globe injuries secondary to blasts. A high ZOI, a low OTS, the expulsive loss of intraocular tissue and retinal detachment seem to be predictors of worse VA at 6 months.

Ophthalmic Injuries After the Port of Beirut Blast-One of Largest Nonnuclear Explosions in History

Importance

A review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans.

Objective

To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020.

Design, Setting, and Participants

A retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports.

Main Outcomes and Measures

Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record.

Exposures

Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion.

Results

A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration.

Conclusions and Relevance

In the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

Characteristics and treatments of ocular blast injury in Tianjin explosion in China

BACKGROUND

To document characteristics and treatments of ocular blast injury from a fire and explosion.

METHOD

Authors retrospectively evaluated 116 patients with 166 eye injuries from six hospitals. Terminology of ocular injury referred to Birmingham Eye Trauma Terminology, and best-corrected visual acuity (BCVA) was categorized with the ocular trauma score (OTS) grading system. Incidence, preoperational and follow-up BCVA, treatment of severe ocular blast injuries were surveyed.

RESULTS

Oculoplastic injuries accounted for the majority of eye injuries, while globe injuries were presented in 52 eyes with median baseline OTS 70 ranging from 26 to 100. No endophthalmitis occurred. The mean timing of the first-stage operations was 9.4 ± 6.4 h after blast, while second-stage operations were performed on average 14.7 ± 0.9 days post blast. Final BCVA of 68.8% of eyes achieved 20/200 or better as followed, 7 open globe injuries had a BCVA of no light perception. Additionally, eyes presenting rupture, retinal detachment, vitreous hemorrhage, choroidal injury and initial BCVA less than 20/200 had worse final visual outcomes, while globe penetration was not associated with poor visual acuity.

CONCLUSION

Various ocular injuries were commonly in the casualties of blast, in which open-globe injuries have worst visual prognosis. OTS is a valid approach for evaluation of prognosis and optimizing the therapeutic strategies subsequently in the massive casualty. Intense rescue and careful examination, proper surgery should be performed correctly to rescue patients.

Bomb Explosion: Ocular Effects of Primary, Secondary and Tertiary Mechanisms

Purpose

To report the type and severity of ocular injuries sustained by the survivors of a bomb-loaded explosion that occurred in Mogadishu, Somalia on December 28, 2019.

Patients and Methods

The recorded data included age, gender, wounded eye, initial examination of ocular injuries and associated systemic injuries, initial visual acuity, anterior and posterior segment examinations. The type of injury (open vs closed globe), the injured zone of the globe, and the presence of a relative afferent pupil defect were evaluated in all cases where possible.

Results

After the explosion, ocular injuries were detected in 28 of 114 patients in our hospital. Thirty-two eyes of 28 patients were included in the study. The mean age was 32.4±6.7 years. The number of open-globe injuries was more than that of closed-globe injuries (26 vs 6; 81.25% vs 18.75%, respectively). Zone 1 was the most affected zone in open-globe injuries (18/26 eyes, 61.6%), followed by Zone 3 in six (23%) patients and Zone 2 in four (15.4%) patients. Sixteen open-globe injuries were laceration type (61.5%) and 10 (38.5%) were rupture type. An intraocular foreign body was detected in eight (30.8%) eyes with open-globe injuries. A total of 28 patients had 11 (39.3%) isolated eye injuries, whereas 17 (60.7%) had concomitant systemic injuries.

Conclusion

The frequency of blast-related ocular injuries is increasing. Today, the increase in the use of vehicle-borne improvised explosives in terrorist-related explosions leads to more frequent and serious ocular injuries.

Analysis of Ocular Injury Characteristics in Survivors of the 8.12 Tianjin Port Explosion, China

Introduction

On the evening of August 12, 2015, a large chemical explosion occurred at Tianjin Port. We analyzed ocular injury characteristics in the survivors of this accident.

Methods

Twenty injured eyes of 17 hospitalized patients were included. Initial best-corrected visual acuity (BCVA), injury type, injury cause, relative afferent pupillary defect (RAPD), zone of injury (ZOI), and ocular trauma score (OTS) were evaluated. Final BCVA and enucleation were the final outcome index. The relationship between risk factors and final outcomes was analyzed.

Results

The patients comprised 14 males and 3 females (mean age, 35.24 ± 12.68 years). Eighteen eyes had open-globe and 2 had closed-globe injuries. Fifteen ocular injury types were reported. Initial visual acuity (VA) was 20/50 to 20/200, 20/200 to finger counting (FC), hand motion to light perception (HM-LP), and no light perception (NLP) in 2, 7, 7, and 4 eyes, respectively. RAPD was found in 5 eyes. Most eyes sustained severe injuries with OTSs of 1 (25%) and 2 (40%). Of the injured eyes, 50% had Zone III injuries. In 95% of the injured eyes, glass was the cause of injury. Three of 4 eyes with an initial VA of NLP had a final VA of NLP and an outcome of enucleation. In 5 eyes with RAPD, 3 had a final VA of NLP and a final outcome of enucleation. Eyes with lower OTSs generally had poorer outcomes. All eyes with a final VA of NLP and an enucleation outcome had Zone III injuries. All 3 eyes with an enucleation outcome had retinal injuries, whereas eyes with no retinal injury had a better final BCVA.

Conclusions

Explosions can inflict severe ocular trauma, even indoors; 90% of injured eyes had open-globe injuries caused by glass fragments. Initial NLP, RAPD, low OTS, posterior extended wound, and retinal injury indicate a poor final outcome.

Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings

Terrorist incidents that target hospitals magnify morbidity and mortality. Before a real or perceived terrorist mass casualty incident threatens a hospital and its providers, it is essential to have protocols in place to minimize damage to the infrastructure, morbidity, and mortality. In the years following the Boston Marathon bombings, much has been written about the heroic efforts of survivors and responders. Far less has been published about near misses due to lack of experience responding to a mass casualty incident resulting from terrorism. After an extensive review of the medical literature and published media in English, Spanish, and Hebrew, we were unable to identify a similar event. To the best of our knowledge, this is the first reported experience of a bomb threat caused evacuation of an emergency department in the United States while actively responding to multiple casualty terrorist incidents. We summarized the chronology of the events that led to a bomb threat being identified and the subsequent evacuation of the emergency department. We then reviewed the problematic nature of our response and described evidence-based policy changes based on data from health care, law enforcement, and counterterrorism. (Disaster Med Public Health Preparedness. 2019;13:791-798).

Computing the stresses and deformations of the human eye components due to a high explosive detonation using fluid-structure interaction model

INTRODUCTION

In spite the fact that a very small human body surface area is comprised by the eye, its wounds due to detonation have recently been dramatically amplified. Although many efforts have been devoted to measure injury of the globe, there is still a lack of knowledge on the injury mechanism due to Primary Blast Wave (PBW). The goal of this study was to determine the stresses and deformations of the human eye components, including the cornea, aqueous, iris, ciliary body, lens, vitreous, retina, sclera, optic nerve, and muscles, attributed to PBW induced by trinitrotoluene (TNT) explosion via a Lagrangian-Eulerian computational coupling model.

MATERIALS AND METHODS

Magnetic Resonance Imaging (MRI) was employed to establish a Finite Element (FE) model of the human eye according to a normal human eye. The solid components of the eye were modelled as Lagrangian mesh, while an explosive TNT, air domain, and aqueous were modelled using Arbitrary Lagrangian-Eulerian (ALE) mesh. Nonlinear dynamic FE simulations were accomplished using the explicit FE code, namely LS-DYNA. In order to simulate the blast wave generation, propagation, and interaction with the eye, the ALE formulation with Jones-Wilkins-Lee (JWL) equation defining the explosive material were employed.

RESULTS

The results revealed a peak stress of 135.70kPa brought about by detonation upsurge on the cornea at the distance of 25cm. The highest von Mises stresses were observed on the sclera (267.3kPa), whereas the lowest one was seen on the vitreous body (0.002kPa). The results also showed a relatively high resultant displacement for the macula as well as a high variation for the radius of curvature for the cornea and lens, which can result in both macular holes, optic nerve damage and, consequently, vision loss.

CONCLUSION

These results may have implications not only for understanding the value of stresses and strains in the human eye components but also giving an outlook about the process of PBW triggers damage to the eye.

The use of rigid eye shields (Fox shields) at the point of injury for ocular trauma in Afghanistan

BACKGROUND

Unlike hemorrhagic injuries in which direct pressure is indicated, any pressure placed on the eye after penetrating trauma can significantly worsen the injury by expulsing intraocular contents. The accepted first response measure for obvious or suspected penetrating ocular injury is placement of a rigid shield that vaults the eye so as to prevent accidental iatrogenic aggravation during transport to the ophthalmologist. Patching and placing intervening gauze between the shield and the eye are both contraindicated. Anecdotally, compliance with these recommendations is poor in the military and civilian communities alike; however, published studies documenting compliance are uniformly lacking. This study was undertaken to provide such an evaluation.

METHODS

In this retrospective observational study, the Department of Defense Trauma Registry was reviewed to identify eye injuries in Afghanistan from 2010 to 2012 and to examine compliance with eye shield recommendations. One hundred fifty-seven records of eye casualties were identified and categorized according to diagnostic codes, noting use of a shield. A subset of 30 records was further analyzed for compliance with other core treatment measures specified by the operant Clinical Practice Guideline. Because comparative studies do not exist, simple statistical analysis was performed.

RESULTS

Overall, 39% of eye injuries received a shield at the point of injury (61% failure), ranging from 0% to 50% between diagnostic subgroups. Subset analysis revealed that only 4.2% of injuries were successfully mitigated at the point of injury (95.8% failure).

CONCLUSION

In one of the few studies documenting the use of eye shields after ocular trauma, anecdotal reports of poor, inadequate, or incorrect compliance with basic recommendations were substantiated. Several factors may account for these findings. Corrective efforts should include enhanced educational emphasis and increased shield availability.

LEVEL OF EVIDENCE

Epidemiologic study, level IV. Therapeutic study, level IV.

Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature

As the threat of international terrorism rises, there is an increasing requirement to provide evidence-based information and training for the emergency personnel who will respond to terrorist incidents. Current major incident training advises that emergency responders prioritize their own personal safety above that of the 'scene and survivors'. However, there is limited information available on the nature of these threats and how they may be accurately evaluated. This study reviews the published medical literature to identify the hazards experienced by emergency responders who have attended previous terrorist incidents. A PubMed literature search identified 10,894 articles on the subject of 'terrorism', and there was a dramatic increase in publications after the 9/11 attacks in 2001. There is heterogeneity in the focus and quality of this literature, and 307 articles addressing the subject of scene safety were assessed for information regarding the threats encountered at terrorist incidents. These articles demonstrate that emergency responders have been exposed to both direct terrorist threats and environmental scene hazards, including airborne particles, structural collapse, fire, and psychological stress. The emphasis of training and preparedness for terrorist incidents has been primarily on the direct threats, but the published literature suggests that the dominant causes of mortality and morbidity in responders after such incidents are the indirect environmental hazards. If the medical response to terrorist incidents is to be based on evidence rather than anecdote, analysis of the current literature should be incorporated into major incident training, and consistent collection of key data from future incidents is required.

Closed-globe injuries of the ocular surface associated with combat blast exposure

PURPOSE

To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics.

DESIGN

Observational cross-sectional study.

PARTICIPANTS

Veterans with a history of blast-related traumatic brain injury (TBI).

METHODS

History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy.

MAIN OUTCOME MEASURES

Type and location of blast injuries to the conjunctiva and cornea.

RESULTS

Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast.

CONCLUSIONS

Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.

Ocular blast injuries in mass-casualty incidents: the marathon bombing in Boston, Massachusetts, and the fertilizer plant explosion in West, Texas

PURPOSE

To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas.

DESIGN

Multicenter, cross-sectional, retrospective, comparative case series.

PARTICIPANTS

Seventy-two eyes of 36 patients treated at 12 institutions were included in the study.

METHODS

Ocular and systemic trauma data were collected from medical records.

MAIN OUTCOME MEASURES

Types and severity of ocular and systemic trauma and associations with mechanisms of injury.

RESULTS

In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified.

CONCLUSIONS

Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Closed globe macular injuries after blasts in combat

PURPOSE

To describe the macular findings after closed globe ocular injuries sustained from blasts.

METHODS

A retrospective chart review from February 2003 to March 2010 of all soldiers with closed globe ocular injuries sustained during combat with macular findings of trauma on examination was completed.

RESULTS

There were 36 eyes that met the inclusion criteria. The mean age of the soldiers was 29.5 years and 97% were men. The average follow-up time was 18.6 months. Improvised explosive device blasts accounted for 86% of injuries. Forty-five percent of soldiers had bilateral ocular injuries. Eight of 36 eyes (22.2%) developed a macular hole. One eye had spontaneous closure and five eyes underwent surgical repair. There was a range of macular findings from retinal pigment epitheliopathy alone to retinal pigment epitheliopathy with full-thickness atrophy. Eight eyes (22.2%) had macular scarring on examination but no optical coherence tomography study. One eye (2.8%) developed phthisis bulbi. Fifteen eyes (42%) had an orbital fracture. Seven eyes (19%) sustained optic neuropathy.

CONCLUSION

Closed globe injuries after blasts resulted in a spectrum of macular findings. The integrity of the foveal inner segment/outer segment junction was the most important retinal factor in visual outcomes. Orbital fractures were not found to be a risk factor for developing optic neuropathy and may improve visual outcomes. The rate of long-term complications is unknown, and it is important for ophthalmologists to follow these patients closely.

Blast Eye Injuries: A Review for First Responders

As the rate of terrorism increases, it is important for health care providers to become familiar with the management of injuries inflicted by blasts and explosions. This article reviews the ocular injuries associated with explosive blasts, providing basic concepts with which to approach the blast-injured patient with eye trauma. We conducted a literature review of relevant articles indexed in PubMed between 1948 and 2007. Two hundred forty-four articles were reviewed. We concluded that ocular injury is a frequent cause of morbidity in blast victims, occurring in up to 28% of blast survivors. Secondary blast injuries, resulting from flying fragments and debris, cause the majority of eye injuries among blast victims. The most common blast eye injuries include corneal abrasions and foreign bodies, eyelid lacerations, open globe injuries, and intraocular foreign bodies. Injuries to the periorbital area can be a source of significant morbidity, and ocular blast injuries have the potential to result in severe vision loss.

(Disaster Med Public Health Preparedness. 2010;4:154-160)

Injury Perceptions of Bombing Survivors—Interviews from the Oklahoma City Bombing

Introduction:

Bombings, including the 1995 Oklahoma City bombing, remain an important public health threat. However, there has been little investigation into the impressions of injury risk or protective factors of bombing survivors.

Objective:

This study analyzes Oklahoma City bombing survivors' impressions of factors that influenced their risk of injury, and validates a hazard timeline outlining phases of injury risk in a building bombing.

Methods:

In-depth, semi-structured interviews were conducted within a sample of Oklahoma City bombing survivors. Participants included 15 injured and uninjured survivors, who were located in three buildings surrounding the detonation site during the attack.

Results:

Risk factor themes included environmental glass, debris, and entrapment. Protective factors included knowledge of egress routes, shielding behaviors to deflect debris, and survival training. Building design and health status were reported as risk and protective factors. The hazard timeline was a useful tool, but should be modified to include a lay rescue phase. The combination of a narrative approach and direct questioning is an effective method of gathering the perceptions of survivors.

Conclusions:

Investigating survivors' impressions of building bombing hazards is critical to capture injury exposures, behavior patterns, and decision-making processes during actual events, and to identify interventions that will be supported by survivors.

Mass-Casualty, Terrorist Bombings: Epidemiological Outcomes, Resource Utilization, and Time Course of Emergency Needs (Part I)

Introduction:

This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties.

Methods:

Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela.

Results:

Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1–25%); terrorist-suicide, 19% (7–44%); confined-space 4% (1–11%); open-air, 1% (0–5%); structural-collapse, 18% (5–26%); structural fire 17% (1–17%); and overall, 3% (1–14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14–50%); terrorist-suicide, 58% (38–77%); confined-space, 52% (36–71%); open-air, 13% (11–27%); structural-collapse, 41% (23–74%); structural-fire, 34% (25–44%); and overall, 34% (14–53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours.

Conclusion:

Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.

Mass-Casualty, Terrorist Bombings: Implications for Emergency Department and Hospital Emergency Response (Part II)

This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.

Retinal detachment due to facial gunshot wound: the utility of ultrasonography in a medically austere environment

BACKGROUND

Retinal detachment is one complication of ocular trauma. Retinal detachments resulting from gunshot wounds are typically associated with significant facial trauma, orbital trauma, or globe penetration. Ultrasonography has been shown to be of diagnostic utility in the evaluation of retinal detachments.

OBJECTIVES

In this case, an atypical mechanism for retinal detachment is described. The aim is to describe the successful use of ultrasound as an aid for accurate diagnosis and disposition of a retinal detachment in practice environments with limited medical resources.

CASE REPORT

We present a case of a low-velocity gunshot wound resulting in retinal detachment from pressure wave forces. A 21-year-old patient sustained a facial gunshot wound injury from a ricocheting AK-47 round, resulting in a closed globe retinal detachment. Portable ultrasonography was utilized as an accurate diagnostic modality in the management and disposition of this patient, allowing prompt confirmation of the diagnosis in a medically austere environment.

CONCLUSION

Ultrasonography can be a valuable diagnostic tool in the evaluation of ocular trauma in medically austere environments.

[Rare mechanisms of blowout fractures. Discussion of two case reports]

In the emergency room different forms of traumata with resulting insulating orbital blowout fracture are observed. The cause of accident is almost always impact to the central face with a solid object or on a hard surface. The hydraulic pressure theory and buckling force theory in terms of the pathomechanism are valid and accepted explanation models. We report two clinical cases of unusual injury mechanisms, which we discuss with reference to the available literature.

A thoracic mechanism of mild traumatic brain injury due to blast pressure waves

The mechanisms by which blast pressure waves cause mild-to-moderate traumatic brain injury (mTBI) are an open question. Possibilities include acceleration of the head, direct passage of the blast wave via the cranium, and propagation of the blast wave to the brain via a thoracic mechanism. The hypothesis that the blast pressure wave reaches the brain via a thoracic mechanism is considered in light of ballistic and blast pressure wave research. Ballistic pressure waves, caused by penetrating ballistic projectiles or ballistic impacts to body armor, can only reach the brain via an internal mechanism and have been shown to cause cerebral effects. Similar effects have been documented when a blast pressure wave has been applied to the whole body or focused on the thorax in animal models. While vagotomy reduces apnea and bradycardia due to ballistic or blast pressure waves, it does not eliminate neural damage in the brain, suggesting that the pressure wave directly affects the brain cells via a thoracic mechanism. An experiment is proposed which isolates the thoracic mechanism from cranial mechanisms of mTBI due to blast wave exposure. Results have implications for evaluating risk of mTBI due to blast exposure and for developing effective protection.

Ocular injuries in survivors of improvised explosive devices (IED) in commuter trains

BACKGROUND

Ocular injuries are common in survivors of terror incidents that involve the use of explosive materials. These explosives are commonly of a High Explosive type (HE) and may be fashioned into improvised explosive devices (IED) that incorporate additional materials to maximise trauma and injuries. Serial IED explosions have occurred in commuter trains in several cities including London and Madrid but data on ocular injuries is limited. We report the ocular injuries of the survivors of a series of IED explosions in crowded commuter trains.

METHODS

28 patients (56 eyes, 28 male, ages ranging from 22 to 52 years (mean 35.27 years) were screened in the triage area or the Intensive Care Unit (ICU). Testing included bedside visual acuity testing, torchlight examination of the anterior segment and dilated (or if necessary, undilated) fundus examination. Selected patients underwent B-scan examination, magnetic resonance imaging of the brain, orbits and the optic nerves or visual evoked potential assessment. The injuries, investigations and procedures were entered into the patient's case sheet as well as into a standardised format suggested by the Indian eye injury registry (IER).

RESULTS

16 of 28 patients (57.1%) had ocular injuries whereas 12 (42.8%) were found to be normal. Injuries were seen unilaterally in 10 patients and bilaterally in six yielding a total of 22 injured eyes. The common injuries were periorbital haemorrhages (09 eyes, 40%); first or second degree burns to the upper or lower lids (seen in 07 eyes, 31.8 %) and corneal injuries (seen in 08 eyes, 36.3%). Open globe injuries were seen in two eyes of two patients (09%). One patient (4.5%) had a traumatic optic neuropathy.

CONCLUSION

Ophthalmologists and traumatologists should be aware of these patterns of ocular injuries. Protocols need to include the screening of large numbers of patients in a short time, diagnostic tests (B scan, visual evoked potential (VEP) etc) and early surgery preferably at the initial triage itself as most of the serious injuries in our studies had been missed or not treated at an initial assessment.

Acute blindness in a dog caused by an explosive blast

A 3-year-old, intact male, mixed breed dog was presented with a complaint of acute blindness. Ten days previously, the area where the dog was walking came under a rocket attack, and a rocket landed and exploded 300 meters away from the dog. Physical examination was unremarkable. Ophthalmoscopic examination revealed posterior segment fibrin clots and extensive vitreal hemorrhage in the right eye. A total retinal detachment (360 degrees retinal dialysis) with no evidence of hemorrhage was noted in the left eye. There was no sign of any penetrating ocular trauma, and it was assumed that the posterior segment findings were primary injuries caused by the blast wave itself. Following anti-inflammatory treatment, partial vision was restored in the right eye. Surgical re-attachment of the retina was discussed and declined by the owner. This report describes, for the first time, vitreal hemorrhage and retinal detachment as the sole injuries caused by an explosive blast wave.

Assessing post-disaster consequences for health at the population level: experience from the AZF factory explosion in Toulouse

BACKGROUND

A major explosion occurred in the AZF chemical factory in Toulouse in September 2001. A comprehensive programme of epidemiological surveillance was set up.

OBJECTIVES

To present an overview of the programme and discuss the methods and potential utility of post-disaster epidemiology. The programme had three objectives: (1) to analyse comprehensively the short-term and long-term effects of air, water and secondary soil pollution on health; (2) to identify health problems needing special attention; and (3) to investigate the long-term direct and indirect effects on the population's health.

METHODS

The programme was organised through three committees: (1) a scientific committee, (2) an executive programme committee and (3) an institutional committee which aimed to facilitate exchanges between the epidemiologists, the regional authorities, the population and the media. As the catastrophe was an industrial disaster that had a major effect on workers and companies, and also caused severe damage to many schools and buildings all over the city, routine and ad hoc surveillance systems were used and three specific ad hoc questionnaire surveys in workers, schoolchildren and the general population were planned.

RESULTS AND CONCLUSIONS

Although the routine surveillance systems had limitations, several sources provided useful information for public health decisions and were found to be concordant with ad hoc epidemiological studies. Defining a victim was central to the choice of a programme design based on an approach either to victims of the disaster or to the entire population in the surrounding region. Anticipation and preparation for such disasters are thus required.

Blast injuries from Madrid terrorist bombing attacks on March 11, 2004

Blast injuries after terrorist attacks are seen with increasing frequency worldwide. Thousands of victims were attended in the hospitals of Madrid, Spain, on March 11, 2004 after the bombing attacks against the commuter trains. Thirty-six patients were attended in our institution. Seventeen of them suffered from severe or life-threatening injuries, and 19 had mild injuries. The most common lesions were thoracic trauma and blast lung injury, acoustic trauma, and orbital and paranasal sinus fractures. Other findings were hepatic and splenic lacerations, and vertebral and limb fractures. Emergency radiology had an important role in the correct management of the victims. Prompt radiological diagnoses of these complex lesions are crucial to efficient treatment. Therefore, radiologists have to become familiar with the injury patterns and specific lesions caused by blast wave.

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 role of the maxillofacial surgeon in the initial 48h following a terrorist attack

On 7 July 2005 there were four explosions in central London, three almost synchronously and a fourth within an hour. The Royal London Hospital received 208 casualties and the Hospital Major Incident Plan was put into action. We report on the events of that day and the role of the maxillofacial surgeons immediately and in the subsequent 48 h.

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.

Oftalmología

The present article describes the eye injuries observed in victims of the terrorist attack of 11 March in our hospital. Of the 325 injured individuals who arrived from the sites of explosion, 47 (15%) required specialized ophthalmologic care. Of these 41 were treated on 11 March and the 6 remaining patients were treated on subsequent days. In 5 patients emergency interventions were required. In 3 patients, interventions were delayed.

RESULTS

anatomical loss in 1 patient and functional loss in 3 patients.

Mass casualties in the Oklahoma City bombing

The Alfred P. Murrah Federal Building in Oklahoma City was partially destroyed by a terrorist bomb on April 19, 1995. Injuries were sustained by 759 people, 168 of whom died. Fatalities occurred primarily among victims in the collapse zone of the federal building. Only 83 survivors required hospitalization. Twenty-two surviving victims sustained multiple fractures. Most victims arrived at local emergency departments by private vehicle within 2 hours. More severely injured survivors were transported by ambulance. The closer receiving hospitals used emergency department facilities and minor treatment areas. Few survivors were extricated from the bombing site more than 3 hours after the detonation. Mass casualty plans must provide for improved communications, diversion and retriage from facilities nearest the disaster site, and effective coordination of community and hospital resources.

Blast injury caused by a booby-trapped cellular phone

Terrorists are recently using cellular phones to remotely detonate bombs. A patient was injured while assembling a bomb connected to a cellular phone. The patient sustained combined injury to the head and to the dominant hand which held the phone. Amputation of the hand was required, the facial injuries were reconstructed. The characteristics of this unusual type of injury are described and compared to injuries caused by other bombs and explosive devices.

Mass casualty terrorist bombings

STUDY OBJECTIVE

We compared the epidemiologic outcomes of terrorist bombings that produced 30 or more casualties and resulted in immediate structural collapse, occurred within a confined space, or occurred in open air.

METHODS

We identified eligible studies of bombings through a MEDLINE search of articles published between 1966 and August 2002 and a manual search of published references. Pooled and median rates of mortality, immediately injured survival, emergency department use, hospitalization, and injury were determined for each bombing type.

RESULTS

We found 35 eligible articles describing 29 terrorist bombings, collectively producing 8,364 casualties, 903 immediate deaths, and 7,461 immediately surviving injured. Pooled immediate mortality rates were structural collapse 25% (95% confidence interval [CI] 6% to 44%), confined space 8% (95% CI 1% to 14%), and open air 4% (95% CI 0% to 9%). Biphasic distributions of mortality were identified in all bombing types. Pooled hospitalization rates were structural collapse 25% (95% CI 6% to 44%), confined space 36% (95% CI 27% to 46%), and open air 15% (95% CI 5% to 26%). Unique patterns of injury rates were found in all bombing types.

CONCLUSION

Patterns of injury and health care system use vary with the type of terrorist bombing.

World Trade Center rescue worker injury and illness surveillance, New York, 2001

BACKGROUND

The September 11, 2001, terrorist attacks on the World Trade Center in New York City, New York, prompted an unprecedented rescue and recovery response. Operations were conducted around the clock, involved over 5000 workers per day, and extended into months following the attacks. The City of New York Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention implemented prospective surveillance to characterize rescue worker-related injury and illness and to help guide public health interventions.

METHODS

From September 11 to October 11, 2001, personnel reviewed medical records at four Manhattan hospital emergency departments (EDs), and healthcare providers completed data collection forms at five temporary Disaster Medical Assistance Team (DMAT) facilities located at the site. Rescue workers included construction workers, police officers, firefighters, emergency medical service technicians, or Urban Search and Rescue workers. Data collected included demographic characteristics, injury type, illness, and disposition.

RESULTS

Of 5222 rescue worker visits, 89% were to DMAT facilities and 12% to EDs. Musculoskeletal conditions were the leading cause of visits (19%), followed by respiratory (16%) and eye (13%) disorders. Incidence rates were estimated based on total injuries and/or illnesses reported times 200,000 (100 equivalent full-time workers in 1 year at 40 hours per week x 50 weeks per year), then divided by the total number of hours worked. Eye disorders (59.7) accounted for the highest estimated injury and illness rate, followed by headache (46.8). One death, 52 hospital admissions, and 55 transports were reported. Findings underscored the need to coordinate distribution and enforcement of personal protective equipment use, purchase of diagnostic equipment to diagnose corneal abrasions, and distribution of health advisories.

CONCLUSIONS

This system provided objective, timely information that helped guide public health interventions in the immediate aftermath of the attacks and during the prolonged rescue and recovery operations. Lessons learned can be used to guide future surveillance efforts.

Disasters and development: Part 2: understanding and exploiting disaster-development linkages

Disasters can impede the effectiveness of development resource allocation. The damage sustained from an event can be classified into four categories: (1) Loss of resources; (2) Interruption of programs and switching of crucial resources to other, shorter-term needs; (3) Negative impacts upon investment climates; and/or (4) Disruption of the non-formal sector (local businesses). Disasters have a particularly destructive economic impact in areas in which there are few alternatives for assets that are destroyed or in areas in which the resources already are at critical levels. Development processes can both increase and/or decrease the vulnerability of a society to hazards. There are dearly established linkages between poverty, marginalization, over-population, and vulnerability. To a large extent, vulnerability derives from poverty. The poor are more likely to live in vulnerable areas (slopes prone to landslides, flood plains, marginal agricultural land), have difficulty accessing education and information, have fewer assets to invest in resources to reduce vulnerability, and are more prone to become malnourished and have chronic illnesses that predispose them to injury and death. Development may be associated with the production of new hazards accepted by a society because the perceived benefits of the development project far exceed the relative risk associated with the project. Therefore, risk assessments must be part of any program planning and evaluation. Training and education are of critical importance in preventing increased vulnerability as a result of development strategies. Development also can progress in a manner that will result in mitigation of the impacts of an event on a given society (increase absorbing capacity and/or buffering capacity, elimination of hazards or the risk of them producing a disaster). Such mitigation measures can be either structural or nonstructural. There exists a wide range of options for incorporating mitigation measures in development projects. Two case studies provide exercises that incorporate the concepts provided in this discussion: (1) The 1985 earthquake in Mexico City; and (2) Agricultural development in northern Sudan.