Blast Trauma: The Fourth Weapon of Mass Destruction

Incidence, casualties and risk characteristics of civilian explosion blast injury in China: 2000-2017 data from the state Administration of Work Safety

BACKGROUND

Civilian explosion blast injury is more frequent in developing countries, including China. However, the incidence, casualties, and characteristics of such incidents in China are unknown.

METHODS

This is a retrospective analysis of the State Administration of Work Safety database. Incidents during a period from January 1, 2000 to April 30, 2017 were included in the analysis. The explosions were classified based on the number of deaths into extraordinarily major, major, serious and ordinary type. Descriptive statistics was used to analyze the incidence and characteristics of the explosions. Correlation analysis was performed to examine the potential correlations among various variables.

RESULTS

Data base search identified a total of 2098 explosions from 2000 to 2017, with 29,579 casualties: 15,788 deaths (53.4%), 12,637 injured (42.7%) and 1154 missing (3.9%). Majority of the explosions were serious type (65.4%). The number of deaths (39.5%) was also highest with the serious type (P = 0.006). The highest incidence was observed in the fourth quarter of the year (October to December), and at 9:00-11:00 am and 4:00-6:00 pm of the day. The explosions were most frequent in coal-producing provinces (Guizhou and Shanxi Province). Coal mine gas explosions resulted majority of the deaths (9620, 60.9%). The number of explosion accidents closely correlated with economic output (regional economy and national GDP growth rate) (r = - 0.372, P = 0.040; r = 0.629, P = 0.028).

CONCLUSIONS

The incidence and civilian casualties due to explosions remain unacceptabe in developing China. Measures that mitigate the risk factors are of urgently required.

Types of Disasters

Disasters are increasing around the world. Children are greatly impacted by both natural disasters (forces of nature) and man-made (intentional, accidental) disasters. Their unique anatomical, physiological, behavioral, developmental, and psychological vulnerabilities must be considered when planning and preparing for disasters. The nurse or health care provider (HCP) must be able to rapidly identify acutely ill children during a disaster. Whether it is during a natural or man-made event, the nurse or HCP must intervene effectively to improve survival and outcomes. It is extremely vital to understand the medical management of these children during disasters, especially the use of appropriate medical countermeasures such as medications, antidotes, supplies, and equipment.

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.

A comparison of CT lung voxel density analysis in a blast and non blast injured casualty

INTRODUCTION

Primary blast lung injury (PBLI) is a prominent feature in casualties following exposure to blast. PBLI carries high morbidity and mortality, but remains difficult to diagnose and quantify. Radiographic diagnosis of PBLI was historically made with the aid of plain radiographs; more recently, qualitative review of CT images has assisted diagnosis.

METHODS

We report a novel way of measuring post-traumatic acute lung injury using CT lung density analysis in two casualties. One casualty presented following blast exposure with confirmed blast lung injury and the other presented following extremity injury without blast exposure. Three-dimensional lung maps of each casualty were produced from their original trauma CT scan. Analysis of the lung maps allowed quantitative radiological comparison exposing areas of reduced aeration of the patient's lungs.

RESULTS

45% of the blast-exposed lungs were non-aerated compared with 10% in the non-blast-exposed lungs.

DISCUSSION

In these example cases quantitative CT lung density analysis allowed blast-injured lungs to be distinguished from non-blast-exposed lungs.

AN ANATOMICALLY-RELEVANT COMPUTATIONAL MODEL FOR PRIMARY BLAST EFFECTS ON THE HUMAN LOWER EXTREMITY

Explosions pose serious threats to US soldiers and civilians, often resulting in disability and death. Due to its direct contact with the ground, the lower extremity is commonly injured, and the blast loading often results in traumatic amputations and soft tissue rupture. The exact overpressure signatures that induce these primary blast injuries are still unknown. A high fidelity FE model of the lower extremity blast condition is thus essential to reveal the underlying injury mechanism. In this study, we created an anatomically-relevant lower extremity model and analyzed several different blast cases using Abaqus/Explicit. Pressures, impulses, stresses, and maximum principal strains were evaluated and compared to previous results in the literature. Our FE model and simulation were able to capture the detailed structural responses to a blast wave in the lower extremity; moreover, we showed that the injury patterns could be correlated to biomechanical metrics that may have incited pathologies such as amputations and compartment syndrome. The lower extremity FE model developed in this project allows for a cost-effective and reproducible analysis of blast events and has the potential to improve injury metrics and personal protective equipment design by accurately evaluating the damage imposed on the lower extremity.

Shock waves increase pulmonary vascular leakage, inflammation, oxidative stress, and apoptosis in a mouse model

Severe lung damage is a major cause of death in blast victims, but the mechanisms of pulmonary blast injury are not well understood. Therefore, it is important to study the injury mechanism of pulmonary blast injury. A model of lung injury induced by blast exposure was established by using a simulation blast device. The effectiveness and reproducibility of the device were investigated. Eighty mice were randomly divided into eight groups: control group and 3 h, 6 h, 12 h, 24 h, 48 h, 7 days and 14 days post blast. The explosive device induced an explosion injury model of a single lung injury in mice. The success rate of the model was as high as 90%, and the degree of lung injury was basically the same under the same pressure. Under the same conditions, the thickness of the aluminum film can be from 0.8 mm to 1.6 mm, and the peak pressure could be from 95.85 ± 15.61 PSI to 423.32 ± 11.64 PSI. There is no statistical difference in intragroup comparison. A follow-up lung injury experiment using an aluminum film thickness of 1.4 mm showed a pressure of 337.46 ± 18.30 PSI induced a mortality rate of approximately 23.2%. Compared with the control group (372 ± 23 times/min, 85.9 ± 9.4 mmHg, 4.34 ± 0.09), blast exposed mice had decreased heart rate (283 ± 21 times/min) and blood pressure (73.6 ± 3.6 mmHg), and increased lung wet/dry weight ratio(2.67 ± 0.11), marked edematous lung tissue, ruptured blood vessels, infiltrating inflammatory cells, increased NF-κB (4.13 ± 0.01), TNF-α (4.13 ± 0.01), IL-1β (2.43 ± 0.01) and IL-6 (4.65 ± 0.01) mRNA and protein, decreased IL-10(0.18 ± 0.02) mRNA and protein ( P < 0.05). The formation of ROS and the expression of MDA5 (4.46 ± 0.01) and IREα (3.43 ± 0.00) mRNA and protein were increased and the expression of SOD-1 (0.28 ± 0.02) mRNA and protein was decreased ( P < 0.05). Increased expression of Bax (3.54 ± 0.00) and caspase 3 (4.18 ± 0.01) mRNA and protein inhibited the expression of Bcl-2 (0.39 ± 0.02) mRNA and protein. The changes of pulmonary edema, inflammatory cell infiltration, and cell damage factor expression increased gradually with time, and reached the peak at 12-24 h after the outbreak, and returned to normal at 7-14 days. Detonation injury can lead to edema of lung tissue, pulmonary hemorrhage, rupture of pulmonary vessels, induction of early inflammatory responses accompanied by increased oxidative stress in lung tissue cells and increased apoptosis in mice experiencing blast injury. The above results are consistent with those reported in other literatures. It is showed that the mouse lung blast injury model is successfully modeled, and the device can be used for the study of pulmonary blast injury. Impact statement The number of patients with explosive injury has increased year by year, but there is no better treatment. However, the research on detonation injury is difficult to carry out. One of the factors is the difficulty in making the model of blast injury. The laboratory successfully developed and produced a simulation device of explosive knocking through a large amount of literature data and preliminary experiments, and verified the preparation of the simulation device through various experimental techniques. The results showed that the device could simulate the shock wave-induced acute lung injury generated, which was similar to the actual knocking injury. The experimental process was controlled. Under the same condition, there was no statistical difference between the groups. It is possible to realize miniaturization and precision of an explosive knocking simulation device, which is a good experimental tool for further research on the mechanism of organ damage caused by detonation and the development of protective drugs.

Computational modeling of blast induced whole-body injury: a review

Blast injuries affect millions of lives across the globe due to its traumatic after effects on the brain and the whole body. To date, military grade armour materials are designed to mitigate ballistic and shrapnel attacks but are less effective in resisting blast impacts. In order to improve blast absorption characteristics of armours, the first key step is thoroughly understands the effects of blasts on the human body itself. In the last decade, a plethora of experimental and computational work has been carried out to investigate the mechanics and pathophysiology of Traumatic Brain Injury (TBI). However, very few attempts have been made so far to study the effect of blasts on the various other parts of the body such as the sensory organs (eyes and ears), nervous system, thorax, extremities, internal organs (such as the lungs) and the skeletal system. While an experimental evaluation of blast effects on such physiological systems is difficult, developing finite element (FE) models could allow the recreation of realistic blast scenarios on full scale human models and simulate the effects. The current article reviews the state-of-the-art in computational research in blast induced whole-body injury modelling, which would not only help in identifying the areas in which further research is required, but would also be indispensable for understanding body location specific armour design criteria for improved blast injury mitigation.

Chitosan oligosaccharide ameliorates acute lung injury induced by blast injury through the DDAH1/ADMA pathway

Objective

To investigate the protective effect of chitosan oligosaccharide (COS) on acute lung injury (ALI) caused by blast injury, and explore possible molecular mechanisms.

Methods

A mouse model of blast injury-induced ALI was established using a self-made explosive device. Thirty mice were randomly assigned to control, ALI and ALI + COS groups. An eight-channel physiological monitor was used to determine the mouse physiological index. Enzyme linked immunosorbent assay was used to measure serum inflammatory factors. Hematoxylin-eosin staining, terminal deoxynucleotidyl transferase dUTP nick end labeling assay, immunofluorescence staining, real time-polymerase chain reaction and western blot assay were used to detect inflammatory reactions, oxidative stress and apoptosis.

Results

Mice were sacrificed 24 hours after successful model induction. Compared with the ALI group, the heart rate, respiration and PCO₂ were significantly lower, but the PO₂, TCO₂ and HCO₃^- were significantly higher in the ALI + COS group. Compared to ALI alone, COS treatment of ALI caused a significant decrease in the wet/dry lung weight ratio, indicating a reduction in lung edema, inflammatory cell infiltration, levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-4, IL-6 and nuclear factor kappa B mRNA and protein expression were reduced and IL-10 mRNA and protein expression was increased (P < 0.05). COS significantly inhibited reactive oxygen species, MDA5 and IREα mRNA and protein expressions, cell apoptosis and Bax and Caspase-3 mRNA and protein expressions, and significantly increased superoxide dismutase-1 mRNA expression, and Bcl-2 and Caspase-8 mRNA and protein expression (all P<0.05). COS significantly increased dimethylarginine dimethylaminohydrolase 1 (DDAH1) protein expression, and reduced ADMA and p38 protein expression (P< 0.05).

Conclusion

Blast injury causes inflammation, oxidative stress and apoptosis in the lung tissues of mice. COS has protective effects on blast injury-induced ALI, possibly by promoting DDAH1 expression and inhibiting ADMA and mitogen-activated protein kinase pathways.

Plastic Surgery Management of Victims of Terrorist Violence in Ankara, Turkey

Terror attacks have been progressively increasing worldwide through the present era. The management of the consequences of terrorism events is under debate in almost every scientific area. The organization and advancement of health services constitute important components of the crisis management. Similar to other specialty areas in medicine, the medical management of terrorist attacks is becoming important in terms of plastic and reconstructive surgery.Ankara, the capital of Turkey, has been subject to 2 terrorist events in public places within a year. The total number of patients involved in both cases was 434. Ankara Numune Training and Research Hospital is a tertiary health care institution and one of the most important trauma centers in the region. A total of 178 Patients exposed to these events referred to our hospital. Of the total, 34 patients were completely or partially treated in the plastic and reconstructive surgery clinic. In this study, we tried to discuss the difficulties encountered in the classification of patients and plastic surgery during the treatment period of patients who experienced these attacks.Data were obtained from The National News Agency, hospital, and our own clinic registries. Patient classification was based on the injured parts of the body. Statistical analysis was performed for all data. In conclusion, the role and the importance of plastic surgery department especially in trauma management have been emphasized in the light of our findings.

Evaluating Primary Blast Effects In Vitro

Exposure to blast events can cause severe trauma to vital organs such as the lungs, ears, and brain. Understanding the mechanisms behind such blast-induced injuries is of great importance considering the recent trend towards the use of explosives in modern warfare and terrorist-related incidents. To fully understand blast-induced injury, we must first be able to replicate such blast events in a controlled environment using a reproducible method. In this technique using shock tube equipment, shock waves at a range of pressures can be propagated over live cells grown in 2D, and markers of cell viability can be immediately analyzed using a redox indicator assay and the fluorescent imaging of live and dead cells. This method demonstrated that increasing the peak blast overpressure to 127 kPa can stimulate a significant drop in cell viability when compared to untreated controls. Test samples are not limited to adherent cells, but can include cell suspensions, whole-body and tissue samples, through minor modifications to the shock tube setup. Replicating the exact conditions that tissues and cells experience when exposed to a genuine blast event is difficult. Techniques such as the one presented in this article can help to define damage thresholds and identify the transcriptional and epigenetic changes within cells that arise from shock wave exposure.

An examination of the spatial distribution of the tissue fragments created during a single explosive attack

Throughout the course of a forensic investigation following an explosive attack, the identification and recovery of tissue fragments is of extreme importance. There are few universally accepted methods to achieve this end. This project aims to explore this issue through the examination of the spatial distribution of the tissue fragments resulting from an explosive event. To address this, a two stage pilot study was conducted: first, a series of controlled explosions on porcine carcases was undertaken. Second, the data produced from these explosions were used to chart the spatial distribution of the tissue debris. In the controlled explosions, 3kg military grade explosive was chosen to create the maximum amount of fragmentation; this level of explosive also prevented the complete disappearance of forensic evidence through evaporation. Additionally, the blast created by military grade explosive is highly powerful and would mean that the maximum possible distance was achieved and would therefore allow the recorded distances and pattern spread to be a guideline for forensic recovery of associated with an explosive amount of an unknown size and quality. A total station was employed to record the location of the resulting forensic evidence, with the collected data analysed using R Studio. The observed patterns suggested that the distribution of remains is fairly consistent in trials under similar environmental conditions. This indicates potential for some general guidelines for forensic evidence collection (for example, the distance from the explosion that a search should cover).

SIMULATION STUDY TO COMPARE THE RELATIONSHIP BETWEEN THE BLAST-INDUCED OBJECTIVE INDICES AND THE SURVIVAL RATE OF SUBJECTS WITH PRIMARY BLAST LUNG INJURY

When an injury due to blast overpressure (BOP) is generated, it is important to estimate the severity of the injury using information about the blast conditions and to supply proper treatments according to the degree of the damage. However, there have been no investigations that have tried to verify the relationship between the blast-related objective indices and the degree of blast-induced injury. In this study, the correlations between the survival rate of the subjects with BOP-induced lung damage and each of four blast-induced indices, first principal strain, first principal strain rate, first principal stress and pulmonary inner pressure, were investigated using a simplified thorax model by introducing the concept of the V ACC –V LUNG ratio graph which represents the volume ratio between the seriously-damaged meshes and the overall meshes of the thorax model in respect to each index. Experimental results demonstrated that the decay parameters of the sigmoidal curve-fitted graphs of the first principal stress are the most effective of the analyzed indices for the estimation of the survival rate in patients with blast-induced lung damage. The results have a potential clinical application to improve the efficacy of treatment for blast injury patients.

A Coupled Experiment-finite Element Modeling Methodology for Assessing High Strain Rate Mechanical Response of Soft Biomaterials

This study offers a combined experimental and finite element (FE) simulation approach for examining the mechanical behavior of soft biomaterials (e.g. brain, liver, tendon, fat, etc.) when exposed to high strain rates. This study utilized a Split-Hopkinson Pressure Bar (SHPB) to generate strain rates of 100-1,500 sec(-1). The SHPB employed a striker bar consisting of a viscoelastic material (polycarbonate). A sample of the biomaterial was obtained shortly postmortem and prepared for SHPB testing. The specimen was interposed between the incident and transmitted bars, and the pneumatic components of the SHPB were activated to drive the striker bar toward the incident bar. The resulting impact generated a compressive stress wave (i.e. incident wave) that traveled through the incident bar. When the compressive stress wave reached the end of the incident bar, a portion continued forward through the sample and transmitted bar (i.e. transmitted wave) while another portion reversed through the incident bar as a tensile wave (i.e. reflected wave). These waves were measured using strain gages mounted on the incident and transmitted bars. The true stress-strain behavior of the sample was determined from equations based on wave propagation and dynamic force equilibrium. The experimental stress-strain response was three dimensional in nature because the specimen bulged. As such, the hydrostatic stress (first invariant) was used to generate the stress-strain response. In order to extract the uniaxial (one-dimensional) mechanical response of the tissue, an iterative coupled optimization was performed using experimental results and Finite Element Analysis (FEA), which contained an Internal State Variable (ISV) material model used for the tissue. The ISV material model used in the FE simulations of the experimental setup was iteratively calibrated (i.e. optimized) to the experimental data such that the experiment and FEA strain gage values and first invariant of stresses were in good agreement.

Experimental Evidence of Mechanical Isotropy in Porcine Lung Parenchyma

Pulmonary injuries are a major source of morbidity and mortality associated with trauma. Trauma includes injuries associated with accidents and falls as well as blast injuries caused by explosives. The prevalence and mortality of these injuries has made research of pulmonary injury a major priority. Lungs have a complex structure, with multiple types of tissues necessary to allow successful respiration. The soft, porous parenchyma is the component of the lung which contains the alveoli responsible for gas exchange. Parenchyma is also the portion which is most susceptible to traumatic injury. Finite element simulations are an important tool for studying traumatic injury to the human body. These simulations rely on material properties to accurately recreate real world mechanical behaviors. Previous studies have explored the mechanical properties of lung tissues, specifically parenchyma. These studies have assumed material isotropy but, to our knowledge, no study has thoroughly tested and quantified this assumption. This study presents a novel methodology for assessing isotropy in a tissue, and applies these methods to porcine lung parenchyma. Briefly, lung parenchyma samples were dissected so as to be aligned with one of the three anatomical planes, sagittal, frontal, and transverse, and then subjected to compressive mechanical testing. Stress-strain curves from these tests were statistically compared by a novel method for differences in stresses and strains at percentages of the curve. Histological samples aligned with the anatomical planes were also examined by qualitative and quantitative methods to determine any differences in the microstructural morphology. Our study showed significant evidence to support the hypothesis that lung parenchyma behaves isotropically.

An objective index to estimate the survival rate of primary blast lung injury

To supply proper treatments to the primary blast lung injury (PBLI) patients, it is important to estimate the severity of the primary blast lung injury in accordance with the blast conditions. In this study, a blast-induced mechanical parameter (first principal stress) of lung was calculated using a finite element thorax model and the correlation between the survival rate of the subjects with blast-induced lung damage and an objective index that was related to the first principal stress of the lung model. This study propose the objective index for the estimation of the degree of PBLI. The results have a potential clinical application to improve the efficacy of treatment for blast injury patients.

"Thunderstruck": penetrating thoracic injury from lightning strike

Lightning strike victims are rarely presented at an emergency department. Burns are often the primary focus. This case report describes the improvised explosive device like-injury to the thorax due to lightning strike and its treatment, which has not been described prior in (kerauno)medicine. Penetrating injury due to blast from lightning strike is extremely rare. These "shrapnel" injuries should however be ruled out in all patients struck by lightning.

Neuro-glial and systemic mechanisms of pathological responses in rat models of primary blast overpressure compared to "composite" blast

A number of experimental models of blast brain injury have been implemented in rodents and larger animals. However, the variety of blast sources and the complexity of blast wave biophysics have made data on injury mechanisms and biomarkers difficult to analyze and compare. Recently, we showed the importance of rat position toward blast generated by an external shock tube. In this study, we further characterized blast producing moderate traumatic brain injury and defined "composite" blast and primary blast exposure set-ups. Schlieren optics visualized interaction between the head and a shock wave generated by external shock tube, revealing strong head acceleration upon positioning the rat on-axis with the shock tube (composite blast), but negligible skull movement upon peak overpressure exposure off-axis (primary blast). Brain injury signatures of a primary blast hitting the frontal head were assessed and compared to damage produced by composite blast. Low to negligible levels of neurodegeneration were found following primary blast compared to composite blast by silver staining. However, persistent gliosis in hippocampus and accumulation of GFAP/CNPase in circulation was detected after both primary and composite blast. Also, markers of vascular/endothelial inflammation integrin alpha/beta, soluble intercellular adhesion molecule-1, and L-selectin along with neurotrophic factor nerve growth factor-beta were increased in serum within 6 h post-blasts and persisted for 7 days thereafter. In contrast, systemic IL-1, IL-10, fractalkine, neuroendocrine peptide Orexin A, and VEGF receptor Neuropilin-2 (NRP-2) were raised predominantly after primary blast exposure. In conclusion, biomarkers of major pathological pathways were elevated at all blast set-ups. The most significant and persistent changes in neuro-glial markers were found after composite blast, while primary blast instigated prominent systemic cytokine/chemokine, Orexin A, and Neuropilin-2 release, particularly when primary blast impacted rats with unprotected body.

Effect of blast exposure on the brain structure and cognition in Macaca fascicularis

Blast injury to the brain is one of the major causes of death and can also significantly affect cognition and physical and psychological skills in survivors of blast. The complex mechanisms via which blast injury causes impairment of cognition and other symptoms are poorly understood. In this study, we investigated the effects of varying degrees of primary blast overpressure (BOP; 80 and 200 kPa) on the pathophysiological and magnetic resonance imaging (MRI) changes and neurocognitive performance as assessed by the monkey Cambridge Neuropsychological Test Automated Battery (mCANTAB) in non-human primates (NHP). The study aimed to examine the effects of neurobehavioral and histopathological changes in NHP. MRI and histopathology revealed ultrastructural changes in the brain, notably in the Purkinje neurons in the cerebellum and pyramidal neurons in the hippocampus, which were most vulnerable to the blast. The results correlated well with the behavioral changes and changes in motor coordination and working memory of the affected monkeys. In addition, there was white matter damage affecting myelinated axons, astrocytic hypertrophy, and increased aquaporin-4 (AQP-4) expression in astrocytes, suggesting cerebral edema. Increased apoptosis appeared to involve astrocytes and oligodendrocytes in the animals following blast exposure. The small sample size could have contributed to the non-significant outcome in cognitive performance post-blast and limited quantitative analyses. Nevertheless, the study has provided initial descriptive changes for establishing a primary BOP threshold for brain injury to serve as a useful platform for future investigations that aim to estimate brain injury potential and set safe limits of exposure.

Managing traumatic brain injury secondary to explosions

Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined.

Otologic considerations of blast injury

The ear by design is exquisitely sensitive to barotrauma. As a result, it is typically the first organ affected in primary blast injury. The most common symptoms encountered include hearing loss, ringing, and drainage. In severe cases, the highest priority is appropriately directed toward diagnosis and treatment of life-threatening injuries; however, injury to the ear is missed frequently. With simple screening procedures, limited management, and appropriate otolaryngologic referral, acute and long-term morbidity can be averted for both critical and noncritical patients. The article provides an overview of blast mechanics and pathophysiology. It details various blast-related injuries to the external, middle, and inner ear. Standard of care assessment and management strategies are presented for acute and late otologic sequelae of the blast-injured patient.

Blast injuries

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

Neurobehavioral management of traumatic brain injury in the critical care setting

Traumatic brain injury (TBI) results in approximately 230,000 hospitalizations annually in the United States. Advances in the acute management of TBI have improved survival after TBI. Many TBI survivors develop neurobehavioral disturbances in the acute post-injury period. Neurobehavioral sequelae present clinical management challenges for critical care professionals. This article defines and describes TBI and reviews its common neuroanatomic and neurobehavioral consequences. These disturbances are organized under the framework of posttraumatic encephalopathy, and the characteristic forms and stages of recovery of this condition are discussed. Recommendations regarding evaluation and management of posttraumatic neurobehavioral problems in the critical care setting are offered.

Injury patterns from major urban terrorist bombings in trains: the Madrid experience

BACKGROUND

Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI.

METHODS

We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS.

RESULTS

The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h.

CONCLUSIONS

Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

Overall Asessment of the Response to Terrorist Bombings in Trains, Madrid, 11 March 2004

OBJECTIVES

To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times.

MATERIALS AND METHODS

Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15.

RESULTS

Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic.

CONCLUSION

There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.

Primary blast injury: update on diagnosis and treatment

BACKGROUND

: Injuries from combat and terrorist explosions are increasing worldwide. As such, physicians can expect to treat more patients with complex and unique patterns of injury produced not only by fragments and blunt trauma, but also by high-pressure air expanding from the detonation center.

DISCUSSION

: Tissue damage from the blast wave or primary blast injury can be an important cause of occult trauma to the ocular, aural, pulmonary, cardiovascular, musculoskeletal, and neurologic systems. Awareness of the extensive corporal effects of the blast wave is an essential prerequisite to diagnosis.

SUMMARY

: This article focuses on the incidence, risk factors, diagnosis, management, and screening for primary blast injury.

Advanced trauma life support, 8th edition, the evidence for change

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.