Imaging features of blast injuries: experience from 2015 Ankara bombing in Turkey

Imaging findings of the injured in the massive Beirut blast

PURPOSE

(1) Describe imaging utilization and findings within two weeks of the 2020 Beirut blast according to the mechanism of injury, (2) determine the appropriate imaging modality per organ/system, and (3) describe changes in the workflow of a radiology department to deal with massive crises.

MATERIALS AND METHODS

Two hundred sixty patients presented to the largest emergency department in Beirut and underwent imaging within 2 weeks of the blast. In this retrospective study, patients were divided into early (1) and late (2) imaging groups. Patients' demographic, outcome, type and time of imaging studies, body parts imaged, and mechanism and types of injuries were documented.

RESULTS

Two hundred five patients in group 1 underwent 502 and 55 patients in group 2 underwent 145 imaging studies. Tertiary blast injuries from direct impact and falling objects were the most common type of injuries followed by secondary (shrapnel) injuries. Both types of injuries affected mostly the head and neck and upper extremities. Plain radiographs were adequate for the extremities and CT for the head and neck. A regularly updated and practiced emergency plan is essential to mobilize staff and equipment and efficiently deliver radiology services during crises.

CONCLUSION

Because the powerful Beirut blast occurred at the port located in the periphery of the city, most injuries seen on imaging were of the upper extremities and head and neck caused by the severe blast wind or penetrating shrapnel and resulted from people using their arms to protect their heads and bodies from direct impact and falling objects.

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.

Secondary blast injury: radiological characteristics of shrapnel injuries in children

PURPOSE

The aim of this study is to examine the radiological images of child victims suffering from secondary blast injuries, to reveal organ-based injury patterns and their interrelationships, and to record mortality rates that may develop due to injured systems.

METHODS

A total of 65 patients with secondary blast injury due to bomb explosion were included in the study. Injury findings due to shrapnel in radiologic images of the patients were examined. Injured systems and types of injuries were recorded.

RESULTS

The most common injuries were intra-abdominal injuries (63%) and fractures (58.5%). Lung injury was observed in 4 (9.8%) of 41 patients with intra-abdominal injury, while 37 (90.2%) did not, and this was statistically significant (p = 0.003). The most common intra-abdominal organ injury was a small bowel injury in 23 (35.4%) patients. The coexistence of small bowel injury and large bowel injury was present in 8 patients (34.8%), and it was statistically significant (p = 0.019). A total of 14 (21.5%) of the patients died. There was no significant relationship between mortality and gender (p = 319). Brain damage was present in 10 (71.4%) of the 14 (21.5%) patients who died, which was statistically significant (p < 0.001).

CONCLUSION

Our results showed that the most common injuries were intra-abdominal injuries, damage to different organs could occur at the same time, and deaths were especially associated with brain injuries. For this reason, it should not be forgotten that CT scans will have an important place in the triage of the patient, especially in victims with shrapnel at the abdominal and cranial levels in radiography examinations.

The risk of fragment penetrating injury to the heart

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

Hand grenade blast injuries in the Eastern Democratic Republic of Congo: a case series of 38 patients

Introduction

The armed conflict in the Kivu province of the Democratic Republic of Congo has caused close to 12,000 deaths. One of the most lethal weapons in armed conflicts is the high explosive hand grenade. The study aimed to describe the epidemiology, presentation, and outcomes of hand grenade blast injuries (HGBI) in the Kivu province.

Methods

In this case series, the authors present 2017 to 2020 HGBI admissions at a Congolese trauma center. Measures of central tendency and spread were computed for continuous data. Complication and mortality rates were equally computed. Admission-to-discharge data were disaggregated by the body part injured and by complication status and visualized using time-to-event curves.

Results

Thirty-eight HGBI patients aged 31.4 (range 17–56) years were included in the study. Twenty-six (68.4%) were male and the patients were admitted 1.8 days post-injury on average. The patients were hemodynamically stable at admission; 84.2% received the antitetanic vaccine, 21.1% received broad-spectrum antibiotics, and all were debrided (100.0%). The complication rate was 13.2%, and the most common complication was anemia (7.9%). In addition, the mortality rate was 2.6%. The median admission-to-discharge time was 17.0 (range 4–71) days, and it was prolonged in patients with lower extremity injuries (23.0 days).

Conclusion

HGBIs cause avertable death and disability in the Kivu regions. These data suggest that the burden of HGBIs can be reduced with appropriate preventive and health systems strengthening interventions.

Penetration of Energised Metal Fragments to Porcine Thoracic Tissues

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

The first case of C4-Blast related death in Malaysia: A multidisciplinary approach illustrated with emphasis on conjoint anthropologic and radiologic expertise in forensic identification of skeletal remains

BACKGROUND

Blast related deaths are often shrouded by diagnostic and medicolegal complexities requiring multidisciplinary expertise in order to gauge accurate identification of the victims and document scientific investigations comprehensively. In the advent of more sophisticated technology, anthropologic methods can now be applied into post mortem imaging interpretation. The traditional imaging roles of characterizing osseous fragmentation, detecting and localizing foreign bodies can be expanded to simulate and support physical anthropologic examination to assist in documentation for court proceedings.

CASE PRESENTATION

An assemblage of unidentified, incomplete, highly fragmented skeletal remains were found scattered on a bare area of land in a forest. There was evidence of an explosion given the pattern of scattered evidentiary material of explosive and ballistic nature. Laboratory analysis of white powder found within the explosive material confirmed the presence of high impact C4-explosive trace containing cyclotrimethylene trinitramin [Royal Demolition Explosive (RDX)] & pentaerythritol tetranitrate (PETN). It took meticulous multidisciplinary efforts to confirm the identity of the victim that was marred by the severe fragmentation and skeletalization of the remains. The initial radiologic interpretation focused more on identification of foreign bodies and supporting documentation of fragmentation. With the current availability of post computed tomography (PMCT) in our center, we reexamined the value and potential of PMXR and PMCT as an adjunctive tool for biological profiling.

CONCLUSION

This was the first case of C4-blast related death reported in Malaysia. The multidisciplinary approach in efforts to identify the victim may serve as a guide in managing, coordinating and maximizing the expertise of different forensic specialists, with emphasis on anthropologic and radiologic collaboration.

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

Background

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

Methods

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

Results

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

Conclusion

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

Head and neck injuries after a bomb explosion: Diagnostic findings and treatment approaches

OBJECTIVE

To identify the types and severity of head, face and neck (HFN) injuries, which occurred as a result of a bomb explosion and reached serious life-threatening levels, using radiological imaging methods, and to discuss the options of treatment at the time of presentation.

METHODS

Of the 16 patients brought to the emergency department, 14 with HFN injuries were included in the study. Computed tomography (CT) and radiography scans were performed at the time of presentation in all patients, except for one. The injuries were divided into three groups according to their localization as head, face, and neck.

RESULTS

A subgaleal hematoma was seen in 10 of 11 (78.5%) patients with head injuries. Eight (57.1%) of nine patients with facial injury had fractures and/or ocular injury in the orbital wall, and seven (50%) patients had maxillofacial bone fractures. Among ocular trauma cases, open-globe injuries were detected in three patients (21.4%), closed-globe in two (14.2%), and both types in three (21.4%). Of the five (35.7%) patients with secondary blast injuries in the neck, three (21.4%) had laryngeal trauma (Zone 2) due to shrapnel, localized in the false vocal cord, epiglottis, and thyrohyoid membrane, respectively. Emergency surgery was performed on a patient with a specific laryngeal injury.

CONCLUSION

We consider that in patients presenting to the emergency department with blast HFN injuries, after providing airway patency and hemodynamic stability, CT and CT angiography should be performed because these modalities guide the treatment accurately and promptly.

Ankara bombing: distribution of injury patterns with radiological imaging

Purpose

To describe and explain the blast injuries and imaging findings in the Ankara terrorist explosion that took place on October 10, 2015.

Material and methods

A total of 77 patients who underwent radiologic imaging were classified as primary, secondary, tertiary, and quaternary, according to the injury type. The patients were evaluated based on body regions, such as head and neck, thorax, abdomen, lower extremity, and upper extremity.

Results

Blast lung injury was identified in one patient and tympanic membrane perforation in seven patients, as the primary injury. Sixty-two of 77 patients had secondary blast injuries caused by shrapnel. The blast injuries were observed in the head and neck (16/77, 20.7%), thorax (11/77, 14.2%), abdomen (16/77, 20.7%), lower extremity (48/77, 62.3%), and upper extremity (5/77, 6.4%). Vascular injuries were seen in eight cases, of which seven were in the lower extremities.

Conclusions

The most common blast injury pattern was of a secondary type in the current study. Lower extremities were the significantly more affected body region, probably due to the bomb exploding at ground level. In mass casualty events, radiologic imaging is located at the centre of patient management.