Ami Mayo, Yoram Kluger
Terrorist bombing.
World J Emerg Surg. 2006 Nov 13;1:33. doi: 10.1186/1749-7922-1-33. Epub 2006 Nov 13.
Abstract/Text
Bombings and explosion incidents directed against innocent civilians are the primary instrument of global terror. In the present review we highlight the major observations and lessons learned from these events. Five mechanisms of blast injury are outlined and the different type of injury that they cause is described. Indeed, the consequences of terror bombings differ from those of non-terrorism trauma in severity and complexity of injury, and constitute a new class of casualties that differ from those of conventional trauma. The clinical implications of terror bombing, in treatment dilemmas in the multidimensional injury, ancillary evaluation and handling of terror bombing mass casualty event are highlighted. All this leads to the conclusion that thorough medical preparedness to cope with this new epidemic is required, and that understanding of detonation and blast dynamics and how they correlate with the injury patterns is pivotal for revision of current mass casualty protocols.
David S Plurad
Blast injury.
Mil Med. 2011 Mar;176(3):276-82.
Abstract/Text
Explosions can cause devastating injuries by various wounding mechanisms. Injuries due to the primary pressure wave are rarely life threatening and those that are lethal are uncommon. We reviewed the pathophysiology of blast-related injuries and their implications for management. There is much overlap in treatment of these wounds, and a detailed description is beyond the scope of this review. A brief summary of the initial surgical and nonsurgical management of blast injury that is useful for civilian and military clinicians is provided.
後藤義孝, 箱崎幸也. 爆発・爆弾テロへの対処. 災害・健康危機管理ハンドブック診断と治療社 (2007/05) 250-256 ISBN-10: 4787815318.
Jeff Garner, Stephen J Brett
Mechanisms of injury by explosive devices.
Anesthesiol Clin. 2007 Mar;25(1):147-60, x. doi: 10.1016/j.anclin.2006.11.002.
Abstract/Text
Explosive devices cause injury by four mechanisms, of which primary blast injury is the least familiar to most non-military clinicians. The pathophysiology of the various mechanisms of injury is described, and the implications for translating a knowledge of mechanism of injury to clinical management is discussed.
Jeffrey V Rosenfeld, Nick L Ford
Bomb blast, mild traumatic brain injury and psychiatric morbidity: a review.
Injury. 2010 May;41(5):437-43. doi: 10.1016/j.injury.2009.11.018. Epub 2010 Feb 26.
Abstract/Text
Traumatic brain injury (TBI) arising from blast exposure during war is common, and frequently complicated by psychiatric morbidity. There is controversy as to whether mild TBI from blast is different from other causes of mild TBI. Anxiety and affective disorders such as Post-traumatic Stress Disorder (PTSD) and depression are common accompaniments of blast injury with a significant overlap in the diagnostic features of PTSD with post-concussive syndrome (PCS). This review focuses on this overlap and the effects of mild TBI due to bomb blast. Mild TBI may have been over diagnosed by late retrospective review of returned servicemen and women using imprecise criteria. There is therefore a requirement for clear and careful documentation by health professionals of a TBI due to bomb blast shortly after the event so that the diagnosis of TBI can be made with confidence. There is a need for the early recognition of symptoms of PCS, PTSD and depression and early multi-disciplinary interventions focussed on expected return to duties. There also needs to be a continued emphasis on the de-stigmatization of psychological conditions in military personnel returning from deployment.
(c) 2009 Elsevier Ltd. All rights reserved.
Leopoldo C Cancio, Robert L Sheridan, Rob Dent, Sarah Gene Hjalmarson, Emmie Gardner, Annette F Matherly, Vikhyat S Bebarta, Tina Palmieri
Guidelines for Burn Care Under Austere Conditions: Special Etiologies: Blast, Radiation, and Chemical Injuries.
J Burn Care Res. 2017 Jan Feb;38(1):e482-e496. doi: 10.1097/BCR.0000000000000367.
Abstract/Text
Danyal Magnus et al. Epidemiology of civilian blast injuries inflicted by terrorist bombings from 1970-2016. Defence Technology 2018; 14 469-476.
Thomas J Nelson, Derek B Wall, Eric T Stedje-Larsen, Richard T Clark, Lowell W Chambers, Harold R Bohman
Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom.
J Am Coll Surg. 2006 Mar;202(3):418-22. doi: 10.1016/j.jamcollsurg.2005.11.011. Epub 2006 Jan 20.
Abstract/Text
BACKGROUND: Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively.
STUDY DESIGN: A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test.
RESULTS: All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p < 0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors.
CONCLUSIONS: Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.
Gidon Almogy, Tal Luria, Elihu Richter, Reuven Pizov, Tali Bdolah-Abram, Yoav Mintz, Gideon Zamir, Avraham I Rivkind
Can external signs of trauma guide management?: Lessons learned from suicide bombing attacks in Israel.
Arch Surg. 2005 Apr;140(4):390-3. doi: 10.1001/archsurg.140.4.390.
Abstract/Text
BACKGROUND: Following a suicide bombing attack, scores of victims suffering from a combination of blast injury, penetrating injury, and burns are brought to local hospitals.
OBJECTIVE: To identify external signs of trauma that would assist medical crews in recognizing blast lung injury (BLI) and effectively triaging salvageable and nonsalvageable victims.
DESIGN: Retrospective analysis of all 15 suicide bombing attacks that occurred in Israel from April 1994 to August 1997.
SETTING: National survey.
PATIENTS: One hundred fifty-three victims died and 798 were injured as a result of 15 attacks. Medical records were reviewed for external signs of trauma, such as burns and penetrating injuries, and the presence of BLI. Main Outcome Measure The odds ratio for BLI and death.
RESULTS: Three settings were targeted: buses, semiconfined spaces, and open spaces. Sixty survivors (7.5%) suffered from BLI, which was more common in buses (37 of 260) than semiconfined spaces (14 of 279) and open spaces (9 of 259) (P<.001). Victims with BLI were more likely to suffer from penetrating injury to the head or torso, burns covering more than 10% of the body surface area, and skull fractures (odds ratios, 4, 11.6, and 55.8, respectively; P<.001). Victims who died at the scene were more likely to suffer from burns, open fractures, and amputations in comparison with survivors (odds ratios, 6.5, 18.6, and 50.1, respectively; P<.001).
CONCLUSIONS: Following a suicide bombing attack, external signs of trauma should be used to triage victims to the appropriate level of care both at the scene and in the hospital. Triage of salvageable and nonsalvageable victims should take into account the presence of amputations, burns, and open fractures.
吉村有也. テロの脅威に備え、銃創・爆傷の臨床を理解する. INTENSIVIST 2020; 12(2) 269-380.
Alison A Smith, Joana E Ochoa, Sunnie Wong, Sydney Beatty, Jeffrey Elder, Chrissy Guidry, Patrick McGrew, Clifton McGinness, Juan Duchesne, Rebecca Schroll
Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications.
J Trauma Acute Care Surg. 2019 Jan;86(1):43-51. doi: 10.1097/TA.0000000000002095.
Abstract/Text
BACKGROUND: Despite increasing popularity of prehospital tourniquet use in civilians, few studies have evaluated the efficacy and safety of tourniquet use. Furthermore, previous studies in civilian populations have focused on blunt trauma patients. The objective of this study was to determine if prehospital tourniquet use in patients with major penetrating trauma is associated with differences in outcomes compared to a matched control group.
METHODS: An 8-year retrospective analysis of adult patients with penetrating major extremity trauma amenable to tourniquet use (major vascular trauma, traumatic amputation and near-amputation) was performed at a Level I trauma center. Patients with prehospital tourniquet placement (TQ) were identified and compared to a matched group of patients without tourniquets (N-TQ). Univariate analysis was used to compare outcomes in the groups.
RESULTS: A total of 204 patients were matched with 127 (62.3%) in the prehospital TQ group. No differences in patient demographics or injury severity existed between the two groups. Average time from tourniquet application to arrival in the emergency department (ED) was 22.5 ± 1.3 minutes. Patients in the TQ group had higher average systolic blood pressure on arrival in the ED (120 ± 2 vs. 112 ± 2, p = 0.003). The TQ group required less total PRBCs (2.0 ± 0.1 vs. 9.3 ± 0.6, p < 0.001) and FFP (1.4 ± 0.08 vs. 6.2 ± 0.4, p < 0.001). Tourniquets were not associated with nerve palsy (p = 0.330) or secondary infection (p = 0.43). Fasciotomy was significantly higher in the N-TQ group (12.6% vs. 31.4%, p < 0.0001) as was limb amputation (0.8% vs. 9.1%, p = 0.005).
CONCLUSION: This study demonstrated that prehospital tourniquets could be safely used to control bleeding in major extremity penetrating trauma with no increased risk of major complications. Prehospital tourniquet use was also associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization and decreased incidence of limb related complications, which may lead to improved long-term outcomes and increased survival in trauma patients.
LEVEL OF EVIDENCE: Therapeutic, level IV.
Alastair Beaven, Paul Parker Blast injuries: a guide for the civilian surgeon. Surgery 2021 July; 39(7): 393-400.
Ralph G DePalma, David G Burris, Howard R Champion, Michael J Hodgson
Blast injuries.
N Engl J Med. 2005 Mar 31;352(13):1335-42. doi: 10.1056/NEJMra042083.
Abstract/Text
Corey D Harrison, Vikhyat S Bebarta, Gerald A Grant
Tympanic membrane perforation after combat blast exposure in Iraq: a poor biomarker of primary blast injury.
J Trauma. 2009 Jul;67(1):210-1. doi: 10.1097/TA.0b013e3181a5f1db.
Abstract/Text
OBJECTIVE: The US military has reported over 10,000 improvised explosive device attacks attributing to over 400 deaths in Iraq in 2005. Otologic blast injury and tympanic membrane (TM) perforation have traditionally been used as a predictor, or biomarker, of serious or occult primary blast injury (PBI). Although combat injuries from the US-Iraq conflict have been described, the utility of TM perforation as a marker of PBI has not. The objective of this study is to determine the incidence of tympanic perforation in patients subject to blast exposures and describe its utility as a biomarker of more serious primary barotrauma, as observed at a US military hospital in Iraq.
METHODS: In our institutional review board-approved study, all patients during a 30-day period who arrived at a tertiary US military hospital in Iraq were evaluated. All patients with blast injures were identified on arrival to the hospital emergency department and were followed up through their hospital course and evacuation to the United States to assure they received proper otolaryngology evaluation and follow-up. Demographic data and manifestations of PBI (TM perforation, pneumothorax, pulmonary contusion, nonpenetrating facial sinus injury, and bowel perforation) and other combat injuries were recorded. The diagnostic tests and clinical examination findings used to identify these complications were also recorded.
RESULTS: One hundred sixty-seven patients were enrolled over 30 days. All blast exposures resulted from primary or secondary explosions from munitions used in combat. This included both combatants and civilians. All patients were men. The mean patient age was 28 years (range, 12-55 years). Sixteen percent (27 of 167) of blast-exposed patients had TM perforation. Thirteen of 27 patients with perforations had bilateral perforations. Twelve of 167 patients (7%) had PBI. Six of 12 patients (50%) with PBI had TM perforation. The use of TM perforation as a biomarker for PBI resulted in a sensitivity of 50% (95% CI, 22-78%) and specificity of 87% (95% CI, 81-92%).
CONCLUSIONS: Both TM perforation and PBI are rare with improvised explosive devices and other explosive devices in the current Iraqi-US conflict. Contrary to previous belief and management guidelines, TM perforation had low sensitivity for serious or occult PBI and was not a good biomarker. On the basis of the findings of this study, the absence of TM perforation does not appear to exclude other serious PBI.
Andrew P Cap et al. Damage Control Resuscitation. Mil Med. 2018 Sep 1; 183(suppl_2): 36-43.
Mackenzie I et al. What the intensive care doctor needs to know about blast-related lung injury. J Intensive Care Soc 2013; 14: 303-312.
