今日の臨床サポート

爆弾テロ

著者: 竹島茂人 沖縄県立八重山病院 救急科

監修: 林寛之 福井大学医学部附属病院

著者校正済:2022/09/14
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 爆弾テロは、救護者等を狙った2つ目の爆弾の爆発に注意しなければならない。
  1. 爆発による損傷は、外見上に異常がなくても、耳、肺、腸管等に損傷があることがある。
  1. 現場での医療対応としては、TCCC(Tactical Combat Casualty Care)に準じて行うことが推奨される。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
竹島茂人 : 特に申告事項無し[2022年]
監修:林寛之 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、新しい知見を追記した。特にTCCC、DCR(Damage Control Resuscitation)、DCS(Damage Control Surgery)について追記した。

まとめ

まとめ  
  1. 爆弾テロは、未だに世界各地で発生している。2013年4月のボストンマラソンでの爆弾テロが有名であるが、2015年8月のバンコックや同年9月には中国、10月にはトルコでも爆弾テロは発生している。2022年4月にはアフガニスタンでも発生している。中東や北アフリカそして南アジアがテロリストによる主戦場となっている。治安が比較的よく、優秀な公安・警察を持つ日本では、爆弾テロの発生は近年みられないが、ガソリン等を使用した放火による無差別殺人は散発している。今後、国内で簡易爆弾等を用いられる可能性はゼロではない。爆弾テロによって引き起こされる多発外傷のメカニズム、そして現場で救護活動を行う際の注意点などについての知識は医療従事者であれば知っておかなければならない必須のものである。
  1. 爆弾テロは、数あるテロ手段のなかでも代表的なものである。爆弾の種類は、多種多様で比較的容易に準備可能なものもある。
  1. 爆発による身体損傷は、鈍的損傷、鋭的損傷、熱傷、四肢断裂、クラッシュ症候群、空気塞栓などが複合した損傷形態を呈する。
  1. 爆弾の爆発による損傷は、その発生メカニズムにより、一次爆風損傷から五次爆風損傷の5つに分類されている[1][2]
  1. 特異的な損傷は一次爆風損傷であり、身体の外見上に損傷がなくても、爆風による風圧により身体内部の鼓膜、肺、腸管などが損傷を受ける[3]
  1. 閉鎖空間(建物内、バス内など)での爆発は、風圧が反射することにより、解放空間(屋外)より大きな損傷を与える[4]
  1. 一次爆風損傷による頭部損傷と外傷後ストレス障害(PTSD)などの精神・神経症状との関係が示唆されている[5]
  1. テロリストは、爆弾内に放射性物質(ダーティーボム)や化学剤(サリンなど)を仕込んだり、救助者に対する二次被害を狙った重複爆弾テロを行うことがあり、不用意に現場に近づかないなどの注意が必要である。

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文献 

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.

PMID 17101058
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.

PMID 21456353
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.

PMID 17400162
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.
PMID 20189170
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
PMID 27355658
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.

PMID 16500245
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.

PMID 15837890
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.

PMID 30358768
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
PMID 15800229
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.

PMID 19590337

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