20051017 Survey Blast Trauma

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Survey of Blast Trauma

from Evolving Tactics of

TerrorismCatherine Y. Lee, MPH

Research Faculty Associate

New York Medical College

School of Public Health

October 17 2005Greater New York Hospital Association



“Analysis of past bombing disasters reveals

definite patterns of injury and mortality,

which provide the opportunity to plan and

prepare for future events.”

Eric Frykberg, MD, FACS



IRA: Hospital Experience, Civilian Blast Injuries

Epidemiology Started Here

1970

Israel: Mix of factors that influence pattern of trauma1990

suicidebombing

1950 Sandia, China, Sweden, Russia: Man and Blast Injury

2004 Global: Complex Tactics: different influences different

bombings – Madrid, Istanbul, London

Epidemiology ShiftEpidemiology Shift

…and non-English studies



Small and Frequent “Traditional”: Solo

OpenOpen StructuralStructural

ConfinedConfinedSuicide Bombing

Complex Bombing…Other Considerations

Explosive Type

Quantity Delivery Method

Epicenter

People in VicinityTime of Day

Etc…

+



I n c r e a s i n g

m o r t a l i t y

Increasing frequency

Catastrophic but rare

Complex Tactics

Traditional-Solo

Small IED, LE



Tactic 1Tactic 1

Small Bombings, High FrequencySmall Bombings, High Frequency

Open and Confined SpacesOpen and Confined Spaces



ProfileProfile

• Small IEDs

• HE or LE• Simple logistics, ease of coordination

• Not high profile targets, symbolic

• Open spaces

• Confined space

• 2004, 26% of combat deaths in Iraq due to thesetypes of small bombs

• Today in 2005? 70%



OpenOpen

• Free field

• Few obstacles and hindrances

• Free movement of blast wave

• Grassy park, parking lot, market place,railroad track

• Secondary injuries most prevalent,psychological trauma/stress



ExamplesExamples



Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement

Principles.

Idealized blast overpressure waveform

Measured in atm’s, psi’s

or kPa’s



SmallSmall IEDsIEDs, LE/HE, LE/HE



Atlanta

70%

50%

30%

10%

0%

10%

20%

30%

40%50%

60%

70%

80%

90%100%

p u l m o n a r y

B o w e l

T y m p a n i c

O c u l a r g l o b e

C o n c u s s i o n

P e n e t r a t i n g

B r u i s e s ,

C l o s e d / O p e n

T r a u m a t i c

N e r v e

p a l s y

C r u s h

i n j u r i e s

C V D

r e l a t e d

o t h e r

Fractures from shrapnel

5: closed/open fxskull, facial skeleton

3 Strains & Sprains

1 case of HeartAttack

7 penetratingwounds



AsaiAsai et alet al

Asai Y, Yoshida M, Jurimoto Y, Arnold JL: Case report: Penetrating cardiac injury secondary to terrorism-related, nail-bomb explosion.Prehosp Disast Med 2003;18(3):249–252.



Victoria StationVictoria StationSimilar to Atlanta Centennial Olympic except H.ESimilar to Atlanta Centennial Olympic except H.E

• Several kilograms of Semtex in a litter bin

• 30 treated at Westminster Hospital

• Majority of injuries caused by shrapnel

Incidents of Injuries

Soft Tissue Injuries 32

Open fx 13

Neurovascular 7

Traumatic Amputation 2

Perforated Organs 4

Bone fx 5No Burns

Johnstone, DJ., Evans, SC., Field, RE., Booth, SJ.The Victoria bomb: a report from the Westminster Hospital. Injury, 1993, 24 (1): 5-9



Secondary Blast

injury agents:

Bomb canister pieces

Glass shards

Particulate Matter

Secondary missiles

Secondary Injuries Most PrevalentSecondary Injuries Most Prevalent““Penetrating WoundsPenetrating Wounds””,, ““Open WoundsOpen Wounds”” Regardless of Bomb Type or EnvironmentRegardless of Bomb Type or Environment



Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003



Low explosive

Deflagration

No overpressure

High explosive

Detonation

Overpressure

“Real life” reflectingsurfaces makecomplex blast pattern – accumulates blastpressures



ConfinedConfined

• Small dimensional space, tight and limited

movement – Bus, Small Bar, Store, Bathroom

• Reflecting surfaces• Magnifies incident 2 – 9 times

– Primary – Energized, Secondary

• Small amount HE needed



Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J

Trauma, 1983, 23 (11): 955-967

CooperCooper



CooperCooper

• “Tavern in the Town”: 11 dead, 89 injured

• “Mulberry Bush”: 10 dead, 30 injured

Data from 42 total admitted from all hospitals that received:

Serious soft tissue damage 22

Burns 23

Fractures 13

Eye Damage 13

Blast Lung 3

TM Perf. 17

Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J

Trauma, 1983, 23 (11): 955-967



Source: www.mfa.il.gov; suicide bombing May 18, 2003, Jerusalem



ConfinedConfined

• According to Peleg, head, neck, extremities

most common injuries in confined space busexplosions

Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”



Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”



Confined Space, 6 kg of high explosive (not a suicide bombing)

10.3% Critical

5.2% Immediate

Katz, E., Ofek, B., Adler, J., Abramowitz, HB., Krausz, MM. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg, Apr 1989, 209 (4): 484-488



38%

24.5%

70%

14%

17.5%



Some of the greater incidences of primary blast injury come from confined space bombingsSome of the greater incidences of primary blast injury come from confined space bombings




2002

Passover dinner, hotel dining room

8 – 10 kg HE TATP packed with

hundreds of small steel balls 3 – 7mm

diameter

250 people present



33% OR, 14% 1st,2nd

burns

14% DIH first 24 hours

5 cases primary blast

50% Level II trauma

centers

75%

admitted

N=91 reflected in

graphic

N=20 (22%) DOS

44.5%PTSD

164 injured

Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.



KlugerKluger: Spherical Shrapnel and: Spherical Shrapnel and

BallisticsBallisticsFrom the distribution of the injured in the hall, the patterns of injuries,

and the specific organ injuries, we concluded that spherical missiles

incorporated in a bomb follow the ballistic patterns of shotgun pelletsthat are shot without choking or constriction at the barrel end. Whereas

immediate mortality resulted from injuries augmented by the addition of

steel balls, their wounding of the surviving patients followed the

classical pattern of low destructive injury.

It was consistent with Ordog’s classification of shotgun injuries:

•Type I: Long Distance (>12 m) resulting in only superficial penetration,

•Type II: close range (<12 m) resulting in penetration beyond the deep fascia,and

•Type III: point blank (<5m) resulting in devastating tissue damage and highmortality rates

Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.



Confined Space ComparisonConfined Space Comparison

5.3%

Peleg

8 – 16%3%14%Criticalmortality(DIH)

12.5%45%Severe

injuries %

4 – 19%29%22%Immediatemortality(DOS)

LeeFrykbergKluger

Kluger, et al. European Journal of Emergency Medicine 12:19–23 c 2005 Lippincott Williams & Wilkins.; Lee, CY Development and Application of the bomb-blast Damage and Injury Scale 2003

Requires much more investigation, several factors to consider other thanpurely the mechanical forces of the explosion & environment



MellorMellor

Mellor, SG., Cooper, GJ. Analysis of 828 servicemen killed or injured by explosion in Northern Ireland 1970-84: the Hostile Action Casualty System. Br J Surg, Oct 1989, 76 (10): 1006-1110



18 – 27 atm

11 – 15 atm7 – 9.5 atm

Solely theoretical, much investigation

continues



Tactic 2Tactic 2

Larger, ConventionalLarger, ConventionalBombingsBombings



ProfileProfile

• Single vehicle IED

• Higher degree of coordination andlogistics

• Structures and Symbolic targets• We deter with technologies and security

countermeasures

• Some cases of primary injury, STILL

secondary most common, some cases of

tertiary, quaternary - crush injuries



VehicleVehicle IEDsIEDs



FEMA 426- Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings



Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387



Frykberg, ER. Medical Management of Disaster and Mass Casualties from Terrorist Bombings: How can we cope? J Trauma2002;53:201–212.




OKC Fatal InjuriesOKC Fatal Injuries

•• 122 Multiple Trauma122 Multiple Trauma

– Multi-system, multi-dimensional injuries, constellationof 1˚, 2 ˚, 3 ˚, 4 ˚ types

– Like “Patient 4” AMIA we just saw

• 24 Head Trauma• 13 Chest Trauma

• 3 Head & Neck Trauma

• 3 Traumatic shock

• 2 Fractures cervical spine




Weapons Systems Division, Defence Science and Technology Organisation, Edinburgh, SA.Dr Anna E Wildegger-Gaissmaier, DipIng(TU), PhD, Head Terminal Effects.Online at: http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/adfhealth_apr03/ADFHealth_4_1_03-06.html



Source: White, Richmond

The Force behind Tertiary InjuriesThe Force behind Tertiary Injuries



Beirut 1983Beirut 1983



Beirut 1983Beirut 1983

• Estimated 6 Ton TNT Equivalent HE

• Complete Structural Collapse of 4 storystructure, 6am

– Medical contingent killed• 37% Critical (7/19)

• 68% Immediate• Simultaneous blast at French

paratrooopers headquarters



AMIA

12%18%

6% 6%

18%

29%

41%

6%

29%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

p u l m o n a r y

b

a r o t r a u m a s ,

B o w e l

p e r f o r a t i o n

T y m p a n i c

m e

m b r a n e ( e a r

O c u l a r g l o b e

r u p t u r e

C o n c u s s i o n

P e n e t r a t i n g

b a l l i s t i c

B r u i s e s ,

c o n t u s i o n s ,

C l o s e d / O p e n

f r a c

t u r e t o s k u l l

T r a u m a t i c

a m p u t a t i o n o f

N e r v e p a l s y

C

r u s h i n j u r i e s

C V D r e l a t e d

o t h e r

Structural bombing, About 1 Ton TNT equivalence

29% Critical

29% ImmediateBiancolini, CA., Del Bosco, CG., Jorge, MA. Argentine Jewish community institution bomb explosion. J Trauma, Oct 1999, 47 (4): 728-732




4%O

4%C

19%S

Lee, CY. Development and Application of the Bomb-blast Damage and Injury Scale. 2003



Tactic 4Tactic 4

Catastrophic, Rare ExplosionsCatastrophic, Rare Explosions



Low explosive

Deflagration

No overpressure

High explosive

Detonation

Overpressure

Nuclear explosion

Fission of nuclearparticles

+ High explosivecomponent

Overpressure

“Real life” reflectingsurfaces makecomplex blast pattern

– accumulates blastpressures



Source: de Candole, 1967

Range

yield



Texas CityTexas City

• Within a 1,000-foot radius, all will be killed or injured.

33% DOS, 50% seriously injured, 17% less injured• Low death rate among hospitalized survivors (6.25% DIH of admitted) and

fewer serious burns that anticipated

• Thick cloud of black smoke and vapor from soot and chemicals

5,000 dead and

injured;3,500 non-fatal

injuries;

800 hospitalized(16% of total

casualties);560 killed, or

missing and

presumed Dead

Additional InformationCasualties

Primary Cause of

Damage and Injury

was the blast (blastwave, blast wind),

missiles, fire, tidal

wave (10 ft high)

1000 ft - Almost all 560

dead and 800

hospitalized; 2000ft;3000 ft damage still

seen up to 10,000 ft

(1.8 mi)

out

1.6 kt TNT-Equivalent2.3 kT AN

Key InjuriesRadius of DamageKiloton equivalentExplosives

April 17, 1947 - cargo munitions ship explodes

Blocker, V., Blocker, TG. The Texas City Disaster, a Survey of 3000 casualties 1949. American J Surgery

S i i j i



Serious injuriesand deaths stillfound out to

1500 ft = 1/3 mi



Tactic 3Tactic 3

Complex Bombings, Current DayComplex Bombings, Current Day



Complex BombingComplex Bombing

1 – Combining open, confined, structural

bombings2 – “Onslaught” of several bombings using

suicide methods to one area3 – Capitalizing on crowds

Differs from a single method to a single target,

potentially increasing casualty count and

making medical response more confusing



““250 Perish as 13 Blasts Rock India250 Perish as 13 Blasts Rock India”” – – 19931993

More than 1000 injuredMore than 1000 injured

IndiaIndia –– Pakistan ConflictPakistan Conflict



ChechnyaChechnya –– Russia ConflictRussia Conflict

• July 2-3, 2000 - Chechen guerrillas launch 5

suicide bomb attacks on bases of Russianforces within 24 hours. In the deadliest, at least54 people are killed at a police base near

Grozny.• December 27, 2002 - Chechen suicide bombers

ram vehicles into the local government

headquarters in Grozny, bringing down the roofand floors of the four-story building. Chechenofficials say about 80 people killed.



July 5 2003

3 SHB

20 Dead



Bali BombingsBali Bombings

• 8/1/2000 – Car bomb, private house

– 2D, 1I• 9/13/2000

– Car bomb, Jakarta StockExchange

– 10D, 16I• 12/25/2000

– 11 churches acrossIndonesia

– 19 D, 100 I• 12/05/2002

– Bomb McDonald’s

– 3D, 11I

• 10/12/2002 – 2 bombs (1 car), Nightclubs

– 202 D• 8/5/2003

– Car bomb Marriott

– 12D, 150I

• 9/9/2004 – Suicide car bomb

Australian Embassy

– 11D, 100 I

• 10/1/2005 – 2 SHBs

– 3 restaurants

– 24D, 132I

Source: CNN, Accessed 10-3-05

AfricaAfrica –– Kenya and TanzaniaKenya and Tanzania



AfricaAfrica Kenya and TanzaniaKenya and Tanzania

U.S EmbassiesU.S Embassies

8/7/19988/7/1998



Riyadh May 12 2003Riyadh May 12 2003

• 4 Bombings in quicksuccession

• Combination of SHB andvehicle bombs

• 34 dead, 190 injured

• Most casualties from the AlHamra compound

• “Commando Op”



Morocco May 16 2003Morocco May 16 2003

• 42 killed including 13 bombers, 100

injured – 24 DOS

• 100 patrons estimated in the Café elSpana at time of bombing (9 pm)

• Blast at club responsible for most

casualties



C.Y.Lee 1 Apr 2004



Increased bomb deliveryIncreased bomb delivery

• Aug 26 2003 - 2 car blasts in Mumbai, 150wounded, 65 dead

– Minutes apart, bodies expelled 10 – 15 meters

– Train derailment blast minutes later

– Worst attack since 1993• Sept 30 2005 - Series of car bombs over 2 days

kill 200 in Iraq

– Since April 25 suicide bombers killed 1,345 people

Transportation TargetsTransportation Targets



MOSCOW Commuter Train DEC 5 2003

745AM, Up to 41 DOS, 2 possible SHB with UXO, problems inrescue, 1st suicide train bombing (before Madrid)

Sept 2003, 6 people died, commuter train similar bombing

Transportation TargetsTransportation Targets



Serious Train Bombings 1976 - 2005Serious Train Bombings 1976 - 2005

0

200

400

600

800

1000

1200

1400

1600

8 / 1 4 / 7 6

3 / 2 9

/ 8 2

6 / 2 6

/ 8 6

9 / 3 / 8 8

3 / 1 9 / 9 4

7 / 2 5

/ 9 5

7 / 2 5

/ 9 5

1 2 / 3 / 9 6

1 0 / 1 / 9 7

2 / 2 3

/ 9 8

2 / 2 6

/ 9 8

3 / 9 / 9 8

3 / 3 1 / 9 8

6 / 7 / 9 8

8 / 1 2 / 9 8

1 1 / 1 1 / 9 9

1 1 / 1 1 / 9 9

2 / 5 / 0 0

2 / 5 / 0 0

8 / 1 3 / 0 1

8 / 1 4 / 0 1

3 / 1 4 / 0 2

3 / 1 2 / 0 3

9 / 3 / 0 3

1 2 / 5 / 0 3

2 / 6 / 0 4

3 / 1 1 / 0 4

7 / 7 / 0 5

Dead

Injured

Dec 5 2003 Russian CommuterDec 5 2003 Russian Commuter



Dec 5 2003 Russian CommuterDec 5 2003 Russian Commuter

TrainTrain• DOS 70% (31/44) of total fatalities

• Critical mortality 9% (13 of 148)• not unlike the 6% critical mortality reported frombombings in Israel

• occupied primarily by college students• 16 to 68 years old

• force ejected several occupants

• Up to 148 victims were admitted

• 50 were treated for minor physical injuries andreleased



Rescue ChallengesRescue Challenges

• Friday morning rush hour

• trapped many severely injured inside• under overturned train carriage

• encumbered by a

– snarl of electrical wires – cables

– and overhead fires

“The Suicide Bombing of the Mineralnye Vody Train: A Case Study in Using Open Source Information (OSINF) for Open Source Health Intelligence (OSHINT)”. Lee, Davis, Noji

Feb 6 2004 Moscow MetroFeb 6 2004 Moscow Metro



Feb 6 2004 Moscow MetroFeb 6 2004 Moscow Metro

8:40 AM

2 SHB’s

39 DOS

70+ injured

Smoke

No electricity

Secondary fires

Rescuers could

not open traindoors for 30minutes



Mar 11 2004 Madrid MetroMar 11 2004 Madrid Metro



Mar 11 2004 Madrid MetroMar 11 2004 Madrid Metro

• 10 Explosions• 15-minute Span,• Started at 7:39 AM• 28 – 33 lb high

explosive

• Backpack, 13 Bombs• 192 Dead• Approx. 1400

Wounded

Source: BBC Online



Sequence of EventsSequence of Events7:39 a.m. – 3 backpacks loaded with explosives blow up on

a commuter train in Madrid's Atocha station.

7:39 a.m.– 4 backpack bombs explode on a commuter trainentering Atocha station.

7:42 a.m. – 1 Backpack bomb explodes as a commuter

train enters Santa Eugenia train station, nine miles fromAtocha.

7:41 a.m. – 2 bombs explode on double-deckercommuter train in El Pozo station, six miles fromAtocha.

Source: Associated Press, “Timeline for Madrid commuter train bombings”, Mar 11, 2004, San Diego-Union Tribune,signon SanDiego.com



Most deaths

on doubledecker 70

fatalities

Source: BBC Online



Madrid Casualty FiguresMadrid Casualty Figures

• Number of victims: 1430

• Primary care: 204 (14%)• Prehospital care: 250 (17%)

• Admitted to any Hospital: 976 (68%)• Total number of deaths: 192 (13%)

• Number DOS: 170

i S j i



Madrid Severe InjuriesMadrid Severe Injuries

1º: Blast injuries (explosion): 56%.

2º: Penetrating injuries (shrapnel): 50%.3º: Blunt trauma (ejection): 53%.

4º: Burn injuries (flash burns): 31%

L d J l 7 2005



London July 7 2005London July 7 2005

Four bombs:

3 on tube carriages1 on commuter bus

Deaths:

26 at Russell Square7 at Aldgate6 at Edgware Road

13 on bus at Tavistock

Place

Source: BBC Online

SS f E l i



Seat of ExplosionsSeat of Explosions

The most deaths at Russell Square, 26 D

Aldgate, 7D, 100 injured, 10 serious

Edgware Station, 6D, 120 injured

Source: BBC Online

SR ll S I D h



Russell Square In-DepthRussell Square In-Depth

Source: BBC Online

T i kT i t k



TavistockTavistock

Source: BBC Online

Li lLi l



LiverpoolLiverpool

• Sliding doors wouldn’t open

• Soot, smoke billowing up• At first panic, then collected calm

• Double-decker bus to Royal UniversityHospital

Source: BBC Online

KiKi ’’ CC



KingKing’’s Crosss Cross

• “Intense heat of up to 60C, dust, fumes,

vermin, asbestos and initial concerns thetunnel might collapse delayed theextraction of bodies and the forensic

operation.” - BBC – 30 minutes for paramedics to arrive

– 15 minutes for survivors to get to surface – Survivor states hospital pretty well organized,

saw a lot of minor scrapes, cut legs

Source: BBC Online

T i t kT i t k S BS B



TavistockTavistock Square, BusSquare, Bus1/81/8thth milemile

200 meters200 meters

660 feet660 feet

Source: BBC Online



I di E l i /FiI di E l i /Fi



Incendiary Explosions/FiresIncendiary Explosions/Fires

• Burns

• Respiratory problems to T3• Common materials in public

• Less technological skill to craft• Post-disaster, possibly more time

consuming to mortuary system• Doesn’t have to be terrorist

• Daily drills with arsons and fires



Deagu, SOUTH KOREA Feb 18 2003

10AM, 120 DOS, incineration, major hurdles to rescue,including entrapment inside once fire started



C lti d I j iC lti d I j i



Casualties and InjuriesCasualties and Injuries

• 182 dead, 340 missing and presumed

dead• 2 subway trains

• Fire engulfed one 6-car train, spread tothe next train which had pulled into station

few minutes later

• Most bodies unidentifiable, charred

• Burned, trampled, suffocated to death

E C li tiE C li ti s



Emergency ComplicationsEmergency Complications

• Fire crippled communication system

• Subway officials couldn’t warn 2nd

train• Station control center cut off electricity

• black out, no sprinkler system

• Most victims in this 2nd train

• Conductor fled without opening doors,

victims trapped• “Toxic Gas”



Thanks for your time!Thanks for your time!

Catherine Y. Lee, MPH

[email protected]

20051017 Survey Blast Trauma

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