No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Blast y lesiones por explosión
Abstract
l término blast engloba las lesiones anatómicas y el síndrome clínico provocados por la exposición del organismo a los efectos de una onda de choque ocasionada por una explosión. Una explosión es una reacción química exotérmica que transforma, en un tiempo muy corto, un cuerpo líquido o sólido en gas y que consta esquemáticamente de tres componentes: la onda de choque, vientos expansivos y el calor. Dependiendo del medio ambiente en el que se propague la onda de choque, se distinguen los blasts en medios aéreos, líquidos o sólidos. Las explosiones pueden deberse a accidentes domésticos o industriales, pero en la mayoría de las ocasiones son secundarias a actos de terrorismo o de guerra, en los que las lesiones por blast provocan secuelas físicas y psicológicas graves. Las lesiones causadas por la explosión se dividen en cuatro categorías relacionadas con una onda de choque: primarias, secundarias, terciarias y cuaternarias e, incluso, quinquenarias. Una víctima de una explosión situada cerca de la fuente explosiva presenta quemaduras, shock hemorrágico por amputaciones de miembros, hipoxia por blast pulmonar o neumotórax, acribillamiento y lesiones por proyección. A una distancia mayor, los heridos puede que sólo presenten lesiones timpánicas y por proyectiles. La peligrosidad de estas últimas no depende tanto del tamaño de los proyectiles (neumotórax a tensión, lesión vascular o traumatismo craneoencefálico, por ejemplo), por lo que las víctimas fallecidas pueden estar situadas a mucha distancia de la explosión: la gravedad de la lesión prevalece sobre su mecanismo. Cuando existen múltiples víctimas, la cadena asistencial suele estar saturada y desorganizada en la fase inicial debido a la llegada masiva de heridos, con muchas víctimas leves: es indispensable un triaje prehospitalario adecuado.
... La explosión crea una rápida expansión de gas, genera aumento de la presión y una onda de viento que se desplaza, y la formación de una esfera de alta temperatura. 1,2 Las lesiones provocadas se dividen en: primarias: por cambios de presión que afectan a los órganos con contenido de aire (oído, pulmón, vísceras). Secundarias: por proyectiles desplazados de la explosión (traumatismo penetrante). ...
... Cuaternarias: causa directa de la explosión, exacerbaciones o complicaciones (quemaduras, inhalación de gases y asfixia). [1][2][3][4] En México se dispone de escasa información acerca de este síndrome, que es decisivo porque afecta a numerosos órganos del cuerpo, provoca amputaciones traumáticas, discretas microperforaciones 2 que requieren una exploración física minuciosa y búsqueda intencionada; su desenlace puede ser fatal si no se tratan oportunamente. Los accidentes en niños son una de las principales causas de morbilidad y mortalidad en menores de 15 años, representan un problema de salud pública con un costo social y económico importante derivado de las lesiones originadas. ...
ANTECEDENTES: El síndrome de Blast es provocado por la exposición del organismo a los efectos de una onda de choque ocasionada por una explosión. En México, los juegos pirotécnicos representan un riesgo de sufrir una lesión traumática.CASO CLÍNICO: Adolescente de 14 años, con múltiples complicaciones derivadas de la explosión de una “paloma”. Requirió cirugía exploratoria abdominal indicada por datos de abdomen agudo posterior a la explosión.CONCLUSIONES: El síndrome de Blast es un padecimiento poco identificado e infradiagnosticado que causa lesiones fatales y múltiples consecuencias que, en la mayoría de los casos, pueden prevenirse.
... -Características anatomopatológicas: Constantes: Orificio de penetración, anillo erosivo o de contusión, anillo de enjugamiento [10]. ...
Las muertes violentas en Ecuador representan una problemática social importante, en este trabajo hemos aplicado una metodología de estudio observacional, retrospectiva, transversal, no experimental, la población fue conformada por el total de personas fallecidas que fueron registradas por el Instituto de ciencias forenses y criminalística, y la muestra se consideró las muertes por lesiones producidas por armas de fuego y explosivos desde enero del 2017 a diciembre del 2019, obteniendo como resultados que el 100% de muertes de esta modalidad fueron catalogadas como muertes violentas y a todos ellos se les realizó autopsia , más del 80% de las víctimas fueron de sexo masculino, el rango de edad con mayor cantidad de víctimas oscila entre los 36 y 64 años de edad, las lesiones mortales por armas de fuego fueron en su mayoría dirigidas a cavidades craneal y toraco-abdominal, mientras que por explosivos las lesiones fueron generalizadas provocando muerte instantánea. Palabras Clave: lesiones, muertes, armas de fuego, explosivos. Referencias [1]UNODC, «Global study on homicide.,» 2013. [2]UNODC, «United Nations Office on Drugs and Crime,» World Drug Report, 2019. [3]C. M. Á. Velasco y G. J. Pontón, «Lesiones con armas de fuego: sobrevivir a las balas en Ecuador.,» Estado & comunes, revista de políticas y problemas públicos, vol. 1 (10), 2020. [4]J. P. Pinto, «Más que plomo,» Perfil Criminológico, vol. 17, 2015. [5]G. J. González Pérez, M. G. Vega López, C. E. Cabrera Pivaral, A. Vega López y A. Muñoz de la Torre, «Mortalidad por homicidios en México: tendencias, variaciones socio-geográficas y factores asociados,» Ciência & Saúde Coletiva, vol. 17, pp. 3195-3208, 2012. [6]J. Cavazos, J. Palacios, F. Reyna, N. Álvarez, L. Alatorres y G. Muñoz, «Epidemiología de las lesiones por proyectil de arma de fuego en el Hospital Universitario “Dr. José Eleuterio González” de la,» Cirugía y Cirujanos, vol. 85, pp. 41-48, 2017. [7]O. S. Castro, La muerte violenta. inspeccion ocular y cuerpo del delito., LA LEY., 2004. [8] M. Zurbarán, F. Calle y R. Restrepo, «Descripción de lesiones por explosivos: revisión de la literatura, reporte de caso y propuesta de nueva clasificación.,» vol. 1(2), pp. Case reports, 1(2), 1-68., 2015. [9]National Center for Injury Prevention and Control, «Explosions and Blast injuries: A primer for Clinicians.,» Atlanta: Centers for Disease Control and Prevention, 2006. [10]P. Pasquier, B. Lenoir, y B. Debien, «Blast y lesiones por explosión.,» EMC-Anestesia-Reanimación,, vol. 40 (1), pp. 1-12., 2014. [11]M. Carnicero y M. Baigorri, «Muerte por explosión: cuestiones y sistemática médico-forenses.,» Cuadmed. forense, pp. 39-52, 2002.
Blasts can cause specific lesions requiring specialized care. After an explosion, primary blast injury (due to the shock wave), secondary blast injury (due to shrapnel) or tertiary blast injury (due to the victim being displaced by the blast) can occur. Secondary and tertiary blasts are much more frequent than primary blasts and can lead to polytrauma. Burns occur in 5% of cases and are termed quaternary blast lesions, which include lesions not due to the above-mentioned mechanisms. Care of secondary and tertiary blasts does not differ to that for any polytrauma. Primary pulmonary blast worsens the prognosis of more serious patients, but seldom requires specific care. Knowledge of both pathophysiologic and injury characteristics would allow better care of seriously burned-blasted patients. We report a case of primary pulmonary blast in a burn patient.
The aim of this study was to analyse war-related and non-war-related extremity injuries in soldiers in the Mali conflict.
This prospective study was performed from 1 May 1 to 31 December 2014. It concerned extremity injuries in soldiers treated at Togo Level 2 Hospital.
Seventy-nine patients with an average age of 31.19 years were assessed. Among them, 50 were admitted after war injury and 29 from nonwar injury. Most war-related injuries were due to improvised explosive devices (IEDs) (36 %); road traffic accidents (51.72 %) were the main mechanism of non-war injury. A total of 125 injuries were analysed. Limb fractures were identified in 37 patients (29.6 %), and 22 cases (59.46 %) were open fractures. Twenty-six (20.8 %) patients had soft tissue wounds. The other injuries were sprains (18.4 %), muscle contusions (15.2 %), dislocations (8.8 %), traumatic amputations (4 %) and burns (3.2 %). Surgical debridement and external fixator application were the most frequently performed surgical procedures. Thirty-nine per cent of patients were evacuated to a level 3 hospital for better care.
The severity of injuries and their rapid treatment require orthopaedic surgeons to have high levels of surgical experience and knowledge pertaining to military or disaster surgical doctrine.
Blast injuries are rare, and although blast-induced perforation of the bowel have been described in the past, the entity of a delayed perforation caused by an evolving injury have not been reported, We report three men injured by the explosion of a terrorist bombing in open air. They suffered primary blast injuries, which resulted in isolated perforations of the terminal ileum, They were operated at different times after the blast event. The resected specimens were examined under light microscopy. One patient was operated immediately, and had three perforations in the terminal ileum, In the other two patients, abdominal complaints appeared only 24 and 48 hours later. These two patients were found to have hematomas in the wall of the terminal ileum, and small perforations therein, with almost no contamination of the peritoneal cavity. On histologic examination, there were small perforations with disruption of all intestinal layers. In the vicinity of the perforations, the mucosa was necrotic and disorganized. The submucosa showed edema and vascular thrombi, and at several points mucus was showed dissecting through the muscularis propria, thus creating minute microperforations. Because of the findings in these patients, we suggest a mechanism of evolving damage to the bowel wall and delayed perforation rather than delayed diagnosis, after blast injuries. We suggest that patients exposed to a significant blast should be watched carefully for at least 48 hours.
Critical hospital resources, especially the demand for ICU beds, are usually limited following mass casualty incidents such as suicide bombing attacks (SBA). Our primary objective was to identify easily diagnosed external signs of injury that will serve as indicators of the need for ICU admission. Our secondary objective was to analyze under- and over-triage following suicidal bombing attacks.
A database was collected prospectively from patients who were admitted to Hadassah University Hospital Level I Trauma Centre, Jerusalem, Israel from August 2001-August 2005 following a SBA. One hundred and sixty four victims of 17 suicide bombing attacks were divided into two groups according to ICU and non-ICU admission.
There were 86 patients in the ICU group (52.4%) and 78 patients in the non-ICU group (47.6%). Patients in the ICU group required significantly more operating room time compared with patients in the non-ICU group (59.3% vs. 25.6%, respectively, p=0.0003). For the ICU group, median ICU stay was 4 days (IQR 2 to 8.25 days). On multivariable analysis only the presence of facial fractures (p=0.014), peripheral vascular injury (p=0.015), injury≥4 body areas (p=0.002) and skull fractures (p=0.017) were found to be independent predictors of the need for ICU admission. Sixteen survivors (19.5%) in the ICU group were admitted to the ICU for one day only (ICU-LOS=1) and were defined as over-triaged. Median ISS for this group was significantly lower compared with patients who were admitted to the ICU for >1 day (ICU-LOS>1). This group of over-triaged patients could not be distinguished from the other ICU patients based on external signs of trauma. None of the patients in the non-ICU group were subsequently transferred to the ICU.
Our results show that following SBA, injury to ≥4 areas, and certain types of injuries such as facial and skull fractures, and peripheral vascular injury, can serve as surrogates of severe trauma and the need for ICU admission. Over-triage rates following SBA can be limited by a concerted, focused plan implemented by dedicated personnel and by the liberal utilization of imaging studies.
The tympanic membrane (TM) has long been viewed as an indicator of primary blast injury. A primary blast injury occurs due overpressure occurring as a result of the detonation of high explosives. Cadaver studies indicated pressure required for perforation of the tympanic membrane to be 137 kPa for adults. The accepted range in which other organs (lung, colon, and intestines) are damaged by the pressure wave emanating from an explosion is in the 400-kPa range. The use of the perforation of the tympanic membrane as an indicator of a primary blast injury missed a range of up to 50% of those suffering a primary blast injury to the lung. The status of the tympanic membrane following exposure to a blast does not preclude the need for further investigations for a primary blast injury and the clinician needs to evaluate the patient dependent on their particular exposure to an explosion.
With the onset of improved protective equipment against fragmentation, blast-induced neurotrauma has emerged as the "signature wound" of the current conflicts in the Middle East. Current research has focused on this phenomenon; however, the exact mechanism of injury and ways to mitigate the ensuing pathophysiology remain largely unknown. The data presented and literature reviewed formed the fundamentals of a successful grant from the U.S. Office of Naval Research to Wayne State University.
This work is a culmination of specialized blast physics and energy-tissue coupling knowledge, recent pilot data using a 12-m shock tube and an instrumented Hybrid III crash test dummy, modeling results from Conventional Weapons effects software, and an exhaustive Medline and government database literature review.
The work supports our hypothesis of the mechanism of injury (described in detail) but sheds light on current hypotheses and how we investigate them. We expose two areas of novel mitigation development. First, there is a need to determine a physiologic and mechanism-based injury tolerance level through a combination of animal testing and biofidelic surrogate development. Once the injury mechanism is defined experimentally and an accurate physiologic threshold for brain injury is established, innovative technologies to protect personnel at risk can be appropriately assessed. Second, activated pathophysiological pathways are thought to be responsible for secondary neurodegeneration. Advanced pharmacological designs will inhibit the key cell signaling pathways. Simultaneously, evaluation of pharmacological candidates will confirm or deny current hypotheses of primary mechanisms of secondary neurodegeneration.
A physiologic- or biofidelic-based blast-induced tolerance curve may redefine current acceleration-based curves that are only valid to assess tertiary blast injury. Identification of additional pharmaceutical candidates will both confirm or deny current hypotheses on neural pathways of continued injury and help to develop novel prophylactic treatments.
The epidemiology of traumatic deaths was periodically described during the development of the American trauma system between 1977 and 1995. Recognizing the impact of aging populations and the potential changes in injury mechanisms, the purpose of this work was to provide a comprehensive, prospective, population-based study of Australian trauma-related deaths and compare the results with those of landmark studies.
All prehospitalization and in-hospital trauma deaths occurring in an inclusive trauma system at a single Level 1 trauma center [400 patients with an injury severity score (ISS) >15/year] underwent autopsy and were prospectively evaluated during 2005. High-energy (HE) and low-energy (LE) deaths were categorized based on the mechanism of the injury, time frame (prehospitalization, <48 hours, 2-7 days, >7 days), and cause [which was determined by an expert panel and included central nervous system-related (CNS), exsanguination, CNS + exsanguination, airway, multiple organ failure (MOF)]. Data are presented as a percent or the mean +/- SEM.
There were 175 deaths during the 12-month period. For the 103 HE fatalities (age 43 +/- 2 years, ISS 49 +/- 2, male 63%), the predominant mechanisms were motor vehicle related (72%), falls (4%), gunshots (8%), stabs (6%), and burns (5%). In all, 66% of the patients died during the prehospital phase, 27% died after <48 hours in hospital, 5% died after 3 to 7 days in hospital, and 2% died after >7 days. CNS (33%) and exsanguination (33%) were the most common causes of deaths, followed by CNS + exsanguination (17%) and airway compromise 8%; MOF occurred in only 3%. Six percent of the deaths were undetermined. All LE deaths (n = 72, age 83 +/- 1 years, ISS 14 +/- 1, male 45%) were due to low falls. All LE patients died in hospital (20% <48 hours, 32% after 3-7 days, 48% after 7 days). The causes of deaths were head injury (26%) and complications of skeletal injuries (74%).
The HE injury mechanisms, time frames, and causes in our study are different from those in the earlier, seminal reports. The classic trimodal death distribution is much more skewed to early death. Exsanguination became as frequent as lethal head injuries, but the incidence of fatal MOF is lower than reported earlier. LE trauma is responsible for 41% of the postinjury mortality, with distinct epidemiology. The LE group deserves more attention and further investigation.
Explosions cause more complex and multiple forms of damage than any other wounding agent, are the leading cause of death on the battlefield, and are often used by terrorists. Because explosion-related injuries are infrequently seen in civilian practice, a broader base of knowledge is needed in the medical community to address acute needs of patients with explosion-related injuries and to broaden mitigation-focused research efforts. The objective of this review is to provide insight into the complexities of explosion-related injury to help more precisely target research efforts to the most pressing areas of need in primary prevention, mitigation, and consequence management.
An understanding of the physics and biological consequences of explosions together with data on the nature or severity of contemporary combat injuries provide an empiric basis for a comprehensive and balanced portfolio of explosion-related research. Cited works were identified using MeSH terms as directed by subtopic. Uncited information was drawn from the authors' surgical experience in Iraq, analysis of current combat trauma databases, and explosion-related research.
Data from Iraq and Afghanistan confirm that survivable injuries from explosions are dominated by penetrating fragment wounds, substantiating longstanding and well-known blast physics mechanisms. Keeping this factual basis in mind will allow for appropriate vectoring of funds to increase understanding of this military and public health problem; address specific research and training needs; and improve mitigation strategies, tactics, and techniques for vehicles and personal protective equipment.
A comprehensive approach to injury from explosions should include not only primary prevention, but also injury mitigation and consequence management. Recalibration of medical research focus will improve management of injuries from explosions, with profound implications in both civilian and military healthcare systems.
Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall "critical mortality" rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.
Blast injuries are rare, and although blast-induced perforations of the bowel have been described in the past, the entity of a delayed perforation caused by an evolving injury has not been reported. We report three men injured by the explosion of a terrorist bombing in open air. They suffered primary blast injuries, which resulted in isolated perforations of the terminal ileum. They were operated at different times after the blast event. The resected specimens were examined under light microscopy. One patient was operated immediately, and had three perforations in the terminal ileum. In the other two patients, abdominal complaints appeared only 24 and 48 hours later. These two patients were found to have hematomas in the wall of the terminal ileum, and small perforations therein, with almost no contamination of the peritoneal cavity. On histological examination, there were small perforations with disruption of all intestinal layers. In the vicinity of the perforations, the mucosa was necrotic and disorganized. The submucosa showed edema and vascular thrombi, and at several points mucus was shown dissecting through the muscularis propria, thus creating minute microperforations. Because of the findings in these patients, we suggest a mechanism of evolving damage to the bowel wall and delayed perforation rather than delayed diagnosis, after blast injuries. We suggest that patients exposed to a significant blast should be watched carefully for at least 48 hours.
The present study investigates whether whole-body or local (chest) exposure to blast overpressure can induce ultrastructural, biochemical, and cognitive impairments in the brain.
Male Wistar rats were trained for an active avoidance task for 6 days. On day 6, rats that had acquired the avoidance response were subjected to whole-body blast injury (WBBI), generated by large-scale shock tube (n = 40); or local (chest) blast injury (LBI), induced by blast overpressure focused on the right middle thoracic region and generated by small-scale shock tube (n = 40) while the heads of animals were protected. At the completion of cognitive testing, rats were killed at 3 hours, 24 hours, and 5 days after injury. Ultrastructural changes in the hippocampus were analyzed electron microscopically. Parameters of oxidative stress (malondialdehyde and superoxide anion generation) and antioxidant enzyme defense (superoxide dismutase and glutathione peroxidase activity) were measured in the hippocampus to assess biochemical changes in the brain after blast.
Ultrastructural findings in animals subjected to WBBI or LBI demonstrated swellings of neurons, glial reaction, and myelin debris in the hippocampus. All rats revealed significant deficits in performance of the active avoidance task 3 hours after injury, but deficits persisted up to day 5 after injury only in rats subjected to WBBI. Oxidative stress development and altered antioxidant enzyme defense was observed in animals in both groups. Cognitive impairment and biochemical changes in the hippocampus were significantly correlated with blast injury severity in both WBBI and LBI groups.
These results confirm that exposure to blast overpressure induces ultrastructural and biochemical impairments in the brain hippocampus, with associated development of cognitive deficits.
The objective of this autopsy-based study was to investigate the pathology of human blast lung injury using histology, Fat Red 7B staining, immunohistochemistry, and scanning electron microscopy on lung specimens from eight medicolegal autopsy cases of fatal close-range detonations of chemical explosives. The micromorphologic equivalents of human blast lung injury can be summarized as follows: diffuse alveolar overdistension, circumscribed interstitial hemorrhages showing a cufflike pattern around pulmonary vessels, venous air embolism, bone marrow embolism, and pulmonary fat embolism. Hemorrhages within the lung parenchyma that were present in this study in blast victims without coexisting blunt or penetrating chest trauma must be regarded as potentially life-threatening intrapulmonary bleeding sites in survivors. In addition, the potential clinical importance of the presence of massive pulmonary fat embolism, which has, to the best of our knowledge, not been described previously in human blast lung injury, must be emphasized because pulmonary fat embolism may be a leading cause of the rapid respiratory deterioration with progressive hypoxia and development of acute respiratory distress syndrome in blast victims who survive. Furthermore, this study provides evidence that air embolism presenting in blast victims is not a mere ventilation-induced artifact.
We compared the epidemiologic outcomes of terrorist bombings that produced 30 or more casualties and resulted in immediate structural collapse, occurred within a confined space, or occurred in open air.
We identified eligible studies of bombings through a MEDLINE search of articles published between 1966 and August 2002 and a manual search of published references. Pooled and median rates of mortality, immediately injured survival, emergency department use, hospitalization, and injury were determined for each bombing type.
We found 35 eligible articles describing 29 terrorist bombings, collectively producing 8,364 casualties, 903 immediate deaths, and 7,461 immediately surviving injured. Pooled immediate mortality rates were structural collapse 25% (95% confidence interval [CI] 6% to 44%), confined space 8% (95% CI 1% to 14%), and open air 4% (95% CI 0% to 9%). Biphasic distributions of mortality were identified in all bombing types. Pooled hospitalization rates were structural collapse 25% (95% CI 6% to 44%), confined space 36% (95% CI 27% to 46%), and open air 15% (95% CI 5% to 26%). Unique patterns of injury rates were found in all bombing types.
Patterns of injury and health care system use vary with the type of terrorist bombing.
John B. Kortbeek, Saud A. Al Turki, Jameel Ali, Jill A. Antoine, Bertil Bouillon, Karen Brasel, Fred Brenneman, Peter R. Brink, Karim Brohi, David Burris, Reginald A. Burton, Will Chapleau, Wiliam Cioffi, Francisco De Salles Collet e Silva, Art Cooper, Jaime A. Cortes, Vagn Eskesen, John Fildes, Subash Gautam, Russell L. Gruen, Ron Gross, K S. Hansen, Walter Henny, Michael J. Hollands, Richard C. Hunt, Jose M. Jover Navalon, Christoph R. Kaufmann, Peggy Knudson, Amy Koestner, Roman Kosir, Claus Falck Larsen, West Livaudais, Fred Luchette, Patrizio Mao, John H. McVicker, Jay Wayne Meredith, Charles Mock, Newton Djin Mori, Charles Morrow, Steven N. Parks, Pedro Moniz Pereira, Renato Sergio Pogetti, Jesper Ravn, Peter Rhee, Jeffrey P. Salomone, Inger B. Schipper, Patrick Schoettker, Martin A. Schreiber, R Stephen Smith, Lars Bo Svendsen, Wa’el Taha, Mary van Wijngaarden-Stephens, Endre Varga, Eric J. Voiglio, Daryl Williams, Robert J. Winchell, Robert Winter. (2008) Advanced Trauma Life Support, 8th Edition, The Evidence for Change. The Journal of Trauma: Injury, Infection, and Critical Care 64, 1638-1650
CrossRef
All doctors should know the basic management of patients injured by explosive blast
Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients.
Injury from blast is becoming more common in the non-military population. This is primarily a result of an increase in politically motivated bombings within the civilian sector. Explosions unrelated to terrorism may also occur in the industrial setting. Civilian physicians and surgeons need to have an understanding of the pathomechanics and physiology of blast injury and to recognize the hallmarks of severity in order to increase survivorship. Because victims may be transported rapidly to the hospital, occult injury to gas and fluid containing organs (particularly the ears, bowel and lungs) may go unrecognized. Information surrounding the physical environment of the explosion (whether inside or outside, underwater, associated building collapse, etc) will prove useful. Most of the immediate deaths are caused by primary blast injury from the primary blast wave, but secondary blast injury from flying debris can also be lethal and involve a much wider radius. Liberal use of X-ray examination in areas of skin punctures will help to identify a need for exploration and/or foreign body removal. Biologic serum markers may have a role in identifying victims of primary blast injury and assist in monitoring their clinical progress. Tertiary blast injury results from the airborne propulsion of the victim by the shockwave and is a source of additional blunt head and torso trauma as well as fractures. Miscellaneous (quaternary) blast injury include thermal or dust inhalation exposure as well as crush and compartment syndromes from building collapse. Any explosion has the potential to be associated with nuclear, biologic or chemical contaminants, and this should remain a consideration for healthcare givers until proven otherwise.
Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall "critical mortality" rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.
Objectives: To compare injury patterns resulting from explosions in the open air versus within confined spaces. Methods: Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale Score, > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations. Results: A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001). Conclusion: Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.
Dans les conflits armés et lors des attentats terroristes, la plupart des décès sont dus à des engins explosifs. Le poumon est un des organes les plus sensibles aux explosions. Il importe donc aujourd’hui que chaque praticien ait une connaissance au moins élémentaire et pratique de la prise en charge de victimes par explosion. Nous proposons, après un rappel théorique sur les explosions et une évaluation des menaces actuelles, de détailler les lésions pulmonaires induites par les explosions et les principales mesures thérapeutiques actuellement recommandées.
Blast injuries cause specific lesions and occur more often than previously, because of the wide use of explosives. This is especially the case in wartime. More and more people lose their lives every day due to blast injuries.The mechanism of the injury and pathophysiology of this trauma are discussed. The clinical effects as well as management are presented.The most dramatic effects observed are fractures to the middle third of the face, reported here for the first time, with their management. New fracture lines are typically seen in fractures of the mandible due to the blast wave effects.This presentation should help in the prevention and management to save the lives of patients in future.
Anti-vehicle mines and improvised explosive devices remain the most prevalent threat to coalition troops operating in Iraq and Afghanistan. Detonation of these devices causes rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a "deck-slap" injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore, the aim of this study is to determine the pattern of injury, medical management, and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions.
From January 2006 to December 2008, using a prospectively collected trauma registry (Joint Theater Trauma Registry), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in-depth review. For each patient, demographic data, New Injury Severity Score, and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilization, local complications, and the need for amputation were noted. Functional recovery was related to the ability of the casualty to return to military duties.
Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median New Injury Severity Score was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the United Kingdom. Four (10%) casualties required a delayed amputation for chronic pain (mean, 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit for any military duty.
Calcaneal injuries following under-vehicle explosions are commonly associated with significant multiple injuries including severe lower limb injury. The frequency of associated spinal injuries mandates radiologic evaluation of the spine in all such patients. The severity of the hindfoot injury is reflected by the high infection rate and amputation rate. Only a small proportion of casualties were able to return to preinjury military duties.
Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated.
Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database.
There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%).
Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.
Blast-related traumatic brain injuries have been common in the Iraq and Afghanistan wars, but fundamental questions about the nature of these injuries remain unanswered.
We tested the hypothesis that blast-related traumatic brain injury causes traumatic axonal injury, using diffusion tensor imaging (DTI), an advanced form of magnetic resonance imaging that is sensitive to axonal injury. The subjects were 63 U.S. military personnel who had a clinical diagnosis of mild, uncomplicated traumatic brain injury. They were evacuated from the field to the Landstuhl Regional Medical Center in Landstuhl, Germany, where they underwent DTI scanning within 90 days after the injury. All the subjects had primary blast exposure plus another, blast-related mechanism of injury (e.g., being struck by a blunt object or injured in a fall or motor vehicle crash). Controls consisted of 21 military personnel who had blast exposure and other injuries but no clinical diagnosis of traumatic brain injury.
Abnormalities revealed on DTI were consistent with traumatic axonal injury in many of the subjects with traumatic brain injury. None had detectable intracranial injury on computed tomography. As compared with DTI scans in controls, the scans in the subjects with traumatic brain injury showed marked abnormalities in the middle cerebellar peduncles (P<0.001), in cingulum bundles (P=0.002), and in the right orbitofrontal white matter (P=0.007). In 18 of the 63 subjects with traumatic brain injury, a significantly greater number of abnormalities were found on DTI than would be expected by chance (P<0.001). Follow-up DTI scans in 47 subjects with traumatic brain injury 6 to 12 months after enrollment showed persistent abnormalities that were consistent with evolving injuries.
DTI findings in U.S. military personnel support the hypothesis that blast-related mild traumatic brain injury can involve axonal injury. However, the contribution of primary blast exposure as compared with that of other types of injury could not be determined directly, since none of the subjects with traumatic brain injury had isolated primary blast injury. Furthermore, many of these subjects did not have abnormalities on DTI. Thus, traumatic brain injury remains a clinical diagnosis. (Funded by the Congressionally Directed Medical Research Program and the National Institutes of Health; ClinicalTrials.gov number, NCT00785304.).
The present retrospective study was performed to determine the incidence and outcome of primary blast injury and to identify possible changes over the course of the conflicts between 2003 and 2006.
Combat physicians treating patients injured in overseas contingency operations observed an increase in the severity of explosion injuries occurring during this period.
This retrospective study included service members injured in explosions between March 2003 and October 2006. The Joint Theater Trauma Registry provided demographic information, injury severity score, and International Classification of Diseases 9 codes used to diagnose primary blast injury. Autopsy reports of the last 497 combat-related deaths of 2006 were also reviewed.
Of 9693 admissions, of which 6687 were injured in combat, 4765 (49%) were injured by explosions: 2588 in 2003-2004 and 1935 in 2005-2006. Dates of injury were unavailable for 242 casualties. Injury severity score (9 +/- 10 vs. 11 +/- 10, P < 0.0001) and incidence of primary blast injury (12% vs. 15%, P < 0.01) increased. The return-to-duty rate decreased (40% vs. 18%, P < 0.001), but mortality remained low (1.4% vs. 1.5%, P = NS). There was no significant difference in incidence of primary blast injury between personnel who were killed in action and those who died of wounds at a medical facility.
Injury severity and incidence of primary blast injury increased during the 4-year period, whereas return-to-duty rates decreased. Despite increasingly devastating injuries, the mortality rate due to explosion injuries remained low and unchanged.
Over the last few years, thousands of soldiers and an even greater number of civilians have suffered traumatic injuries due to blast exposure, largely attributed to improvised explosive devices in terrorist and insurgent activities. The use of body armor is allowing soldiers to survive blasts that would otherwise be fatal due to systemic damage. Emerging evidence suggests that exposure to a blast can produce neurologic consequences in the brain but much remains unknown. To elucidate the current scientific basis for understanding blast-induced traumatic brain injury (bTBI), the NIH convened a workshop in April 2008. A multidisciplinary group of neuroscientists, engineers, and clinicians were invited to share insights on bTBI, specifically pertaining to: physics of blast explosions, acute clinical observations and treatments, preclinical and computational models, and lessons from the international community on civilian exposures. This report provides an overview of the state of scientific knowledge of bTBI, drawing from the published literature, as well as presentations, discussions, and recommendations from the workshop. One of the major recommendations from the workshop was the need to characterize the effects of blast exposure on clinical neuropathology. Clearer understanding of the human neuropathology would enable validation of preclinical and computational models, which are attempting to simulate blast wave interactions with the central nervous system. Furthermore, the civilian experience with bTBI suggests that polytrauma models incorporating both brain and lung injuries may be more relevant to the study of civilian countermeasures than considering models with a neurologic focus alone.
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.
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.
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.
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%).
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.
A 6-kg explosive charge detonated under a seat in the center of a crowded city bus in Jerusalem, killing three passengers immediately. Of the 55 survivors, all of whom were transferred to two major medical centers, 29 were hospitalized. Among those admitted, a high rate of primary blast injuries was found, including perforated ear drums (76%), blast lung (38%), and abdominal blast injuries (14%). Two of the latter patients suffered bowel perforations, which were diagnosed with considerable delay. Eight patients (31%) had sustained life-threatening trauma, consisting of a combination of primary, secondary, and tertiary blast injuries. The overall mortality rate was 10.3%. The large number of primary blast injuries, including the unexpected finding of bowel perforations, is explained by the high amplitude of the air pressure wave (3.8-5.2 atm) and its relatively long duration (2-3 msec) resulting from the detonation of the high-energy explosive charge in the small, enclosed space of the bus. Besides the usual wounds sustained by victims of an explosion that occurs in a confined space, the possibility of primary blast injury to the abdomen and to the lungs should be taken into account by the treating surgeon.
Ballistic wounds have been and will remain the principal cause of casualties in combat. Cloth ballistic vests (CBV) play an important role in limiting critical wounds from fragments and small-arms fire. There is an increased risk of primary blast injury on the modern battlefield. In a previous study, volunteers were exposed to short-duration blast waves of low peak pressure (18.6 +/- 0.8 kPa). Pressure measurements made in the distal esophagus as an estimate of intrathoracic pressure (ITP) were significantly higher (p less than 0.05) when the standard U.S. Army ballistic jacket was worn (8.7 +/- 1.2 kPa) than when fatigues alone were worn (7.4 +/- 0.7 kPa). In this study 58 sheep were exposed to nominal blast levels of 115, 230, 295, and 420 kPa peak pressure in groups of 12, 18, 16, and 12, respectively. Half of each group was fitted with a CBV. Lung weight index (LWI), lung weight expressed as a percentage of body weight, was used as a measure of blast injury. Use of the CBV was associated with a significant increase in LWI (p less than 0.05) which averaged 21% for the two middle exposure groups. At the 420 kPa level, two of six non-CBV animals died as opposed to five of six animals wearing the CBV. Intrathoracic pressure was generally higher in the CBV group. Likely mechanisms of injury enhancement include an increase in target surface area and an alteration of the effective loading function on the thorax. This information may be useful in the triage and treatment of casualties exposed to intense blast environments.
Terrorist bombings remain a not uncommon problem. Most of the victims suffering primary blast injury die, if not from the blast then from secondary missile injuries, while most of the survivors have more or less serious secondary injuries alone. A small percentage have either pure blast injury or secondary injuries complicated by blast phenomena. It is important to recognize this group and treat it appropriately.
Blast injury is uncommon in many parts of the world but sporadic cases occur. The ear is particularly susceptible to damage and easily forgotten in patients with multiple injuries. The aim of this review article is to draw together the more important aspects of blast ear injury for those who are unfamiliar with it and to serve as a reminder of the problems to others. It covers the interactions of blast waves with the ear giving a summary of the mechanisms and types of injury. The management of blast-related injuries is discussed.
Systemic air embolism has been frequently reported after penetrating thoracic trauma. In blunt thoracic trauma, systemic air embolism has been rarely diagnosed, and then only after an invasive procedure such as thoracotomy. Transesophageal echocardiography has been recently introduced for the early assessment of trauma patients and is considered a sensitive noninvasive procedure to diagnose air embolism. We report three cases of systemic air embolism in patients with pulmonary contusion secondary to a blunt thoracic trauma requiring controlled ventilation. Transesophageal echocardiography was performed for evaluation of hemodynamic instability, and it showed air bubbles in the left atrium and left ventricle during the insufflation phase, which disappeared during apnea. A decrease in airway pressure (release of PEEP, low tidal volume, high frequency jet ventilation) significantly reduced the systemic air embolism. We concluded that systemic air embolism can occur after blunt thoracic trauma, and transesophageal echocardiography enables a rapid and accurate diagnosis that may be useful for therapeutic management.
The mechanism of traumatic amputation of limbs by explosion is presented. A survey of blast casualties from Northern Ireland revealed that amputations through joints were very uncommon--the principal site was through the shaft of the long bones. Computer modelling of a bone exposed to blast forces reinforced the hypothesis developed from the casualty survey, that the primary mechanism of the bone injury was the direct coupling of the blast wave into the tissues. The fracture occurs from the resulting axial stresses in the bone, prior to limb flailing from the gas flow over the limb. The gas flow completes the amputation. Field trials employing a goat hind limb model have confirmed the hypothesis. Having identified the mechanism, concepts to develop protective clothing may now be proposed.
To compare injury patterns resulting from explosions in the open air versus within confined spaces.
Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations.
A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001).
Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.
Bomb blast survivors are occasionally found in profound shock and hypoxic without external signs of injury. We investigated the cardiovascular and pulmonary responses of rats subjected to a blast pressure wave.
Prospectively randomized, controlled animal study.
Rats were instrumented and subjected to a blast pressure wave of different intensities from a blast wave generator. Cardiopulmonary parameters were recorded for 3 hours or until death.
The cardiovascular response to a blast pressure wave was immediate bradycardia, hypotension, and low cardiac index. Three hours later, the rats developed hypotension, low cardiac index, and low stroke volume. Interestingly, systemic vascular resistance remained unchanged. The pulmonary response was a decreased PaO2 and stable PacO2, suggesting a ventilation-perfusion mismatch from massive pulmonary hemorrhage.
Blast-induced circulatory shock resulted from immediate myocardial depression without a compensatory vasoconstriction. Hypoxia presumably resulted from a ventilation-perfusion mismatch caused by pulmonary hemorrhage.
The objective of this study was to analyze the utilization of surgical staff and facilities during an urban terrorist bombing incident.
A discrete-event computer model of the emergency room and related hospital facilities was constructed and implemented, based on cumulated data from 12 urban terrorist bombing incidents in Israel.
The simulation predicts that the admitting capacity of the hospital depends primarily on the number of available surgeons and defines an optimal staff profile for surgeons, residents, and trauma nurses. The major bottlenecks in the flow of critical casualties are the shock rooms and the computed tomographic scanner but not the operating rooms. The simulation also defines the number of reinforcement staff needed to treat noncritical casualties and shows that radiology is the major obstacle to the flow of these patients.
Computer simulation is an important new tool for the optimization of surgical service elements for a multiple-casualty situation.
TRAUMA is the leading cause of death among young people in developed countries. 1 Because up to 80% of trauma deaths occur during the first 24 h after trauma, 1 early resuscitation and rapid assessment of trauma lesions are of paramount importance to improving the prognosis. Among traumatic lesions, pulmonary contusion is frequent but has not been recognized as an independent prognosis factor. 2-4 In very few cases, pulmonary contusion may lead to severe hypoxia and hypercarbia, which cannot be adequately controlled using conventional mechanical ventilation. Hypoxia and hypercarbia may have deleterious effects, such as enhancement of brain injury and development of circulatory shock. 5 In the most severe cases, aggressive therapeutic methods, such as extracorporeal membrane oxygenation (ECMO), have been reported. 6 At our institution, high-frequency jet ventilation (HFJV) has been used routinely for many years for the treatment of severe acute respiratory distress syndrome. 7,8 We report a series of severe trauma patients with life-threatening pulmonary contusion successfully treated with HFJV when the conventional mechanical ventilation approach failed to provide appropriate gas exchange. The current data suggest that HFJV can be a life-saving technique in severely hypoxemic patients with bilateral pulmonary contusion.
Traumatic combat injuries differ from those encountered in the civilian setting in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Except for a few notable exceptions, data sources for combat injuries have historically been inadequate. Although the pathophysiologic process of dying is the same (i.e., dominated by exsanguination and central nervous system injury) in both the civilian and military arenas, combat trauma has unique considerations with regard to acute resuscitation, including (1) the high energy and high lethality of wounding agents; (2) multiple causes of wounding; (3) preponderance of penetrating injury; (4) persistence of threat in tactical settings; (5) austere, resource-constrained environment; and (5) delayed access to definitive care. Recognition of these differences can help bring focus to resuscitation research for combat settings and can serve to foster greater civilian-military collaboration in both basic and transitional research.
To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning.
Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances.
A retrospective analysis of medical evacuations from MCIs (29.9.2000-31.9.2002) performed by the Israeli National EMS rescue teams.
Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15-20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001).
Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care.
St. Vincent's Hospital in New York City was the primary recipient of patients after the 1993 bombing of the World Trade Center. This experience prompted the drafting of a formal disaster plan, which was implemented during the terrorist attack on the World Trade Center on September 11, 2001. Here, we outline the Emergency Management External Disaster Plan of St. Vincent's Hospital and discuss the time course of presentation and medical characteristics of the critically injured patients on that day. We describe how the critical care service adapted to the specific challenges presented and the lessons that we learned. We hope to provide other critical care systems with a framework for response to such large-scale disasters.
At 07:39 am on March 11th, 2004, ten terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing instantly 177 people and injuring >2,000. There were 14 subsequent in-hospital deaths, bringing the definite death toll to 191 victims. This article describes the organization of the clinical management and patterns of injuries in casualties who were taken to the closest hospital, with emphasis on the critical patient population.
There were 312 patients taken to that center, and 91 were hospitalized, 89 of them (28.5%) for >24 hrs. Sixty-two patients only had superficial bruises or emotional shock, but the remaining 250 patients had more severe lesions. The data on 243 of the latter form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first- or second-degree burns in 18%, eye lesions in 18%, head trauma in 12%, and abdominal injuries in 5%. Between 8:00 am and 5:00 pm, 34 surgical interventions were performed on 32 victims. Twenty-nine casualties (12% of the total or 32.5% of those hospitalized) were deemed in critical condition, and two of them died within minutes of arrival. The other 27 survived to be admitted to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores of critical patients were 34 and 23, respectively. Among these critical patients, soft-tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67%, and blast lung injury was present in 63% (17 cases). Fifty-two percent suffered head trauma.
There was probably an overtriage to the closest hospital, and the time of the blasts proved crucial for the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.
Suicidal bombing is particularly devastating and an increasingly common form of terrorist violence. In this paper, we present an epidemiologic description of the physical injuries of patients who survived the suicidal bombing attack in the context of the limited medical resources of a developing nation.
The management of individual patients was reviewed from a preprinted trauma form. Information on the nature of injuries, operative management and hospital course was recorded and data analyzed using the Trauma Registry.
Twelve survivors out of 36 bomb blast victims brought to the Aga Khan University Hospital were transferred from primary receiving hospitals. The average number of injuries per patient was eight. The mean Injury Severity Score was 10.8. The majority of patients had secondary and tertiary blast injuries. Most of the survivors had calcaneal injuries; these have not been reported in the literature in similar terrorist attacks. Twelve operative interventions were undertaken. All of the 12 patients were stabilized and evacuated within 24 h of admission.
All of the 12 patients transferred to the Aga Khan University Hospital survived. Unlike the reported injuries, calcaneal fractures were most commonly encountered in the survivors.
Blast lung injury (BLI) is a major cause of morbidity after terrorist bomb attacks (TBAs) and is seen with increasing frequency worldwide. Yet, many surgeons and intensivists have little experience treating BLI. Jerusalem sustained 31 TBAs since 1983, resulting in a local expertise in treating BLI.
A retrospective study of clinical and radiologic characteristics, management, and outcome of victims of TBAs sustaining BLI who were admitted to ICU during December 1983 to February 2004. Long-term outcome was determined by a telephone interview.
Twenty-nine patients met inclusion criteria. Hypoxia and pulmonary infiltrates in chest x-ray were sine qua non for the diagnosis. Seventy-six percent required mechanical ventilation, all within 2 hours of admission. One patient died. Seventy-six percent had no long-term sequelae.
Most patients with significant BLI injury require mechanical ventilation. Late deterioration is rare. Death because of BLI in patients who survived the explosion is unusual. Timely diagnosis and correct treatment result in excellent outcome.
Delayed presentation of secondary airway injury is a significant clinical entity following blast injury.
Retrospective review.
Combat Support Hospital, Operation Iraqi Freedom.
Twenty-three blast injury patients with bronchoscopic evidence of secondary airway injury.
Symptom development and time frame, bronchoscopic findings, and requirement for mechanical ventilation.
All of the 23 patients presented within 12 hours of injury. Eleven patients (48%) arrived at the hospital after prior endotracheal intubation. The majority (17 patients [74%]) of patients had no carbonaceous sputum, singed nasal hair, or thoracic trauma that would suggest possible airway injury. Bronchoscopy revealed mucosal erythema and edema in 16 (70%) of the patients, 6 (23%) had additional airway carbonaceous deposits, and 5 (21%) had normal findings on initial bronchoscopy. Eight patients (35%) initially breathing spontaneously and demonstrating no thoracic trauma required intubation within 12 hours of admission owing to impending loss of airway patency. Bronchoscopy revealed significant airway edema (>50% patency loss) in 6 (75%) of these 8 patients, with additional carbonaceous deposits in 3 patients (38%). Patients requiring delayed intubation had a significantly greater respiratory rate on initial examination.
Manifestation of secondary airway injury may be delayed up to 12 hours following blast injury. We believe that blast injury patients should be observed for at least 18 hours after injury or until edema has resolved and in a setting amenable to emergent airway support and rapid bronchoscopic evaluation at the earliest indication of possible airway compromise.
Traumatic brain injury (TBI) is an important source of morbidity in the Iraq and Afghanistan wars. Although penetrating brain injuries are more readily identified, closed brain injuries occur more commonly. Explosion or blast injury is the most common cause of war injuries. The contribution of the primary blast wave (primary blast injury) in brain injury is an area of active research. Lessons learned from the sports concussion and civilian mild TBI literature are useful. Individuals with TBI and posttraumatic stress disorder require treatment of both conditions. Families and communities need to be cognizant of the needs of these returning veterans.
Neurological injuries produced by explosive blasts are the result of a cascade of events that begin with the initial explosion and evolve from the secondary, tertiary, and quaternary effects that the explosion engenders [Lavonis EJ. Blast Injuries. EMedicine.htm]. Only the results of the primary blast are predictable, and subsequent actions ripple outward in an increasingly random and chance sequence. This article reviews and explains how the ensuing chain of circumstances injures the nervous system, and what examining physicians should anticipate when they treat these patients.