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Edirisinghe A., and Samarasekera A. (2016) Injury, Fatal and Nonfatal: Explosive Injuries

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Injuries and effects on the human body due to explosions in general, and in modern warfare in particular, have certain patterns which can be identified and classified depending on their causation, properties of the explosive material and device used, motive, and the target. Predetermined action plans together with disaster preparedness and response are important for proper and effective medicolegal management of dead bodies and survivors after an explosion, and the key to success is a coordinated multidisciplinary and humanitarian approach.
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Edirisinghe A., and Samarasekera A. (2016) Injury, Fatal and Nonfatal: Explosive Injuries. In: Payne-James J. and
Byard R.W. (eds.) Encyclopedia of Forensic and Legal Medicine, 2nd editon, Vol. 3, pp. 182-202. Oxford: Elsevier.
© 2016 Elsevier Ltd. All rights reserved.
Injury, Fatal and Nonfatal: Explosive Injuries
A Edirisinghe, University of Kelaniya, Ragama, Sri Lanka
A Samarasekera, South Asian Institute of Technology and Medicine, Malabe, Sri Lanka
r2016 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by J. Crane, volume 3, pp 98110, © 2005, Elsevier Ltd.
Abstract
Injuries and effects on the human body due to explosions in general, and in modern warfare in particular, have
certain patterns which can be identied and classied depending on their causation, properties of the explosive
material and device used, motive, and the target. Predetermined action plans together with disaster preparedness
and response are important for proper and effective medicolegal management of dead bodies and survivors after
an explosion, and the key to success is a coordinated multidisciplinary and humanitarian approach.
Introduction
Various types of explosions, including bombs, land
mines, hand grenades, industrial fuel eruptions, mine
explosions, and explosion of reworks, result in injuries.
The effects of explosions on humans lead to multi-
system, life-threatening injuries in single or multiple
persons simultaneously. The injury patterns seen in an
individual or individuals involved in the explosion of
arecracker (Witsaman et al., 2006) or an explosion in
a chemical plant (Pavelites et al., 2011) differ from those
due to explosions during to war or terrorist attacks
(Golan et al. 2014;Lerner et al., 2007).
The original descriptive work on the pathology of
bombing and explosion-related injuries was derived
from studies by Marshall, Crane, and Mason (Marshall
1976,1977,1988;Hull et al., 1994;Lucas and Crane,
2008;Mason, 1965). Since then, particularly in the last
few years, the body of knowledge has improved with the
increase in terrorist bombings and armed conicts all
over the world (Patel et al., 2012;Bala et al., 2010;
Kluger et al., 2007;Ramasamy et al., 2009).
Explosions and Their Effects
An explosion refers to a rapid increase in volume and
release of energy in an extreme manner, usually with the
generation of high temperatures and release of gases.
Supersonic explosions created by high-order explosives
(HOE) are known as detonations; they travel via super-
sonic shock wave/blast wave, whereas subsonic explo-
sions created by low-order explosives (LOE) involve a
slow burning process known as deagration. The mech-
anisms of causation of damage in explosions include
blast, fragmentation, crater formation, shaped charged
penetration, and incendiary effect. The explosive pressure
decays very rapidly (Figure 1), and the damage closer to
(+)
Pressure
()
Pressure Arrival
time
Base-line or
ambient
atmospheric
pressure
Compression phase
Time
Static overpressure
Dynamic or blast wind pressure
Figure 1 Variations of overpressure and dynamic pressure with time.
Encyclopedia of Forensic and Legal Medicine, Volume 3 doi:10.1016/B978-0-12-800034-2.00221-4182
Author's personal copy
and facing the explosion is signicantly greater compared
to the damage away from the explosion (Figure 2). In
HOE a unidirectional cone-shaped shock wave is dis-
charged (Figure 3). Although the extent and severity of
damage and injuries cannot be predicted with certainty,
some general indications of the overall damage and injury
to be expected in an explosive event can be predicted
based on size of the explosion, distance from it, sur-
roundings, and whether the space is open or closed.
Injuries and Their Effects in Bomb Explosions
Different types of injuries are seen in individuals sub-
jected to explosions (Figures 48). Currently, explosive
BLAST
Blast wind
Blast wave
Debris
Shock front with
incident overpressure
Figure 2 Blast wave and associated components. Air is highly compressed on the leading edge of the blast wave, creating a shock front. The
body of the wave, including the associated mass outward movement of air (sometimes called the blast wind), follows this front. Adapted from
Hull, J.B., 1992. Blast: Injury patterns and their recording. Journal of Audiovisual Media in Medicine 15, 121127.
Tertiary injuries
from impact on hard
surface-multiple
injuries possible
Primary blast force
Secondary
missile etc.,
being propelled
injuries: 1 ears
2 lungs
3 GI tract
Figure 3 Conical shaped shock wave and injuries produced. Courtesy of Charles Stewart.
Injury, Fatal and Nonfatal: Explosive Injuries 183
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injuries are classied into ve categories based on their
causation as shown in Table 1 (Mayo and Kluger,
2006;Kluger et al., 2007;Wolf et al., 2009;Champion
et al., 2009;Commandeur et al., 2012;Mackenzie and
Tunnicliffe, 2011). The air blast shock seen in HOE
is not encountered in LOE, whereas blast wind is en-
countered in both. Thus, depending on the explosive
material and the device used, the damages encountered
in each type of event are different (Table 1).
Figure 4 A split laceration in the forehead from a secondary
projectile and a periorbital hematoma (photograph obtained from
author A. Samarasekeras original work).
Figure 5 Incised injury in the neck from a glass projectile emitted
from shattered glass in an explosion (photograph obtained from
author A. Samarasekeras original work).
Figure 6 Fracture and contusion in the thigh with associated burn
injury (photograph obtained from author A. Edirisinghes original work).
Figure 7 Traumatic amputation of third and fourth ngers with burn
injuries (photograph obtained from author A. Samarasekeras original
work).
Figure 8 Complete disruption of the body caused by a terrorist
bomb. The remains were scattered over a large area and consisted of
pieces of scalp, skin, lumps of muscle, and a few of the major limb
joints. The severities of the injuries indicate that the victim must have
been in contact with the bomb when it exploded. In fact he was a
terrorist, the bomb blown up when he was loading into a vehicle, it
exploded prematurely. Reproduced from Crane, J. 2005, Injury, fatal
and nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W.,
Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
184 Injury, Fatal and Nonfatal: Explosive Injuries
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Injury Patterns
The descriptions below mainly involve explosions of
terrorist and modern war activities involving HOE. The
injuries can be separated into six categories:
complete disruption;
explosive injury;
ying-missile injury;
injury from falling masonry;
burns; and
blast.
Complete Disruption
Complete disruption occurs when an individual is
actually carrying or sitting on a large bomb, and the
body is in contact with the epicenter of the explosion.
The victim is literally blown to pieces, and the parts may
be scattered over an area of 200 m radius (Marshal
1988;Oliver et al., 2002;Wightman and Gladish,
2001). When collected, washed, and examined, the
identiable remains are typically seen to comprise pieces
of scalp and skin, portions of the spine, major limb
joints, and lumps of muscle. Usually most of the internal
organs are missing (Figure 8). Nonhuman tissue may be
found among the material submitted for examination,
depending on the place where the explosion has taken
place (e.g., sh or meat market). Suicide bombers who
carry the bomb on their chest (vest or jacket type kit)
are reduced a blown off head and dismembered limbs
with complete disruption or absent torso (Samarasekera,
2008;Figure 9).
Explosive Injuries
Mangling and traumatic amputation
Although most individuals close to the epicenter remain
in one piece, parts of the body can be badly traumatized
and/or limbs can be blown off (Figures 10 and 11).
A detailed study of the mechanism of amputation
in bomb blasts concluded that the trauma to limbs
(Figure 11) is not due to the direct effect of the blast
at the joints, but preferential amputation through the
shafts of long bones (Hull et al., 1994). The same was
concluded from examinations after the London bomb-
ings in 2005, where lower limb amputations were due to
Table 1 Type of blast injury, causations, and injuries
Type of injury Caused by Injuries and effects
Primary injury Air blast shock wave (unique to high-order
explosives)
Body disintegration, fragmentation, body mutilation/mangling,
traumatic amputation, decapitation, and internal blast wave
damage (tympanic membrane rupture/blast lung/GI
hemorrhage/TBI/eye injuries)
Secondary injuries Shrapnel or container fragmentation (projectile
trauma)
Penetrating injuries, blunt and fragmentation injuries of different
types
Tertiary injuries Blunt- or sharp-force trauma when the blast wind
thrusts the victim against stationary objects,
falling objects, crushing, acceleration, and
deceleration
Most fracture, blunt trauma and tissue contusion, crush injuries,
fractures and traumatic amputations, and open or closed brain
injuries
Quaternary injuries Heat, chemicals, and toxins emanated by the device
or event
Thermal burns (ash, ame re), chemical burns, injuries due to
burns from secondary re, asphyxia, toxic inhalation and
exposure to radiation, and psychological trauma
Quinary injuries Systemic inammatory response provoked in the
host
Systemic inammatory response immediately after exposure
Figure 9 Suicide bomber who detonated himself in the midst of a
crowed near the stage at a political rally. There were 19 deaths
including those on the stage and in the vicinity (photograph obtained
from author A. Samarasekeras original work).
Figure 10 Severe mutilation/mangling of the head, trunk, and limbs.
The victim was a terrorist killed by his own bomb which exploded
prematurely. Identication required comparison of his teeth with
dental records. Reproduced from Crane, J. 2005, Injury, fatal and
nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W., Corey,
T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
Injury, Fatal and Nonfatal: Explosive Injuries 185
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blast waves affecting victims at very close range (o2m)
(Patel et al., 2012).
Penetrating, perforating, and peppering (body stippling)
injuries and dust tattooing
Material propelled in all directions from the seat of the
explosion that has insufcient energy to enter the body
may impact on the skin and cause an array of injuries.
These have been described by Marshal as a triad
of small bruises, punctuate abrasions, and irregular
puncture lacerations (Figures 1215), and are thought to
be highly characteristic of explosive injury (Marshall
1976,1977,1988;Tsokos et al., 2003a,b). The bruises
and abrasions tend to be quite small range (up to 1 cm in
diameter), whereas the lacerations range between 1 and
3 cm in diameter, and may contain small fragments of
metal or wood derived from the bomb or its container
(Figures 1216).
Superimposed on this triad of small lesions, larger la-
cerations may be present due to the penetration of frag-
ments of greater size (Figure 13). When large amounts of
dust or minute fragments of dirt which are propelled by the
explosion they can be driven into the skin to cause a fairly
Figure 12 The triad of small bruises, abrasions, and puncture
lacerations typical of bomb explosions. This victim was several meters
away from the bomb when it exploded. Reproduced from Crane, J.
2005, Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J.,
Byard, R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of
Forensic and Legal Medicine. Oxford: Elsevier, pp. 98110.
(a)
(b)
(c)
Figure 11 (a) Traumatic amputation of right lower limb and left
forearm following a bomb explosion. Reproduced from Crane, J.
2005, Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J.,
Byard, R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of
Forensic and Legal Medicine. Oxford: Elsevier, pp. 98110. (b)
Amputated lower limb with part of the pelvis at the scene of explosion
following a suicide bomber attack. Note the left leg has blown off
from the pelvis. (c) Mutilation and mangling of bodies in an explosion
involving a suicide bomber. Note the amputated limbs and several
fairly intact bodies. Courtesy of Sapugaskanda SOCO Unit.
186 Injury, Fatal and Nonfatal: Explosive Injuries
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uniform tattooing and a dusky purple discoloration of the
skin. The fragments that cause the triad of injuries have
sufcient momentum to perforate clothing, whereas the
dust/dirt tattooing is typically only seen on exposed skin
(Figures 17 and 18). Peppering and dust tattooing are
observed within a range of a few meters from the
explosion.
Flying-Missile Injury
Flying missiles of various shapes and sizes cause pene-
trating and perforating injuries. These missiles are
fragments of the casing of the bomb, metallic constitu-
ents of the bomb, or secondary debris from disinte-
gration of materials around the explosion (e.g., the
undercarriage of a vehicle) (De Palma et al., 2005;
Covey, 2002;Spalding et al., 1991;Bowyer et al.,
1996). These fragments can penetrate the soft tissues
of the body quite deeply, even traversing bone, their
momentum being obtained not from their mass but from
Figure 13 In addition to the triad of small bruises, abrasions, and
puncture lacerations there are larger irregular lacerated wounds due to
penetration by larger fragments. Reproduced from Crane, J. 2005,
Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J., Byard,
R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and
Legal Medicine. Oxford: Elsevier, pp. 98110.
Figure 15 Varying degrees of bruises, abrasions, and puncture
lacerations in a victim subjected to a high-powered terrorist bomb
loaded into a lorry. Up to 103 people died in the blast (photograph
obtained from author A. Edirisinghes original work).
Figure 16 Varying degrees of bruises, abrasions, and puncture
lacerations on the face and trunk of a victim subjected to a high-
powered terrorist bomb (photograph obtained from author A.
Edirisinghes original work).
Figure 14 Punctate lacerations, small busies, and abrasions seen on
the back of an individual subjected to a bomb blast (photograph
obtained from author A. Samarasekeras original work).
Injury, Fatal and Nonfatal: Explosive Injuries 187
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their velocity (Figures 1921). When one or two pene-
trating injuries are present in the absence of other in-
juries, they may be difcult to distinguish from rearm
injuries (pellets) (Figures 21 and 22).
Injury from Falling Masonry
Many terrorist bomb explosions target not only people,
but also buildings, to increase property damage and
wounding. Persons inside or adjacent to a building de-
molished by an explosion can be buried under the rubble
and may receive serious or even fatal impact injuries
from the collapse of heavy structural components, or
they may suffer crush asphyxia. When removed from the
rubble the body and its clothing are soiled by dust from
brick, cement, or plaster (Figure 23).
Burns
Radiant heat
The temperature of explosive gases can rise to 3000 1C.
Contact with the momentary ame causes burns. Burns
from radiant heat (ash burns) have been observed in
the dismembered heads of suicide bombers (Figure 24).
Figure 18 Severe dust tattooing seen in a suicide bomb attack
involving damage to a nearby building (photograph obtained from
author A. Samarasekeras original work).
Figure 19 Flying missile injury. This victim was struck by a solitary
fragment of metal from a window frame. The fragment penetrated the
underlying chest causing fatal hemorrhage. She sustained no other
injuries. Reproduced from Crane, J. 2005, Injury, fatal and nonfatal:
Explosive injury. In: Payne-James, J., Byard, R.W., Corey, T.S.,
Henderson, C. (Eds.), Encyclopedia of Forensic and Legal Medicine.
Oxford: Elsevier, pp. 98110.
Figure 21 A death due to penetrating shrapnel injury to the heart in
a victim of a terrorist bomb blast involving a lorry that killed 93103
people. The deceased sustained only one penetrating injury to the
chest measuring 3 mm in diameter with an abrasion collar
(photograph obtained from author A. Edirisinghes original work).
Figure 20 Penetration of the skull by a fragment of door handle from
a car which was packed with explosives. The victim was over 100 m
away from the vehicle when it blew up. Reproduced from Crane, J.
2005, Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J.,
Byard, R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of
Forensic and Legal Medicine. Oxford: Elsevier, pp. 98110.
Figure 17 Dust tattooing of the lower limbs following a bomb
explosion. Note how the feet have been protected by footwear and the
thighs by clothing. Reproduced from Crane, J. 2005, Injury, fatal and
nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W., Corey,
T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
188 Injury, Fatal and Nonfatal: Explosive Injuries
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Commonly, ash burns are seen on exposed parts of the
body, typically the dorsum of the hands, face, and fore-
head, accompanied by singeing (Kauvar et al., 2006;
Roeder and Schulman, 2010;Figures 25 and 26). Indi-
viduals outside this range can be burned by the radiant
heat, but the effects decrease rapidly away from the site of
the explosion, and protection from heat radiation is af-
forded by solid objects and even clothing (Figure 27). Flash
burns may also be seen when bomb-making chemicals
ignite. The ignition is associated with a momentary ash of
very high temperature, and those exposed can have their
outer clothing burned off, and may sustain extensive uni-
form-thickness cutaneous burns (Figure 28).
Other types of burns
Severe burns may result from a re started later by the
bomb, either because of the incorporation of incendiary
materials into the device or as a result of disruption of a
source of ammable material. Severe burns may lead to
difculties in identication and obliteration of surface
injuries (Figure 29). Sometimes burns may be very
severe, with incineration of bones (Figure 30). Chemical
and radiation burns due to accidental explosions in
industries are other examples.
Blast Injuries
The shock wave produced in explosions causing injuries
to or around gas-lled tissues are well-known primary
blast injuries (PBI) (Phillips, 1986). A commonly en-
countered PBI is rupture of the tympanic membrane.
Pulmonary hemorrhage (blast lung) and sero-muscular
intestinal injury are occasionally seen (De Palma et al.,
2005;Wightman and Gladish, 2001;Phillips, 1986;
Jensen and Bonding, 1993). PBI may progressively en-
large to encompass uid-lled organs, including the
central nervous system and the eye (Rossi et al., 2012).
Blast injuries to the ear
Acoustic barotrauma consists of the following:
Tympanic membrane rupture (most common)
Hemotympanum without perforation
Ossicle fracture or dislocation (with very high-energy
explosions).
The ears are the organs of the body most sensitive
to the effects of blast. It is thought that if the blast had
been sufcient to cause damage to any other part of
the body, it will also have affected the ears unless they
have been specically protected (Jagade et al., 2008).
Tympanic membrane rupture occurs during the positive
pressure phase of the blast wave, which lasts for a few
milliseconds (Figure 1). Most victims who survive an
Figure 24 Radiant burns in the head of the suicide bomber with
singeing of hair (photograph obtained from author A. Samarasekeras
original work).
Figure 23 Injury from falling masonry. A body recovered from a
building demolished by a bomb explosion. The exposed skin and
clothing are heavily soiled by dust, plaster, and cement. Death was
due to crush injuries of the trunk. Reproduced from Crane, J. 2005,
Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J., Byard,
R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and
Legal Medicine. Oxford: Elsevier, pp. 98110.
Figure 22 Penetrating injuries to the heart of the deceased in
Figure 21 (photograph obtained from author A. Edirisinghes original
work).
Injury, Fatal and Nonfatal: Explosive Injuries 189
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explosion may initially complain of deafness associated
with tinnitus, but they usually recover if the ossicles have
not been damaged. The tympanic rupture (Figure 31)
heals on its own, but some victims may develop chronic
otitis media or nerve deafness.
Blast lung
Pulmonary barotrauma, the most common fatal PBI,
may include the following:
pulmonary contusion;
systemic air embolism, which most commonly
occludes blood vessels in the brain or spinal cord;
Figure 25 Singeing of the hair and scorching of the skin of the face
and neck in an individual close to the seat of an explosion.
Reproduced from Crane, J. 2005, Injury, fatal and nonfatal: Explosive
injury. In: Payne-James, J., Byard, R.W., Corey, T.S., Henderson, C.
(Eds.), Encyclopedia of Forensic and Legal Medicine. Oxford: Elsevier,
pp. 98110.
Figure 26 Singeing of the hair and scorching of the skin of the face
and neck in an individual subjected to terrorist attack. Note the
presence of explosive injuries too (photograph obtained from author
A. Edirisinghes original work).
Figure 27 Flash burns from radiant heat in a terrorist bomb attack.
Observe the sparing of the skin due to protection from underwear
(photograph obtained from author A. Edirisinghes original work).
Figure 28 Flash burns associated with the ignition of bomb-making
chemicals. Reproduced from Crane, J. 2005, Injury, fatal and nonfatal:
Explosive injury. In: Payne-James, J., Byard, R.W., Corey, T.S.,
Henderson, C. (Eds.), Encyclopedia of Forensic and Legal Medicine.
Oxford: Elsevier, pp. 98110.
190 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
free radical-associated injuries such as thrombosis,
lipoxygenation, and disseminated intravascular co-
agulation (DIC);
impaired pulmonary performance lasting hours
to days; and
acute respiratory distress syndrome (ARDS) may be a
result of direct lung injury or of shock from other
body injuries.
Lung injuries from a blast wave are characterized by
rupture of the alveolar capillaries, inux of blood, and
extravasations of edema uid into lung tissue (Brown
et al., 1993;Gorbunov et al., 1997). Blast lung injury
is a clinical diagnosis characterized by respiratory dif-
culty and hypoxia, which may occur without any
obvious trauma to the chest wall.
Signs and symptoms of blast lung include dyspnea,
hemoptysis, cough, chest pain, tachypnea, cyanosis,
apnea, wheezing, reduced breath sounds, and charac-
teristic buttery pattern in X-ray (Barnard and Johnston,
2013;Figure 32). Associated pathologies include
broncho-pleural stula, air embolism, hemothorax, and
pneumothorax.
At postmortem examination blast lung shows blot-
chy, purple-black areas of subpleural hemorrhage, with
parallel bands of bruising related to the overlying ribs
(Figures 33 and 34). Sectioning the lungs reveals more
discrete areas of hemorrhage scattered in the tissue.
The overall weight of the damaged lung is increased due
to hemorrhage and edema.
Microscopically, there is intra-alveolar hemorrhage,
sometimes conned to intact alveoli, together with larger
areas of conuent hemorrhage and disruption of alveo-
lar walls (Figure 35). Hemorrhage may extend into the
bronchioles, and variable amounts of edema uid are
found in the alveoli. Emphysematous dilatation of some of
the alveolar ducts may be present. In patients who survive,
the changes are modied by inltration with a neutrophilic
inammatory response, often developing into ARDS.
Thoracic blast effects
PBI produces the following unique cardiovascular
responses:
a decrease in heart rate, stroke volume, and
cardiac index;
Figure 29 These victims were inside a building which caught re
after an explosive device, incorporating cans of petrol, exploded on an
outside wall. 12 badly charred bodies were recovered from the scene.
Reproduced from Crane, J. 2005, Injury, fatal and nonfatal: Explosive
injury. In: Payne-James, J., Byard, R.W., Corey, T.S., Henderson, C.
(Eds.), Encyclopedia of Forensic and Legal Medicine. Oxford: Elsevier,
pp. 98110.
Figure 30 Incinerated bones and body parts brought for examination
from a building destroyed by re following a terrorist bomb attack
(photograph obtained from author A. Samarasekeras original work).
Figure 31 Eardrum perforation caused by blast (google images from
http://www.entusa.com/eardrum_and_middle_ear.htm and https://
www.google.lk/search?q=traumatic+rupture+of+the+tympanic+
membrane&espv=2&biw=1093&bih=534&source=lnms&tbm=
isch&sa=X&ei=OLRaVbu7DsiNuATtiYPIDg&ved=0CAYQ_
AUoAQ#imgrc=7ec6cx0sRciOcM%253A%3BIlzfkYHKRhs7HM%3Bhttp
%253A%252F%252Fwww.entusa.com%252FEar_Photos%252Ftraumatic_
perforation_0601_small1.jpg%3Bhttp%253A%252F%252Fwww.entusa.
com%252Feardrum_and_middle_ear.htm%3B177%3B193).
Injury, Fatal and Nonfatal: Explosive Injuries 191
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the normal reex increase in systemic vascular
resistance does not occur, so blood pressure falls; and
if this response is not fatal, recovery usually occurs
within 15 min to 3 h.
Blast damage to the bowel
Gastrointestinal tract injury following blast is seen as
hemorrhage into the peritoneum and intestinal wall.
These injuries are primarily observed in the colon and
to a lesser extent in the small intestine. Perforation of
the bowel is uncommon, though occasionally reported.
One of the characteristic features of this injury pattern is
intramural hemorrhage splaying the muscularis propria.
The injury may progress to ischemic necrosis of the
intestinal wall, leading to delayed perforation (Kluger
et al., 2004).
Traumatic brain injuries following blast
Traumatic brain injuries (TBIs) following a bomb blast can
be divided into primary, secondary, tertiary, and quater-
nary. The mechanisms responsible for PBI are increasingly
understood compared to a few decades ago (Rosenfeld
et al., 2013;Risdall and Menon, 2011). It is now accepted
that the mechanical forces transmitted (shock wave)
through the cerebral white matter can result in axonal
injury and hippocampal vulnerability in persons exposed
to bomb blasts (Elder and Cristian, 2009), Further, the
strong association between posttraumatic stress disorder
(PTSD) and TBI suggests that mild TBI seems to increase
the risk of PTSD (Vasterling et al., 2009). Preliminary
evidence suggests that chronic traumatic encephalopathy
can develop after repeated blast-related mild TBIs. How-
ever, further research is needed since there are many other
conditions that could produce similar pathological changes
in the brain. Neuroimaging studies, cerebral markers, and
animal models are increasingly used in research to nd the
answers to unresolved questions in mild TBI resulting from
bomb blasts.
Primary blast injury to the eye
PBI of the eye is due to the shock wave traveling across the
eye, causing tissue shearing. It is believed that reection of
the shock wave by the orbit may amplify the effect (Cha-
lioulias et al., 2007). The posterior chamber is predomin-
antly affected. Injuries in the anterior segments are
conjunctival lacerations, subconjunctival hemorrhages,
ocular hypotony, and cataracts; vitreous hemorrhage, ret-
inal tears or detachments, retinal epithelial pigment dis-
turbance, and retinal swelling occur in the posterior
segment. Although some effects are temporary, occasional
profound loss of central vision is reported (Scott, 2011).
Research based on models and animal studies has shown
promising results in understanding and developing eye
protection in military medicine (Rossi et al., 2012).
AP SUPINE
(a) (b)
Figure 32 (a) Chest radiography and (b) computed tomography revealed typical appearances of blast lung (pulmonary barotrauma), with
interstitial and alveolar lling defects and prominent air bronchograms in a butterypattern. Reproduced from Barnard, E., Johnston, A., 2013.
Images in clinical medicine. Blast lung. New England Journal of Medicine 368 (11), 1045. Available at: http://www.nejm.org/doi/full/10.1056/
NEJMicm1203842) (accessed 20.05.15).
Figure 33 Blast lungs. There are extensive areas of blotchy purple-
black subpleural hemorrhage on the surfaces of both lungs.
Reproduced from Crane, J. 2005, Injury, fatal and nonfatal: Explosive
injury. In: Payne-James, J., Byard, R.W., Corey, T.S., Henderson, C.
(Eds.), Encyclopedia of Forensic and Legal Medicine. Oxford: Elsevier,
pp. 98110.
192 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
Injuries Due to Explosions of Mines and Hand
Grenades
Mines are hidden explosives designed to detonate/
explode by pressure and to maim rather than kill (Hiss
and Kahana, 2000). Although they contain high explo-
sives, the amount is generally not large enough to cause
blast/explosive effects, but shrapnel makes them lethal,
especially if they penetrate vital organs. Improvised
Claymore mines (anti-material mines) used by terrorists
targeting civilian transport or VIPs (Ministry of Foreign
Affairs, Sri Lanka, 2007) have led to deaths from all
types of injuries, mainly due to ying missiles including
shrapnel (Figure 36).
Injuries due to the explosion of an anti-personnel
land mine (APLM) are seen in the lower limbs and oc-
casionally the hands or face (Goonetilleke, 1995).
The initial blast of an APLM tears the foot apart,
(a) (b)
Figure 34 (a) Subplural hemorrhage. (b) Cut section of the lungs showing paranchymal hemorrhage in a person traveling in a vehicle subjected
to claymore mine explosion. He had respiratory difculty at admission and received ventilator support. He died within an hour of admission to
hospital (photograph obtained from author A. Edirisinghes original work).
(a) (b)
(c) (d)
Figure 35 Hematoxylin and eosin stained sections of lung tissues from control (a), and low-intensity blast-exposed animals at day 1 (b), day 4
(c), and day 7 (d) after blast. Signs of hemorrhage, macrophage inltration, and thickening of the alveolar septae were observed at day 4 and day
7 after blast injury. Google image from Pun, P.B.L., Kan, E.M., Salim, A., et al., 2011. Low level primary blast injury in rodent brain. Frontiers in
Neurology 4 (2), 19. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083909/ (accessed 27.04.15).
Injury, Fatal and Nonfatal: Explosive Injuries 193
Author's personal copy
causing the foot and toes to peel away from the leg
(Figures 37(b) and (c)). The Sri Lankan experience
of improvised APLMs, colloquially known as Joney
Batta,showed that injured combatants and civilians
often needed below-knee amputations (Goonetilleke,
1995;Meade and Mirocha, 2000). APLMs have also led
to upper limb blast injuries and face injuries, especially
in children who pick them up accidentally (Coupland
and Korver, 1991;Figure 37). They have even been
reported to cause limb amputations in wild elephants
(Rodrigo, 2011;Figures 38(a) and (b)).
Forensic examination of injuries due to hand gren-
ades may be encountered in all types of situations from
homicides and accidents to suicides. In homicidal situ-
ations, deaths are mainly due to shrapnel causing in-
ternal injuries, while survivors may have multiple
peppering injuries in exposed areas (Figures 39(a)(c)).
Medicolegal Management of the Dead and Surviving
Individuals in Explosions
The medicolegal management of the dead and living after
an explosion is important for the administration of justice,
provision of humanitarian care, and for future plans for
prevention and safety. Predetermined action plans, disaster
preparedness, and response are vital for proper and effec-
tive management of dead bodies and survivors. The key
to success is a coordinated multidisciplinary approach in-
volving volunteers, technical experts, administrators, law
enforcement agencies, governmental and nongovernmental
(a) (b)
(c) (d)
1. 2. 3.
Figure 37 (a) Mechanism of causation of injuries from an antipersonnel land mine (from Google image. http://members.iinet.net.au/~pictim/
mines/victims/victim.html). (b,c,d) Blast injuries in a child from an antipersonnel land mine (from Google image. http://www.dhushara.com/book/
explod/mine/mine.htm).
Figure 36 Penetrating shrapnel injuries in victim of a terrorist
Claymore mine. He was inside a vehicle sitting on the right side of the
back seat. Multiple pieces of shrapnel were recovered from the thorax
and abdomen (photograph obtained from author A. Edirisinghes
original work).
194 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
organizations, healthcare and social workers, and others,
depending on the situation. Dealing with the media and
caring for the bereaved and victims are other important
aspects in the management.
At the end of the investigation, the cause of the ex-
plosion, whether it is man-made or natural, and if man-
made whether a criminal element is involved need to be
determined by law enforcement agencies. Thus, forensic
medical investigation has a vital role to play in estab-
lishing the identity and number of the dead, retrieval of
scientic evidence, study of injury patterns for re-
construction, and identifying the perpetrators.
(a)
(b) (c)
Figure 39 (a, b,c) Penetrating shrapnel injuries from a hand grenade. The victim was sleeping when a hand grenade was thrown into the bedroom.
There were no blast injuries or peppering injuries. The victim died due to penetrating shrapnel to the heart and brain. His wife and child who were
sleeping in the same bed escaped with minor penetrating shrapnel injuries (photograph obtained from author A. Edirisinghes original work).
(a) (b)
Figure 38 (a) Blast injuries in a wild elephant due to antipersonnel land mines. (b) Blast injuries in a wild elephant receiving treatment by
veterinary surgeons (from Google image. http://www.sundaytimes.lk/110410/News/nws_07.html).
Injury, Fatal and Nonfatal: Explosive Injuries 195
Author's personal copy
Once the safety of the site of the explosion is assured,
rescue of survivors should take precedence over all other
activities, and initial steps of the management of the dead
may commence. All matters related to chain of custody
must be adhered to, and impartiality must be maintained.
Identication
Identication of the dead in explosions by conventional
methods such as visual identication, though possible in
many instances when facial features are preserved, may
not be reliable in subjects with secondary or tertiary
injuries (Figures 4043). Standard protocols and guides
such as those published by INTERPOL, Pan American
Health Organization, or national protocols and
guidelines can be used. (INTERPOL, Disaster Victim
Identication Guide, 2009;Morgen et al., 2009). If an
explosion is suspected to result from terrorist activities,
special precautions must be taken to identify the possible
perpetrator(s) among the dead or survivors. This is
important if the victims are to be compensated or if there
is a political issue involved.
The identication of body parts using DNA is increas-
ingly used. The experience of DNA identication from the
World Trade Center disaster (9/11) led to development of
bioinformatics software (Leclair et al.,2007). Most of the
identication methods involve comparison of postmortem
and antemortem data, and thus collection and processing
of data needs careful consideration.
Establishing the Number of Dead
When a terrorist bomb is exploded, the rst question
is the number of fatalities and casualties. Therefore, it is
important to ascertain the minimum number involved.
Most of the dead will be sufciently intact to be counted,
but occasionally those victims near the seat of the ex-
plosion may be so disintegrated that their presence is
Figure 41 A distinctive tattoo, including the individuals name on the
forearm. The deceased was a soldier who was killed in a bomb
explosion. The extent of the injuries to the head precluded visual
identication. Reproduced from Crane, J. 2005, Injury, fatal and
nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W., Corey, T.S.,
Henderson, C. (Eds.), Encyclopedia of Forensic and Legal Medicine.
Oxford: Elsevier, pp. 98110.
Figure 40 Severe facial injuries precluding visual identication,
following a bomb explosion. Note that the absence of injury to the mouth
enabled a dental comparison to be carried out. Reproduced from Crane,
J. 2005, Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J.,
Byard, R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic
and Legal Medicine. Oxford: Elsevier, pp. 98110.
196 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
only recognized after a careful search and examination
of material collected from the scene. A careful analysis of
data from all forensic teams should be considered when
arriving at the nal number of deaths.
Retrieval of Forensic Evidence
Retrieval of forensic evidence includes those items ob-
tained from the external examination (e.g., clothing,
swabs, or uids and residues) and internal examination.
It is essential to document, label, store, and transfer the
evidence collected to the forensic investigators while
maintaining the chain of custody. On occasion, frag-
ments recovered from the bodies of explosion victims
may have important forensic signicance. They may
help to determine the particular characteristics of the
explosive device and thus implicate a specic terrorist
organization (Figure 44).
X-raying bodies prior to autopsy will assist in the
identication (Kahana et al., 1997) and recovery of
shrapnel, bullets, and fragments of the explosive
device, including parts of the detonator itself. Forensic
toxicology will be also be needed in some deaths, for
example, those with severe burns and chemical injuries.
Figure 44 A nail embedded in the skull following detonation of a
nail bomb. The retrieved fragment was compared with nails seized at
the premises of a suspect. Reproduced from Crane, J. 2005, Injury,
fatal and nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W.,
Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
Figure 42 Amongst the mangled remains of this explosion victim
was a relatively well-preserved hand from which ngerprints could be
taken. Note also the engraved signet ring, which was of assistance in
identifying the victim. Reproduced from Crane, J. 2005, Injury, fatal
and nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W.,
Corey, T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
Figure 43 Two uterine cervices and two prostate glands
recovered after a number of bodies were disintegrated by a large
bomb conclusive proof of at least four victims, two male and
two female. Reproduced from Crane, J. 2005, Injury, fatal and
nonfatal: Explosive injury. In: Payne-James, J., Byard, R.W., Corey,
T.S., Henderson, C. (Eds.), Encyclopedia of Forensic and Legal
Medicine. Oxford: Elsevier, pp. 98110.
Injury, Fatal and Nonfatal: Explosive Injuries 197
Author's personal copy
Study of Injury Pattern for Reconstruction
When a badly injured body is retrieved after an explo-
sion, the prima facie inference is that death was caused
by the explosion, and cursory external examination is
required. There is little doubt when severe localized ex-
plosive injury or the triad of peppering injuries are
apparent, that death was due to the explosion. However,
the cause of death of a victim pulled from the rubble, or
a victim found in a burned-out building after an explo-
sion is different; thus, a meticulous postmortem is nee-
ded to nd the cause of death. However, victims who
died later in hospital may have other associated path-
ologies. Terrorists have been known to re projectile
weapons before planting bombs. Therefore, it is possible
for a person to be fatally shot and left at the scene
while others ee (Figure 45). Likewise, it is also possible
that the terrorists were killed by rearms while pre-
paring for the explosion. In such situations, the cause of
death is rearm injuries, and any explosion injuries may
be postmortem. Again, imaging of bodies is of assistance
in locating bullets and particles of the bomb.
Reconstruction of the incident and describing the cir-
cumstances is the most rewarding aspect of autopsies. The
opinions expressed by forensic pathologists are based on
scientic reasoning regarding the severity, distribution, and
pattern of injuries. In this regard, two principles to keep in
mind are: (1) the closer the victim is to the seat of explo-
sion, the greater is the trauma; and (2) the force in an
explosion is highly directional (Oliver et al.,2002). For
example, the legs show severe injuries when an under-car
booby trap device explodes (Figure 46), whereas a bomb
handler will tend to have injuries to the chest and hands
(Figure 47). However, the nal conclusions regarding the
circumstances and reconstruction must done as a team
after considering all evidence.
Suicide Bombers and Human Bombs
Although suicide attacks have been recognized phenomena
in recent history, the rst modern human bombattack
was reported in the early 1980s, as used by Palestinians in
the Middle East. This was followed by the Liberation
Tigers of Tamil Elam (LTTE) attack in Sri Lanka in 1987.
A human bomb is dened as a type of suicide attack where
the perpetrator carries the explosive device strapped to his
(a) (b)
Figure 47 Injuries seen in a bomb handler. Note the explosion injuries with burns in the front of the chest and the amputation of the right arm
(photograph courtsey of Dr. P. Paranitharan).
Figure 45 This mans mangled body was recovered from the scene
of a bomb explosion. Note the bullet wound on the back of the chest.
Reproduced from Crane, J. 2005, Injury, fatal and nonfatal: Explosive
injury. In: Payne-James, J., Byard, R.W., Corey, T.S., Henderson, C.
(Eds.), Encyclopedia of Forensic and Legal Medicine. Oxford: Elsevier,
pp. 98110.
Figure 46 Mangling and traumatic amputation of the lower limbs
due to an under-car booby trap device. Reproduced from Crane, J.
2005, Injury, fatal and nonfatal: Explosive injury. In: Payne-James, J.,
Byard, R.W., Corey, T.S., Henderson, C. (Eds.), Encyclopedia of
Forensic and Legal Medicine. Oxford: Elsevier, pp. 98110.
198 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
or her body, using a garment specially designed for the
purpose, with the intention of killing others along with
him/herself (Samarasekera, 2008). However, not all suicide
attacks can be categorized as human bombs. From 1987 to
2009 in Sri Lanka, 109 suicidal bomb attacks took place,
according to statistics from the Institute for Conict
Management: South Asia Terrorism Portal (South Asia
Terrorism Portal: Institute for Conict Management,
2013).
Suicide kits used by human bombers differ. Palestinian
suicide bombers use a belt worn (Figure 48)atthewaist
consisting of several cylinders lled with high explosives
(Figure 48), while the LTTE used various type of kits
(Figures 4951) incorporating plates of explosives and
shrapnel to mimic a body-worn Claymore mine. The rst
human suicide bomber used a pair of shorts (Figure 49);
however, the majority of suicide bombers wear jackets or
vests (Figure 50;Ministry of Foreign Affairs, Sri Lanka,
2007). In the case of a female suicide bomber with blown
off breasts and relatively intact torso the possibility of a
bomb kit in a brassiere can be suspected (Figure 52).
Complete disruption of the body is expected in an
individual strapped with large amounts of HOE. How-
ever, in human bombs, most of the trunk is blown away,
but remarkably the head and lower limbs remain rela-
tively intact and are usually found some distance away
from the seat of the explosion (Hiss and Kahana, 1998;
Samarasekera, 2008;Figures 5357). Analysis of injur-
ies observed in the suicide bombers from Sri Lanka
has shown distinctive injury patterns consisting of
detachment of the head and limbs, severe disruption of
the trunk, burns at the transected tissue margins, and
absence of shrapnel injuries (Samarasekera, 2008;
Ruwanpura et al., 2008).
Identication of suicide bombers is a challenge to any
forensic team because intelligence information has to be
coupled with scientic/biological investigations. Familial
dental features may help to locate the family and mito-
chondrial DNA can be used to establish the family link
(Samarasekera, 2003). It has been reported that human
body parts acting as projectiles from the suicide bombers
(a) (b)
Figure 48 (a) Hamas’‘suicide bombersduring a demonstration in Gaza. (b) Palestinian Islamic Jihad activists parade with explosive belts lled
with mock charges during a 2005 rally in the West Bank (from Google image: http://www.waronline.org/en/terror/suicide.htm and http://www.
dailymail.co.uk/news/article-2317792/Four-Afghan-Palestinian-Muslims-support-suicide-bombing-survey-claims.html)
Figure 49 Explosive device in a pair of shorts. Courtesy of Ministry
of Foreign Affairs, Sri Lanka, 2007. LTTE: A trail of atrocities.
Available at: www.defence.lk and http://www.defence.lk/LTTE%
20Attrocities/LTTE_Atrocities14june.pdf (accessed 16.06.15).
Injury, Fatal and Nonfatal: Explosive Injuries 199
Author's personal copy
(a) (b)
Figure 51 (a) A captured female suicide bombers vest (ripped apart for analysis). Courtesy of Ministry of Foreign Affairs, Sri Lanka, 2007. LTTE:
A trail of atrocities. Available at: www.defence.lk and http://www.defence.lk/LTTE%20Attrocities/LTTE_Atrocities14june.pdf (accessed 16.06.15). (b)
worn by a member of the antiterrorism team (http://asiantribune.com/node/7021).
(a) (b)
Figure 52 Female suicide bomber: note the injuries in the anterior chest (a) and absence of injuries in the back (b). The shrapnel injuries are
hardly found or absent in the back. The body is intact and indicates that the amount of explosives carried were not large enough to cause
dismemberment of the limbs or head (photograph obtained from author A. Samarasekeras original work).
(a) (b)
Figure 50 (a) Jacket or vest type suicide bomb kit. Courtesy of Ministry of Foreign Affairs, Sri Lanka, 2007. LTTE: A trail of atrocities. Available
at: www.defence.lk and http://www.defence.lk/LTTE%20Attrocities/LTTE_Atrocities14june.pdf (accessed 16.06.15). (b) Suicide kit for chest.
Courtesy of WDGS Gunahilake, Government Analyst Sri Lanka.
200 Injury, Fatal and Nonfatal: Explosive Injuries
Author's personal copy
that implanted in the living victims of a suicidal bomb
attack may have been infected with hepatitis B
(Braverman et al., 2002). Therefore, it is important to
consider prophylaxis for hepatitis B infections and the
possibility of HIV in such situations (Patel et al., 2012).
There have been instances of suicide bomb attacks
mimicking human bomb explosions, for example, a
motorcycle crashing into a motor vehicle where the
bomb was on the upper part of the petrol tank. The
injury pattern observed in this particular suicide bomber
differed from the normal pattern, although all four limbs
were detached. The reconstruction inferred that the rider
detonated the bomb while bending over the petrol tank
(Samarasekera, 2008).
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202 Injury, Fatal and Nonfatal: Explosive Injuries
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