54 page TERRORISM BOMB BLAST TRAUMA Presentation on CD

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An Introduction to Asymmetric War (Terrorism)and the Epidemiology of Blast Trauma, 2004, 54 pages

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An Introduction to Asymmetric War (Terrorism) and the Epidemiology of Blast Trauma Timothy E. Davis, MD, MPH Lt. Commander, USPHS Commissioned Corps CDC/NCIPC/DIDOP/OD Asst. Professor of Emergency Medicine, Emory University Rules of Engagement (ROE) “… directives … under which military forces initiate engagement with belligerent forces…” 1. Presentations developed from domestic and foreign open source information (OSINF) including health, engineering, intelligence, national security, and military. 2. This area of study is problematic a. Lack of data standards - definitions, analyses, reporting b. Prone to misinformation & propaganda 3. The opinions are those of the cited sources, and does not constitute an endorsement by the CDC, DHHS, or Emory University. Objectives Blast Epidemiology 1. Discuss terrorism and asymmetric war 2. Review the limits of epidemiologic data 3. Examine why conventional weapon terrorism (blast trauma) is both a public health and healthcare system problem Weapons of Mass Destruction “… any explosive, incendiary, or poison gas - (i) bomb, (ii) grenade, (iii) rocket ..., (iv) missile ..., (v) mine, or (vi) ... similar ... devices” – U.S. Code, Title 18, Part I, Chapter 113b, Sections 2332a and 921a 17,579 criminal bombings in U.S, 1988-1997 (FBI) Average of 5 bombings per day Bombings doubled over the 10-year period 214 U.S. Embassy bombings, 1988-1997 (State) - Average ~ 2 per month 2001 Worldwide Terror Against U.S. Concerns 2001 Total U.S. Worldwide Terror Casualties 5 Billion Pounds Produced Each Year in U.S. Explosives are Terrors’ Perfect Storm 1. Available – 5 billion pounds legally made in U.S. Understanding Terrorism Who Gets Targeted? Almost all terror campaigns target free-press countries Representative governments are especially vulnerable Russia Chechens used suicide tactics against free-press Russia, but not U.S.S.R. Kurds – “Kurdistan” – parts of Iran, Iraq, and Turkey Used terrorism against Turkey, only as Turkey moved toward more representative government in the 1980s Never used terror tactics against Iran or Iraq, yet where severely repressed by Saddam Hussein Terror Tactics are Escalating Civilians now more than collateral damage The 1980s – The “IRA era” Placement / stationary bombs - package, culvert, or car bombs targeted against government or rivals “Gentlemen’s agreement” - advanced warning limits casualties –>evacuations, & staging of medical resources What’s The Trend? Why Is Terror Growing? Because it works In 6 of the 11 suicide campaigns successful (55%) terrorists achieved at least partial victory airpower or economic sanctions < 15% success Targeted states Fully or partially withdrew from territory Began negotiations Released a terrorist leader Suicide campaigns - successful against even hawkish governments Reagan Netanyahu Why Is Terror Growing? Because it works Democratic leaders publicly confirmed suicide attacks pushed them to make concessions Examples U.S. left Lebanon in 1983 - Marine barracks bombing Israel followed in 1985 after > 800 IDF deaths / 18 mo. Spain left Iraq after March 2004 Madrid bombings Military Data Less Helpful Objectives Blast Epidemiology 1. Discuss terrorism and asymmetric war 2. Review the epidemiologic data and the limits 3. Examine why conventional weapon terrorism (blast trauma) is both a public health and healthcare system problem The Basics of Explosives and Bomb-blast Trauma Timothy E. Davis, MD, MPH Lt. Commander, Commissioned Corps, USPHS CDC/NCIPC/DIDOP/OD Asst. Professor of Emergency Medicine, Emory University Objectives Basics of Bomb Blast Trauma 1. Recognize how injuries and casualty mix are affected by a. bomb type b. terrorist tactic c. bombing environment 2. Anticipate casualty severity profile, and identify common, occult, and high risk injuries following a. open space bombing b. confined space bombing c. bombing with structural collapse Explosives Classified by the Speed of Explosion High-order (HE) versus Low-order (LE) High-explosives (HE) = detonation Supersonic – Explosion is faster than the speed of sound Blast over-pressurization impulse wave HE does not mean “large” – a hand grenade is a HE HE blast injuries are characterized as a) Primary, b) Secondary, c) Tertiary, d) Quaternary E.g., all military bombs, TNT, Dynamite, Semtex, ANFO Low-order explosives (LE) = deflagration – not detonation Subsonic – explosion occurs < the speed of sound NO blast over-pressurization wave LE does not mean “small” – 9-11 attacks involved LE LE injuries can be characterized as a) shrapnel, b) blunt, c) crush, d) burn E.g., Napalm, gunpowder, Molotov cocktail, many petroleum-based (but ANFO is HE) Bombs can be Classified based on Adulterants “Dirty Bomb” - addition of bio-chem-rad agents Cyanide, Warfarin, Hepatitis have been used Exothermic reaction may alter biologics and chemicals Radiologicals are not affected by heat Shrapnel Criminals lack access to high tech shrapnel or canisters Use less efficient bolts, nails, glass Compensate with excess bulk explosives Size Does Matter Environment can Protect or Harm Open, Confined, and Enclosed space explosions Blast-Injury Vocabulary Specific for High-order Explosives (HE) 1. Primary (1°) Blast Injury (e.g. blast lung) – over-pressurization impulse wave – often fatal Blast Injuries Do Not Occur in Isolation A Casualty with “Blast Lung” (1°) will also have 1. Penetrating glass shards (2°) 2. Traumatic amputation (3°) 3. Burns, inhalation injury, deafness (4°) The Injury Severity Score (ISS) does not accurately measure complexity, or resource utilization Other Typical confined space (bus) injuries (1°) Blast lung, bowel rupture, TM rupture (2°) Penetrating foreign body to globe, chest, abdomen (3°) Traumatic amputations, Fx to face, pelvis, ribs, spine (4°) crush injuries, 1° & 2° burns Primary Blast Injury associated exclusively with high-order (HE) explosives 1. Caused by the over-pressure blast wave Invisible, supersonic 2. Lethal radius rapidly diminishes with distance 1 / radius3 . Lethal radius is 3x in water 3. Affects most air filled structures Lungs, GI tract, Sinuses, Middle ear (TM rupture) But also brain – “shell shock” “White Butterfly Sign” Blast Abdomen Blast Brain concussion, TBI, shell shock, misdiagnosed behavioral disorder Blast over-pressure wave – not always a straight path Dampened, reflected, or amplified off solid surfaces Helmets, Kevlar stop shrapnel, but magnify blast waves Do not assume all dysfunctional actions are behavioral Future treatment for IC bleed may be rF VIIa Animal studies promising Human recombinant Factor VIIa used in Israel under a humanitarian protocol Not U.S.-FDA approved or recommended 1. Penetrating injury from shrapnel or debris. 2. Open-space bombings – nails out to 100 meters - from 5 kg bomb 3. Makeshift bomb shrapnel unpredictable path - high use of CT and X-ray in Israel 4. Treat as dirty grossly contaminated – delayed primary closure Tertiary Blast Injury ”Tertiary” applied exclusively for high-order (HE) injuries 1. Caused by displacement of body, or body parts, by force of blast wind – includes traumatic amputations 2. Blunt trauma – solid object strikes, or victim is thrown against solid object, includes impalement 3. Care follows standard blunt trauma protocols Quaternary Blast Injury “Quaternary” applied exclusively for high-order (HE) injuries Classified by some disciplines as “miscellaneous” 1. Crush injuries 2. Suffocation and Fume poisonings 3. Burns 4. Exacerbation of chronic disease Asthma, COPD, diabetes, hypertension, CAD, PUD, alcohol and drug abuse, mental health 5. New behavioral problems Low-order Explosives (LE) uses “clear text” mechanism descriptions – differ from HE Low-order explosives (LE) differ in mechanism: 1. Deflagration not detonation (HE) 2. Subsonic “slow burn” versus supersonic explosion 3. No over-pressurization and blast wave impulse Ballistic effect – shrapnel and debris Thermal effect – burns from the heat generation Suffocation – all oxygen is consumed Also -> fume poisonings, crush injuries, exacerbation of chronic disease (asthma, COPD, diabetes, hypertension, MI, PUD, mental health) Low-order Explosives (LE) versus High-order Explosives Trauma Patterns Small (5 kg) Open Space Suicide Bombing Casualties – 1-30 (Israel - average 23, range 1-99) Severity – killed 1-5 – admitted 5-10 – treat & release 20 Injury patterns - 1° Blast trauma < 5 meters - occult nails < 100 meters - temporary deafness - risk of Hepatitis, Tetanus, HIV Trauma Patterns Small (10 kg) Confined Space Backpack Bomb Casualties – 20-50 bus and 150-200 train / bomb - 70% of fatalities are Dead on Scene (DOS) Severity – killed 20% – admitted 20% – treat and release 60% Injury patterns - 1° Blast trauma – anywhere within bus or train cabin - temporary deafness, risk of Hepatitis, Tetanus, HIV Complicated train rescue Structural collapse bombing (100-1,000 kg TNT-eq) Casualties – 100 – 3,000 – largely based on bomb size, time of day, warning, building structure, and evacuation proficiency – 90% of fatalities are DOS