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REVIEW ARTICLE
Blast injuries from Madrid terrorist bombing attackson March 11, 2004
Milagros Mart & Manuel Parrn &Franziska Baudraxler & Aranzazu Royo &Nieves Gmez Len & Rodolfo lvarez-Sala
Received: 11 May 2006 /Accepted: 24 July 2006 / Published online: 14 November 2006# Am Soc Emergency Radiol 2006
Abstract Blast injuries after terrorist attacks are seen withincreasing frequency worldwide. Thousands of victimswere attended in the hospitals of Madrid, Spain, on March11, 2004 after the bombing attacks against the commutertrains. Thirty-six patients were attended in our institution.Seventeen of them suffered from severe or life-threateninginjuries, and 19 had mild injuries. The most commonlesions were thoracic trauma and blast lung injury, acoustictrauma, and orbital and paranasal sinus fractures. Otherfindings were hepatic and splenic lacerations, and vertebraland limb fractures. Emergency radiology had an importantrole in the correct management of the victims. Promptradiological diagnoses of these complex lesions are crucialto efficient treatment. Therefore, radiologists have tobecome familiar with the injury patterns and specificlesions caused by blast wave.
Keywords Terrorism . Blast injuries . Blunt injuries .
Diagnostic imaging . Computed tomography . Radiography
Introduction
There are various scenarios that lead to injury from blast,sometimes referred to as blast overpressure injury. Howev-er, the number and extent of worldwide terrorist attacks hasrisen sharply in recent years [1, 2].
Terrorism has been defined as all kinds of criminal actsdirected against a state and intended or calculated to createa state of terror in the minds of particular persons or a groupof persons or the general public [3].
An explosive is any substance or device capable of asudden expansion of gas, which upon release of itspotential energy creates a pressure wave. Compression ofair in front of the pressure wave, which heats andaccelerates air molecules, leads to a sudden increase inatmospheric pressure (overpressure) and temperature trans-mitted into the surrounding environment as a radiallypropagating shock wave known as the blast wave [4, 5].The blast wave consists of two parts: a shock wave of highpressure, followed closely by a blast wind or air in motion[6] (Fig. 1).
Injuries provoked by explosive blasts were classified byZuckerman during the Second World War according to thephysical effects on the body caused by the released energy(Table 1) [4, 6]:
Primary blast injuries are caused solely by the directeffect of blast overpressure on tissue. Unlike water, airis easily compressible. As a result, primary blastinjuries usually affect air-filled organs and airfluidinterfaces such as the lungs, the middle ear, and thegastrointestinal tract. Rupture of tympanic membranes,pulmonary damage, and air embolization, as well asrupture of hollow viscera, are the most importantprimary forms of blast injury.
Emerg Radiol (2006) 13:113122DOI 10.1007/s10140-006-0534-4
M. Mart :M. Parrn (*) : F. Baudraxler :A. Royo :N. Gmez LenDepartment of Radiology, University Hospital La Paz,Paseo de la Castellana, 261,28046 Madrid, Spaine-mail: [email protected]
M. Marte-mail: [email protected]
R. lvarez-SalaDepartment of Pneumology, University Hospital La Paz,Paseo de la Castellana, 261,28046 Madrid, Spain
Secondary blast injuries, like penetrating trauma andfragmentation injuries, are caused by bomb fragmentsand other displaced objects.
Tertiary blast injuries are caused by the effects ofstructural collapse and of persons being thrown by theblast wind (penetrating or blunt trauma, fractures, andtraumatic amputations).
Quaternary blast injuries refer to burns, toxic inhala-tion, exposure to radiation, asphyxiation, and inhalationof dust and include exacerbations or complications ofpersisting conditions (e.g., patients receiving antico-agulants, pregnant women, etc.).
The injuries suffered by survivors of these attackscombine the lethal effects of penetrating trauma, blastinjury, and burns [2, 7, 8]. However, bombing incidents areprone to be highly variable concerning scene settings,victim populations, and explosive charge properties includ-ing weight and chemical structure [9]. In general, damagedecreases exponentially with distance from the point sourceof the blast [10]. When explosions take place insidebuildings, trains, and busses, standing waves and enhanceddifferences in pressure occur because of the additive effectsof reflections or reverberations from walls and rigid objects[6, 9]. Reflection from surfaces such as walls can increasethe blast effect by a factor to two to eight [11].
The Madrid train bombing attacks on the morning ofMarch 11, 2004 (also known as 11/3, 3/11, M-11, and 11-M) were a series of coordinated terrorist bombings againstthe commuter train system of Madrid that killed 191 peopleand wounded almost 2,000 (Fig. 2). Of the 13 Madridhospitals, the University Hospital La Paz is located furthestfrom the bombing places (8.2 km); still, emergency medicalservices were instructed to evacuate injured victims to allhospitals. La Paz is a level I trauma center in Madrid, withexperience in recognizing and treating complex injuries.
This article provides a description of radiologicalfindings of blast injuries among victims admitted to theUniversity Hospital La Paz on March 11, 2004, emphasiz-ing specific lesions like blast lung injury. It is our intentionto review the injury patterns resulting from explosions in asemi-confined space.
Table 1 Zuckerman classification
Category Characteristics Body part affected Types of injuries
Primary Caused by the impact of the over-pressurizationwave with body surfaces
Air containing structuresare most vulnerable (ear,lungs, gastrointestinaltract)
Blast lung, bowel perforation and hemorrhage,mesenteric shear injuries, solid organlacerations, eye perforation, tympanicmembrane rupture, ossicular disruption,cochlear damage, brain contusions withoutphysical signs of head injury
Secondary Caused by bomb fragments and other displacedobjects
Any body part may beaffected
Penetrating ballistic (fragmentation) or bluntinjuries
Tertiary Caused by individuals being thrown by the blastwind
Any body part may beaffected
Penetrating or blunt trauma, fractures andtraumatic amputations, closed and open braininjury
Quaternary All explosion-related injuries, illnesses, ordiseases not due to primary, secondary, ortertiary mechanisms. Includes exacerbation orcomplications of existing conditions
Any body part may beaffected
Burns, breathing problems from toxic fumes
The effects of blasts consist of primary, secondary, tertiary, and quaternary injuries; this was modified from the Centers for Disease Control andPrevention (http://www.bt.cdc.gov/masstrauma/explosions.asp).
Fig. 1 The blast wave moves outward radially from the center of theexplosion with very high velocities. As it expands, the peak pressuresand energy of the blast wave diminish, and the speed of propagationdecreases from the initial supersonic velocity to that of sound in thetransmitting medium in inverse proportion to distance from theexplosion focus
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Materials and methods
Within the short period of 30 min, 36 patients were broughtto the emergency department. Twenty patients were menand 16 were women, including one pregnant woman.
The patients hospitalized had a median age of 37 years(1656 years; Fig. 3). Patients were classified by means ofa color code: green for mild injuries, yellow for severeinjuries, and red for life-threatening injuries.
Each severely injured patient (yellow and red) wassurveyed by a physician team (intensivist, orthopedic, andgeneral surgeon).
On March 11, the radiologic team consisted of onecoordinator radiologist, one emergency radiologist, twoneuroradiologists, and three radiologists in training.
The means at our disposal at the emergency radiologyarea were:
Plain radiograph (GE; two systems) Portable plain radiograph (GE; two systems) Ultrasonography, Power Vision (Toshiba)
Portable ultrasonography (Tosbee) Dual multidetector helical Computed Tomography
(CT), Asteion Dual (Toshiba)
In addition, there were other two helical CT systems(Somaton Plus, Siemens) available in the general radiologyarea.
CT examinations were performed in accordance with ourroutine departmental protocol. Sequential cranial CT wasundergone first. Then, thoracic and abdominal scans wereobtained from the apex of the lungs to the inferior edge ofischia after intravenous contrast injection. One hundred andthirty milliliters of contrast material was administered bybolus injection with a scan delay of 50 s. No oral contrastmedium was given before the examinations. Approximate-ly, the total scan time was 25 s. In some patients, cervical orfacial CT was also performed. Oral and handwritten reportswere immediately elaborated.
Results
After the initial evaluation, 19 (57%) patients wereclassified as green, four (10%) as yellow, and 13 (33%) asred patients (Fig. 4).
Imaging approach
During the first 3 h after the admittance of these patientsin the emergency area, there were 17 cranial CTperformed, 16 body CT, 2 cervical spine CT, 4 facialCT, 6 focused abdominal sonogram for trauma (FAST), 3abdominal sonograms, 24 plain chest radiographs, 16lower limb radiographs, and 24 radiographs of otheranatomic regions.Fig. 3 Number of patients according to their age
Fig. 2 The bombing attacks onMarch 11, 2004 consisted of aseries of ten explosions thatoccurred at the height of theMadrid rush hour aboard fourcommuter trains (Cercanas inSpain). Thirteen improvised ex-plosive devices were reported tohave been used, three of themdetonated. This picture showsone of the trains minutes afterthe bomb explosion. Note thevast shattering of the traincasing
Emerg Radiol (2006) 13:113122 115
Distribution of injuries
Green patients
The most frequent injuries were acoustic trauma and minorthoracic lesions (Table 2). Rupture of tympanic membranewas present in 14 of the 19 green patients (63%) andbilateral in two of them (11%). Twelve patients sufferedfrom minor thoracic lesions (63%). None of them showedlung findings on plain chest radiograph. In addition, minorskin lesions were also present, namely in the face and neck(10 patients) and limbs (13 patients).
All of the 19 green patients were discharged from theemergency department throughout March 11.
Severely injured (yellow and red) patients
Overall, the chest was the most commonly affected bodyregion (n=16, 94%), followed by head/neck (n=13, 77%),blunt abdominal injury (n=4, 24%), high grade skin burns(n=4, 24%), and open lower limb fracture (n=2%; seeTables 3 and 4).
Head, neck, and spine
The most frequent head and neck injuries were tympanicmembrane perforation, paranasal sinus fractures (n=9,53%), and petrous fractures (n=3, 18%). Maxillary sinuseswere the most frequently injured one (Fig. 5). However,these fractures were associated with other injuries (zygo-maticomaxillary complex, frontoethmoidal, orbital, andendocranial lesions) in most of the patients (Fig. 6).
The orbital injuries consisted of fractures (n=8, 47%)and hemovitreous (n=1, 6%; Fig. 7).
Blast injuries to the brain included parenchymal con-tusions (n=3, 18%) and subarachnoid hemorrhage (n=1,6%; Fig. 8).
Body CT revealed two dorsal vertebral body fracturesand lumbar transverse apophysis fractures in two patients(one of them developed a psoas hematoma).
Thorax
There were radiological findings consistent with blast lunginjury in 16 patients (94%). Radiological findings ofprimary blast lung injury were characterized by ground-glass opacities or consolidations. Some of them showedperihilar lung consolidation, which had been previously
Table 2 Distribution of injuries in green patients
Injury Number of patients (%)
Acoustic traumaUnilateral rupture of tympanic membrane 12/19 (63%)Bilateral rupture of tympanic membrane 2/19 (11%)Minor thoracic trauma 12/19 (63%)Skin injuries 13/19 (68%)
Fig. 4 The number of victims injured according to the triageclassification
Table 4 Head and neck, thoracic, and abdominal lesions in severelyinjured patients diagnosed in the first imaging approach
Patients Imagingstudies
Head and neckParanasal sinus fracture 9/17 (53%) CTOrbit fracture 8/17 (47%) CTPetrous fracture 3/17 (18%) CTHemorrhagic brain contusions 3/17 (18%) CTSubarachnoid hemorrhage 1/17 (6%) CTHemovitreous 1/17 (6%) CTThoraxBlast lung injury 16/17(94%) CTPleural effusion 7/17 (41%) CTRib fractures 5/17 (29%) CTPneumothorax (tension) 3 (1)/17 (18%) CTVertebral fractures 2/17 (12%) CTMediastinal hematoma 2/17 (12%) CTSubcutaneous emphysema 2/17 (12%) CTPneumomediastinum 2/17 (12%) CTAbdomenLiver laceration 1/17 (6%) US+CTSpleen laceration 1/17 (6%) CTFree peritoneal fluida 1/17 (6%) US+CTAbdominal pain without imagingfindings
1/17 (6%) 2 US+CT
CT Computed tomography, US abdominal sonogram.a The patient underwent a laparotomy to have the peritoneal cavityexplored, but no lesions were found.
Table 3 Main injured body region in yellow and red patients
Region Number of patients (%)
Thorax 16/17 (94%)Head, face, and neck 13/17 (77%)Abdomen 4/17 (24%)Limbs 4/17 (24%)Skin (severe burns) 4/17 (24%)
116 Emerg Radiol (2006) 13:113122
described in blast-injured patients (Figs. 9, 10, and 11).However, other patients had patchy, subpleural opacities inone or both lungs. It was accompanied by significantbarotrauma in these patients (Figs. 12 and 13).
CT was found to be more sensitive than plain chestradiography in the detection of subtle pulmonary lesions(Fig. 14).
The spectrum of associated thoracic lesions includedpleural effusion (n=7, 41%), rib fractures (n=5, 29%),
pneumothorax (n=3, 18%, a tension pneumothorax in onepatient, with contralateral deviation of mediastinal struc-tures), mediastinal hematoma (n=2, 12%), pneumomedias-tinum (n=2, 12%), vertebral fracture (n=2, 12%), andsubcutaneous emphysema (n=2, 12%; Figs. 9b, 12, and13). No great mediastinal vessel injuries were detected.
Fig. 5 Bilateral floor blowout fracture. Reformatted coronal CTimage shows the fracture of each orbital floor. Note the mass of orbitalsoft tissues herniated through the fracture defect (arrows), includingthe inferior rectus muscle (asterisk)
Fig. 6 Severely comminuted left zygomaticomaxillary complex. Thefracture axial CT image shows the anterolateral and posterolateralantral wall fractures, associated with left zygomatic arch fractures(arrows). The left antrum is completely opacified, presumably byblood (asterisk). Note the soft tissue swelling and subcutaneousemphysema (arrowhead)
Fig. 7 Hemovitreous. a Axial CT scan through midorbits shows highattenuation material within the right vitreous chamber correspondingto hemorrhages (arrows). There is a high-density blood-vitreous levelwithin the dependent portion of the left globe (asterisk). b Rightocular globe ultrasonography demonstrates biconvex choroidal hem-orrhages (arrows) and heterogeneous echogenic foci (hemorrhage)within the vitreous (asterisk)
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Significant changes were detected by serial chest radio-graphs, showing an increasing density and number ofconsolidation, especially in two patients who underwentabdominal surgery (Fig. 15).
Abdomen
Blunt abdominal trauma was observed in four patients(24%). Two patients suffered solid organ laceration, ahepatic laceration, and a splenic laceration. In anotherpatient, the abdominal ultrasound and CT scan showedintraperitoneal free fluid. He underwent laparotomy to havethe peritoneal cavity explored, but no lesions were found.The fourth patient had an important abdominal pain withoutfindings on FAST, abdominal ultrasonogram, and CT. Thesymptoms improved with conservative treatment.
Pregnancy
A 29-year-old woman at 7 months gestation was evacuatedto our hospital. She underwent sudden hypotension andshock. The FAST revealed fetal death and massivehemoperitoneum. CT showed a hepatic laceration and
hemoperitoneum (Fig. 16). She was taken to the operatingroom to undergo a laparotomy, but she died.
Extremities
Some patients sustained fractures in the extremities, two ofthem being comminuted, open fractures (Fig. 17). Burnsand penetrating soft tissue injuries from fragments andforeign bodies were severe in some of these patients.
Discussion
During the last years, Spain has experienced its share ofdeath and injury including the casualties of the terrorist
Fig. 8 Subarachnoid hemorrhage. Axial CT image shows highattenuation subarachnoid hemorrhage in the suprasellar cistern(arrow). Note the presence of pneumocephalus due to a frontal sinusfracture
Fig. 9 Serial appearance in a patient with radiographical improve-ment. Frontal chest radiography (a) and axial (b) CT imagesperformed within the initial 2 h show diffuse confluent air spaceopacities, predominantly involving central regions of both lungs. Notethe presence of posterior mediastinal hematoma (asterisk), but nogreat vessel injury was detected
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bombing attacks on March 11, 2004 in Madrid. Traumaticinjury is a disease of the young, and the patientshospitalized at our center had a median age of 36 years,which is comparable to casualties of previously knowntrauma types, but higher than in other series [12]. This isdue to the fact that most of the victims were workers orstudents.
In-hospital fatality rates were significantly lower than inother terrorist acts or in the case of war fatalities [12, 13].The remoteness of our hospital from the explosion scenariomay explain this event. The bombing incidents occurredwithin a train coach that is a confined space. Previousstudies have claimed that, compared to patterns of injury inthe open air blasts, explosions in confined spaces imply an
overall increased mortality, more severe injuries, and higherincidence of primary blast injuries. However, there is nodifference regarding the incidence of penetrating trauma ortraumatic amputations [8, 9, 14] between the two groups.
The distribution and pattern of injuries are fundamental-ly comparable to the epidemiology of other series [9, 12,1518]. Injuries occurred predominantly to the head, neckand limbs, followed by the chest and abdominal organs.
Fig. 11 Blast lung injury. Axial CT image (mediastinal window)demonstrates an extensive hemorrhagic area of increased attenuationwith air bronchogram sign in the center of the consolidation
Fig. 10 Blast lung injury. Vague, ill-defined, and poorly marginatedperihiliar densities in the frontal projection (butterfly wind-likepattern)
Fig. 12 Pneumothorax. Axial CT image displays anteromedial andapicolateral left air pleural collection (asterisk), which induces acontralateral shift of the mediastinum, corresponding to a pneumo-thorax, with a lateral rib fracture (arrow). The posterior lungconsolidations (arrowheads) are probably related to lung contusions
Fig. 13 Blunt lung injuries. Axial CT image shows bilateral,peripheral pulmonary areas of increased density, irregularly distributedamong both lungs, which is the typical radiological appearance ofpulmonary contusion (arrows). The left contusion is due to a ribfracture, probably caused by a direct blow to the thoracic wall. Notethe subcutaneous emphysema (arrowheads) and the tracheal tube
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The tympanic membrane is the structure most frequentlyinjured by blast [6]. Therefore, rupture of the tympanicmembranes observed in otoscopy serves as a sensitivemarker for blast injuries in the triage [19].
The lungs are particularly susceptible to damage due tothe extensive air/lung tissue interfaces. In addition, blastenergy has been associated to tissue hypoxia, antioxidantdepletion, and subsequent oxidative damage [11, 2022].Furthermore, the development of pulmonary dysfunctionand sepsis/systemic inflammatory response syndromeremains a major threat to survival [9, 11, 23].
There were radiological findings consistent with blast lunginjury in 94% of our severely injured patients. However,primary blast lung injury was associated to injury due to blunttrauma, with rib fractures or chest wall injury. Radiologicalfindings of primary blast lung injury are characterized byground-glass opacities or consolidations. Perihilar lung con-solidations have been previously described in blast-injuredpatients. Still, patchy, diffuse, and subpleural opacities, mightbe explained by rib imprint hemorrhages across the surfaceof the pleura. Early characteristic infiltrates on chest radio-graphs, accompanied by severe barotrauma without ribfractures, strongly support the hypothesis that the main lunginjury was caused by the blast wave itself [8]. Theseradiological findings show the diffuse alveolar over-disten-sion characterized by alveolar ruptures; thinning of alveolarseptae; and enlargement of alveolar spaces, subpleural, intra-alveolar, and perivascular interstitial hemorrhage aroundpulmonary vessels; venous air embolism; and bone marrow
and fat embolism observed in the histopathologic specimen[4, 24, 25]. In addition, the delayed effects observed over thenext 24 to 48 h bear similarities to acute respiratory distresssyndrome [26], which is more evident in patients whounderwent a surgical operation.
Most of the head and neck injuries are due to direct blasteffect (primary blast injuries) over air-filled cavities (middleear, paranasal sinuses, and mastoid cells). Maxillary sinuses
Fig. 14 CT accurately reflects subtle thoracic lesions. The initialsupine anteroposterior chest radiography was interpreted as beingnormal (not shown). CT image revealed ill-defined perihiliarpulmonary infiltrate surrounded by a ground-glass opacity area.There was a very small, subtle right pneumothorax (arrow) thatwas not apparent on plain radiography
Fig. 15 Serial appearance in a patient with progressive deterioration.Frontal chest radiography obtained at admission to the hospital (a)demonstrated multifocal, peripheral lung opacities. Note the presenceof right pleural effusion. Follow-up frontal chest radiography obtained7 days later (b) showed a progression of radiographic findings, withmultifocal bilateral air space opacities in both lungs. In this patient,respiratory failure might have been induced by the severe skin burns,requiring assisted ventilation
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were the most commonly injured ones. However, thesefractures were associated with other injuries (zygomatico-maxillary complex, frontoethmoidal, orbital, and endocra-nial lesions) in most of patients. Orbital injuries were due to acombination of direct blast effect over the fluid-filled globe(primary blast injuries) and blunt trauma (secondary ortertiary injuries) in which fragments of glass, bomb casing,masonry, or any other unsecured items were propelled by theexplosion [27]. Despite the relatively small surface area ofthe eyes, ocular injuries are not an uncommon cause ofmorbidity in victims of terrorist blasts [2729]. Brain andspine lesions are mainly due to blunt trauma, althoughprimary blast waves can cause concussions or mildtraumatic brain injury without a direct blow to the head.
Blunt abdominal trauma was only observed in four of thevictims. Rupture of the hollow viscera did not occur in our
patients, although the colon shows to be the most frequentabdominal visceral structure injured in other series [30, 31].Aside from laceration and hemorrhage of solid organs suchas the liver and spleen, mesenteric ischemia or infarct mayoccur. The primary blast injuries to the abdomen areassociated to barotraumas caused by secondary or tertiarymechanism. Quaternary blast injuries include complicationsof preexisting conditions, e.g., pregnancy. The pregnantwoman who fell victim of the terrorist bombing had ahepatic laceration causing a massive hemoperitoneum.Probably the gravid uterus blunted the liver and causedthe hemoperitoneum and shock. Transmission blast andstress wave energy is higher in fluid environments. In thiscase, the fetal death could directly be due to the collision ofthe blast wave with the fetus surrounded by the amnioticfluid, although the most common cause of fetal death ismaternal shock.
Traumatic limb injuries are a consequence of the blasteffect and high-energy primary fragment (part of theweapon) and secondary fragment (those that result from
Fig. 16 Hepatic laceration in a pregnant woman. a Axial CT scan(without intravenous contrast media) demonstrates a poorly definedarea of low attenuation in the right lobe (arrows), representing animportant hepatic laceration. Note the presence of a massivehemoperitoneum (asterisk). b Pelvic CT image shows the 29-weekfetus. A previous ultrasound was performed just before the CT scanand revealed absent fetal heartbeat
Fig. 17 Opened limb fracture. Anteroposterior projection showscomminuted, displaced fracture of the tibial and fibular diaphyses.Multiple foreign bodies (arrowheads) are present in soft tissues
Emerg Radiol (2006) 13:113122 121
the explosion) injuries. Approximately 60% of the patienthad orthopedic injuries. These lesions spanned a broadspectrum including soft tissue injuries, fractures, or evencomminute fractures. Lower extremity is more frequentlyinvolved than the upper extremities. The complex nature ofthe injuries implies a high risk of infection and the need ofadditional surgical treatments [15].
In summary, the injuries suffered by the victims of thebombing attacks to the commuter trains on March 11, 2004in Madrid had been produced by different mechanisms ofblast injury simultaneously, and they were multiple andsevere. When dealing with blast-injured patients, a precisetriage in the emergency room is mandatory for an adequateimaging approach. Based on our experience, the radiologistshould be able to recognize the whole spectrum of injuriesinflicted by blasts and explosions. Prompt radiologicaldiagnosis of these complex lesions is crucial to the efficientmanagement of the victims.
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Blast injuries from Madrid terrorist bombing attacks on March 11, 2004AbstractIntroductionMaterials and methodsResultsImaging approachDistribution of injuriesGreen patientsSeverely injured (yellow and red) patients
Head, neck, and spineThoraxAbdomenPregnancy
Extremities
DiscussionReferences
