masstrauma14Sept2004

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An Introduction to

Asymmetric War (Terrorism)and the

Epidemiology of Blast TraumaTimothy E. Davis, MD, MPH

Lt. Commander, USPHS Commissioned Corps

CDC/NCIPC/DIDOP/ODAsst. Professor of Emergency Medicine,

Emory University


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Rules of Engagement (ROE)

directives under which militaryforces initiate engagement with

belligerent forces1. 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.


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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 publichealth and healthcare system problem


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Weapons of MassDestruction

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

Make-shift bombs are WMD

Alternative terms for WMDCBRNE chemical, biological, radiological, nuclear, explosive

BNICE biological, nuclear, incendiary, chemical, explosive


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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

Bombings in the U.S.

CDC, FBI, State Bomb-related data, 1988-1997

830 bomb-related deaths, 1988-1997 (CDC/NCHS)

US bombing death counts exceed deaths for most USdisasters - floods, hurricanes, lightening. (NOAA)

4,063 bomb-related injuries (FBI)


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FBI Reported Bombings, 1988-1997

0

500

1000

1500

2000

2500

3000

1988 1990 1992 1994 1996

WTC OKC


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NOAA224Hurricanes

NCHS276Earthquakes

NOAA437Tornadoes

NCHS712LightningNCHS830Bombs

NOAA903Floods

Data sourceCountCause

Selected Causes of Deaths,United States, 1988-1997


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2001 Worldwide TerrorAgainst U.S. Concerns

Bombs were used in of the 348 terror attacks in 200198% of terror attacks used conventional weapons.

Almost one terror attack per day in 2001.


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2001 Total U.S. WorldwideTerror Casualties

Majority of casualties in 2001occurred at non-Gov. sites


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5 Billion PoundsProduced Each Year in U.S.

Explosive matter

Explosives

Chemicals for non-explosive purpose

High explosives(HE) Propellants(LE) Pyrotechnic (LE)

1 2

Military-grade Industrial-grade

Gun

Rocket

Lead azide

Hg fulminate

Tetrazene

Singles = TNT;

RDX; PETN;

Mixes = CB; RDX-

based plastics;

Torpex

Gelatins;

powders;

permitted;

ANFO; slurries,

emulsions

Black

powder

Double base;

composites;liquid fuels;

oxidizers

Flashes, Flares

Fume generators

Optical/acoustic

signals, fireworks

Fertilizer grade

ammonium nitrate

Chlorates as weed

killersGas generating for

foam plastics

Organic peroxides as

catalysts

NTG and PETN-soln

for pharmaceuticals

Salts of nitrated

organic acids for pest-

control

From Explosives, R. Meyer 5th Edition


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Explosives are

Terrors Perfect Storm

1. Available 5 billion pounds legally made in U.S.

2. Low tech Literacy helpful

3. Scalable 1 kilogram to 1 kiloton TNT-equivalents

4. Simple delivery - hand-carried, truck, plane, train, ship

5. Simple Guidance system placed, thrown, or suicide

6. Human factors available financing and volunteers


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Understanding Terrorism

1. Intent to induce fearin someone other than its victims,with the goal to change an entitys political behavior.

2. Independent of the cause that motivates it can be

unjust or righteous the end justifies the means.

3. Neither spontaneous nor random it is a staged

psychological act conducted for its impact on an audience.

4. Not aimed at personal gain it can be motivated by

political, religious, or ideological objectives.

5. Requires ever escalating shock and awe

to remain effective maintain sense of helplessness


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Who GetsTargeted?

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


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Terror Tactics are EscalatingCivilians now more than collateral damage

The 1980s The IRA era Placement / stationary bombs - package, culvert, or car bombs

targeted against government or rivals Gentlemens agreement - advanced warning limits casualties

>evacuations, & staging of medical resources

The 2000s Complex tactics era couples mega-bombs with multiple synchronized attacks often suicide pioneered in 1983 Beirut

large or multiple suicide smart bombs against soft targets

The 1990s The Suicide bomber era Human smart bomb for precise placement

Used only against soft civilian targets


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0

50

100

150

200

250

300

350

1980 1985 1990 1995 2000 2005

Whats The Trend?

Desert

Storm

9/11

Kob

arTowers

Ma

rineBarracks

IsraelisLvLebanon

IntifadaII

IRA era Solo Suicide era Complex tactic era


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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

Succeeded despite military raids

to kill or arrest terrorist leaders

Wh I T


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Why Is TerrorGrowing?

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

We couldnt stay there and run the risk of another

suicide attack on the Marines.

-- Ronald Reagan,An American Life


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BombBombSize & weight

Explosive choice

Purpose & Source

Delivery system

AdulterantsTactic

HumanHuman

Age, sex, & weight

Fitness, PPE

Nutrition, health

Access to care

Open Space, Confined Space,Structural Collapse

Reflecting or Shielding surfaces

Building and non-structural debris

Air and liquid hazards

Bomb-Injury Threat ModelLee-Davis


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Military Combatant Civilian

Host Mostly male, healthy,

athletic, 18-35 years

More young, older,

female, poor health

Personal Protective

Equipment (PPE)

Helmet, armored vest,

armored vehicles

No PPE or armor

Agent(weapon type)

Manufactured high-order (HE) military

ordnance

Makeshift low- andhigh-order bombs

Injury Patterns Well-studied

High tech shrapnel

Poorly studied

Nails, bolts, glass

Access

(Environment)

Organized trauma care

- long-term rehab.,

comp., life-long assist.,

Pres.-Cabinet advocate

Variable access to

care, rehabilitation,

and assistance.

Ad hoc advocacyTE Davis, CY Lee

Military Data Less Helpful


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J Trauma. 2004;56: 1033-1041

27% of trauma surgeons

not prepared to treat

blast trauma


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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

a. coercion of a strong state by a weak stateless entity

a. bombings occur daily in the U.S.

b. terrorists use bombs > 98%c. No standard terms, analyses, reporting

a. An unanticipated event that adversely affects of a largesegment of the population and potentially overwhelmsregional health infrastructure.


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The Basics of Explosives

and

Bomb-blast Trauma

Timothy E. Davis, MD, MPHLt. Commander, Commissioned Corps, USPHS

CDC/NCIPC/DIDOP/ODAsst. Professor of Emergency Medicine,

Emory University


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Objectives

Basics of Bomb Blast Trauma

1. Recognize how injuries and casualty mixare affected by

a. bomb type

b. terrorist tactic

c. bombing environment

2. Anticipate casualty severity profile, and identifycommon, occult, and high risk injuries following

a. open space bombingb. confined space bombing

c. bombing with structural collapse


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Explosives Are Ubiquitous

1. Legally made illegally obtained explosivesfrom commercial and military sources

5 billion poundsproduced legally

3. Commandeered fuel-laden commercial vehicles Plane, train, fuel oil truck, LNG fuel super tanker ship

Explosive recipesavailable in libraries, bookstores, www

- ANFO fertilizer, acetone-H2O2, Molotov cocktail


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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 asa) Primary, b) Secondary, c) Tertiary, d) Quaternary

E.g., all military bombs, TNT, Dynamite, Semtex, ANFO


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PRESSURE

TIME(microseconds)

PEAK OVERPRESSURE

POSITIVE PHASE OVERPRESSURE DURATIO

0 ATMZero

AtmospherePressure

Horrocks, CL. Blast Injuries: Biophysics,

Pathophysiology and Mnaagement Principles.

Idealized blast overpressure waveform

seen only in high-order explosives (HE)

NEGATIVE PHASE

VACUUM

Zero

ATMDetonation


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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 asa) shrapnel, b) blunt, c) crush, d) burn

E.g., Napalm, gunpowder, Molotov cocktail,many petroleum-based (but ANFO is HE)

Explosives Classified by the

Speed of Explosion


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Bombs can be

Classified by Size and Weight

Small Arms 1-person carry- hand grenades, rocket propelled grenades (RPG),

also machine guns, assault rifles

Light Arms 1 or 2-person carry- makeshift bombs < 10 kg gross weight,

mortars, shoulder-held missile launchers, and

some landmines, surface mines, grenades

Heavy Weapons mechanized- makeshift car, truck, plane, train, or ship bombs,

also air bombs, rockets, tanks, artillery


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Bombs can be

Classified by TNT-equivalents

TNT-eq = the amount of TNT needed to create the same blast effect

TNT-eq calculations 7 different formulas with differing results

A measure of energy not of raw weight

- a 10 kg (TNT-eq) backpack bomb has 2 kg of explosives

Shock waves and heat waves decrease rapidly 1 / radius2

+35+2+20-1-2

Anti-matterNTGPlasticTNTDynamiteBlack Powder


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Original Purpose

Military-grade government sanctioned

Civilian-grade legally manufactured assault-lite- Uzi, Glock, Mauser, Berretta, Bushmaster AR-15

Source

Mass-produced manufactured by arms industry

Makeshift Improvised, small assembly line

Bombs can be Classified by

Source and Original Purpose

Bombs can be Classified


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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 canistersUse less efficient bolts, nails, glass

Compensate with excess bulk explosives


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Size Does Matter

2,13018027,273 kgSemi-trailer

1,98014013,636

(~ Beruit)

Fuel truck

1,150914,545(~ Khobar)

Panel truck

840801,180(~ OKC)

Passenger van53060455Sedan

45030227Compact car

10-30 meters5 meters1 5 kgSuicide bomber

Explosives Lethal Blast Serious Injury

in Kg TNT-eq. Range (meters) Range (meters)


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Surrounding structures can eithe

shield, dampen, or amplify the

blast over-pressure wave.

Environment Characteristics

Confined & Enclosed Space

Bl t I j V b l


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Blast-Injury VocabularySpecific for High-order Explosives (HE)

1. Primary (1)Blast Injury (e.g. blast lung) over-pressurization impulse wave often fatal

Secondary (2) Blast Injury(e.g. glass shards)

penetrating shrapnel and debris

Tertiary (3)Blast Injury (e.g. traumatic amputation)

blunt - blast wind throws the individual

4. Quaternary (4)Blast Injury (miscellaneous) burns, fume poisonings, suffocation, building collapse,

crush injuries, chronic disease flare, mental health


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Blast Injuries Do Not Occurin Isolation

A Casualty with Blast Lung (1) will also have1. Penetrating glass shards (2)

2. Traumatic amputation (3)

3. Burns, inhalation injury, deafness (4)

The Injury Severity Score (ISS) does not accuratelymeasure 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 & 2burns


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Primary Blast Injuryassociated 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

Courtesy: Battlefield Wounds,

JR Mechtel, RN, MSN DMRTI


40/54

White ButterflySign

CL Horrocks, Wounds of Conflict

Blast Lung 70% fatal- A clinical diagnosis, confirmed with X-ray- A severe pulmonary contusion from air compression re-expansion

Symptoms exposure plus SOB, cough, hemoptysis, retrosternal pain

Signs Tachypnea, cyanosis, decrease BS, dull to percussion, rales /crackles, hemo/pneumo-thorax, subcutaneous emphysema,

retro-sternal crunch, air emboli, retinal artery emboli

Management Similar to severe pulmonary contusion complex fluid management

mechanical ventilation further increases chance of air emboli


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Delayed onset> 8-36 hours more common in submersion1. Intestinal intra-wall hemorrhages

2. Shearing of local mesenteric vessels

3. Sub-capsular and retroperitoneal hematomas,

5. Fracture of liver and spleen, and testicular rupture

6. Zero in Madrid (?)

Symptoms exposure plus abdominal pain, nausea, vomiting,

hematemesis (rare), rectal pain and tenesmus, testicular pain

Signs abdominal tenderness, rebound, guarding, absent bowel

sounds, signs of hypovolemia

Management Rescect small bowel contusions > 15 mm,

and large bowel contusions > 20 mm

CL Horracks, Wounds of Conflict, 2001

Blast Abdomen

Blast Brain


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Blast Brainconcussion, 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

J Neurosurgery Jan 2002

S d Bl t I j


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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


JR Mechtel, RN, MSN DMRTI

Secondary Blast InjurySecondary applied exclusively to high-order

(HE) injuries


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Glazed Glass Retrofitting


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Tertiary Blast InjuryTertiary 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 isthrown against solid object, includes impalement

3. Care follows standard blunt trauma protocols


John R. Mechtel, RN, MSN

DMRTI

Quaternary Blast Injury


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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 health5. New behavioral problems

Low-order Explosives (LE)


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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)


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Low-order Explosives (LE)versus

High-order Explosives

HE and LE producedirty contaminated wounds in devitalized tissue.

Survivability largely depends on proximity to theexplosion, building construction, evacuation

proficiency, and luck.

70-90% of fatalities are DOS.

Trauma Patterns


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Small (5 kg) Open SpaceSuicide 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

}1/3rdkilled or admitted} 2/3rd outpatient treatment

Trauma Patterns


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Small (10 kg) Confined SpaceBackpack 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

} Simplified Severity Predictor= 1/3rd killed or admitted > 24.


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Structural collapse bombing(100-1,000 kg TNT-eq)

Casualties 100 3,000 largely based on bomb size, time of day, warning, buildingstructure, and evacuation proficiency

90% of fatalities are DOS

Severity follows pattern of Earthquake or structural collapse killed if in the wake treat and release if nearby, but not in direct path

small percentage admitted (


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BombBombSize & weight

Explosive choice

Purpose & Source

Delivery system

Adulterants

Tactic

HumanHuman

Age, sex, & weight

Fitness, PPE

Nutrition, health

Access to care

Open Space, Confined Space,Structural Collapse

Reflecting or Shielding surfaces

Building and non-structural debris

Air and liquid hazards

Bomb-Injury Threat Model


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Questions ?

Tim Davis, MD, MPH Catherine Y. Lee, MPH Sherlita Amler, MD

[email protected] [email protected] [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Questions ?

Sherlita Amler, MDMedical Epidemiologist

CDC/NCIPC/DIDOP

[email protected]

Tim Davis, MD, MPHMedical EpidemiologistCDC/NCIPC/DIDOP

[email protected]

Catherine Y. Lee, MPHResearch Analyst, EmoryRollins School of Public Health

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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