bombing events may 2014 blog

Bobby Kapur, M.D., M.P.H.

Associate Professor of Medicine & Pediatrics

Associate Chief for Academic Affairs

Section of Emergency Medicine

Bombing Events in the US: Public Health Analysis and

Acute Management

Bombing Events & Blast Injuries 2


Objectives

• Definitions• Recent global historical perspectives• US bombings epidemiology• Pre-Hospital Care response• Acute hospital management


Definitions: Terrorism

6Bombing Events & Blast Injuries

“A policy intended to strike with terror those against whom it is adopted; the employment of methods of intimidation; the fact of terrorising or condition of being terrorised."

The Oxford English Dictionary


U.S Federal Criminal Code

“(A) involve acts dangerous to human life that are a violation of the criminal laws of the United States or of any State (B) appear to be intended: to intimidate or coerce a civilian population, or to influence the policy of a government by intimidation or coercion, or to affect the conduct of a government by mass destruction, assassination, or kidnapping…”

United States Code Title 18, Part I, Chapter 113B, Section 2331


Medical Definition

“The intentional use of violence - real or threatened- against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.”

“A Proposed Universal Medical and Public Health Definition of Terrorism.” Prehosp Disast Med. 2003;18(2):47-52.


Medical Codes

National Center for Health Statistics at the CDC has developed within the WHO’s International Classification of Diseases, Tenth Revision (ICD-10) terrorism-related codes:

• *U01-*U02 for mortality due to assault (homicide) for terrorism,

• *U03 for mortality due to intentional self harm (suicide) for terrorism

• E979 for morbidity due to terrorism• E999.1 for late effect of injury due to terrorism


Madrid, Spain: March 11, 2004


1. Mitsubishi Triumph mobile phone2. Copper detonator3. Explosives (8-12kg)4. Metal fragments

Madrid Train Bombings: March 11, 2004

7:37 am - 7:40 am

• 10 bombs explode in 4 commuter trains in downtown Madrid• 3 undetonated bombs found later• Explosive material: Dynamite (used in construction)



• EMS: 291 ambulances mobilized• 112 Call center: >20,000 calls• Injuries: >1,800 • Deaths: 191


Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33(1):S107-S112.



Key Pre-Hospital Care Logistical Issues• Mobile phones and radios: do not work underground• Minor injuries or uninjured evacuated 1st : delayed

evacuation of seriously injured• Scene safety: possibility of structural collapse or

secondary devices• Going “back to normal”: difficult for pre-hospital

and emergency services



Key Hospital Logistical Interventions• Cancel all elective surgeries• Transfer stable patients out of ED and ICU• Triage of patients by senior physicians • Use of FAST to quickly diagnose abdominal trauma

Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med. 2005;33(1):S107-S112.



Global Experiences


Blast Injuries. The Lancet, Volume 374, Issue 9687, 2009, 405 – 415.


Europe: UK IRA Bombings 1970-1980s


Middle East: Israel


Middle East: Beirut


Africa: Kenya & Tanzania Embassies 1998


International Terrorism & Bombing Events

• Change in the targets and materials used in bombing events

• Increased sophistication and planning of events• Greater coordination among terrorists


US Experiences


The U.S. Experience

World Trade Center 1993 Oklahoma City 1995 Atlanta Olympics 1996


The U.S. Experience

World Trade Center 9/11 Pentagon 9/11


The U.S. Experience?

• Few large-scale events or Endemic problem?• Domestic or International issue?• Impact of bombing events on medical and public

health institutions? • How the U.S. data on bombings can improve planning

and response for future events?

No longitudinal data on bombing events in the US


Bombing Events: Impact Issues

• Incidents• Injuries & Deaths• Etiology (Motives) • Location (Targets)• Materials


ATF Designations for Bombing Events

Explosive: Chemical compound or mixture with a primary purpose to function by explosion

Incendiary: Device made of an inflammable or ignitable liquid

Premature: Bombing event, either explosive or incendiary, that occurs when the device functions prior to placement on a target

Attempted: Incident where the device, either explosive or incendiary, is placed against a target and fails to function or is made safe before detonation


Type of Bombing Incident Incidents (%) Injuries (%) Deaths (%)

Actual Bombings 28,529 (79.0) 5,931 (100.0) 699 (100.0)

Explosive 21,237 (58.8) 4,056 (68.4) 386 (55.2)

Incendiary 6,185 (17.1) 579 (9.8) 139 (19.9)

Premature 1,107 (3.1) 1,296 (21.8) 174 (24.9)

Attempted Bombings 7,581 (21.0) 0 (0.0) 0 (0.0)

Explosive 5,616 (15.6) 0 (0.0) 0 (0.0)

Incendiary 1,965 (5.4) 0 (0.0) 0 (0.0)

Total 36,110 (100.0) 5,931 (100.0) 699 (100.0)

U.S. Bombing Incidents from 1983-2002


Number of Explosive and Incendiary Bombing Events from 1983-2002

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 20020

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Number of Attempted and Premature Bombing Events from 1983-2002

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 20020

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200

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Number Attempted

Number Premature

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Etiology of Bombing Event ATF Definition

Attempted homicide or Homicide Intent to kill another individual or group of individuals

Suicide Intent to kill oneself

Vandalism Intent to cause property damage

Revenge Intent to respond to a prior action of another individual or group

Protest Intent to gain publicity or support for a protest group

Labor-related Intent to impact a labor dispute

Extortion Intent to receive goods or services from another individual or group

Excitement Intent to observe the effects of a bombing event

Domestic violence Intent to cause injury or death to a partner

Insurance fraud Intent to make insurance claims from the bombing event

Intimidation Intent to frighten another individual or group without injury or death


Etiology of Bombing Injuries Explosive (%) Incendiary (%) Premature (%)

Determined 2,483 (61.2) 359 (62.0) 296 (22.8)

Attempted homicide 1,810 (44.6) 42 (7.3) 9 (0.7)

Suicide 44 (1.1) 3 (0.5) 0 (0.0)

Vandalism 398 (9.8) 35 (6.0) 206 (15.9)

Revenge 209 (5.2) 132 (22.8) 33 (2.5)

Protest 30 (0.7) 22 (3.8) 4 (0.3)

Labor-related 24 (0.5) 8 (1.4) 1 (0.1)

Extortion 29 (0.7) 113 (19.5) 4 (0.3)

Excitement 20 (0.5) 4 (0.7) 32 (2.5)

Domestic violence 19 (0.5) 0 (0.0) 7 (0.5)

Insurance fraud 0 (0.0) 0 (0.0) 0 (0.0)

Intimidation 0 (0.0) 0 (0.0) 0 (0.0)

Undetermined 1,573 (38.8) 220 (38.0) 1,000 (77.2)

Total 4,056 (100.0) 579 (100.0) 1,296 (100.0)


Etiology of Bombing Deaths Explosive (%) Incendiary (%) Premature (%)

Determined 363 (94.0) 129 (92.8) 75 (43.1)

Homicide 268 (69.4) 69 (49.6) 10 (5.7)

Suicide 53 (13.7) 3 (2.2) 1 (0.6)

Vandalism 10 (2.6) 3 (2.2) 54 (31.0)

Revenge 14 (3.6) 40 (28.8) 5 (2.9)

Protest 0 (0.0) 0 (0.0) 0 (0.0)

Labor-related 0 (0.0) 0 (0.0) 0 (0.0)

Extortion 1 (0.3) 1 (0.7) 1 (0.6)

Excitement 1 (0.3) 0 (0.0) 3 (1.7)

Domestic violence 13 (3.4) 3 (2.2) 0 (0.0)

Insurance fraud 3 (0.8) 3 (2.2) 1 (0.6)

Intimidation 0 (0.0) 7 (5.0) 0 (0.0)

Undetermined 23 (6.0) 10 (7.2) 99 (56.9)

Total 386 (100.0) 139 (100.0) 174 (100.0)


Target Institution Type Institution Subtype

Residential Single family Structure, Condominium, Apartment

Commercial Bank/ATM, Bar/Restaurant, Hotel/Motel, Independent food store, Manufacturing plant, Shopping center/Mall, Warehouse

Governmental Local, State, Federal, Foreign, Military

Educational School, College/University

Transportation Airport, Bus/Train terminal, Port, Railway, Subway

Mailbox Residential, Commercial

Vehicle Residential, Commercial


Target Institution Type Incidents (%) Injuries (%) Deaths (%)

Determined 32,849 (91.0) 5,081 (85.7) 680 (97.3)

Residential 10,465 (29.0) 1,866 (31.5) 388 (55.5)

Commercial 5,151 (14.3) 1,740 (29.3) 74 (10.6)

Governmental 1,596 (4.4) 756 (12.7) 178 (25.5)

Educational 1,847 (5.1) 464 (7.8) 3 (0.4)

Transportation 723 (2.0) 79 (1.3) 7 (1.0)

Mailbox 7,404 (20.5) 75 (1.3) 2 (0.3)

Vehicle 5,663 (15.7) 101 (1.7) 28 (4.0)

Undetermined 3,261 (9.0) 850 (14.3) 19 (2.7)

Total 36,110 (100.0) 5,931 (100.0) 699 (100.0)


Bombing Materials

• Ammonium nitrate• Black powder (gunpowder)• Smokeless powder• C-4 (RDX “research development explosive”) • Dynamite• TNT• Match heads• Pyrotechnic mixes


Type of Material Injuries (%) Deaths (%)

Determined 4,050 (68.3) 595 (85.1)

Nitrate-based fertilizers 1,586 (26.7) 181 (25.9)

Smokeless powder 818 (13.8) 114 (16.3)

Inflammable liquids 579 (9.8) 139 (19.9)

Black powder 526 (8.9) 47 (6.7)

Pyrotechnics 232 (3.9) 18 (2.6)

Dynamite 161 (2.7) 90 (12.9)

Match heads 139 (2.3) 2 (0.3)

C-4 5 (0.1) 1 (0.1)

TNT 4 (0.1) 3 (0.4)

Undetermined 1,881 (31.7) 104 (14.9)

Total 5,931 (100.0) 699 (100.0)


Terrorism and Bombing Events: Global or Local Problem for US Population?

• 1996 to 2002: 925 international terrorist events involving U.S citizens

• Bombing events: 776 (84%)• 1992 to 2002: more bombing injuries & deaths in the

U.S. than terrorist injuries & deaths of U.S. citizens internationally


Analysis

• Access • Internet• Panic & Instability• Public health focus: Bombing events vs.

“N/B/C” events?


Pre-Hospital Care & Bombing Events


Pre-Hospital Care Systems and Bombing Events

• Classic models usually do not occur: 75% of patients will not interact with the EMS system

• Classic system of triage, triage classifications, triage tags, flow points, and treatment areas only applies to a one-sided or one-dimensional scene

• Ambulances transport patients to nearest facility:–Rapid turn around time–Instructed to take critical patients to nearest facility–Roads may be impassable except to a few hospitals–May not know route to outlying hospitals–Nearest hospitals may delay closure during disasters


U.S Bombings: Pre-Hospital Care Data

Event Hospital Data Injuries (*Total)

Deaths EMS

Oklahoma City 1995 434 (592) 167 90 (20.7%)

Atlanta Olympics 1996 111 1 111 (100.0%)

WTC 9/11 1,103 (7,250) 2,749 282 (25.5%)

Pentagon 9/11 106 189 93 (87.7%)


• Initiate fundamental resuscitation protocols: Airway Breathing Circulation

• Address blast injuries• Attempt to gather basic epidemiologic data from scene

Pre-Hospital Management of Bombing Victims


Primary

Blast lung injury (pulmonary barotrauma) TM rupture and middle ear damage Abdominal hemorrhage and perforation Globe ruptureConcussion (TBI without physical signs of head injury)

SecondaryPenetrating ballistic (fragmentation) or blunt injuries Eye penetration (can be occult)

TertiaryFracture and traumatic amputation Closed and open brain injury

QuaternaryBurns (flash, partial, and full thickness), Crush injuriesAsthma or COPD (from dust, smoke, or toxic fumes) Angina, Hyperglycemia, Hypertension

Blast Injuries

http://www.bt.cdc.gov/masscasualties/explosions.asp


No Pre-Hospital Care Protocol for Bombing Injuries

52

Pre-hospital Care Blast Injuries AlgorithmInitial evaluation:

Airway, Breathing, Circulation

Primary Blast Injuries

Secondary Blast Injuries

Assess Lungs, TM’s, AbdomenO2, IV access, Monitor

Tertiary Blast Injuries

Quaternary Blast Injuries

Assess Soft tissue injuries, EyesApply dressings

Assess Fractures, Head injuriesSplint fractures

Assess Burns, Crush injuries, Exacerbations of Chronic diseases

Bombing Events & Blast Injuries

53

Pre-hospital Care Blast Injuries Algorithm

Initial evaluation: Airway

BreathingCirculation


Lungs TM’s Abdomen

Non-rebreather mask

Monitor*Thoracentesis

Avoid probing ear Continuous assessment

Eye

Cover ruptured globe

Brain

Monitor neurological

status


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Initial evaluation: Airway, Breathing, Circulation



Soft Tissue Injuries Eye

Apply sterile dressingsDo not remove fragments

Cover globeDo not remove fragments


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Fractures Amputations Head Injuries

Apply splintsCover open wounds

HemostasisCover and transport amputated

part

Apply dressing to open injuriesMonitor neuro status


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Quaternary Blast Injuries

Burns Crush Injuries Chronic Disease Exacerbations

Cover with sterile dressingIVF IVF NRM, Albuterol

NTG for chest pain



Acute Hospital Management of Bombing Injuries


Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33(1):S107-S112.


Management of Bombing Injuries

Primary Survey

Secondary Survey

Blast Lung Injury

Soft Tissue &Bone Injuries

Eye & Ear Injuries

AbdominalInjuries

HeadInjuries

Burns

CXR X-raysCK, Electrolytes

T&S

Visual AcuityCorneal Exam

CT Face?

FAST USCT A/P

T&S

CT Head Electrolytes

High flow O2Chest Tube?

Abx & TetanusWound Care

Ophtho? Nuerosurg? IVF

Serial Exams & ObservationOR as needed


Blast Injuries. N Engl J Med.2005;352:1335-42.


Tympanic Membrane Evaluation:Indicator of Internal Blast Injuries

Otoscopic Exam of Tympanic

Membrane

RuptureObserve O2 saturationfor 6-8 hrs

IntactDischarge

Decreased O2Admit for further

care

Normal O2Discharge with

warnings

Otoscopic Exam of Tympanic

Membrane

Rupture Admit and anticipate

further injuries

Intact Treat injuries

No obvious injuries present Injuries present

DePalma RG, Champion HR, Hodgson MJ. Current Concepts: Blast injuries. N Engl J Med. 2005;352(13): 1335-1342.Blast Injuries. N Engl J Med.2005;352:1335-42.


Summary

• Urban areas around the world face the risk of bombing events

• US citizens are at more risk of domestic bombing events than international events

• Local jurisdictions (hospitals, EMS, fire, police) should be prepared for both explosive and incendiary blast events

• Pre-hospital and Emergency Department management of blast injuries should be implemented in an algorithm manner

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