Published on February 6, 2008
An Introduction to Asymmetric War (Terrorism)and the Epidemiology of Blast Trauma : 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…”: 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. ObjectivesBlast Epidemiology: 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: 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 Make-shift bombs are WMD Alternative terms for WMD CBRNE – chemical, biological, radiological, nuclear, explosive BNICE – biological, nuclear, incendiary, chemical, explosive Slide5: 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 US disasters - floods, hurricanes, lightening. (NOAA) 4,063 bomb-related injuries (FBI) Slide6: WTC OKC Slide7: Selected Causes of Deaths, United States, 1988-1997 2001 Worldwide Terror Against U.S. Concerns: 2001 Worldwide Terror Against U.S. Concerns Bombs were used in ¾ of the 348 terror attacks in 2001 98% of terror attacks used conventional weapons. Almost one terror attack per day in 2001. 2001 Total U.S. Worldwide Terror Casualties: 2001 Total U.S. Worldwide Terror Casualties Majority of casualties in 2001 occurred at non-Gov. sites 5 Billion Pounds Produced Each Year in U.S.: 5 Billion Pounds Produced 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 killers Gas 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 Explosives areTerrors’ Perfect Storm: 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 Understanding Terrorism: Understanding Terrorism 1. Intent to induce fear in someone other than its victims, with the goal to change an entity’s 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 Who Gets Targeted?: 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 : 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 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 What’s The Trend?: What’s The Trend? IRA era Solo Suicide era Complex tactic era Why Is Terror Growing?Because it works: 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: 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 Slide18: Bomb Size & weight Explosive choice Purpose & Source Delivery system Adulterants Tactic Human 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 Lee-Davis Military Data Less Helpful: TE Davis, CY Lee Military Data Less Helpful Slide20: J Trauma. 2004;56: 1033-1041 27% of trauma surgeons not prepared to treat blast trauma ObjectivesBlast Epidemiology: 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 large segment of the population and potentially overwhelms regional health infrastructure. The Basics of Explosives and Bomb-blast Trauma: 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 ObjectivesBasics of Bomb Blast Trauma: 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 Slide24: Explosives Are Ubiquitous 1. Legally made – illegally obtained explosives from commercial and military sources 5 billion pounds produced legally 3. Commandeered fuel-laden commercial vehicles Plane, train, fuel oil truck, LNG fuel super tanker ship Explosive “recipes” available in libraries, bookstores, www - ANFO fertilizer, acetone-H2O2, Molotov cocktail Explosives Classified by the Speed of ExplosionHigh-order (HE) versus Low-order (LE) : 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 Slide26: PRESSURE TIME (microseconds) PEAK OVERPRESSURE POSITIVE PHASE OVERPRESSURE DURATION 0 ATM Zero Atmosphere Pressure Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement Principles. Idealized blast overpressure waveform seen only in high-order explosives (HE) NEGATIVE PHASE VACUUM Zero ATM Detonation Slide27: 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) Explosives Classified by the Speed of Explosion Slide28: 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 Slide29: 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 Slide30: 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 based on Adulterants: 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: Size Does Matter Explosives Lethal Blast Serious Injury in Kg TNT-eq. Range (meters) Range (meters) Environment can Protect or Harm Open, Confined, and Enclosed space explosions : Environment can Protect or Harm Open, Confined, and Enclosed space explosions Structural collapse (Enclosed space) – inside a reinforced multi-story building - Complex reflections, blast pressure up x2-9, structural collapse, complicated rescue, delayed care, 20% fatalities, 90% DOS Confined space – inside bus, train, or auditorium Blast pressures intensified x2-9, 20% fatalities, 70% DOS, complicated rescue Open Space – street corner, open market, stadium Blast impulse weakens rapidly ~ 1 / radius2 10% fatalities, straight-forward rescue and transport Slide36: Surrounding structures can either shield, dampen, or amplify the blast over-pressure wave. Environment Characteristics Confined & Enclosed Space Blast-Injury Vocabulary Specific for High-order Explosives (HE) : Blast-Injury Vocabulary Specific 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 Blast Injuries Do Not Occur in Isolation: 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 Injuryassociated exclusively with high-order (HE) explosives: 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” Courtesy: Battlefield Wounds, JR Mechtel, RN, MSN – DMRTI “White Butterfly Sign”: “White Butterfly Sign” 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 Blast Abdomen : Delayed onset > 8-36 hours – more common in submersion 1. Intestinal intra-wall hemorrhages 2. Shearing of local mesenteric vessels 3. Sub-capsular and retroperitoneal hematomas, Fracture of liver and spleen, and testicular rupture 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 Brainconcussion, TBI, shell shock, misdiagnosed behavioral disorder : 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 J Neurosurgery Jan 2002 Slide43: 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 Courtesy: Battlefield Wounds, JR Mechtel, RN, MSN – DMRTI Secondary Blast Injury “Secondary” applied exclusively to high-order (HE) injuries Slide44: Glazed Glass Retrofitting Tertiary Blast Injury ”Tertiary” applied exclusively for high-order (HE) injuries: 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 Courtesy: Battlefield Wounds, John R. Mechtel, RN, MSN – DMRTI Quaternary Blast Injury “Quaternary” applied exclusively for high-order (HE) injuries: 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) 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: Low-order Explosives (LE) versus High-order Explosives HE and LE produce dirty contaminated wounds in devitalized tissue. Survivability largely depends on proximity to the explosion, building construction, evacuation proficiency, and luck. 70-90% of fatalities are DOS. Trauma PatternsSmall (5 kg) Open Space Suicide Bombing: 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 } 1/3rd killed or admitted } 2/3rd outpatient treatment Trauma Patterns Small (10 kg) Confined Space Backpack Bomb: 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 } Simplified Severity Predictor = 1/3rd killed or admitted > 24°. Structural collapse bombing (100-1,000 kg TNT-eq): 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 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 (<1-5%) Injury patterns - respiratory problems, temporary deafness Rescue must weigh risk versus benefit of rapid ingress Slide52: Bomb Size & weight Explosive choice Purpose & Source Delivery system Adulterants Tactic Human 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 Slide53: Questions ? Tim Davis, MD, MPH Catherine Y. Lee, MPH Sherlita Amler, MD TDavis1@cdc.gov CLee9@emory.edu SAmler@cdc.gov Slide54: Questions ? Sherlita Amler, MD Medical Epidemiologist CDC/NCIPC/DIDOP SAmler@cdc.gov Tim Davis, MD, MPH Medical Epidemiologist CDC/NCIPC/DIDOP TDavis1@cdc.gov Catherine Y. Lee, MPH Research Analyst, Emory Rollins School of Public Health CLee9@emory.edu
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