Survey of Blast Trauma

from Evolving Tactics of

Terrorism
Catherine Y. Lee, MPH
Research Faculty Associate
New York Medical College
School of Public Health

October 17 2005
Greater New York Hospital Association
“Analysis of past bombing disasters reveals
definite patterns of injury and mortality,
which provide the opportunity to plan and
prepare for future events.”

Eric Frykberg, MD, FACS

 Epidemiology Shift
1950 Sandia, China, Sweden, Russia: Man and Blast Injury

1970 IRA: Hospital Experience, Civilian Blast Injuries

Epidemiology Started Here

suicide
bombing

1990 Israel: Mix of factors that influence pattern of trauma

2004 Global: Complex Tactics: different influences different

bombings – Madrid, Istanbul, London

…and non-English studies

Small and Frequent “Traditional”: Solo

Open Structural Explosive Type

Quantity
+ Delivery Method
Epicenter
Confined People in Vicinity
Time of Day
Suicide Bombing Etc…

Complex Bombing
…Other Considerations
Catastrophic but rare

Increasing mortality
Complex Tactics

Traditional-Solo

Small IED, LE

Increasing frequency
Many Factors

One for example,

Explosive type and detonation
velocity – some HE’s “push”
while others have the
characteristics to “shatter”

Blast injury is an incomplete

science
 Tactic 1

Small Bombings, High Frequency

Open and Confined Spaces
 Profile
• Small IEDs
• HE or LE
• Simple logistics, ease of coordination
• Not high profile targets, symbolic
• Open spaces
• Confined space
• 2004, 26% of combat deaths in Iraq due to these
types of small bombs
• Today in 2005? 70%
 Open
• Free field
• Few obstacles and hindrances
• Free movement of blast wave
• Grassy park, parking lot, market place,
railroad track
• Secondary injuries most prevalent,
psychological trauma/stress
Examples
 Idealized blast overpressure waveform


 




 










Measured in atm’s, psi’s
or kPa’s
Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement
Principles.
Small IEDs, LE/HE
 Atlanta

100% 7 penetrating
90% wounds

80% 70% 5: closed/open fx

70% skull, facial skeleton

60% 50% 3 Strains & Sprains

50%
40% 30% 1 case of Heart
30% Attack

20% 10%
10%
0%
Bowel

Tympanic

Bruises,
Concussion

Nerve palsy

Crush injuries
Traumatic
pulmonary

Ocular globe

Penetrating

Closed/Open

CVD related

other
Fractures from shrapnel
 Asai et al

Asai Y, Yoshida M, Jurimoto Y, Arnold JL: Case report: Penetrating

cardiac injury secondary to terrorism-related, nail-bomb explosion.
Prehosp Disast Med 2003;18(3):249–252.
 Victoria Station
Similar to Atlanta Centennial Olympic except H.E

• Several kilograms of Semtex in a litter bin

• 30 treated at Westminster Hospital
• Majority of injuries caused by shrapnel
Incidents of Injuries
Soft Tissue Injuries 32
Open fx 13
Neurovascular 7
Traumatic Amputation 2
Perforated Organs 4
Bone fx 5 Johnstone, DJ., Evans, SC., Field, RE., Booth, SJ.
The Victoria bomb: a report from the Westminster
No Burns Hospital. Injury, 1993, 24 (1): 5-9
Secondary Injuries Most Prevalent
“Penetrating Wounds”, “Open Wounds” Regardless of Bomb Type or Environment

Secondary Blast
injury agents:
Bomb canister pieces
Glass shards
Particulate Matter
Secondary missiles
Lee, CY Development and Application of the bomb-blast
Damage and Injury Scale 2003
 “Real life” reflecting
surfaces make
complex blast pattern
– accumulates blast
pressures

Low explosive High explosive

Deflagration Detonation
No overpressure Overpressure
 Confined
• Small dimensional space, tight and limited
movement
– Bus, Small Bar, Store, Bathroom
• Reflecting surfaces
• Magnifies incident 2 – 9 times
– Primary
– Energized, Secondary
• Small amount HE needed
 Cooper

Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
Trauma, 1983, 23 (11): 955-967
 Cooper
• “Tavern in the Town”: 11 dead, 89 injured
• “Mulberry Bush”: 10 dead, 30 injured

Data from 42 total admitted from all hospitals that received:

Serious soft tissue damage 22
Burns 23
Fractures 13
Eye Damage 13
Blast Lung 3
TM Perf. 17
Cooper, G.J., Maynard, R.L., Cross, N.L., Hill, J.F. Casualties from Terrorist Bombings. J
Trauma, 1983, 23 (11): 955-967
Source: www.mfa.il.gov; suicide bombing May 18, 2003, Jerusalem
 Confined
• According to Peleg, head, neck, extremities
most common injuries in confined space bus
explosions

Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”

Used with permission: Kobi Peleg, Ph.D – “Epidemiology of Terror Injuries”
Confined Space, 6 kg of high explosive (not a suicide bombing)
10.3% Critical
5.2% Immediate

Katz, E., Ofek, B., Adler, J., Abramowitz, HB., Krausz, MM. Primary blast injury after a bomb
explosion in a civilian bus. Ann Surg, Apr 1989, 209 (4): 484-488
 14%
17.5%

38%

24.5%

70%
Some of the greater incidences of primary blast injury come from confined space bombings

Lee, CY Development and Application of the bomb-blast

Damage and Injury Scale 2003
2002
Passover dinner, hotel dining room
8 – 10 kg HE TATP packed with
hundreds of small steel balls 3 – 7mm
diameter
250 people present
 164 injured 44.5%
PTSD
N=20 (22%) DOS

N=91 reflected in 75%

graphic admitted
50% Level II trauma
centers
14% DIH first 24 hours

33% OR, 14% 1st,2nd

burns
5 cases primary blast

Kluger, et al. European Journal of Emergency Medicine

12:19–23 c 2005 Lippincott Williams & Wilkins.
 Kluger: Spherical Shrapnel and
Ballistics
From the distribution of the injured in the hall, the patterns of injuries,
and the specific organ injuries, we concluded that spherical missiles
incorporated in a bomb follow the ballistic patterns of shotgun pellets
that are shot without choking or constriction at the barrel end. Whereas
immediate mortality resulted from injuries augmented by the addition of
steel balls, their wounding of the surviving patients followed the
classical pattern of low destructive injury.
It was consistent with Ordog’s classification of shotgun injuries:

•Type I: Long Distance (>12 m) resulting in only superficial penetration,

•Type II: close range (<12 m) resulting in penetration beyond the deep fascia,
and
•Type III: point blank (<5m) resulting in devastating tissue damage and high
mortality rates

Kluger, et al. European Journal of Emergency Medicine

12:19–23 c 2005 Lippincott Williams & Wilkins.
 Confined Space Comparison
Kluger Frykberg Peleg Lee

Immediate 22% 29% 4 – 19%

mortality
(DOS)
Severe 45% 12.5%
injuries %
Critical 14% 3% 5.3% 8 – 16%
mortality
(DIH)

Requires much more investigation, several factors to consider other than

purely the mechanical forces of the explosion & environment

Kluger, et al. European Journal of Emergency Medicine

12:19–23 c 2005 Lippincott Williams & Wilkins.; Lee, CY Development and
Application of the bomb-blast Damage and Injury Scale 2003
Mellor

Mellor, SG., Cooper, GJ. Analysis of 828 servicemen killed or injured by

explosion in Northern Ireland 1970-84: the Hostile Action Casualty System. Br
J Surg, Oct 1989, 76 (10): 1006-1110
 18 – 27 atm
Solely theoretical, much investigation
continues 11 – 15 atm
7 – 9.5 atm
 Tactic 2

Larger, Conventional
Bombings
 Profile
• Single vehicle IED
• Higher degree of coordination and
logistics
• Structures and Symbolic targets
• We deter with technologies and security
countermeasures
• Some cases of primary injury, STILL
secondary most common, some cases of
tertiary, quaternary - crush injuries
Vehicle IEDs
FEMA 426- Reference Manual to Mitigate Potential Terrorist Attacks Against Buildings
Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the
Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
Frykberg, ER. Medical Management of Disaster and Mass Casualties from Terrorist
Bombings: How can we cope? J Trauma2002;53:201–212.

Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the
Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
 OKC Fatal Injuries
• 122 Multiple Trauma
– Multi-system, multi-dimensional injuries, constellation
of 1˚, 2 ˚, 3 ˚, 4 ˚ types
– Like “Patient 4” AMIA we just saw
• 24 Head Trauma
• 13 Chest Trauma
• 3 Head & Neck Trauma
• 3 Traumatic shock
• 2 Fractures cervical spine
Mallonee, S., Shariat, S., et al. Physical Injuries and Fatalities Resulting from the
Oklahoma City Bombing, JAMA, Aug 1996, 276 (5): 382-387
Weapons Systems Division, Defence Science and Technology Organisation, Edinburgh, SA.
Dr Anna E Wildegger-Gaissmaier, DipIng(TU), PhD, Head Terminal Effects.
Online at: http://www.defence.gov.au/dpe/dhs/infocentre/publications/journals/NoIDs/adfhealth_apr03/ADFHealth_4_1_03-06.html
The Force behind Tertiary Injuries

Source: White, Richmond

Beirut 1983
 Beirut 1983
• Estimated 6 Ton TNT Equivalent HE
• Complete Structural Collapse of 4 story
structure, 6am
– Medical contingent killed
• 37% Critical (7/19)
• 68% Immediate
• Simultaneous blast at French
paratrooopers headquarters
 Number of Injury Types Among Admitted Survivors of the Beirut Bombing

100%

90%

80% 73%
70%

60%
51%
50%

40% 33%
29%
30%
22%
20% 16%
11%
10% 6% 4% 6% 5% 6%
1% 1%
0%
Concussion
membrane (ear

Ocular globe

Nerve palsy

other
Crush injuries
barotraumas,

perforation

Penetrating

contusions,

CVD related
fracture to skull

amputation of
pulmonary

Closed/Open
ballistic

Bruises,

Traumatic
Tympanic
Bowel

rupture

Frykberg, ER., Tepas, JJ 3rd , Alexander, RH. The 1983 Beirut Airport terrorist bombing. Injury
patterns and implications for disaster management. Am Surg, Mar 1989, 55(3): 134-141.

Lee, CY Development and Application of the bomb-blast

Damage and Injury Scale 2003
 AMIA

100%
90%
80%
70%
60%
50%
41%
40%
29% 29%
30%
18% 18%
20% 12%
10% 6% 6% 6% 6%
0%

other
perforation

Nerve palsy
fracture to skull
barotraumas,

membrane (ear

Ocular globe

Penetrating

contusions,

amputation of

CVD related
Concussion

Crush injuries
Bruises,

Traumatic
pulmonary

Bowel

Closed/Open
ballistic
Tympanic

rupture

Structural bombing, About 1 Ton TNT equivalence

29% Critical
Biancolini, CA., Del Bosco, CG., Jorge, MA. Argentine Jewish community
29% Immediate institution bomb explosion. J Trauma, Oct 1999, 47 (4): 728-732
Lee, CY Development and Application of the bomb-blast
Damage and Injury Scale 2003
 S 19%
C 4%
O 4%

Lee, CY. Development and Application of the Bomb-blast Damage and

Injury Scale. 2003
 Tactic 4

Catastrophic, Rare Explosions

 “Real life” reflecting
surfaces make
complex blast pattern
– accumulates blast
pressures

Low explosive High explosive Nuclear explosion

Deflagration Detonation Fission of nuclear
particles
No overpressure Overpressure
+ High explosive
component
Overpressure
Range

yield

Source: de Candole, 1967

 Texas City
April 17, 1947 - cargo munitions ship explodes

Explosives Kiloton equivalent Radius of Damage Key Injuries

2.3 kT AN 1.6 kt TNT-Equivalent 1000 ft - Almost all 560 Primary Cause of
dead and 800 Damage and Injury
hospitalized; 2000ft; was the blast (blast
3000 ft damage still wave, blast wind),
seen up to 10,000 ft missiles, fire, tidal
(1.8 mi) wave (10 ft high)
out
Casualties Additional Information
5,000 dead and • Within a 1,000-foot radius, all will be killed or injured.
injured; 33% DOS, 50% seriously injured, 17% less injured
3,500 non-fatal • Low death rate among hospitalized survivors (6.25% DIH of admitted) and
injuries; fewer serious burns that anticipated
800 hospitalized • Thick cloud of black smoke and vapor from soot and chemicals
(16% of total
casualties);
560 killed, or
missing and
presumed Dead

Blocker, V., Blocker, TG. The Texas City Disaster, a Survey of 3000 casualties
1949. American J Surgery
Serious injuries
and deaths still
found out to
1500 ft = 1/3 mi
 Tactic 3

Complex Bombings, Current Day

 Complex Bombing
1 – Combining open, confined, structural
bombings
2 – “Onslaught” of several bombings using
suicide methods to one area
3 – Capitalizing on crowds

Differs from a single method to a single target,

potentially increasing casualty count and
making medical response more confusing
India – Pakistan Conflict

“250 Perish as 13 Blasts Rock India” – 1993

More than 1000 injured
 Chechnya – Russia Conflict
• July 2-3, 2000 - Chechen guerrillas launch 5
suicide bomb attacks on bases of Russian
forces within 24 hours. In the deadliest, at least
54 people are killed at a police base near
Grozny.
• December 27, 2002 - Chechen suicide bombers
ram vehicles into the local government
headquarters in Grozny, bringing down the roof
and floors of the four-story building. Chechen
officials say about 80 people killed.
July 5 2003
3 SHB
20 Dead
 Bali Bombings
• 8/1/2000 • 10/12/2002
– Car bomb, private house – 2 bombs (1 car), Nightclubs
– 2D, 1I – 202 D
• 9/13/2000 • 8/5/2003
– Car bomb, Jakarta Stock – Car bomb Marriott
Exchange – 12D, 150I
– 10D, 16I • 9/9/2004
• 12/25/2000 – Suicide car bomb
– 11 churches across Australian Embassy
Indonesia – 11D, 100 I
– 19 D, 100 I • 10/1/2005
• 12/05/2002 – 2 SHBs
– Bomb McDonald’s – 3 restaurants
– 3D, 11I – 24D, 132I

Source: CNN, Accessed 10-3-05

Africa – Kenya and Tanzania
U.S Embassies
8/7/1998
 Riyadh May 12 2003
• 4 Bombings in quick
succession
• Combination of SHB and
vehicle bombs
• 34 dead, 190 injured
• Most casualties from the Al
Hamra compound
• “Commando Op”
 Morocco May 16 2003
• 42 killed including 13 bombers, 100
injured
– 24 DOS
• 100 patrons estimated in the Café el
Spana at time of bombing (9 pm)
• Blast at club responsible for most
casualties
C.Y.Lee 1 Apr 2004
C.Y.Lee 1 Apr 2004
 Increased bomb delivery
• Aug 26 2003 - 2 car blasts in Mumbai, 150
wounded, 65 dead
– Minutes apart, bodies expelled 10 – 15 meters
– Train derailment blast minutes later
– Worst attack since 1993
• Sept 30 2005 - Series of car bombs over 2 days
kill 200 in Iraq
– Since April 25 suicide bombers killed 1,345 people
 Transportation Targets

MOSCOW Commuter Train DEC 5 2003

745AM, Up to 41 DOS, 2 possible SHB with UXO, problems in
rescue, 1st suicide train bombing (before Madrid)
Sept 2003, 6 people died, commuter train similar bombing
 8/

1000
1200
1400
1600

200
400
600
800
14

0
/
3/ 76
29
/8
6/ 2
26
/8
6
9/
3/
3/ 88
19
/
7/ 94
25
/9
7/ 5
25
/
12 95
/3
/9
10 6
/1
/
2/ 97
23
/9
2/ 8
26
/9
8
3/
9/
3/ 98
31
/9
8
6/
7/
8/ 98
12
11 /98
/1
1
11 /99
/1
1/
99
2/
5/
0
2/ 0
5/
8/ 00
13
/0
8/ 1
14
/
3/ 01
14
/0
3/ 2
12
/0
3
9/
3/
12 03
/5
/0
3
2/
6/
3/ 04
11
/0
4
7/
7/
05
Serious Train Bombings 1976 - 2005

Dead
Injured
 Dec 5 2003 Russian Commuter
Train
• DOS 70% (31/44) of total fatalities
• Critical mortality 9% (13 of 148)
• not unlike the 6% critical mortality reported from
bombings in Israel
• occupied primarily by college students
• 16 to 68 years old
• force ejected several occupants
• Up to 148 victims were admitted
• 50 were treated for minor physical injuries and
released
 Rescue Challenges
• Friday morning rush hour
• trapped many severely injured inside
• under overturned train carriage
• encumbered by a
– snarl of electrical wires
– cables
– and overhead fires

“The Suicide Bombing of the Mineralnye Vody Train: A Case Study in Using Open Source Information
(OSINF) for Open Source Health Intelligence (OSHINT)”. Lee, Davis, Noji
Feb 6 2004 Moscow Metro
8:40 AM
2 SHB’s
39 DOS
70+ injured
Smoke
No electricity
Secondary fires
Rescuers could
not open train
doors for 30
minutes
Mar 11 2004 Madrid Metro
 Mar 11 2004 Madrid Metro
• 10 Explosions
• 15-minute Span,
• Started at 7:39 AM
• 28 – 33 lb high
explosive
• Backpack, 13 Bombs
• 192 Dead
• Approx. 1400
Wounded

Source: BBC Online

 Sequence of Events
7:39 a.m. – 3 backpacks loaded with explosives blow up on
a commuter train in Madrid's Atocha station.

7:39 a.m.– 4 backpack bombs explode on a commuter train

entering Atocha station.

7:42 a.m. – 1 Backpack bomb explodes as a commuter

train enters Santa Eugenia train station, nine miles from
Atocha.

7:41 a.m. – 2 bombs explode on double-decker

commuter train in El Pozo station, six miles from
Atocha.

Source: Associated Press, “Timeline for Madrid commuter train bombings”, Mar 11, 2004, San Diego-Union Tribune,
signon SanDiego.com
 Most deaths
on double
decker 70
fatalities

Source: BBC Online

 Madrid Casualty Figures
• Number of victims: 1430
• Primary care: 204 (14%)
• Prehospital care: 250 (17%)
• Admitted to any Hospital: 976 (68%)
• Total number of deaths: 192 (13%)
• Number DOS: 170
 Madrid Severe Injuries
1º: Blast injuries (explosion): 56%.
2º: Penetrating injuries (shrapnel): 50%.
3º: Blunt trauma (ejection): 53%.
4º: Burn injuries (flash burns): 31%
 London July 7 2005

Four bombs:
3 on tube carriages
1 on commuter bus

Deaths:
26 at Russell Square
7 at Aldgate
6 at Edgware Road

13 on bus at Tavistock
Place

Source: BBC Online

Seat of Explosions

The most deaths at Russell Square, 26 D

Aldgate, 7D, 100 injured, 10 serious

Edgware Station, 6D, 120 injured

Source: BBC Online

Russell Square In-Depth

Source: BBC Online

Tavistock

Source: BBC Online

 Liverpool
• Sliding doors wouldn’t open
• Soot, smoke billowing up
• At first panic, then collected calm
• Double-decker bus to Royal University
Hospital

Source: BBC Online

 King’s Cross
• “Intense heat of up to 60C, dust, fumes,
vermin, asbestos and initial concerns the
tunnel might collapse delayed the
extraction of bodies and the forensic
operation.” - BBC
– 30 minutes for paramedics to arrive
– 15 minutes for survivors to get to surface
– Survivor states hospital pretty well organized,
saw a lot of minor scrapes, cut legs
Source: BBC Online
1/8th mile Tavistock Square, Bus
200 meters
660 feet

Source: BBC Online

 Incendiary Explosions/Fires
• Burns
• Respiratory problems to T3
• Common materials in public
• Less technological skill to craft
• Post-disaster, possibly more time
consuming to mortuary system
• Doesn’t have to be terrorist
• Daily drills with arsons and fires
 Deagu, SOUTH KOREA Feb 18 2003
10AM, 120 DOS, incineration, major hurdles to rescue,
including entrapment inside once fire started
 Casualties and Injuries
• 182 dead, 340 missing and presumed
dead
• 2 subway trains
• Fire engulfed one 6-car train, spread to
the next train which had pulled into station
few minutes later
• Most bodies unidentifiable, charred
• Burned, trampled, suffocated to death
 Emergency Complications
• Fire crippled communication system
• Subway officials couldn’t warn 2nd train
• Station control center cut off electricity
• black out, no sprinkler system
• Most victims in this 2nd train
• Conductor fled without opening doors,
victims trapped
• “Toxic Gas”
Thanks for your time!

Catherine Y. Lee, MPH

catherine_lee@nymc.edu