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Epidemiology

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Terrorism-related bombings using conventional explosives comprise the vast majority of blast injuries. The Memorial Institute for the Prevention of Terrorism estimated terrorist activity in 2005 to include 2650 bombings, with an annual death rate from terrorism-related activity of 10,860 in 2004, 6200 in 2003, 7349 in 2002, and 6403 in 2001.1 An analysis of 44 mass casualty, terrorist bombings found an overall 3% (1% to 14%) mortality and hospital admission rate of 34% (14% to 53%).2 Although bombing of civilian targets by terrorist groups is not new, the events of 9/11 have resulted in a heightened awareness and interest in the medical management of mass casualty incidents.2,3 In the U.S. between 1980 and 1990, there were 12,216 intentional bombings.3 Explosions from intentional bombings are among the few instantaneous traumatic events that can produce massive numbers of casualties requiring immediate medical attention. A review of 14 published studies of terrorist attacks that occurred between 1969 and 1983 involving a combined population of 3357 casualties demonstrated that the overall mortality at the scene was 12.6%, with 30% of the immediate survivors requiring hospital admission.4 Thus, although some victims die immediately at the scene, the majority of injuries suffered by the immediate survivors of bombings are not life-threatening. At the same time, blast injuries commonly occur not as isolated incidents but as part of multiple casualty incidents of varying sizes. This pattern, combined with the fact that most emergency physicians have never encountered a blast injury victim, makes the care of such often eminently salvageable victims contingent upon appropriate training and skill retention by the individual emergency physician, along with appropriate institutional planning and preparation.

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Terrorist bombings result in high injury scores for victims as well as higher hospital resource use than for victims of other trauma. One study found that bombing casualties had higher injury severity scores (>16, 30% vs. 10% for other trauma), increased immediate mortality (as high as 29% for closed space bombings), greater inhospital mortality rate (6% vs. 3% for other trauma), more frequent need for surgical intervention (especially orthopedic), longer hospital stays, and greater use of critical care.5

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Pathophysiology

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Explosions occur when energy is transformed extremely quickly from one form (e.g., chemical potential energy in an explosive) to another (e.g., heat energy and kinetic energy). The detonation of a conventional high explosive generates a blast wave that spreads out from a point source. The blast wave consists of two parts: a shock wave of high pressure followed closely by a blast wind (or air mass in motion).

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There are four main types of blast effects. A primary injury is caused by a direct effect of blast overpressure on tissue. Primary blast injury affects air-filled structures such as the lungs, ears, and GI tract via the following mechanisms: spalling (e.g., from lung parenchyma to alveolar space, causing tissue surfaces to ...

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