Bombs, Explosions and Faculty Preparedness: A New Role for Public Ziad N. Kazzi, MD, FAAEM Health and First Assistant Professor Responders Co-Director Center for Emergency Infections & Satellite Conference and Live Webcast Emergency Preparedness Tuesday, March 27, 2007 Department of Emergency Medicine 12:00 - 1:30 p.m. (Central Time) University of Alabama at Birmingham

Produced by the Alabama Department of Public Health Video Communications and Distance Learning Division

Program Objectives FBI Reported Bombings, 1988-1997 • Describe important historical events involving explosions.

• Discuss different clinical aspects of blast injuries.

• Describe public health and first responder activities in reaction to explosions and blasts.

FBI Bombing Database 1988-1997 FBI Bombing Database

2000 1916 1911 1880 1988-1997 1800

1600 1551 1552 • 17,579 bombings 1457 1400 1212 1200 • Numbers doubled over the 10 year 1000 931 period 800 641 Number of Bombings 593 582 600 538 545 423 427 406 378 • Number of bombing peaked in 1992 400 267 203 200 156

0 • 78% were explosives and 22% were 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Explosive Bombing Years 1988-1997 incendiaries Incendiary Bombing FBI Bombing Database 1988-97 FBI Bombing Database 1988-1997 14001400

12001200 • 427 deaths with a peak in 1995 10001000 (Oklahoma City bombing) 800800

600 600 • 4,063 bomb-related injuries 400400

200200 Number of FBI Reported Deaths and Injuries Number of FBI Reported Deaths and Injuries • Incendiary bombs caused more 0 19881988 19891989 19901990 1991 1992 1993 1994 1995 1996 1997 injuries than explosives InjuriesInjuries Deaths Years 1998 - 1997

Special Characteristics of Special Characteristics of Bombing Victims Bombing Victims • Bombing resulted in significantly different: • Victims of terrorist bombings (906) –Injury complexity were compared with 55,033 –Increased severity casualties of non-terror related –More body regions involved –Enhanced use of intensive care trauma. –Prolonged hospital stay –More surgical interventions –Increased hospital mortality

Discovery Discovery • Believed to be discovered in China in the 10th century • A Mongol bomb thrown against a charging Japanese samurai during • Called black powder or gun powder the Mongol invasions of Japan, 1281. –Charcoal –Potassium nitrate –Sulfur • Used for signals and fireworks • Then used in warfare Spread Nitroglycerin • Brought to Europe by an English monk named Roger Bacon who • Invented by Italian chemist Ascanio published the formula. Sobrero in 1846

• Developed further by a German • Liquid form Franciscan monk, Berthold Schwarts. • Ignites and explodes spontaneously

Dynamite Ammonium Nitrate/Fuel Oil • Invented by Alfred Noble (ANFO) • Added silica to liquid nitroglycerine • Fuel oil (diesel but can be kerosene making the more malleable dynamite or molasses) • Also invented blasting caps that • 80% of explosives used in the USA were made with a fuse and • High explosive gunpowder –Requires a booster

Texas City Disaster 1947 1983 - US Marine Barracks and Embassy Bombings, Beirut • Seven KiloT of ANFO exploded on • At 6:20 a.m. a yellow truck drove into board of SS Grandcamp in the port the US Marine headquarters. killing 581 people. • Truck carried explosives equivalent to 12,000 pounds of TNT. • This initial explosion was coupled with another explosion 20 seconds later at the French Marine barracks. • 307 people died and 75 were injured. 1995 - Oklahoma City Bombing U.S. Embassy Bombings • Ryder truck detonated in front of Dar es Salaam, Tanzania and building containing 2,300 kg of Nairobi, Kenya explosive material. August 7, 1998 • Blast destroyed or damaged 324 buildings within radius of sixteen- • Car bombs in vehicles, each adjacent blocks. to the embassies, were detonated • 168 confirmed dead. simultaneously at 10:45 a.m. • 153 victims had been treated at St. Anthony Hospital, eight blocks from • Total of 257 people were killed and the blast. 7,000 wounded.

World Trade Center Iraq 2003 - Present September 11, 2001 • Bombing tactics have largely been • Both Twin Towers of the World Trade Center were destroyed. composed of military bombings, suicide bombings, and car • 25 surrounding buildings were damaged. bombings.

• 2749 people were killed in WTC and on board both American Flight 11 and United Flight 175.

Iraq 2003 - Present Madrid Commuter Train • As of late 2003, 40 to 60 percent of all March 11, 2004 attacks began with an IED. • Using 13 IEDs in backpacks, ten –Some of these attacks included explosions occurred aboard four direct fire attacks immediately commuter trains over 3 minutes. following the detonation of the device. • All trains were traveling on the same –More and more IEDs were line and in the same direction. subsequently being used as a stand-alone means to engage a • 191 people were killed and 2050 were convoy. injured. London Underground and Bomb-Injury Threat Model Double Decker Bus, July 7, 2005

Bomb • Three suicide bombs exploded Size & weight Human Explosive choice Age, sex, & weight within 30 seconds of each other on Purpose & Source Fitness, PPE Delivery system Nutrition, health the underground system. Adulterants Access to care • Almost one hour after the Tactic underground explosions, a suicide

bomb was detonated on a double Open Space, Confined Space, decker bus. Structural Collapse Reflecting or Shielding surfaces • 52 people were killed and around 700 Building and non-structural debris Air and liquid hazards were injured.

Explosives High Explosives

• Chemical compound that is able to • Stored energy is released rapidly release stored energy in the form of • Detonation rapidly expanding gases. • Examples: TNT and dynamite

Idealized Blast Overpressure Waveform Idealized Blast Overpressure Waveform Seen Only in High-order Explosives (HE) Seen Only in High-order Explosives (HE)

PEAK OVERPRESSURE

PRESSURE

POSITIVE PHASE OVERPRESSURE DURATION

NEGATIVE PHASE 0 ATM Zero Atmosphere Zero ATM Pressure Detonation VACUUM

TIME (microseconds) Low Explosives Host • Stored energy is released slowly • Age • Combustion or deflagration • Examples: gun powder, fuel • Sex • No blast wave or over pressurization • Height • Injury results from: –Thermal burns, • Medical history –Ballistic (shrapnel) • Access to care –Suffocation (fumes and toxins)

Environment Open Space

• Open space • Potential for shrapnel to travel a • Enclosed or confined space large distance (>100 m) • Structural collapse • Less primary blast injuries

Enclosed Space Structural Collapse

• Increased mortality • Increased mortality: –Primary blast wave • Increased blast pressure –Tertiary and quaternary injuries • Complicated rescue • Crush syndrome Impact of Building Collapse on Madrid Bombing Outcome In Oklahoma City • Rupture of the tympanic membranes Terrorist Bombing, 1995 occurred in 99 of 243 victims • Chest injuries in 97/243 victims Casualty No. of No. of No. of No. of Survivors Location Casualties Dead(%) Survivors Hospitalized (%) • Shrapnel wounds in 89/243 • Fracture in 44 Collapsed 175 153 (87) 22 18 (82) • Burns in 45 Uncollapsed 186 10 (5) 176 32 (18) • Eye injuries in 41 Total 361 163 (45) 198 50 (25) • Abdominal injuries in 12 • Traumatic amputations in 5

Immediate Effects of Blast Immediate Effects of Blast and Explosions and Explosions • Primary - direct effects (e.g., • Tertiary - effects of structural overpressurization and collapse and of persons being underpressurization) thrown by the blast wind –Rupture of tympanic membranes –Crush injuries and blunt trauma –Pulmonary damage –Penetrating or blunt trauma –Rupture of hollow viscera –Fractures and traumatic amputations • Secondary –Open or closed brain injuries –Penetrating trauma • Quaternary - burn, asphyxia, and –Fragmentation injuries exposure to toxic inhalants

Primary Blast Injuries • Result from overpressurization or underpressurization relative to atmospheric pressure

• Result from the interaction of high frequency stress waves and low frequency shear forces Primary Blast Injuries Tympanic Membrane Rupture • Occurs at the lowest pressure (5 psi) • Affect air-filled organs or air-fluid • May be bilateral interfaces • May be the earliest sign to look for –Deafness, tinnitus and vertigo • Rupture of tympanic membranes, • If more severe, may cause dislocation of the oval, round pulmonary injury, air embolization window or the ossicles and rupture of hollow viscera are the –Permanent hearing loss • Other organs need higher pressures most common patterns (56-76 psi) so if the TM is intact, they are unlikely

Tympanic Membrane Rupture Normal and Perforated Right Tympanic Membranes

The drawing of a traumatic perforation shows an irregular margin or rim with blood or a blood clot, and the drawing of a permanent central perforation shows a tympanocele.

Pulmonary Injuries Pulmonary Injuries • Second most common primary blast • Onset of symptoms is commonly injury within minutes. • Hemorrhage –Pulmonary contusion (appearing • Body armor protects from as a bihilar "butterfly" pattern on chest radiographs) penetrating (secondary) but not –Pneumothorax primary blast injuries. –Hemothorax Early onset pulmonary edema carries –Pneumomediastinum • a grave prognosis. –Subcutaneous emphysema TM Perforation - Pulmonary Screening Injury • 647 survivors of explosions on • Among 17 critically ill victims with buses used immediate radiography pulmonary injuries from the blast: of the chest to screen for pulmonary –13 had ruptured tympanic injuries from the blasts. membranes and 4 did not –Rupture of tympanic membranes • Primary injuries, in some form, were occurred in 18 of 27 critically found in 193 persons: injured victims –142 had isolated perforation of the • 17 of these were bilateral eardrum. Data from Madrid

Screening Visceral Injury • 51 had other forms of primary blast • Visceral injury is third most common injuries: primary blast injury. • Rupture of the colon and, less –18 with isolated pulmonary injuries frequently, the small intestine may –31 with combined otic and occur as an immediate result of a blast. pulmonary injuries • Mesenteric ischemia or infarct can –Two with intestinal injuries cause delayed rupture of the large or the small intestine; these injuries are difficult to detect initially.

Other Injuries Secondary Injuries • Ruptured globe or serous retinitis • Penetrating injuries from: –Primary fragments (fragments that Concussion • are part of the weapon) –Secondary fragments (those that • Air embolism may be seen and can result from the explosion) present as stroke, MI, acute abdomen, blindness, deafness, Ocular war injuries in Iraq are common spinal cord injury, or claudication Tertiary Injuries Crush Syndrome • Caused by trauma from falling • Entrapment increases mortality objects or from bodies being thrown against other objects • Rhabdomyolysis: Myoglobinuric –Blunt and penetrating injuries renal failure and hyperkalemia

–Crush syndrome and secondary rhabdomyolysis

–Open or closed head injuries

Crush Syndrome Rhabdomyolysis Statistics Related to Major Earthquakes in the Past 18 Years • Secondary complication of crush

Location and Year Death Crush Victims syndrome Spitak, Armenia, 1988 25,000 600 Northern Iran, 1990 >40,000 ? Kobe, Japan, 1995 5,000 372 • Myoglobinurea and CK elevation Marmara, Turkey, 1999 >17,000 639 Chi-Chi, Taiwan, 1999 2,405 52 Gujarat, India, 2001 20,023 35 • Treatment is IV hydration, urinary Boumerdes, Algeria, 2003 2,266 20? alkalinization (with mannitol) Bam, Iran, 2003 26,000 124 Kashmir, Pakistan, 2005 >80,000 118 Total >217,000 >1900

Quaternary Injuries Carbon Monoxide - • Burns (chemical or thermal) Mechanism • Toxic inhalation of carbon monoxide • Binds hemoglobin to form or hydrogen cyanide gas carboxyhemoglobin that is unable to • Exposure to radiation carry oxygen • Inhalation of dust containing coal or • Uncouples oxidative asbestos phosphorylation • Exacerbation of chronic illnesses Carbon Monoxide - Clinical Carbon Monoxide - Labs

• Neurological manifestations • Carboxyhemoglobin level

• Cardiovascular manifestations • Creatine kinase

• Gastrointestinal manifestations • EKG, CXR

Hydrogen Cyanide - Hydrogen Cyanide Mechanism • Clinical: • Inhibits cytrochrome oxidase and –Neurological uncouples oxidative phosphorylation –Cardiovascular –Bitter almond: only 60% of population can detect • Cells are unable to use oxygen –Cherry red skin, fundoscopic exam • Labs: • Anaerobic metabolism prevails –Lactic acid

–O2 extraction and venous O2 saturation

Exacerbation of Chronic Prehospital Illnesses • Airway • Asthma and COPD • Breathing • Circulation • Diabetes Mellitus • Triage categorization • Hypertension • Did the blast occur in an enclosed • Coronary artery disease setting? • Peptic ulcer disease • Regular trauma/burn protocols • Radiation survey • Alcohol and substance abuse • Secondary device survey • Mental health • Survey for chemical contamination Prehospital Prehospital Special • Incident command Considerations • Securing the area • Judicious use of IV fluids: • Cautious air transport –Overzealous fluid administration may worsen primary pulmonary • Air embolization: injury or even bleeding. –Place patient in a prone left lateral • Cautious mechanical ventilation: position –Mechanical ventilation and positive pressure may increase the risk of alveolar rupture and air embolism.

Triage Categorization Transport

• Red –Immediate • Transport to the nearest facility of red patients. • Yellow –Delayed

• Black –Dead or expectant • Green patients should be directed to other hospitals that are further away • Green –Minimal and that are not necessarily level I trauma centers.

Blast Lung Injury Blast Lung Injury • Should not rely on TM rupture to • Patients with normal CXR and ABGs, predict lung injury: who have no complaints that would –TM perforations are found in only 60% of patients with clinically suggest BLI, may be discharge after significant injuries. 4-6 hours of observation. –Clinically significant injuries are present in less than 30% of patients with TM perforations. Blast Lung Injury Management of Secondary Injuries • Management similar to pulmonary contusions • As per protocol

• Complex fluid management • Watch for unusual shrapnel such as nails and bolts • Mechanical ventilation will increase the risk of air embolization

Management of Tertiary Major Steps in Treating Patients Injuries With The Crush Syndrome • Consider the importance of early • As per trauma protocols fluid administration in the field. • Look for crush syndrome especially –Initiate an infusion of isotonic in structural collapse: saline at the earliest convenience, followed by hypotonic saline- –Myoglobinurea alkaline solution. –In patients with adequate urinary –Renal failure flow, add mannitol to the solution. –Hyperkalemia –Avoid empirical administration of potassium-containing fluids.

Major Steps in Treating Patients Major Steps in Treating Patients With The Crush Syndrome With The Crush Syndrome • Closely monitor each patient's fluid • Correct electrolyte abnormalities. intake and urinary output. –Hyperkalemia is often fatal and –Administer up to 6 to 12 liters of appropriate fluids per day. should be corrected vigorously. –Remember that urinary output may –Hypocalcemia should be corrected be substantially lower than the only if it causes symptoms. amount of administered fluid. –Amount of fluid defined by the basis –Remember that virtually any other of the clinical course or central electrolyte disturbance may occur venous pressure measurements. as well and should be treated. Major Steps in Treating Patients Major Steps in Treating Patients With The Crush Syndrome With The Crush Syndrome • Consider dialysis as a lifesaving • Consider the initiation of prophylactic procedure. dialysis in patients at high risk for hyperkalemia. • Begin dialysis when indicated by the • In order to estimate logistic needs, presence of any of the following: remember that the average duration of oliguria or anuria, volume overload, or dialysis will be 13 to 18 days. biochemical abnormalities such as • Consider continuing dialysis support severe uremia, hyperkalemia, and until patients' kidney function has acidemia. recovered.

Management of Crush Management of Quaternary Syndrome Injuries • IVF: Start in the field • Inhalational injuries • Urinary alkalinization: –Myoglobinurea, Urine pH>7 • Carbon monoxide • Mannitol • Hemodialysis: • Hydrogen cyanide –Anuric patients, acidemic patients • Contamination with radionuclides –Correction of electrolyte abnormalities –Advanced surge capacity planning

Carbon Monoxide Cyanide Antidotes The Lilly kit Hydroxocobalamin • 100% oxygen therapy • Amyl nitrite • Bind cyanide to form • Hyperbaric oxygen therapy pearls cyanocobalamin or Vitamin B12 • Sodium nitrite • Recently FDA • Sodium approved thiosulfate Dirty Bombs Radiopharmaceuticals • Scene decontamination: • Radionuclide • Medication – Iodine – KI (potassium iodide) –Removal of clothes – Transuranics – Zn-DTPA such as Ca-DTPA Plutonium & –Soap and water Americium – Uranium – Bicarbonate –Life saving procedure should – Cesium, – Prussian Blue precede decontamination Rubidium, [Ferrihexacyano- Thallium Ferrate(II)] – Tritium – Water

Mental Health Background Long-term Effects After the • Mental illness is common after Tokyo Sarin Attack disasters in victims and first Residual symptoms after 1 year (n=303) responders. Eye symptoms 56 (18.5%) Fear of the subway 39 (12.9%) • Psychopathology similar in different Easy fatiguability 36 (11.9%) cultures. Fear concerning escape from the attack 35 (11.6%) Flashbacks 32 (10.6%) • Responses and coping mechanisms Headache 26 (8.6%) may be different amongst different Depressive feelings 24 (7.9%) people or cultures. Lack of concentration 23 (7.6%)

Reactions to Stress Clinical Illnesses • Occur in stages, each one • Post Traumatic Stress Disorder characterized by a specific (PTSD) psychological mechanism. • Symptoms include: • Depression –Flashbacks –Difficulties in remembering • Anxiety –Avoidance of stimuli • Alcohol abuse –Blunting of responses –High arousal level –Obsessive ruminations Special Aspects - Victims Special Aspects - Responders • Events are unexpected • Bombing victims sustain traumatic disfiguring injuries • Often affect civilians • Scene may be hazardous –Structural collapse • Bombing victims sustain traumatic –Secondary devices disfiguring injuries –Inhalational injuries from potential toxins • Distress from inability to save entrapped victims

World Trade Center Interventions • After Sept. 11, at least three New • Increased awareness York men involved in rescue and recovery efforts have committed • Debriefing suicide: • Mental health specialist –James Kay Jr., an emergency –Screening medical technician, shot himself –Psychotherapy early last year. –Pharmacologic therapies –Six months later, Daniel Stewart, another EMT, hanged himself. –Other methods

Physical Rehabilitation for Upcoming Programs Head Injury Pandemic Influenza: • Constrain-induced therapy Alabama Schools Need to Plan Now Monday, April 2, 2007 • Optimal at 3 months after what injury 3:30 - 5:00 p.m. (Central Time) • University of Alabama at Birmingham For complete list of upcoming –Taub Therapy Clinic programs visit our website www.adph.org/alphtn