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Bombs, Explosions and Preparedness 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
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