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The Quinary Pattern of Blast Injury

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The Quinary Pattern of Blast Injury JEM The quinary pattern of blast injury Yoram Kluger, MD, FACS Adi Nimrod, MD Philippe Biderman, MD Ami Mayo, MD Patric Sorkin, MD AbstrAct for blast victims should be aware of this new type of Objective: Bombing is the primary weapon of bombing injury. global terrorism, and it results in a complicated, Key words: terrorism, blast injury, hyperinflam- multidimensional injury pattern. It induces bodily mation injuries through the well-documented primary, sec- ondary, tertiary, and quaternary mechanisms of IntroductIon blast. Their effects dictate special medical concern Bombings and explosions are the hideous tool of and timely implementation of diagnostic and man- terrorism. Their simple manufacture and easy con- agement strategies. Our objective is to report on new cealment ensure that they will remain the main clinical observations of patients admitted to the Tel weapon of terrorists. Using suicide bombers, terror Aviv Medical Center following a recent terrorist groups can reach and explode within crowded areas bombing. filled with unprotected civilians. In his Presidential Results: The explosion injured 27 patients and Address in September 2001, President Bush stated three died. Four survivors, who had been in close that war on terror would not cease until every terror- proximity to the explosion as indicated by their ist group of global reach was found, stopped, and eardrum perforation and additional blast injuries, defeated. But since then the number of terrorist were exposed to the blast wave. They exhibited a bombing attacks has steadily increased, and during unique and immediate hyperinflammatory state, two 2003 it has reached the level of global epidemic. upon admission to the intensive care unit and two In past years at the Rabin Trauma Center, we during surgery. This hyperinflammatory state was have experienced the aftermath of a long series of ter- manifested by hyperpyrexia, sweating, low central ror attacks. The most complicated trauma victims are venous pressure, and positive fluid balance. This state those admitted after bombing. Explosions involve did not correlate with the complexity of injuries sus- more bodily regions than other kinds of trauma and tained by any of the 67 patients admitted to the inten- affect the release of greater quantities of cellular sive care unit after previous bombings. mediators.1 Therefore, increased in-hospital mortali- Conclusion: The patients’ hyperinflammatory ty is encountered in these events (6 percent vs. 2 per- behavior, unrelated to their injury complex and sever- cent for conventional trauma).2 ity of trauma, indicates a new injury pattern in explo- Mellor explored the causes of death among vic- sions, termed the quinary blast injury pattern. tims of bomb explosions and found that 14 percent Unconventional materials used in the manufacture of had disrupted bodies, 39 percent suffered multiple the explosive can partly explain the observed early injuries, 11 percent chest injuries alone, 12 percent hyperinflammatory state. Medical personnel caring head injuries alone, and 21 percent combined head Journal of Emergency Management 51 Vol. 4, No. 1, January/February 2006 and chest injuries.3 From this important work it was energized by the wave of air. Metal particles are usu- concluded that the main factor affecting mortality in ally added to the charge to increase the wounding an explosion is the proximity to the center of detona- potential. Steel balls, nails, and other sharp particles tion. Bodies of victims who had suffered only minor are the terrorists’ favorites. The velocity of these mis- external injuries imparted greater knowledge of the siles depends on their shape and distance of flight, devastating effects of the blast.4 and they are influenced by yaw and drag, just like The explosive material is composed of trinitro- classic missiles. Peppering of the skin is the distinc- toluene (TNT) or other explosives from military, com- tive sign of this ballistic effect. Multiple penetrations mercial, or homemade sources. Detonation is trig- of the skin are common and often represent only the gered by an electrical current, and the solid explosive tip of the iceberg. is transformed into gas to create a very high-pressure The tertiary blast injury is the result of overpres- wave of air that emanates radially at the speed of sure. It is responsible for total body destruction in sound. This creates a peak of over-pressure, a shock- some patients and, for others, can cause amputation front that is only 3 to 5 mm thick, and is followed by of limbs. The blast wind alone can accelerate the body the blast wind. For example, 25 kg of TNT produces a and thrust it against stationary objects. peak over-pressure of 150 psi (10.5 kg/cm²). These The quaternary blast injury is related to the ther- pressures last 2 ms and traverse at a speed of 3,000 mal effects of the blast. Burns are caused by ignition to 8,000 m/sec. Greater explosives produce longer of flammable materials. Thermal lung injury can duration of the front shock wave and more damage develop directly from the very high air temperatures results. created at the site of the explosion. There are four injury patterns related to the Following we report on some unique clinical blast. The primary blast injuries occur from the blast observations of patients admitted after a recent wave passing through the victim. The human body is bombing. Their clinical picture may be attributed to a remarkably resistant to the blast wave, and the tis- new, quinary pattern of blast injury. sues will respond according to their composition, with air-containing organs suffering the most. Three puta- cAse reports tive mechanisms, spalling, implosion, and accelera- On April 30, 2003, a suicide bomber exploded in a tion and deceleration are associated with the primary Tel Aviv nightclub. Twenty-seven patients were evac- blast injury. Spalling occurs as the blast wave passes uated to the Rabin Trauma Center; two of them were through organs filled with gas and fluid and gener- dead on arrival. Five patients were rushed to the ates high velocity bubbles that hit the wall of the operating theatre due to life-threatening injuries, organ and damage it. Implosion originates from the where one of them succumbed to his injuries. blast passing through air-filled organs, initially com- All the victims arrived at our hospital 20 to 30 pressing its air-filled spaces and then inflating them minutes after the event. They were evaluated in the rapidly, damaging the surrounding tissue. Ac - emergency department by trauma teams guided by celeration and deceleration are similar to what is the medical director and team leaders. Advanced seen in conventional trauma. The hallmarks of the Trauma Life Support (ATLS) protocols and the hospi- primary blast injuries are eardrum perforation and tals’ mass casualty protocols were applied. blast lung injuries. Perforations of hollow abdominal We present four cases of victims who were very viscera are rare (³ 1.2 percent). Solid organs are near the center of the explosion (e.g., Patient 4 was one rarely damaged by the blast itself, and acceleration meter away from the suicide bomber). Two patients and deceleration mechanisms are the true cause of (Patients 2 and 3) were admitted to the intensive care injury to these organs. unit (ICU) one hour after arrival. Patients 1 and 4 had The secondary blast injury results from the cas- surgical interventions and were admitted to the ICU two ings, debris, and particles added to the bomb that are and four hours after admission, respectively. In the 52 Journal of Emergency Management Vol. 4, No. 1, January/February 2006 table 1. clinical details of the patients Hr sVr Lung Injury bp t Leu po /F patient Age (beats/ (dynes · 2 compliance Iss AIs (per l) (io ) complex (mm Hg) (°c) m -5 2 -1 min) s · cm ) (L · cm H2o ) Lung-4 Lung, colon, 1 27 120 90 39 9,000 120 31 33 Skin-1 burn 7% Colon-4 2 32 Burn 9% 130 110 39 8,700 400 242 28 9 Skin-3 Lung, Skin-1 3 24 170 138 39 8,300 138 40 10 burn 3.5% Lung-3 Colon, Colon-4 4 38 amputation, 125 90 39 11,700 233 43 29 Skin-2 burn 7% Extremity-3 HR, heart rate; BP, blood pressure; T, temperature; Leu, Leukocytes; SVR, systemic vascular resistance; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale. immediate post-trauma phase, these four patients patient’s blood pressure stabilized. No signs of bleed- developed a unique clinical state that was manifested ing were noted. Although fluid therapy was at room in increased heart rate, fever, and increased fluid temperature, the patient’s fever rose to 39°C. The demand, and was unrelated to the severity of their white blood cell count was slightly elevated with mod- injuries (Table 1). erate left shift. The hyperdynamic circulatory state resolved after 24 hours, the cardiac output and sys- Patient 1 temic vascular resistance normalized, and noradren- A healthy 27-year-old male was conscious on alin was withdrawn. All blood and sputum cultures admission, hypoxemic and in hemodynamic shock. A were negative, and the patient’s fever gradually left pneumothorax was relieved by tube thoracostomy, decreased over the next four days. and fluid resuscitation was started. He also suffered from first and second degree burns of the face and Patient 2 chest (7 percent) and from bilateral eardrum perfora- A 32-year-old male was hemodynamically stable tion. A positive diagnostic peritoneal lavage (DPL) upon arrival with Glasgow Coma Score of 15. resulted in exploratory laparotomy. Colonic wall per- Physical examination revealed second degree burns foration led to ileocecectomy with anastomosis. No of the face and hands, bilateral eardrum perforation, other injuries were found.
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