Disaster and Terrorism
Mass casualty terrorist bombings: A comparison of outcomes by bombing type

https://doi.org/10.1016/S0196-0644(03)00723-6Get rights and content

Abstract

Study objective

We compared the epidemiologic outcomes of terrorist bombings that produced 30 or more casualties and resulted in immediate structural collapse, occurred within a confined space, or occurred in open air.

Methods

We identified eligible studies of bombings through a MEDLINE search of articles published between 1966 and August 2002 and a manual search of published references. Pooled and median rates of mortality, immediately injured survival, emergency department use, hospitalization, and injury were determined for each bombing type.

Results

We found 35 eligible articles describing 29 terrorist bombings, collectively producing 8,364 casualties, 903 immediate deaths, and 7,461 immediately surviving injured. Pooled immediate mortality rates were structural collapse 25% (95% confidence interval [CI] 6% to 44%), confined space 8% (95% CI 1% to 14%), and open air 4% (95% CI 0% to 9%). Biphasic distributions of mortality were identified in all bombing types. Pooled hospitalization rates were structural collapse 25% (95% CI 6% to 44%), confined space 36% (95% CI 27% to 46%), and open air 15% (95% CI 5% to 26%). Unique patterns of injury rates were found in all bombing types.

Conclusion

Patterns of injury and health care system use vary with the type of terrorist bombing.

Introduction

Explosions are by far the most common cause of casualties associated with terrorism. Of 93 reported terrorist attacks producing more than 30 casualties in the world from 1991 to 2000, 88% involved explosions.1 These mass casualty events not only resulted in significant death and destruction but also challenged emergency medical care systems in 27 countries.1 The largest of these attacks were catastrophic medical disasters, generating thousands of casualties and acutely overwhelming local emergency medical and hospital resources.

Capsule Summary

What is already known on this topic

Very little has been reported about the epidemiology and outcomes of mass casualty terrorist bombing attacks in the civilian setting.

What question this study addressed

Thirty-five published reports of terrorist bombings producing 30 or more casualties and with sufficient data on outcomes were reviewed and summarized.

What this study adds to our knowledge

Among the 8,634 casualties, most deaths were immediate (and untreatable). Both early (emergency department [ED]) and late (inhospital) mortality rates were 1% or less, ED utilization by victims ranged from 48% to 94%, and hospitalization rates ranged from 15% to 36%.

How this might change clinical practice

EDs will rarely be presented with a large influx of critical patients. Rates of ED utilization vary with the structural environment of the bombing site, allowing some prediction of ED and hospital bed capacity needs. Enhancing field care and rescue, especially for victims of structural collapse, may be important.

Despite the importance of terrorist bombings to contemporary emergency department (ED) and hospital disaster planning and preparedness, little has been reported about the comparative epidemiology of mass casualty terrorist bombings and the factors affecting their outcomes.2, 3 The objective of this study was to compare the epidemiologic outcomes among mass casualty terrorist bombings causing immediate structural collapse, those taking place within a confined space, and those occurring in open air, as reported in the medical literature.

Section snippets

Study design

A primary MEDLINE search was conducted with an OVID interface for articles that reported the epidemiologic outcomes of terrorist bombings and were published between 1966 and September 2002 in the English language. The keywords “bombing,” “explosions,” “terrorism,” or “terrorist bombing” were used. The reference lists within these initially identified articles were then searched for further articles relevant to the topic.

Articles that reported the epidemiologic outcomes of terrorist bombings

Results

The primary and hand searches yielded 76 articles reporting epidemiologic outcomes of terrorist bombings.2, 3, 4, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 Further review found that only 57 articles reported the epidemiologic outcomes of 80 specific

Limitations

This study also has a number of limitations. First, the inclusion criterion that a mass casualty terrorist bombing must produce 30 or more casualties may seem arbitrary because some health care systems may be overwhelmed by fewer than 30 victims. Nevertheless, the simultaneous occurrence of 30 casualties will at least temporarily disrupt the capacity of most emergency care systems to respond and result in external disaster response resources being placed on alert. The use of this cutoff point

Discussion

The median number and range of injured in each bombing type reflect multiple factors, including the explosion magnitude, composition, environment, and location relative to the number of potential victims at risk. For example, in the 6 structural collapse bombings, relatively large bombs were detonated within or beside structures containing large numbers of potential victims. Because these explosions tended to be quite large, potential victims outside the target structure were also at risk. In

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  • Cited by (0)

    Author contributions: JLA and PH conceived the study. JLA organized the literature search and data abstraction. HS performed the statistical analysis. JLA, PH, and MCT analyzed the results and drafted the manuscript. JLA takes responsibility for the paper as a whole.

    The authors report this study did not receive any outside funding or support.

    1

    Dr. Arnold is currently affiliated with the Yale New Haven Center for Emergency and Terrorism Preparedness, New Haven, CT.

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