Elsevier

Injury

Volume 40, Issue 7, July 2009, Pages 698-702
Injury

Medical consequences of suicide bombing mass casualty incidents: The impact of explosion setting on injury patterns

https://doi.org/10.1016/j.injury.2008.06.037Get rights and content

Abstract

Background

The increase in the incidence of suicide bombings on urban civilian populations in the recent years necessitates a better understanding of the related epidemiology in order to improve the outcome of future casualties.

Objective

To characterise the epidemiology of mass casualty incidents following suicide explosions in relation to the surrounding settings.

Methods

This study presents an analysis of the immediate medical consequences of 12 consecutive multiple casualty incidents (MCI's). Both pre-hospital and in-hospital data was assessed for each event including EMS evacuation times, types of injuries, body regions involved, Emergency Department (ED) triage, ED interventions and surgical procedures performed.

Results

The average arrival time of the first ambulance to the scene was 6.8 ± 2.3 min. The first “urgent” patient was evacuated in average of 7.6 ± 5.3 min later, while the last “urgent” patient was evacuated 27.8 ± 7.9 min after the explosion. Explosions that occurred in buses had the worst rates of overall mortality (21.2%). However, those who survived closed space explosions suffered from the highest number of severe and moderate (ISS > 8) injuries (22.9%). Casualties in this group underwent the largest number of both Emergency Room and Surgical interventions. Of the three settings, open space explosions resulted in the largest numbers of casualties with the smallest percentage of severe injuries or death.

Conclusions

MCIs resulting from suicide explosions can be classified according to the setting of the event since each group was found to have distinct epidemiological characteristics.

Introduction

Suicide bombing attacks against civilian population in urban settings have become frequent phenomenon in recent years. Many countries in Europe, North and South America, as well as the Middle East and Asia have experienced such events and are subjected to an ongoing threat. Some countries such as Israel, Russia, India and Spain have been affected by repeated attacks over many years. In Israel, the most frequent site of suicide bombings in the past decade, hundreds of civilians have lost their lives and thousands of others were wounded as a consequence of these actions.

Suicide bombings often entail a high rate of blast and penetrating injuries to a large and a diverse group of victims. This type of attack involves characteristic features of both, military and civilian trauma. Urban civilian trauma differs from military trauma in several ways. In civilian trauma, there is a high prevalence of blunt trauma and the time of evacuation is relatively short, while in military casualties, penetrating trauma predominates, and the time of evacuation is considerably longer. In addition, military casualties are quite homogenous, consisting mainly of young, healthy people while, in the civilian milieu, the endangered population tends to be much more varied.2, 5, 6, 8, 9, 10, 11 The injured often include women, children, and seniors, who may suffer from other medical co-morbidities and low physiological reserves. Therefore, neither “civilian” nor “military” medical doctrines are satisfactory, and a modified approach should be implemented.

Suicide bombings pose a major challenge to Emergency Medical Systems (EMS) and hospitals across the globe. Their complexity derives from the high number of casualties with various injury severities and medical needs, all encountered in a very short period of time. The medical system main goal is to identify and properly treat those casualties who are critical but salvageable, yet provide other casualties with an acceptable level of care. A detailed learning of these events may result in better understanding of these complex situations and a higher level of preparedness.

Section snippets

Materials and methods

Pre-hospital and in-hospital data was collected from 903 casualties injured in 12 consecutive multiple casualty incidents (MCI's) caused by suicide bombings in a civilian setting. These events occurred between March 2002 and January 2003. Pre-hospital data was retrieved from the Israeli Emergency Medical Service operation centre recordings and debriefings. Full scale EMS data was available for 10 out of 12 incidents involving 818 of the casualties. Data included the times of the first

General

There were five bus explosions (BE) with a total of 264 casualties (average 52.8 ± 23.8, range 22–84). Three explosions occurred in closed spaces (CSE) with a total of 308 casualties (average 102.7 ± 56.5, range 58–156). Four explosions occurred in an open space (OSE) with a total of 331 casualties (average 82.8 ± 50.7, range 47–164). The most severe BE resulted in 17 deaths and 60 casualties. The highest number of casualties in an OSE, 156 individuals, occurred when two bombers exploded

OR surgical interventions

Surgical procedures were performed in 114 patients (Table 7). The highest rate of interventions (17.6%) was needed post-CSE. In all three suicide bombing settings, orthopaedic surgical procedures (Table 7) were the most commonly performed (9.4%, 9.6% and 9.8%, for BE, CSE and OSE, respectively). The high frequency of orthopaedic surgical procedures was statistically significant in comparison to all other operative procedures aside from the incidence of laparotomies in CSE. In this direct

Discussion

This study presents an integrative analysis of both pre-hospital and in-hospital data regarding the immediate medical consequences related to suicide bomb attacks in a civilian setting. Our data suggest that the physical setting in which the suicide bombings occurs, influences dramatically the pattern of injury, the casualties’ outcome and the associated impact on the health services. Since similar explosive devices were used in all the MCI's, the differences seen should be primarily attributed

Conclusions

Suicide bombing attacks in civilian settings result in multiple casualty incidents with an enormous challenge to both the Emergency Medical services and Hospital Systems. Proper preparation for these events mandates that the EMS will be able to concentrate large numbers of trained personnel and ambulances on scene in a very short period of time. These teams must operate under strict central control and adhere to clear triage protocols to allow attention to be directed to those critical

Conflict of interest

None of the authors or their relatives have received any financial or other sorts of support during the preparation of the study.

References (13)

  • E.B. Lucci

    Civilian preparedness and counter-terrorism: conventional weapons

    Surg Clin North Am

    (2006)
  • C.R. Brewin et al.

    Acute stress disorder and post traumatic stress disorder in victims of violent crime

    Am J Psychiatry

    (1999)
  • J.P. De Ceballos et al.

    11 March 2004: the terrorist bomb explosions in Madrid, Spain—an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital

    Crit Care

    (2005)
  • Y. Kluger

    Bomb explosions in acts of terrorism—detonation, wound ballistics, triage and medical concerns

    IMAJ

    (2003)
  • D. Leibovici et al.

    Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open air versus confined-space explosions

    J Trauma

    (1996)
  • E.B. Lerner et al.

    Blast-related injuries from terrorism: an international perspective

    Prehosp Emerg Care

    (2007)
There are more references available in the full text version of this article.

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