Characteristics of Terrorist Related Blast Injuries

The epidemiological and clinical outcomes of an explosion depend on several prognostic factors: the magnitude of explosion, the composition and amount of the explosive material, the surrounding environment, and the distance between the blast and the victim. The blast-induced injuries are considerably influenced by whether the blast occurs in an open or in a confined space. For example, in an open-air terroristbombingin Istanbul, Turkey on November 15, 2005, there were 69 casualties that were treated in the American Hospital in Istanbul. Only four of them (5 %) had an Injury Severity Score of 16 or more and none of them had primary blast injury (Rodoplu et al. 2005). On the other hand, blast victims in confined spaces have an increased mor-talityrate (15.8 %vs 2.8%), a higher mean Injury Severity Score (ISS) in survivors (11% vs 6.8%), a higher incidence of primary blast injury, and more extensive burn injuries (Kluger 2003; Rodoplu 2005). In ultracon-fined spaces such as buses, the overpressure from the explosion is instantly magnified by reflections from the walls and has devastating consequences with an exceptionally high fatalities-to-casualties ratio and mortality rate (49 %) (Almogy et al. 2004; Kluger et al. 1997; Sha-loner 2005; Sutphen 2005). Moreover, blasts that cause structural collapse are associated with an immediate mortality rate as high as 25 % (Arnold et al. 2003,2004).

A terrorist attack can cause a unique form of severe intentional injury and it presents with a unique epidemiology and several distinctive features, differing from conventional trauma injuries. Several studies from Israel, based on the Israeli National Trauma Registry, have tried to characterize patients hospitalized as a result of terrorist injuries and to compare them to other trauma casualties (Kluger 2003; Kluger et al. 2004; Pe-leg et al. 2003). According to these studies, the maj ority of terrorist-related victims were relatively young, half of them in their 20s, since crowded public places such as malls, pubs, and buses are frequently crowded by young people (Kluger 2003; Kluger et al. 2004). It is noteworthy that children, especially adolescents, are frequently injured in terrorist attacks and the injury severity, as well as the subsequent morbidity and mortality, is exceptionally high among children injured by explosions (Aharonson-Daniel et al. 2003; Amir et al. 2005; DePalma et al. 2005).

The terrorist-related injuries were generally more severe and 29% of them had an Injury Severity Score (ISS) above 16, as compared to 10 % in all other conventional trauma admissions (Kluger 2003; Kluger et al.

2004). The severity of inj uries is also manifested by the state of consciousness on admission (as represented by the Glasgow Coma Scale scores), the increased frequency of hypotension on admission, and the fact that the majority of the victims sustain injuries to multiple body regions (Kluger et al. 2004). Furthermore, survivors of terrorist-related bomb explosions underwent significantly more surgical interventions (53 %, especially orthopedic and abdominal surgery), they more frequently required the services of intensive care units (23%), their overall hospital stay was remarkably prolonged (20% were hospitalized for more than 14 days), and they required more rehabilitation treatment compared to casualties of other types of trauma (Kluger 2003; Kluger et al. 2004; Mintz et al. 2002; Sutphen

2005). However, despite all efforts, this group of patients eventually had an increased in-hospital mortality rate of 6.1 %, as compared to 3% in motor vehicle accidents and 1.8 % in other trauma, probably related to the increased injury complexity (Kluger et al. 2004). Several studies have noted that the high specific mortality rate in explosions is primarily due to abdominal injuries (19%) and severe head injuries (20-25%) (Amir et al. 2005).

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