Bombing events may 2014 blog
Upcoming SlideShare
Loading in...5
×
 

Like this? Share it with your network

Share

Bombing events may 2014 blog

on

  • 137 views

 

Statistics

Views

Total Views
137
Views on SlideShare
119
Embed Views
18

Actions

Likes
0
Downloads
5
Comments
0

2 Embeds 18

http://emergencypublichealth.net 17
http://www.slideee.com 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Bombing events may 2014 blog Presentation Transcript

  • 1. Bobby Kapur, M.D., M.P.H. Associate Professor of Medicine & Pediatrics Associate Chief for Academic Affairs Section of Emergency Medicine Bombing Events in the US: Public Health Analysis and Acute Management
  • 2. Bombing Events & Blast Injuries 1
  • 3. Bombing Events & Blast Injuries 2
  • 4. Bombing Events & Blast Injuries 3 Objectives • Definitions • Recent global historical perspectives • US bombings epidemiology • Pre-Hospital Care response • Acute hospital management
  • 5. Bombing Events & Blast Injuries 4 Definitions: Terrorism
  • 6. Bombing Events & Blast Injuries “A policy intended to strike with terror those against whom it is adopted; the employment of methods of intimidation; the fact of terrorising or condition of being terrorised." The Oxford English Dictionary 5
  • 7. Bombing Events & Blast Injuries U.S Federal Criminal Code “(A) involve acts dangerous to human life that are a violation of the criminal laws of the United States or of any State (B) appear to be intended: to intimidate or coerce a civilian population, or to influence the policy of a government by intimidation or coercion, or to affect the conduct of a government by mass destruction, assassination, or kidnapping…” United States Code Title 18, Part I, Chapter 113B, Section 2331 6
  • 8. Bombing Events & Blast Injuries Medical Definition “The intentional use of violence - real or threatened- against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.” “A Proposed Universal Medical and Public Health Definition of Terrorism.” Prehosp Disast Med. 2003;18(2):47- 52. 7
  • 9. Bombing Events & Blast Injuries Medical Codes National Center for Health Statistics at the CDC has developed within the WHO’s International Classification of Diseases, Tenth Revision (ICD-10) terrorism-related codes: • *U01-*U02 for mortality due to assault (homicide) for terrorism, • *U03 for mortality due to intentional self harm (suicide) for terrorism • E979 for morbidity due to terrorism • E999.1 for late effect of injury due to terrorism 8
  • 10. Bombing Events & Blast Injuries 9
  • 11. Bombing Events & Blast Injuries 10 Madrid, Spain: March 11, 2004
  • 12. Bombing Events & Blast Injuries 11 1. Mitsubishi Triumph mobile phone 2. Copper detonator 3. Explosives (8-12kg) 4. Metal fragments Madrid Train Bombings: March 11, 2004 7:37 am - 7:40 am • 10 bombs explode in 4 commuter trains in downtown Madrid • 3 undetonated bombs found later • Explosive material: Dynamite (used in construction)
  • 13. Bombing Events & Blast Injuries Madrid Train Bombings: March 11, 2004 • EMS: 291 ambulances mobilized • 112 Call center: >20,000 calls • Injuries: >1,800 • Deaths: 191 12
  • 14. Bombing Events & Blast Injuries Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33(1):S107-S112. 13 Madrid Train Bombings: March 11, 2004
  • 15. Bombing Events & Blast Injuries Key Pre-Hospital Care Logistical Issues • Mobile phones and radios: do not work underground • Minor injuries or uninjured evacuated 1st : delayed evacuation of seriously injured • Scene safety: possibility of structural collapse or secondary devices • Going “back to normal”: difficult for pre-hospital and emergency services 14 Madrid Train Bombings: March 11, 2004
  • 16. Bombing Events & Blast Injuries Key Hospital Logistical Interventions • Cancel all elective surgeries • Transfer stable patients out of ED and ICU • Triage of patients by senior physicians • Use of FAST to quickly diagnose abdominal trauma Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med. 2005;33(1):S107-S112. 15 Madrid Train Bombings: March 11, 2004
  • 17. Bombing Events & Blast Injuries 16 Global Experiences
  • 18. Bombing Events & Blast Injuries 17 Blast Injuries. The Lancet, Volume 374, Issue 9687, 2009, 405 – 415.
  • 19. Bombing Events & Blast Injuries 18 Europe: UK IRA Bombings 1970-1980s
  • 20. Bombing Events & Blast Injuries 19 Middle East: Israel
  • 21. Bombing Events & Blast Injuries 20 Middle East: Beirut
  • 22. Bombing Events & Blast Injuries 21 Africa: Kenya & Tanzania Embassies 1998
  • 23. Bombing Events & Blast Injuries International Terrorism & Bombing Events • Change in the targets and materials used in bombing events • Increased sophistication and planning of events • Greater coordination among terrorists 22
  • 24. Bombing Events & Blast Injuries 23
  • 25. Bombing Events & Blast Injuries 24 US Experiences
  • 26. Bombing Events & Blast Injuries The U.S. Experience World Trade Center 1993 Oklahoma City 1995 Atlanta Olympics 1996 25
  • 27. Bombing Events & Blast Injuries The U.S. Experience World Trade Center 9/11 Pentagon 9/11 26
  • 28. Bombing Events & Blast Injuries The U.S. Experience? • Few large-scale events or Endemic problem? • Domestic or International issue? • Impact of bombing events on medical and public health institutions? • How the U.S. data on bombings can improve planning and response for future events? No longitudinal data on bombing events in the US 27
  • 29. Bombing Events & Blast Injuries 28
  • 30. Bombing Events & Blast Injuries 29 Bombing Events: Impact Issues • Incidents • Injuries & Deaths • Etiology (Motives) • Location (Targets) • Materials
  • 31. Bombing Events & Blast Injuries ATF Designations for Bombing Events Explosive: Chemical compound or mixture with a primary purpose to function by explosion Incendiary: Device made of an inflammable or ignitable liquid Premature: Bombing event, either explosive or incendiary, that occurs when the device functions prior to placement on a target Attempted: Incident where the device, either explosive or incendiary, is placed against a target and fails to function or is made safe before detonation 30
  • 32. Bombing Events & Blast Injuries 31
  • 33. Bombing Events & Blast Injuries Type of Bombing Incident Incidents (%) Injuries (%) Deaths (%) Actual Bombings 28,529 (79.0) 5,931 (100.0) 699 (100.0) Explosive 21,237 (58.8) 4,056 (68.4) 386 (55.2) Incendiary 6,185 (17.1) 579 (9.8) 139 (19.9) Premature 1,107 (3.1) 1,296 (21.8) 174 (24.9) Attempted Bombings 7,581 (21.0) 0 (0.0) 0 (0.0) Explosive 5,616 (15.6) 0 (0.0) 0 (0.0) Incendiary 1,965 (5.4) 0 (0.0) 0 (0.0) Total 36,110 (100.0) 5,931 (100.0) 699 (100.0) U.S. Bombing Incidents from 1983-2002 32
  • 34. Bombing Events & Blast Injuries Number of Explosive and Incendiary Bombing Events from 1983-2002 0 500 1000 1500 2000 2500 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 Numberofincidents Year 33
  • 35. Bombing Events & Blast Injuries Number of Attempted and Premature Bombing Events from 1983-2002 0 100 200 300 400 500 600 700 800 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Numberofincidents YearNumber Attempted Number Premature 34
  • 36. Bombing Events & Blast Injuries Etiology of Bombing Event ATF Definition Attempted homicide or Homicide Intent to kill another individual or group of individuals Suicide Intent to kill oneself Vandalism Intent to cause property damage Revenge Intent to respond to a prior action of another individual or group Protest Intent to gain publicity or support for a protest group Labor-related Intent to impact a labor dispute Extortion Intent to receive goods or services from another individual or group Excitement Intent to observe the effects of a bombing event Domestic violence Intent to cause injury or death to a partner Insurance fraud Intent to make insurance claims from the bombing event Intimidation Intent to frighten another individual or group without injury or death 35
  • 37. Bombing Events & Blast Injuries Etiology of Bombing Injuries Explosive (%) Incendiary (%) Premature (%) Determined 2,483 (61.2) 359 (62.0) 296 (22.8) Attempted homicide 1,810 (44.6) 42 (7.3) 9 (0.7) Suicide 44 (1.1) 3 (0.5) 0 (0.0) Vandalism 398 (9.8) 35 (6.0) 206 (15.9) Revenge 209 (5.2) 132 (22.8) 33 (2.5) Protest 30 (0.7) 22 (3.8) 4 (0.3) Labor-related 24 (0.5) 8 (1.4) 1 (0.1) Extortion 29 (0.7) 113 (19.5) 4 (0.3) Excitement 20 (0.5) 4 (0.7) 32 (2.5) Domestic violence 19 (0.5) 0 (0.0) 7 (0.5) Insurance fraud 0 (0.0) 0 (0.0) 0 (0.0) Intimidation 0 (0.0) 0 (0.0) 0 (0.0) Undetermined 1,573 (38.8) 220 (38.0) 1,000 (77.2) Total 4,056 (100.0) 579 (100.0) 1,296 (100.0) 36
  • 38. Bombing Events & Blast Injuries Etiology of Bombing Deaths Explosive (%) Incendiary (%) Premature (%) Determined 363 (94.0) 129 (92.8) 75 (43.1) Homicide 268 (69.4) 69 (49.6) 10 (5.7) Suicide 53 (13.7) 3 (2.2) 1 (0.6) Vandalism 10 (2.6) 3 (2.2) 54 (31.0) Revenge 14 (3.6) 40 (28.8) 5 (2.9) Protest 0 (0.0) 0 (0.0) 0 (0.0) Labor-related 0 (0.0) 0 (0.0) 0 (0.0) Extortion 1 (0.3) 1 (0.7) 1 (0.6) Excitement 1 (0.3) 0 (0.0) 3 (1.7) Domestic violence 13 (3.4) 3 (2.2) 0 (0.0) Insurance fraud 3 (0.8) 3 (2.2) 1 (0.6) Intimidation 0 (0.0) 7 (5.0) 0 (0.0) Undetermined 23 (6.0) 10 (7.2) 99 (56.9) Total 386 (100.0) 139 (100.0) 174 (100.0) 37
  • 39. Bombing Events & Blast Injuries Target Institution Type Institution Subtype Residential Single family Structure, Condominium, Apartment Commercial Bank/ATM, Bar/Restaurant, Hotel/Motel, Independent food store, Manufacturing plant, Shopping center/Mall, Warehouse Governmental Local, State, Federal, Foreign, Military Educational School, College/University Transportation Airport, Bus/Train terminal, Port, Railway, Subway Mailbox Residential, Commercial Vehicle Residential, Commercial 38
  • 40. Bombing Events & Blast Injuries Target Institution Type Incidents (%) Injuries (%) Deaths (%) Determined 32,849 (91.0) 5,081 (85.7) 680 (97.3) Residential 10,465 (29.0) 1,866 (31.5) 388 (55.5) Commercial 5,151 (14.3) 1,740 (29.3) 74 (10.6) Governmental 1,596 (4.4) 756 (12.7) 178 (25.5) Educational 1,847 (5.1) 464 (7.8) 3 (0.4) Transportation 723 (2.0) 79 (1.3) 7 (1.0) Mailbox 7,404 (20.5) 75 (1.3) 2 (0.3) Vehicle 5,663 (15.7) 101 (1.7) 28 (4.0) Undetermined 3,261 (9.0) 850 (14.3) 19 (2.7) Total 36,110 (100.0) 5,931 (100.0) 699 (100.0) 39
  • 41. Bombing Events & Blast Injuries Bombing Materials • Ammonium nitrate • Black powder (gunpowder) • Smokeless powder • C-4 (RDX “research development explosive”) • Dynamite • TNT • Match heads • Pyrotechnic mixes 40
  • 42. Bombing Events & Blast Injuries Type of Material Injuries (%) Deaths (%) Determined 4,050 (68.3) 595 (85.1) Nitrate-based fertilizers 1,586 (26.7) 181 (25.9) Smokeless powder 818 (13.8) 114 (16.3) Inflammable liquids 579 (9.8) 139 (19.9) Black powder 526 (8.9) 47 (6.7) Pyrotechnics 232 (3.9) 18 (2.6) Dynamite 161 (2.7) 90 (12.9) Match heads 139 (2.3) 2 (0.3) C-4 5 (0.1) 1 (0.1) TNT 4 (0.1) 3 (0.4) Undetermined 1,881 (31.7) 104 (14.9) Total 5,931 (100.0) 699 (100.0) 41
  • 43. Bombing Events & Blast Injuries Terrorism and Bombing Events: Global or Local Problem for US Population? • 1996 to 2002: 925 international terrorist events involving U.S citizens • Bombing events: 776 (84%) • 1992 to 2002: more bombing injuries & deaths in the U.S. than terrorist injuries & deaths of U.S. citizens internationally 42
  • 44. Bombing Events & Blast Injuries 43 Analysis • Access • Internet • Panic & Instability • Public health focus: Bombing events vs. “N/B/C” events?
  • 45. Bombing Events & Blast Injuries 44 Pre-Hospital Care & Bombing Events
  • 46. Bombing Events & Blast Injuries Pre-Hospital Care Systems and Bombing Events • Classic models usually do not occur: 75% of patients will not interact with the EMS system • Classic system of triage, triage classifications, triage tags, flow points, and treatment areas only applies to a one-sided or one-dimensional scene • Ambulances transport patients to nearest facility: –Rapid turn around time –Instructed to take critical patients to nearest facility –Roads may be impassable except to a few hospitals –May not know route to outlying hospitals –Nearest hospitals may delay closure during disasters 45
  • 47. Bombing Events & Blast Injuries U.S Bombings: Pre-Hospital Care Data Event Hospital Data Injuries (*Total) Deaths EMS Oklahoma City 1995 434 (592) 167 90 (20.7%) Atlanta Olympics 1996 111 1 111 (100.0%) WTC 9/11 1,103 (7,250) 2,749 282 (25.5%) Pentagon 9/11 106 189 93 (87.7%) 46
  • 48. Bombing Events & Blast Injuries • Initiate fundamental resuscitation protocols:  Airway  Breathing  Circulation • Address blast injuries • Attempt to gather basic epidemiologic data from scene Pre-Hospital Management of Bombing Victims 47
  • 49. Bombing Events & Blast Injuries Primary Blast lung injury (pulmonary barotrauma) TM rupture and middle ear damage Abdominal hemorrhage and perforation Globe rupture Concussion (TBI without physical signs of head injury) Secondary Penetrating ballistic (fragmentation) or blunt injuries Eye penetration (can be occult) Tertiary Fracture and traumatic amputation Closed and open brain injury Quaternary Burns (flash, partial, and full thickness), Crush injuries Asthma or COPD (from dust, smoke, or toxic fumes) Angina, Hyperglycemia, Hypertension Blast Injuries http://www.bt.cdc.gov/masscasualties/explosions.asp 48
  • 50. Bombing Events & Blast Injuries 49 No Pre-Hospital Care Protocol for Bombing Injuries
  • 51. Bombing Events & Blast Injuries 50
  • 52. 51 Pre-hospital Care Blast Injuries Algorithm Initial evaluation: Airway, Breathing, Circulation Primary Blast Injuries Secondary Blast Injuries Assess Lungs, TM’s, Abdomen O2, IV access, Monitor Tertiary Blast Injuries Quaternary Blast Injuries Assess Soft tissue injuries, Eyes Apply dressings Assess Fractures, Head injuries Splint fractures Assess Burns, Crush injuries, Exacerbations of Chronic diseases Bombing Events & Blast Injuries
  • 53. 52 Pre-hospital Care Blast Injuries Algorithm Initial evaluation: Airway Breathing Circulation Primary Blast Injuries Lungs TM’s Abdomen Non-rebreather mask Monitor *Thoracentesis Avoid probing ear Continuous assessment Eye Cover ruptured globe Brain Monitor neurological status Bombing Events & Blast Injuries
  • 54. 53 Pre-hospital Care Blast Injuries Algorithm Initial evaluation: Airway, Breathing, Circulation Primary Blast Injuries Secondary Blast Injuries Soft Tissue Injuries Eye Apply sterile dressings Do not remove fragments Cover globe Do not remove fragments Bombing Events & Blast Injuries
  • 55. 54 Pre-hospital Care Blast Injuries Algorithm Initial evaluation: Airway, Breathing, Circulation Primary Blast Injuries Secondary Blast Injuries Tertiary Blast Injuries Fractures Amputations Head Injuries Apply splints Cover open wounds Hemostasis Cover and transport amputated part Apply dressing to open injuries Monitor neuro status Bombing Events & Blast Injuries
  • 56. 55 Pre-hospital Care Blast Injuries Algorithm Initial evaluation: Airway, Breathing, Circulation Primary Blast Injuries Secondary Blast Injuries Tertiary Blast Injuries Quaternary Blast Injuries Burns Crush Injuries Chronic Disease Exacerbations Cover with sterile dressing IVF IVF NRM, Albuterol NTG for chest pain Bombing Events & Blast Injuries
  • 57. Bombing Events & Blast Injuries Acute Hospital Management of Bombing Injuries
  • 58. 57Bombing Events & Blast Injuries Gutierrez de Caballos JP, Fuentes FT, Diaz DP, Sanchez MS, Llorente CM, Sanz JEG. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33(1):S107-S112. 57
  • 59. Bombing Events & Blast Injuries 58 Management of Bombing Injuries Primary Survey Secondary Survey Blast Lung Injury Soft Tissue & Bone Injuries Eye & Ear Injuries Abdominal Injuries Head Injuries Burns CXR X-rays CK, Electrolytes T&S Visual Acuity Corneal Exam CT Face? FAST US CT A/P T&S CT Head Electrolytes High flow O2 Chest Tube? Abx & Tetanus Wound Care Ophtho? Nuerosurg? IVF Serial Exams & Observation OR as needed
  • 60. Bombing Events & Blast Injuries 59 Blast Injuries. N Engl J Med.2005;352:1335-42.
  • 61. 60Bombing Events & Blast Injuries Tympanic Membrane Evaluation: Indicator of Internal Blast Injuries Otoscopic Exam of Tympanic Membrane Rupture Observe O2 saturation for 6-8 hrs Intact Discharge Decreased O2 Admit for further care Normal O2 Discharge with warnings Otoscopic Exam of Tympanic Membrane Rupture Admit and anticipate further injuries Intact Treat injuries No obvious injuries present Injuries present DePalma RG, Champion HR, Hodgson MJ. Current Concepts: Blast injuries. N Engl J Med. 2005;352(13): 1335-1342. Blast Injuries. N Engl J Med.2005;352:1335-42.
  • 62. Bombing Events & Blast Injuries Summary • Urban areas around the world face the risk of bombing events • US citizens are at more risk of domestic bombing events than international events • Local jurisdictions (hospitals, EMS, fire, police) should be prepared for both explosive and incendiary blast events • Pre-hospital and Emergency Department management of blast injuries should be implemented in an algorithm manner 61 Kapur@bcm.edu