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An Introduction to Asymmetric War Terrorism and the Epidemiology of Blast Trauma

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Title: An Introduction to Asymmetric War Terrorism and the Epidemiology of Blast Trauma


1
An Introduction to Asymmetric War
(Terrorism)and the Epidemiology of Blast
Trauma
  • Timothy E. Davis, MD, MPH
  • Lt. Commander, USPHS Commissioned
    CorpsCDC/NCIPC/DIDOP/OD
  • Asst. Professor of Emergency Medicine, Emory
    University

2
Rules of Engagement (ROE) directives under
which military forces initiate engagement with
belligerent forces
  • 1. Presentations developed from domestic and
    foreign open source information (OSINF) including
    health, engineering, intelligence, national
    security, and military.
  • 2. This area of study is problematic
  • a. Lack of data standards - definitions,
    analyses, reporting
  • b. Prone to misinformation propaganda
  • 3. The opinions are those of the cited sources,
    and does not constitute an endorsement by the
    CDC, DHHS, or Emory University.

3
ObjectivesBlast Epidemiology
  • 1. Discuss terrorism and asymmetric war
  • 2. Review the limits of epidemiologic data
  • 3. Examine why conventional weapon terrorism
    (blast trauma) is both a public health and
    healthcare system problem

4
Weapons of Mass Destruction
Make-shift bombs are WMD
  • any explosive, incendiary, or poison gas - (i)
    bomb, (ii) grenade, (iii) rocket ..., (iv)
    missile ..., (v) mine, or (vi) ... similar ...
    devices U.S. Code, Title 18, Part I,
    Chapter 113b, Sections 2332a and 921a

Alternative terms for WMD CBRNE chemical,
biological, radiological, nuclear,
explosive BNICE biological, nuclear,
incendiary, chemical, explosive
5
Bombings in the U.S. CDC, FBI, State
Bomb-related data, 1988-1997
  • 17,579 criminal bombings in U.S, 1988-1997 (FBI)
  • Average of 5 bombings per day
  • Bombings doubled over the 10-year period
  • 214 U.S. Embassy bombings, 1988-1997 (State) -
    Average 2 per month

830 bomb-related deaths, 1988-1997 (CDC/NCHS) US
bombing death counts exceed deaths for most US
disasters - floods, hurricanes, lightening.
(NOAA) 4,063 bomb-related injuries (FBI)
6
WTC
OKC
7
Selected Causes of Deaths, United States,
1988-1997
8
2001 Worldwide Terror Against U.S. Concerns
Bombs were used in ¾ of the 348 terror attacks
in 2001 98 of terror attacks used conventional
weapons.
Almost one terror attack per day in 2001.
9
2001 Total U.S. Worldwide Terror Casualties
Majority of casualties in 2001 occurred at
non-Gov. sites
10
5 Billion Pounds Produced Each Year in U.S.
Explosive matter
From Explosives, R. Meyer 5th Edition
Chemicals for non-explosive purpose
Explosives
Fertilizer grade ammonium nitrate Chlorates as
weed killers Gas generating for foam
plastics Organic peroxides as catalysts NTG and
PETN-soln for pharmaceuticals Salts of nitrated
organic acids for pest-control
High explosives(HE)
Propellants(LE)
Pyrotechnic (LE)
Flashes, FlaresFume generators Optical/acoustic
signals, fireworks
Gun
  • 1
  • 2

Lead azideHg fulminateTetrazene
Black powder
Rocket
Double base composites liquid fuels
oxidizers
Military-grade
Industrial-grade
Gelatins powders permitted ANFO slurries,
emulsions
Singles TNT RDX PETN Mixes CB RDX-based
plastics Torpex
11
Explosives areTerrors Perfect Storm
  • 1. Available 5 billion pounds legally made in
    U.S.

2. Low tech Literacy helpful
3. Scalable 1 kilogram to 1 kiloton
TNT-equivalents
4. Simple delivery - hand-carried, truck,
plane, train, ship
5. Simple Guidance system placed, thrown, or
suicide
6. Human factors available financing and
volunteers
12
Understanding Terrorism
1. Intent to induce fear in someone other than
its victims, with the goal to change an entitys
political behavior.
2. Independent of the cause that motivates it
can be unjust or righteous the end justifies
the means.
3. Neither spontaneous nor random it is a
staged psychological act conducted for its impact
on an audience.
4. Not aimed at personal gain it can be
motivated by political, religious, or
ideological objectives.
5. Requires ever escalating shock and awe
to remain effective maintain sense of
helplessness
13
Who Gets Targeted?
  • Almost all terror campaigns target free-press
    countries
  • Representative governments are especially
    vulnerable
  • Russia
  • Chechens used suicide tactics against free-press
    Russia, but not U.S.S.R.
  • Kurds Kurdistan parts of Iran, Iraq, and
    Turkey
  • Used terrorism against Turkey, only as Turkey
    moved toward more representative government in
    the 1980s
  • Never used terror tactics against Iran or Iraq,
    yet where severely repressed by Saddam Hussein

14
Terror Tactics are Escalating Civilians now more
than collateral damage
  • The 1980s The IRA era
  • Placement / stationary bombs - package, culvert,
    or car bombs targeted against government or
    rivals
  • Gentlemens agreement - advanced warning limits
    casualties
  • evacuations, staging of medical resources

The 1990s The Suicide bomber era Human
smart bomb for precise placement Used only
against soft civilian targets
The 2000s Complex tactics era couples
mega-bombs with multiple synchronized attacks
often suicide pioneered in 1983 Beirut large
or multiple suicide smart bombs against soft
targets
15
Whats The Trend?
IRA era
Solo Suicide era
Complex tactic era
16
Why Is Terror Growing?Because it works
  • In 6 of the 11 suicide campaigns successful (55)
  • terrorists achieved at least partial victory
  • airpower or economic sanctions
  • Targeted states
  • Fully or partially withdrew from territory
  • Began negotiations
  • Released a terrorist leader
  • Suicide campaigns - successful against even
    hawkish governments
  • Reagan
  • Netanyahu

17
Why Is Terror Growing?Because it works
  • Democratic leaders publicly confirmed suicide
    attacks pushed them to make concessions
  • Examples
  • U.S. left Lebanon in 1983 - Marine barracks
    bombing
  • Israel followed in 1985 after 800 IDF deaths /
    18 mo.
  • Spain left Iraq after March 2004 Madrid bombings

18
Bomb-Injury Threat Model
Lee-Davis
Bomb Size weightExplosive choice Purpose
Source Delivery system Adulterants Tactic
Human Age, sex, weight Fitness,
PPE Nutrition, health Access to care
Open Space, Confined Space,Structural
Collapse Reflecting or Shielding
surfaces Building and non-structural debris Air
and liquid hazards
19
Military Data Less Helpful
TE Davis, CY Lee
20
J Trauma. 200456 1033-1041
27 of trauma surgeonsnot prepared to treat
blast trauma
21
ObjectivesBlast Epidemiology
  • 1. Discuss terrorism and asymmetric war
  • 2. Review the epidemiologic data and the
    limits
  • 3. Examine why conventional weapon terrorism
    (blast trauma) is both a public health and
    healthcare system problem

a. coercion of a strong state by a weak stateless
entity
a. bombings occur daily in the U.S. b.
terrorists use bombs 98 c. No standard terms,
analyses, reporting
a. An unanticipated event that adversely affects
of a large segment of the population and
potentially overwhelms regional health
infrastructure.
22
The Basics of Explosives and Bomb-blast Trauma
  • Timothy E. Davis, MD, MPH
  • Lt. Commander, Commissioned Corps,
    USPHSCDC/NCIPC/DIDOP/OD
  • Asst. Professor of Emergency Medicine,
  • Emory University

23
ObjectivesBasics of Bomb Blast Trauma
  • 1. Recognize how injuries and casualty mix are
    affected by
  • a. bomb type
  • b. terrorist tactic
  • c. bombing environment
  • 2. Anticipate casualty severity profile, and
    identify common, occult, and high risk injuries
    following
  • a. open space bombing
  • b. confined space bombing
  • c. bombing with structural collapse

24
Explosives Are Ubiquitous
  • 1. Legally made illegally obtained explosives
    from commercial and military sources
  • 5 billion pounds produced legally
  • Explosive recipes available in libraries,
    bookstores, www
  • - ANFO fertilizer, acetone-H2O2, Molotov cocktail
  • 3. Commandeered fuel-laden commercial vehicles
  • Plane, train, fuel oil truck, LNG fuel super
    tanker ship

25
Explosives Classified by the Speed of
ExplosionHigh-order (HE) versus Low-order (LE)
  • High-explosives (HE) detonation
  • Supersonic Explosion is faster than the speed
    of sound
  • Blast over-pressurization impulse wave
  • HE does not mean large a hand grenade is a HE
  • HE blast injuries are characterized as a)
    Primary, b) Secondary, c) Tertiary, d) Quaternary
  • E.g., all military bombs, TNT, Dynamite, Semtex,
    ANFO

26
Idealized blast overpressure waveformseen only
in high-order explosives (HE)
PEAK OVERPRESSURE
PRESSURE
POSITIVE PHASE OVERPRESSURE DURATION
NEGATIVE PHASE
0 ATM Zero Atmosphere Pressure
Zero ATM
VACUUM
Detonation
TIME(microseconds)
Horrocks, CL. Blast Injuries Biophysics,
Pathophysiology and Mnaagement Principles.
27
Explosives Classified by the Speed of Explosion
  • Low-order explosives (LE) deflagration not
    detonation
  • Subsonic explosion occurs
  • NO blast over-pressurization wave
  • LE does not mean small 9-11 attacks involved
    LE
  • LE injuries can be characterized as a) shrapnel,
    b) blunt, c) crush, d) burn
  • E.g., Napalm, gunpowder, Molotov cocktail, many
    petroleum-based (but ANFO is HE)

28
Bombs can be Classified by Size and Weight
  • Small Arms 1-person carry - hand grenades,
    rocket propelled grenades (RPG), also machine
    guns, assault rifles
  • Light Arms 1 or 2-person carry - makeshift
    bombs shoulder-held missile launchers, and some
    landmines, surface mines, grenades
  • Heavy Weapons mechanized- makeshift car,
    truck, plane, train, or ship bombs, also air
    bombs, rockets, tanks, artillery

29
Bombs can be Classified by TNT-equivalents
TNT-eq the amount of TNT needed to create the
same blast effect TNT-eq calculations 7
different formulas with differing results A
measure of energy not of raw weight - a 10 kg
(TNT-eq) backpack bomb has 2 kg of explosives
Shock waves and heat waves decrease rapidly 1
/ radius2
30
Bombs can be Classified by Source and Original
Purpose
  • Original Purpose
  • Military-grade government sanctioned
  • Civilian-grade legally manufactured
    assault-lite - Uzi, Glock, Mauser, Berretta,
    Bushmaster AR-15
  • Source
  • Mass-produced manufactured by arms industry
  • Makeshift Improvised, small assembly line

31
Bombs can be Classified based on Adulterants
  • Dirty Bomb - addition of bio-chem-rad agents
  • Cyanide, Warfarin, Hepatitis have been used
  • Exothermic reaction may alter biologics and
    chemicals
  • Radiologicals are not affected by heat
  • Shrapnel
  • Criminals lack access to high tech shrapnel or
    canisters
  • Use less efficient bolts, nails, glass
  • Compensate with excess bulk explosives

32
Size Does Matter
Explosives Lethal Blast Serious Injury in Kg
TNT-eq. Range (meters) Range (meters)
33
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34
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35
Environment can Protect or Harm Open, Confined,
and Enclosed space explosions
  • Open Space street corner, open market, stadium
  • Blast impulse weakens rapidly 1 / radius2
  • 10 fatalities, straight-forward rescue and
    transport
  • Confined space inside bus, train, or auditorium
  • Blast pressures intensified x2-9,
  • 20 fatalities, 70 DOS, complicated rescue

Structural collapse (Enclosed space) inside
a reinforced multi-story building - Complex
reflections, blast pressure up x2-9,
structural collapse, complicated rescue,
delayed care, 20 fatalities, 90 DOS
36
Environment CharacteristicsConfined Enclosed
Space
Surrounding structures can either shield,
dampen, or amplify the blast over-pressure wave.
37
Blast-Injury Vocabulary Specific for High-order
Explosives (HE)
  • 1. Primary (1) Blast Injury (e.g. blast lung)
    over-pressurization impulse wave often fatal
  • Secondary (2) Blast Injury (e.g. glass shards)
    penetrating shrapnel and debris
  • Tertiary (3) Blast Injury (e.g. traumatic
    amputation) blunt - blast wind throws the
    individual

4. Quaternary (4) Blast Injury (miscellaneous)
burns, fume poisonings, suffocation, building
collapse, crush injuries, chronic disease
flare, mental health
38
Blast Injuries Do Not Occur in Isolation
  • A Casualty with Blast Lung (1) will also have
  • 1. Penetrating glass shards (2)
  • 2. Traumatic amputation (3)
  • 3. Burns, inhalation injury, deafness (4)
  • The Injury Severity Score (ISS) does not
    accurately measure complexity, or resource
    utilization
  • Other Typical confined space (bus) injuries
  • (1) Blast lung, bowel rupture, TM rupture
  • (2) Penetrating foreign body to globe, chest,
    abdomen
  • (3) Traumatic amputations, Fx to face, pelvis,
    ribs, spine
  • (4) crush injuries, 1 2 burns

39
Primary Blast Injuryassociated exclusively with
high-order (HE) explosives
  • 1. Caused by the over-pressure blast wave
  • Invisible, supersonic
  • 2. Lethal radius rapidly diminishes with distance
  • 1 / radius3 . Lethal radius is 3x in water
  • 3. Affects most air filled structures
  • Lungs, GI tract, Sinuses, Middle ear (TM rupture)
  • But also brain shell shock

Courtesy Battlefield Wounds, JR Mechtel, RN,
MSN DMRTI
40
White Butterfly Sign
  • Blast Lung 70 fatal
  • A clinical diagnosis, confirmed with X-ray
  • A severe pulmonary contusion from air
    compression re-expansion
  • Symptoms exposure plus SOB, cough, hemoptysis,
    retrosternal pain
  • Signs Tachypnea, cyanosis, decrease BS, dull to
    percussion, rales / crackles, hemo/pneumo-thorax,
    subcutaneous emphysema, retro-sternal crunch,
    air emboli, retinal artery emboli
  • Management Similar to severe pulmonary
    contusion
  • complex fluid management
  • mechanical ventilation further increases
    chance of air emboli

CL Horrocks, Wounds of Conflict
41
Blast Abdomen
  • Delayed onset 8-36 hours more common in
    submersion
  • 1. Intestinal intra-wall hemorrhages
  • 2. Shearing of local mesenteric vessels
  • 3. Sub-capsular and retroperitoneal hematomas,
  • Fracture of liver and spleen, and testicular
    rupture
  • Zero in Madrid (?)
  • Symptoms exposure plus abdominal pain, nausea,
    vomiting, hematemesis (rare), rectal pain and
    tenesmus, testicular pain
  • Signs abdominal tenderness, rebound, guarding,
    absent bowel sounds, signs of hypovolemia
  • Management Rescect small bowel contusions 15
    mm, and large bowel contusions 20 mm
  • CL Horracks, Wounds of Conflict, 2001

42
Blast Brainconcussion, TBI, shell shock,
misdiagnosed behavioral disorder
  • Blast over-pressure wave not always a straight
    path
  • Dampened, reflected, or amplified off solid
    surfaces
  • Helmets, Kevlar stop shrapnel, but magnify blast
    waves
  • Do not assume all dysfunctional actions are
    behavioral
  • Future treatment for IC bleed may be rF VIIa
  • Animal studies promising
  • Human recombinant Factor VIIa used in Israel
    under a humanitarian protocol
  • Not U.S.-FDA approved or recommended

J Neurosurgery Jan 2002
43
Secondary Blast InjurySecondary applied
exclusively to high-order (HE) injuries
  • 1. Penetrating injury from shrapnel or debris.
  • 2. Open-space bombings nails out to 100
    meters- from 5 kg bomb
  • 3. Makeshift bomb shrapnel unpredictable path -
    high use of CT and X-ray in Israel
  • 4. Treat as dirty grossly contaminated delayed
    primary closure

Courtesy Battlefield Wounds, JR Mechtel, RN,
MSN DMRTI
44
Glazed Glass Retrofitting
45
Tertiary Blast Injury Tertiary applied
exclusively for high-order (HE) injuries
  • 1. Caused by displacement of body, or body parts,
    by force of blast wind includes traumatic
    amputations
  • 2. Blunt trauma solid object strikes, or victim
    is thrown against solid object, includes
    impalement
  • 3. Care follows standard blunt trauma protocols

Courtesy Battlefield Wounds, John R. Mechtel,
RN, MSN DMRTI
46
Quaternary Blast Injury Quaternary applied
exclusively for high-order (HE) injuries
  • Classified by some disciplines as miscellaneous
  • 1. Crush injuries
  • 2. Suffocation and Fume poisonings
  • 3. Burns
  • 4. Exacerbation of chronic disease
  • Asthma, COPD, diabetes, hypertension, CAD, PUD,
    alcohol and drug abuse, mental health
  • 5. New behavioral problems

47
Low-order Explosives (LE) uses clear text
mechanism descriptions differ from HE
  • Low-order explosives (LE) differ in mechanism
  • 1. Deflagration not detonation (HE)
  • 2. Subsonic slow burn versus supersonic
    explosion
  • 3. No over-pressurization and blast wave impulse
  • Ballistic effect shrapnel and debris
  • Thermal effect burns from the heat generation
  • Suffocation all oxygen is consumed
  • Also - fume poisonings, crush injuries,
    exacerbation of chronic disease (asthma, COPD,
    diabetes, hypertension, MI, PUD, mental health)

48
Low-order Explosives (LE) versus High-order
Explosives
HE and LE produce dirty contaminated wounds in
devitalized tissue. Survivability largely
depends on proximity to the explosion, building
construction, evacuation proficiency, and
luck. 70-90 of fatalities are DOS.
49
Trauma PatternsSmall (5 kg) Open Space Suicide
Bombing
  • Casualties 1-30 (Israel - average 23, range
    1-99)
  • Severity
  • killed 1-5
  • admitted 5-10
  • treat release 20
  • Injury patterns
  • - 1 Blast trauma
  • - occult nails
  • - temporary deafness
  • - risk of Hepatitis, Tetanus, HIV

1/3rd killed or admitted
2/3rd outpatient treatment
50
Trauma Patterns Small (10 kg) Confined Space
Backpack Bomb
  • Casualties 20-50 bus and 150-200 train /
    bomb - 70 of fatalities are Dead on Scene (DOS)
  • Severity
  • killed 20
  • admitted 20
  • treat and release 60
  • Injury patterns
  • - 1 Blast trauma anywhere within bus or train
    cabin
  • - temporary deafness, risk of Hepatitis,
    Tetanus, HIV
  • Complicated train rescue


Simplified Severity Predictor 1/3rd killed or
admitted 24.
51
Structural collapse bombing (100-1,000 kg TNT-eq)
  • Casualties 100 3,000
  • largely based on bomb size, time of day,
    warning, building structure, and evacuation
    proficiency
  • 90 of fatalities are DOS

Severity follows pattern of Earthquake or
structural collapse killed if in the wake
treat and release if nearby, but not in direct
path small percentage admitted (
Injury patterns - respiratory problems,
temporary deafness
Rescue must weigh risk versus benefit of rapid
ingress
52
Bomb-Injury Threat Model
Bomb Size weightExplosive choice Purpose
Source Delivery system Adulterants Tactic
Human Age, sex, weight Fitness,
PPE Nutrition, health Access to care
Open Space, Confined Space,Structural
Collapse Reflecting or Shielding
surfaces Building and non-structural debris Air
and liquid hazards
53
Questions ?
Tim Davis, MD, MPH Catherine Y. Lee, MPH
Sherlita Amler, MD TDavis1_at_cdc.gov
CLee9_at_emory.edu SAmler_at_cdc.gov
54
Questions ?
Sherlita Amler, MD Medical Epidemiologist CDC/NCIP
C/DIDOP SAmler_at_cdc.gov Tim Davis, MD,
MPH Medical Epidemiologist CDC/NCIPC/DIDOP
TDavis1_at_cdc.gov Catherine Y. Lee, MPH Research
Analyst, Emory Rollins School of Public
HealthCLee9_at_emory.edu
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