# Presentation: 559628

## 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

## 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.

## ObjectivesBlast 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

## Weapons of Mass Destruction

- “... 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

- Make-shift bombs are WMD

- Alternative terms for WMD
- CBRNE – chemical, biological, radiological, nuclear, explosive
- BNICE – biological, nuclear, incendiary, chemical, explosive

## 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

- 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

**Bombings in the U.S.**
- CDC, FBI, State –  Bomb-related data, 1988-1997

**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)

## WTC

- OKC

## Selected Causes of Deaths, United States, 1988-1997

| Cause | Count | Data source |
| --- | --- | --- |
| Floods  | 903 |  NOAA |
| Bombs | 830 | NCHS |
| Lightning | 712 | NCHS |
| Tornadoes | 437 | NOAA |
| Earthquakes | 276 | NCHS |
| Hurricanes | 224 | NOAA |

- Selected Causes of Deaths, United States, 1988-1997

## 2001 Worldwide Terror Against U.S. Concerns

- Bombs were used in **3⁄4**  of the 348 terror attacks in 2001
- 98% of terror attacks used conventional weapons.

- Almost one terror attack per day in 2001.

## 2001 Total U.S. Worldwide Terror Casualties

- Majority of casualties in 2001 occurred at non-Gov. sites

## 5 Billion Pounds Produced Each Year in U.S.

**Explosive matter**

**Explosives**

**Chemicals for non-explosive purpose**

**High explosives(HE)**

**Propellants(LE)**

**Pyrotechnic **(LE)

**1**

**2**

**Military-grade**

**Industrial-grade**

**Gun**

**Rocket**

- Lead azideHg fulminateTetrazene

- Singles = TNT; RDX; PETN; Mixes = CB; RDX-based plastics; Torpex

- Gelatins; powders; permitted; ANFO; slurries, emulsions

- Black powder

- Double base; composites; liquid fuels; oxidizers

- Flashes, FlaresFume generators
- Optical/acoustic signals, fireworks

**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

- From *Explosives*, R. Meyer – 5th Edition

## Explosives areTerrors’ 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

## Understanding Terrorism

**1.****	****Intent to induce fear **in someone other than its victims,  with the goal to change an entity’s 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

## 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

## 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
- “Gentlemen’s agreement” - advanced warning limits casualties
- –>evacuations, & staging of medical resources

- 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

- The 1990s – The Suicide bomber era
-   – Human “smart bomb” for precise placement
-   – Used only against “soft” civilian targets

## What’s The Trend?

**What’s The Trend?**

**   ****IRA era    **

**Solo Suicide era**

**Complex tactic era**

## 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 < 15% success
- Targeted states
- Fully or partially withdrew from territory
- Began negotiations
- Released a terrorist leader
- Suicide campaigns - successful against even hawkish governments
- Reagan
- Netanyahu

## 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

## 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**

**Bomb-Injury Threat Model**** **

**Lee-Davis**

## Military Data Less Helpful

- TE Davis, CY Lee

## 27% of trauma surgeonsnot prepared to treat 

**J Trauma. 2004;56: 1033-1041**

- 27% of trauma surgeonsnot prepared to treat
- blast trauma

## ObjectivesBlast 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.  *

## 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

## ObjectivesBasics 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

## Explosives Are Ubiquitous

**1****.  Legally made – illegally obtained explosives **from commercial and military sources
- _5 billion pounds_ produced legally

**3.  Commandeered fuel-laden commercial vehicles**
-  Plane, train, fuel oil truck, LNG fuel super tanker ship

**Explosive “recipes”** available in libraries, bookstores, www
- -	ANFO fertilizer, acetone-H2O2, Molotov cocktail

## Explosives Classified by the Speed of ExplosionHigh-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

## Idealized blast overpressure waveformseen only in high-order explosives (HE)

**PRESSURE**

- TIME(microseconds)

**PEAK OVERPRESSURE**

**POSITIVE PHASE OVERPRESSURE DURATION**

**0 ATM** Zero
- Atmosphere Pressure

- Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement Principles.

**Idealized blast overpressure waveform****seen only in high-order explosives (HE)**

**NEGATIVE PHASE**

**VACUUM**

**Zero ATM**

- Detonation

## Low-order explosives (LE) = deflagration – not detonation 
Subsonic – explosion occurs < the speed of sound
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)

- _Subsonic _– explosion occurs < the speed of sound
- 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)

- Explosives Classified by the Speed of Explosion

## Classified by Size and Weight

- _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 < 10 kg gross weight, mortars, 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

## Classified by TNT-equivalents

- _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

## Bombs can be Classified by 

- 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

- Bombs can be Classified by_ _
- _Source and Original Purpose_

## 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**

## Size Does Matter

- Explosives	Lethal Blast 	Serious Injury
- in Kg TNT-eq.	Range (meters)	 Range (meters)

## Slide 33

## Slide 34

## Environment can Protect or Harm Open, Confined, and Enclosed space explosions 

**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

**Confined space** – inside bus, train, or auditorium
-  Blast pressures intensified x2-9,
-  20% fatalities, 70% DOS, complicated rescue

**Open Space** – street corner, open market, stadium
-  Blast impulse weakens rapidly ~ 1 / radius2
-  10% fatalities, straight-forward rescue and transport

## Environment CharacteristicsConfined & Enclosed Space 

- shield, dampen, or amplify the
- blast over-pressure wave.

- Environment CharacteristicsConfined & Enclosed Space

## 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

## 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

## Primary Blast Injuryassociated 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*

**Notes:**
Fuel-air explosives are those that are dropped dispurse a cloud of flammable 
substance and then are ignited- especially nasty as the blast wave comes down 
from above and remember the ground is a reflective surface.
Underwater explosions have a larger concussive area ( genade 25meters/in 
water 75meters). Think of how a depth charge gets the submarine, you don’t 
hit it with the fragments, you rip it open with the concussive force from the 
explosion in water.

## “White Butterfly Sign”

- CL Horrocks, Wounds of Conflict

**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

## Blast Abdomen 

- 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

**Blast Abdomen**** **

## Blast Brainconcussion, 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

## 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

- 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*

- Secondary Blast Injury“Secondary” applied exclusively to high-order (HE) injuries

**Notes:**
This is the injury caused by flying debris, either shrapnel from the device or pieces
that where created by the explosion and projected by the explosive force
The one difference is that shrapnel is not a smooth projectile. Therefore these
projectiles impart their kinetic energy early causing large ragged wounds. 
Entrance wounds can be large and exit wounds small

## Glazed Glass Retrofitting

## 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*

## 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

## 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)

## 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.

## Trauma PatternsSmall (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 < 5 meters
- 	- occult nails < 100 meters
- 	- temporary deafness
- 	- risk of Hepatitis, Tetanus, HIV

**}**** ****1/3****rd**** **killed or admitted

- }   2/3rd outpatient treatment

## 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°.

## 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 (<1-5%)

- Injury patterns
- 	- respiratory problems, temporary deafness

- Rescue must weigh risk versus benefit of rapid ingress

## 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**

**Bomb-Injury Threat Model**** **

## Questions ?

- Tim Davis, MD, MPH 	   Catherine Y. Lee, MPH     Sherlita Amler, MD
-  _[TDavis1@cdc.gov](mailto:TDavis1@cdc.gov)__ __	__   __[CLee9@emory.edu](mailto:CLee9@emory.edu)__	__          __[SAmler@cdc.gov](mailto:SAmler@cdc.gov)__ _

## Questions ?

- Sherlita Amler, MD
- Medical Epidemiologist
- CDC/NCIPC/DIDOP
-         _[SAmler@cdc.gov](mailto:SAmler@cdc.gov)__ _
- Tim Davis, MD, MPH
- Medical Epidemiologist
- CDC/NCIPC/DIDOP     _[TDavis1@cdc.gov](mailto:TDavis1@cdc.gov)_
- Catherine Y. Lee, MPH
- Research Analyst, Emory
- Rollins School of Public Health_[CLee9@emory.edu](mailto:CLee9@emory.edu)__ _