Collective review
The Surgeon and Acts of Civilian Terrorism: Blast Injuries

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Weapons of mass destructions

We love death. The US loves life. That is the big difference between us.

Osama bin Laden, 1998

The Defense Against Weapons of Mass Destruction Act of 1996 defines a weapon of mass destruction (WMD) as any weapon or device that is intended or has the capability to cause death or serious bodily injury to a large number of people through the release, dissemination, or impact of toxic or poisonous chemicals or their precursors, disease-causing organisms or their biologic toxins, or radiation or

Surgeon preparedness

A survey assessment of preparedness of surgeons for disaster management that was conducted by the Eastern Association for the Surgery of Trauma before the terrorist attacks on the World Trade Center and Pentagon on September 11, 2001, demonstrated that its membership of leading US trauma surgeons was not well prepared to respond to the health-care needs of mass casualties from biologic, chemical, nuclear, or blast disasters.7 These trauma surgeons were best prepared to manage blast injury, but

Weapons of opportunity

The attractiveness of explosives and incendiary devices is related to the ready and inexpensive availability of precursors for making bombs, the relative ease of learning how to make a destructive explosive device, and the potential opportunities for using preexisting commercial resources as explosive devices. This was exemplified by the events of September 11, with the use of airplanes as guided missiles operated by suicide bombers. Similar opportunities present themselves in the form of

Physics and biodynamics of blast injury

Blast injury is the physiologic and anatomic insult to the human body caused by the physical properties of an explosion. Molecules in air are constantly in a state of motion and impart intrinsic properties of pressure, temperature, and density, which are referred to as the state of the gas.9 When this state of the gas is disturbed from normal conditions, it can result in an escalation of molecular speed and an increase in the number of molecules occupying a defined space, causing the density,

Blast pathophysiology

Blast injury has been classified into four specific and distinct categories that reflect the mechanism of tissue injury and physical tissue damage that occur as a result of the blast phenomena: primary, secondary, tertiary, and quaternary blast injury.10, 17

Primary blast injury

This form of blast injury results from the deleterious effects of the blast wave passing through the body. A blast wave has two damaging components: the stress wave, which causes damage in relation to the wave’s peak of intensity, and the sheer wave, which is related to the peak velocity strain force of the initiating explosion.18 These waves have little or no effect on solid or fluid-filled organs, but have their major destructive potential in air-containing organs, most specifically at

Secondary and tertiary blast injury

This is by far the most common injury mechanism among blast survivors, so it is the most important to anticipate and to be prepared to treat. In general, management of secondary blast injury is typical of the contemporary management of trauma, although the complex multidimensional nature of these injuries, as described previously, makes them more challenging to treat. Secondary blast injury refers to the impact on a patient’s body of projectiles that are propelled forward from the pressure

Quaternary blast injury

Quaternary blast injury refers to the miscellaneous forms of injury resulting from byproducts of explosions, such as burns from the fireball and resulting fires that may accompany explosions, inhalation of dust particles by both casualties and first responders, chemical and radiologic exposure and contamination from “dirty bombs,” crush injury from falling or entrapping debris, and the effects of building collapse. It also refers to the special needs of the patient as a result of preexisting

Obstetric considerations

The fetus does not possess gas-filled structures, protecting it from this component of the primary blast wave. But recognizing that the primary blast wave is amplified threefold in an aqueous environment should prompt concern about potential maternal-fetal primary blast injury as a result of the amniotic fluid, which surrounds the fetus. In evaluation of the obstetric patient after blast injury, attention should be directed to sonographic examination of the gravid uterus to rule out uterine

Dirty bombs

By definition, “dirty bomb” can refer to any contaminant dispersed as a result of an explosion and falls under the category of quaternary forms of blast injury. Perhaps the most widely publicized dirty bombs are radiologic dispersal devices, which will release radiation without nuclear explosion. The blast effect of the radiologic dispersal device is limited to the explosive potential of the material being used to disperse the radionuclides. Their greatest impact is the fear and social

Acknowledgment

Members of the Ad Hoc Subcommittee on Disaster and Mass Casualty Management of the Committee on Trauma of the American College of Surgeons are:

Dennis Ashley, MD, FACS, John A Armstrong, MD, FACS, Palmer Q Bessey, MD, FACS, Christopher T Born, MD, FACS, Susan M Briggs, MD, FACS, Eileen Bulger, MD, FACS, Patty Byers, MD, FACS, Quirico Canario, MD, FACS, Philip Caropreso, MD, FACS, William Cioffi, MD, FACS, Gerald Demarest, MD, FACS, Jay Doucet, MD, FACS, David Evans, MD, FACS, Richard Fantus, MD,

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      The injuries resemble ballistic injuries, with blunt or ballistic penetration injuries [13–15]. Tertiary injuries are characterised by the movement of the body and its subsequent impact on structures, resulting in blunt injuries [12,16–18], resembling falls from height or the impact of an object on a bone [19]. Quaternary blast injuries are those which do not fall into the previous categories, such as burns.

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    This review is a project of the Ad Hoc Subcommittee on Disaster and Mass Casualty Management of the Committee on Trauma of the American College of Surgeons. Members of this subcommittee are listed in the Acknowledgment.

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