Suicide bombing attacks: update and modifications to the protocol

Abstract

Objective: To review the experience of a large-volume trauma center in managing and treating casualties of suicide bombing attacks.

Summary background data: The threat of suicide bombing attacks has escalated worldwide. The ability of the suicide bomber to deliver a relatively large explosive load accompanied by heavy shrapnel to the proximity of his or her victims has caused devastating effects.

Methods: The authors reviewed and analyzed the experience obtained in treating victims of suicide bombings at the level I trauma center of the Hadassah University Hospital in Jerusalem, Israel from 2000 to 2003.

Results: Evacuation is usually rapid due to the urban setting of these attacks. Numerous casualties are brought into the emergency department over a short period. The setting in which the device is detonated has implications on the type of injuries sustained by survivors. The injuries sustained by victims of suicide bombing attacks in semi-confined spaces are characterized by the degree and extent of widespread tissue damage and include multiple penetrating wounds of varying severity and location, blast injury, and burns.

Conclusions: The approach to victims of suicide bombings is based on the guidelines for trauma management. Attention is given to the moderately injured, as these patients may harbor immediate life-threatening injuries. The concept of damage control can be modified to include rapid packing of multiple soft-tissue entry sites. Optimal utilization of manpower and resources is achieved by recruiting all available personnel, adopting a predetermined plan, and a centrally coordinated approach. Suicide bombing attacks seriously challenge the most experienced medical facilities.

FIGURE 1. The number of fatalities per suicide bombing attack according to the different setting. OS, open space; SCS, semi-confined space. *P = 0.0003 versus OS (Mann-Whitney U test).

FIGURE 2. The number of victims injured per suicide bombing attack according to the different setting. OS: open space; SCS: semi-confined space. *P < 0.02 versus OS and bus (Mann-Whitney U test).

FIGURE 3. An “ordinary household” nut removed from the thigh of a 19-year-old female.

FIGURE 4. Timing of arrival, location, surgical procedures, and discharge for the 8 survivors.

FIGURE 5. Lateral film of the left arm of 25-year-old male showing compound fractures of the humerus, radius, and ulna caused by foreign bodies.

FIGURE 6. A 16-year-old female who was standing with her back towards the attacker. She sustained penetrating rectal injury.

FIGURE 7. The “accordion” approach. Control and prioritization are achieved by a centrally coordinated effort centered on the surgeon-in-charge.

FIGURE 8. The left lower limb of a 14-year-old female who sustained multiple shrapnel injuries. Note extensive soft-tissue damage.