C H A P T E R 1 4

EXPLOSIVE EVENT
PREPAREDNESS/RESPONSE
Angelo Agostini

ESPITE RECENT CONCERNS about nuclear, biological,

D and chemical (NBC) weapons of mass destruction, explosions are

the most common cause of mass-casualty incidents associated
with terrorism. Although most blast events tend to be related to
industrial accidents, worldwide terrorism has risen sharply, with 14,966 terror-
ist events occurring between 01 January, 2003 and 31 December, 2006; bomb-
ings comprised 53% of these terrorist events and produced 85% of the injuries
caused by all terrorist attacks.1
For the most part, countries have not balanced their preparedness efforts
to properly reflect this increasing threat from blast events. The US govern-
ment has increased its spending on bioterrorism preparedness, and currently
funds more than 50 centers for bioterrorism preparedness.2 However, there
are no similar efforts for ensuring preparedness for blast events; in fact, fund-
ing for any blast preparedness has been almost non-existent.

OBJECTIVES:
ã
ã
Describe the four categories of blast injuries;

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Understand the mechanics of a blast; and
Understand the treatment priorities for blast-injured patients.

Healthcare facilities also have not balanced their preparedness efforts to

address blast incidents. Plans must be in place to enhance the facility’s and the
community’s level of preparedness for explosive events. Nurses must be made
aware of the unique aspects of blast-related injuries, and the triage, diagnos-
tic, and management challenges of caring for these victims.

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EXPLOSIONS
Explosions involve the transformation of explosive substances from a solid or
liquid state to a gaseous state with the release of energy under extremely high
pressure. A large amount of heat and gaseous products are transmitted from the
site of the explosion, moving outward in every direction.
There are two types of explosions:
1. High-order Explosives, which produce blast waves that are
supersonic (>1,200 meters per second) pressure waves caused by
explosives such as C4, Semtex, trinitrotoluene (TNT), nitroglycerin,
dynamite, and ammonium nitrate fuel oil (ANFO); and
2. Low-order Explosives, which produce subsonic blast waves, but
lack the high pressure of high-order explosives. Examples of
low-order explosives include petroleum-based bombs, such as
pipe bombs, gun powder, Molotov cocktails, or non-conven-
tional weapons (e.g. like aircrafts improvised as smart bombs).
During an explosion, the blast wave pressure almost instantaneously reaches
its maximum velocity of up to 8,000 meters per second, depending on the type of
explosive. Blast wind is produced as the expanding gas of the explosion displaces
a large volume of air. As the peak pressure decreases, it creates a negative pressure
with a “suction effect” that pulls debris back into the site of the explosion.
Explosions occurring in confined spaces, e.g., buildings and buses, cause
more serious injury than do open-air bombings. The reflection of the blast
waves by rigid objects (e.g., the ground, walls, or metallic materials) causes an
increase in power and, therefore, damage.

CATEGORY CHARACTERISTICS POTENTIAL TYPES OF INJURIES

Primary Direct effect of blast wave Blast lung
pressure on body organs Tympanic membrane rupture
and tissues Abdominal hemorrhage/perforation
Traumatic brain injury
Globe (eye), liver, spleen, kidney rupture

Secondary Victim impacted by propelled objects Penetrating ballistic or blunt injuries

Eye penetration

Tertiary Victim thrown into air or into Traumatic amputation

other solid objects by blast wind Fractures
Brain injury (closed and open)

Quaternary Pre-existing illnesses exacerbated Asthma/COPD

by blast event; other injuries not Myocardial ischemia/infarction
due to primary, secondary, tertiary Hypertension
or quarternary effects Burns
Crush injuries

Table 14.1: Categories, types, and characteristics of blast injuries (COPD = chronicobstructive pulmonary
disease)23

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The amount of damage caused to humans and structures is related to: (1)
the amount and composition of the explosive material used; (2) the proximity
to the explosion; (3) the delivery system deployed; (4) the presence of any pro-
tective barriers or environmental hazards; and (5) associated damages, such as
a building collapse or a fire from the explosion.

BLAST INJURIES
Explosions can produce unique patterns of complicated, multi-system in-
juries. There are four general categories of blast injuries: (1) primary; (2) sec-
ondary; (3) tertiary; and (4) quaternary; however, these categories are not
mutually exclusive and a victim may suffer blast-related injuries in each of
these catgories. Table 14.1 lists these blast categories as well as their character-
istics and the potential types of injuries they can inflict.
Primary Blast Injury

Causes
Primary blast injuries are caused by the direct effect of the pressure of the
blast wave on body organs and tissues. The ensuing damage is caused by three
different mechanisms:3
1. Implosion — As the shock wave travels through the body, the
pressure compresses air-filled structures, e.g., the lungs, the middle
ear, and the gastrointestinal tract. After the wave has passed, there
is a rapid re-expansion of these compressed structures that
damages both the organs and adjacent structures. In effect, these
are miniature internal explosions;
2. Spalling effect — When the shock wave passes from a high-density
organ to a lower-density organ, the associated reverberation can
cause molecular disruption; and
3. Acceleration/deceleration — Organs and tissues of different
densities also cause different rates of shock wave acceleration,
resulting in stretching and tearing of the tissues. Additional
damage is caused by the sudden shock wave deceleration impact
within these organs against other internal surfaces.

Types of Injuries
The body parts most vulnerable to the effects of an explosion are the air-filled
interfaces within the body, such as the lungs, bowel, and middle ear. Table
14.2 provides an overview of explosive-related injuries. The main types of pri-
mary blast injuries are: (1) blast lung injury; (2) tympanic membrane injury;
(3) traumatic brain injury; and (4) other miscellaneous injuries.

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Blast Lung Injury (BLI) — Blast lung injury results from the blast’s direct
effects on the lung causing biochemical and histological changes in that organ.
The extent of injury is determined by the peak and duration of the blast wave.
One of the highest incidences of recorded blast lung injury occurred in 44%
of the total patients injured from two suicide bombings on enclosed public
buses in Jerusalem between 25 February and 4 March 1996.4

SYSTEM INJURY OR CONDITION

Auditory Tympanic membrane rupture, ossicular disruption, cochlear damage, foreign

body

Eye, orbit, face Perforated globe, foreign body, air embolism, fractures

Respiratory Blast lung, hemothorax, pneumothorax, pulmonary contusion, and

hemorrhage, arterio-venous fistulas (potential source of air embolism),
airway epithelial damage, aspiration pneumonitis, sepsis

Table 14.2: Overview of explosive-related injuries26

Through both the Spalling effect and implosion, the alveolar membranes of the
lung become torn and damaged, and the alveolar-capillary interface is disrupted.
The pressure differential between the blood vessels and the air-filled alveoli causes
rupture of the alveoli and microvessels with infiltration of blood into the alveolar
spaces. Blast lung injury is the most fatal injury associated with explosive events.
Blast lung injuries include: pulmonary contusion, pulmonary edema, air
embolism, hemo/pneumothorax, hemo/pneumo-mediastinum, disseminated in-
travascular coagulation (DIC), and Acute Respiratory Distress Syndrome
(ARDS). Victims of blast lung injury may present with acute respiratory failure
(apnea, bradycardia, and hypotension) or milder symptoms, including dyspnea,
tachypnea, air hunger, cough, hemoptysis, chest pain, or subcutaneous emphyse-
ma. Blast lung injury may occur without any external signs of injury to the vic-
tim, but should be suspected in all victims involved in an explosion who present
with tachypnea, hypoxia, and respiratory distress.5 Chest radiography is used to
confirm the diagnosis of blast lung injury, to determine the severity of injury to
the lung, and to monitor its progression;6 blast lung injury may not develop until
24 to 48 hours after the event.7 The chest radiograph typically will demonstrate a
“butterfly” image; occasionally this image will appear as a “snow storm”.

Tympanic Membrane Injury — The anatomic structure injured most fre-

quently by explosions, and at the lowest pressure blast, is the tympanic mem-
brane of the ear. An increase of pressure of as little as 5 PSI above atmospher-
ic pressure can rupture the human ear drum.8 Ear injury from the blast must
be suspected with the presence of blood in the external canal, hearing loss,
tinnitus, vertigo, or otalgia in patients involved in any explosion.

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TYMPANIC MEMBRANE EXAM FOR BLAST PATIENTS

Some clinicians have suggested utilizing portable otoscopes to check all victims involved
in a blast event for rupture of the tympanic membranes.9 If the tympanic membranes are
intact, and other symptoms (e.g., respiratory distress and abdominal pain) are absent, other
serious primary blast injuries can be conditionally excluded. Those victims with ruptured
tympanic membranes should then have chest radiography and be observed for at least eight
hours to rule out other blast injuries.

However, a study of 647 survivors of 11 blast events in Israel between 1994 and 1996 revealed
193 persons who sustained primary blast injuries. Of these, 142 persons (73.5%) sustained
isolated ear drum perforation, 51 (26%) experienced other forms of blast injuries, and 18 (9%)
had isolated pulmonary blast injury. None of the 142 patients with eardrum perforation
developed a blast lung injury, and of the 18 who developed a blast lung injury, none had a
tympanic membrane rupture. The results of this study demonstrate a lack of any relationship
with eardrum perforation and concealed blast lung injury.10

Traumatic Brain Injury — A traumatic brain injury (TBI) can result from the
blast effects of an explosion. The most common types of brain injury resulting
from a blast are axonal injury, contusion, and traumatic subdural he-matoma.11
Victims may experience a mild concussion with only a limited change in con-
sciousness, or severe concussion with a long-term change in consciousness or
cognitive abilities, often without physical evidence of head injury. These victims
may be agitated and present with symptoms similar to those of a patient with
post-traumatic stress disorder (PTSD). It is important to remember that dys-
functional actions of victims of an explosion are not necessarily behavioral;
traumatic brain injury should be suspected in all victims with headache or
changes in neurological function or behavior following an explosive event.12 In
a study of patients who sustained explosive injuries involving only their lower
extremities, neurological symptoms (e.g., headache, vertigo, agitation, insom-
nia, and poor concentration) were present in 51% of the patients.13

Other Injuries — Other injuries that may occur from an explosion include
rupture or hemorrhage of solid organs, e.g., the liver, spleen, kidney, and eye.
These usually are the result of very high blast forces in confined spaces and
with close proximity to the blast center.

Secondary Blast Injury

Secondary blast injuries are caused by bodily impact with primary fragments
(i.e., the bomb itself) or secondary fragments (i.e., surrounding materials,
such as concrete, glass, or wood), which are impelled by the blast wave and
blast wind. These injuries are referred to as ballistic trauma. Next to injuries

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resulting from collapsed buildings, penetrating injuries are the leading causes
of deaths and injuries resulting from terrorist bomb attacks.10
In a terrorist attack, the explosive material often is surrounded or embedded
with metal objects (such as nails, screws, or spheres), to enhance its damaging
capability. These metal objects may be small and produce tiny holes in the vic-
tim that are difficult to locate; however, these minute penetrations can cause life-
threatening injuries due to the velocity of their impact. Such penetrating, nearly
invisible wounds have occurred inside a victim’s mouth, and, in one case, a small
nail was discovered nestled in the pituitary gland of a 14-year-old girl.14
In suicide bombings, heavy shrapnel, such as bolts and nuts, replace the
lighter nails and nail heads used by terrorists. These elements constitute the
heaviest part of the projectile and, thus, will impact first. The vast array of pro-
jectiles used causes extensive soft tissue damage due to the combined surface area
impacted (Figure 14.1). As these wounds usually are grossly contaminated, it is
important to determine the status of the victim’s tetanus vaccination protection.
Severe contamination also may delay performing primary closure of the wound.
In the case of suicide bombings, the terrorists, themselves, become part of
the bomb; that is, their body parts (tissues, bone fragments, etc.) as well as
those of other victims, can become flying debris capable of impacting the vic-
tims. In addition to the penetrating injuries caused by these projectiles, they
carry the risk of transmitting infectious diseases, such as hepatitis and human
immunodeficiency virus (HIV).15
In March 2002, a hotel bombing at a Passover dinner celebration in Ne-

Reprinted with permission from EB Practice, LLC © 2006. Stewart C: Blast injuries: Preparing for
the inevitable. Emergency Medicine Practice 2006;8(4) (www.EB Medicine.net April 2006).

Figure 14.1: Lower extremity of a young victim of a suicide bomb attack who sustained multiple
shrapnel injuries

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tanya, Israel resulted in 164 victims being transported to the Netanya Hospital
Emergency Department. One of the injured victims arrived with what was orig-
inally thought to be an open fracture of the femur. However, after radiological
examination, it was determined that the bone protruding from the patient’s
quadriceps actually belonged to the suicide bomber.
As a result of infection concerns, Israel’s Ministry of Health has mandat-
ed active immunization against hepatitis B for all victims of suicide bombings.
Additionally, consideration should be given for follow-up HIV testing for all
surviving bombing victims.

Tertiary Blast Injury

Tertiary blast injuries are caused when the force of the blast throws a victim into
other solid objects or into the air. The injuries sustained can include head injuries,
fractures, traumatic amputations of long bones, and chest trauma. Generally, a per-
son with tertiary blast injury is fairly close to the location of the explosion.

Quaternary (or Miscellaneous) Blast Injury

Quaternary blast injuries are related to pre-existing illnesses or conditions that
may become exacerbated by the blast event, e.g., asthma, myocardial infarction,
or pregnancy. Quaternary blast injuries also encompass injuries re-sulting from
the effects of the explosion, e.g., burns or crush injuries from resultant fire or
building collapse, chemical or radiation exposure, and inhalation injury or
asphyxiation.
Often these types of injuries occur in conjunction with each other. For
example, toxic inhalation and burns are common injuries from fires, as cyanide
and other toxins often are present. Inhalation injuries often occur with the crush
injuries associated with a building collapse, as occurred in the World Trade Cen-
ter collapse, in which 49% of the injured sustained inhalation injuries.16,17

Crush Injury/Syndrome
Building collapse or other similar results of bombings (e.g., movement of
large pieces of debris) can result in the entrapment of victims with crush
injuries due to compression or pressure on parts of the body. Crush injury
more frequently affects the extremities, but also can affect the torso of the vic-
tim(s). When the entrapped body part is relieved after being compressed for
a prolonged period, crush syndrome can result from the release of built-up
chemicals that produce systemic effects, including lethal arrhythmias, renal
failure, hypovolemic shock, and electrolyte disturbances.
Early fluid therapy, even before the victim is extricated, is essential to lim-
iting hypovolemia and shock when the victim’s compressed body parts are
released from entrapment. Evidence suggests that adding 50 milliequivalents of

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sodium bicarbonate to liter bags of normal saline infusions may help to pre-
vent the build-up of myoglobin and uric acid and the resulting obstruction of
urine flow.18,19
Patients who develop crush-induced renal failure may require dialysis man-
agement if fluid therapy fails to maintain urinary output. A particular challenge
in disasters from events such as earthquakes, which typically cause crush
injuries, is the ability to provide dialysis effectively. For example, the 1999 Bam
earthquake resulted in >600 victims with acute renal failure.18 With limited
electrical availability as a result of the earthquake, peritoneal dialysis may be the
only treatment option; however, difficulties arise in performing peritoneal dial-
ysis on patients with torso-related trauma.18 Hyperkalemia resulting from
crush injuries also can be life-threatening and may require treatment with kay-
exalate, both orally and rectally.

Burn Injuries
Explosions often produce burn injuries as a result of high temperatures, burn-
ing fuel and materials, and direct contact with heated objects. Weapons of
mass destruction also can cause burn injuries through chemical and radiation
exposure. Confined space blasts tend to inflict a higher percent of burn
injuries to the blast victims than do open air bombings, chiefly as a result of
the concentrated heat of the explosion.20
Some clothing materials can melt and can continue to burn the victim
beyond the initial explosion event. Treatment priorities for patients with burn
injuries, therefore, begin with carefully removing the patient’s clothes to stop the
burning process. The next priority, along with immediately addressing life-
threatening issues, is assessing the burns and associated injuries to determine the
appropriate amount of fluid resuscitation required. Patients with burns involv-
ing >20% Total Body Surface Area (TBSA) require that their estimated fluid
replacement needs be calculated using one of several different available formu-
las. The Parkland Fluid Replacement Formula calculates the fluid need of the
burn victim for the first 24 hours post-event in the following way: 21

4 ml x Body Weight (kg) x % TBSA burned

Half of the total fluid replacement needed should be administered within the
first eight hours, with the remaining half administered over the next 16 hours.
However, there is a dilemma regarding fluid management in victims with blast
lung injury who also suffer burns; generally, fluids are restricted in patients with
a blast lung injury, while a burn patient requires aggressive fluid administration.
This unique combination of injuries requires careful monitoring of urine output
along with invasive monitoring of intravascular volume indicators, such as cen-

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tral venous pressure (CVP), to guide correct fluid management.22

Airway management also is a priority in burn patients, particularly in the
presence of inhalation injury. Patients with inhalation injury may present
with facial burns, cough, respiratory distress, soot around the mouth or nose,
or an inflamed airway. Consideration should be given to early intubation to
protect the airway from occlusion secondary to post-inhalation edema.

TREATMENT
As penetrating and blunt trauma are the most commonly noted injuries
among victims of explosions, arriving victims should be treated according to
standard triage and trauma protocols.23 Victims with symptoms of blast lung
injury as well as those with multiple entry sites and extensive tissue damage
should be tended to rapidly. The extent and type of the trauma, along with the
incidence of multiple trauma, often require specialty care and, sometimes, the
simultaneous involvement of multiple specialty teams (e.g., vascular, surgical,
neurosurgical, neurological, orthopedic) in the treatment of one patient.24
Rapid and appropriate triage of blast-injured victims performed by experi-
enced surgeons or emergency physicians can be difficult as only a few seconds
are allowed for each triage assessment and decision; lengthier examinations
often are necessary to locate potentially life-threatening, penetrating injuries in
victims who appear to be stable.25 Particular attention should be given to exam-
ination of victims’ lungs, abdomen, and tympanic membranes. Additionally,
these victims’ conditions can change rapidly; frequent re-evaluation of these
patients is mandatory.
Plans for patient flow throughout the hospital are essential to prevent a
patient backlog, or “bottleneck”. A limited number of surgeons and available
operating rooms necessitate the postponement of elective surgeries, and only
performing surgery on unstable victims, hypotensive victims with abdominal
or thoracic injuries, and those at risk for loss of a limb. Both Radiology and
Computerized Tomography (CT) departments also are prone to develop bot-
tlenecks; these services should be both prioritized and used as sparingly as pos-
sible during the rapid influx of victims with blast injuries. Focused abdominal
sonography for trauma (FAST) should be utilized for these patients rather than
the time-consuming diagnostic peritoneal lavage assessment.
All patients with suspected blast lung injury should be placed on high-flow
oxygen with continuous monitoring of their oxygenation status with a pulse oxime-
ter. Decreasing arterial oxygen saturation levels may be an early indicator of the
development of blast lung injury prior to the manifestation of other symptoms.9
Air embolism is not an uncommon occurrence in blast victims. Depending
on the location of the embolism, it may produce symptoms similar to those of a
stroke, myocardial infarction, or central nervous system injury. If the patient

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develops an air embolism, hyperbaric treatment may be effective.

Generally, victims from the blast site who are without complaints can be
discharged from the hospital after four to six hours of observation.26 Those
sustaining tympanic membrane ruptures should undergo chest radiography
and remain in the hospital for observation for at least eight hours; tympanic
membrane ruptures usually heal within a few months post-event. Patient dis-
charge instructions regarding follow-up audiometry assessment must be writ-
ten to ensure communication in these hearing-impaired victims.

CONCLUSION
Victims with blast injury require specialized assessment and treatment due to
the unique nature of blast injuries. Blast victims have a higher rate of critical
injuries and require more specialized care and a greater use of critical care
resources than do other trauma victims. Among terrorism-induced incidents,
blast events are the leading cause of death and injury.
The preparedness of healthcare facilities to care for blast victims has not
reflected the high incidence of blast terrorist events over events involving nu-
clear, biological, or chemical (NBC) agents. Nursing preparedness involves
gaining knowledge in the unique aspects of blasts and blast injuries. Nurses
also should advocate for their healthcare facility to properly balance pre-
paredness among likely scenarios and participate in the development of plans
for receiving and treating victims of blast injury.

7/7 LONDON BOMBINGS: LESSON LEARNED

The 7 July 2005 London bombings (also known as the 7/7 bombings) were caused by
homemade explosive devices packed into backpacks. The bombings killed 56 people
(including the four bombers), injured 700 passengers, and disrupted the city's transportation
system. Lessons learned from the bombings include:27
1. Prepare for events that involve multiple sites;

2. Prepare for events that damage transportation capabilities;

3. Educate all physicians in blast injury recognition and treatment;

4. In addition to the emergency medical service, it is necessary to train other medical

personnel in emergency skills, e.g., triage and extrication; and

5. Planning should include systems to handle the increased communication needs of

responders during a large event.

Robert Powers

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REFERENCES
1. Memorial Institute for the Prevention of Terrorism (MITP): Terrorism Knowledge Base:
Available at: www.tkb.org. Accessed 02 January 2007.
2. Kellerman AL: Crisis in the emergency department. N Engl J Med 2006;355(13):1300–1303.
3. Mellor SG: The pathogenesis of blast injury and its management. Br J Hosp Med
1988; 39:536–539.
4. Leibovici DN, Gofrit ON, Stein M, et al: Blast injuries: Bus versus open air bombings.
A comparative study of injuries in survivors of open air versus confined space explosions.
J Trauma 1996:41:1030–1035.
5. Hirshberg B, Oppenheim-Eden A, Pizov R, et al: Recovery from blast lung injury. Chest
1999;116:1683–1688.
6. Shaham D, Sella T, Goitein O, et al: Terror attacks: The role of imaging. In: Shemer J, Shoenfeld
Y (eds), Terror and Medicine. Berlin: Pabst Science Publishers, 2003, pp 394–408.
7. Centers for Disease Control and Prevention: Blast Lung Injury: An Overview for Prehospital
Care Providers. Available at www.bt.cdc.gov/masscasualties/blastlunginjury_prehospital.asp.
Accessed 10 June 2007.
8. Kerrmy R, Kissinger D, Golokosky M, Champion J: Bomb related injuries. Mil Med 1994:159:
536–539.
9. De Palma RG, Burris DG, Champion HR, Hogdson MJ: Blast injuries. N Engl J Med 2005:
1335–1342.
10. Leibovici D, Gofrit N, Shapira S: Eardrum perforation in explosions survivors: Is it a marker of
pulmonary blast injury? Ann Emerg Med 1999;34(2):168–172.
11. Gutierrez-Cadavid JE: Imaging of head trauma. In: Latchaw RE, Kucharczyk J, Moseley ME
(eds), Imaging of the Nervous System. Philadelphia: Elsevier Mosby, 2005: pp 869–904.
12. Centers for Disease Control and Prevention. Brain Injuries and Mass Casualty Events.
Available at www.bt.cdc.gov/masscasualties/braininjuriespro.asp. Accessed 10 June 2007.
13. Cernak I, Savic J, Ignjatovic D, Miodrag J: Blast injury from explosive munitions. J Trauma
1999;47:96–103.
14. Stein M, Hirsberg A: Limited mass casualties due to conventional weapons: The daily reality of a
Level 1 Trauma Center. In: Shemer J, Shoenfeld Y (eds), Terror and Medicine. Berlin: Pabst
Science Publishers, 2003, pp 378–393.
15. Baverman I, Wexler D, Abu-Mouch S, et al: Penetrating bone fragments in suicide bombings: A
potential new mode of infection. In: Shemer J, Shoenfeld Y (eds), Terror and Medicine. Berlin:
Pabst Science Publishers, 2003, pp 456–467.
16. Quenemoen LE, Davis YM, Malilay J, et al: The World Trade Center bombing: Injury
prevention strategies for high-rise building fires. Disaster 1996;20:125–132.
17. Centers for Disease Control and Prevention: Rapid Assessment of Injuries Among Survivors of the
Terrorist Attack on the World Trade Center New York City, September 2001. Available at
www.cdc.gov/mmwr/preview/mmwr html/mm5101a1.htm. Accessed 01 December 2006.
18. Sukru Sever M,Vanholder R, Lameire N: Management of crush related injuries after disaster
N Engl J Med 2006;354:1052–1063.
19. American College of Surgeons: Advanced Trauma Life Support 1997;8:252.
20. Eldad A, Peleg K, Tzur T: Terror and war burn in Israel. In: Shemer J, Shoenfeld Y (eds), Terror
and Medicine. Berlin: Pabst Science Publishers, 2003, pp 433–445.
21. Blumetti J, Hunt JL, Arnoldo BD, Parks JK, Purdue GF:The Parkland formula under fire: Is the
criticism justified? J Burn Care Res 2008;29:180–186.
22. Peleg K, Aharonson-Daniel L, Stein M, et al: Gunshot and explosion injuries. Ann Surg
2004;239:311–318.
23. Centers for Disease Control and Prevention: Explosions and Blast Injuries: A Primer for Clinicians.
Available at www.bt.cdc.gov/masscasualties/explosions.asp. Accessed 10 June 2007.
24. Almogy G, Rivkind AI: Suicide bombings: The general surgeon’s view. In: Shemer J, Shoenfeld Y
(eds), Terror and Medicine. Berlin: Pabst Science Publishers, 2003, pp 409–419.
25. Ashkenzai I, Kessel B, Khashan T, et al: Precision in hospital triage in mass casualty incidents
after terror attacks. Prehosp Disaster Med 2006;21(1):20–23.
26. Center for Disease Control and Prevention: Blast Lung Injury: What Clinicians Need to Know.
Available at http://bt.cdc.gov/masscasulaties/blastlunginjurie.asp. Accessed 10 June 2007.
27. Ryan J, Montgomery H: Terrorism and the medical response. N Engl J Med 2005,353:543–545.

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