In a World of Hurt

Vol. 20 •Issue 25 • Page 29
In a World of Hurt

Health Care Providers Must Prepare for Mass Trauma and Casualties

An 18-year-old gunman recently killed seven other students and the principal of Jokela High School in Tuusula, Finland, during an armed rampage. The melee also resulted in dozens of injuries while individuals fled the scene.

The gunman, who committed suicide, warned of the attack online and posted overtures of the upcoming violence on YouTube.

How many times have we experienced deja vu with this type of nightmarish scenario?

The events of Virginia Tech, Columbine, Jonesboro, Ark., and the Amish schoolhouse in Pennsylvania remind us of the senseless violence and tragedies associated with random or planned armed assaults.

Health care providers must be prepared for such incidents.

Terrorists’ Tools

Called the top killer of American troops, improvised explosive devices (IEDs) have caused more than one-third of the U.S. troop fatalities in Iraq. Vehicle-borne IEDs, suicide-homicide bombers and other devices and methods of explosive-related trauma pose a continuous and deadly threat to U.S. and coalition forces and are a clear danger to domestic security.

Ninety-five percent of terrorist incidents involve energetic materials (i.e., explosives and incendiaries). Understanding the basics of these materials, their physiological effects and clinical implications become of paramount importance across the broad spectrum of the emergency response community, including health care facility-based clinicians.

The term “weapon of mass destruction” (WMD) often is used inappropriately to denote only chemical, biological, radiological or nuclear devices or materials. WMDs include conventional explosive devices and, in some instances, firearms.

Materials to construct destructive devices are common, and the ready availability of firearms through legitimate and underground channels makes energetic materials/devices and firearms convenient weapons of choice.

It’s important to remember that energetic materials may be used to disseminate radiological, chemical and biohazardous materials and generate other hazards and comorbidities, such as exposures to ionizing radiation, toxic inhalations, collapsed structures, confined spaces/oxygen deficient atmospheres and even infectious processes.

Credible intelligence sources believe terrorists are actively recruiting suicide bombers who may be infected with communicable diseases like hepatitis C and HIV/AIDS to maximize the potential physical and psychological impacts of attacks.

Dangerous pathogens may be spread on bone fragments and body parts which often impact and inflict penetrating trauma to victims.

Moreover, blood and body fluid-borne pathogens create risks for health care providers and other first responders. This holds true during the triage, treatment and transport of armed assault victims with gunshot wounds, as well as explosive trauma casualties.

Of course, the use of body substance isolation/universal precautions as protective countermeasures is critical.

Types of Injuries

Common mechanisms of injury include ballistic, blast, burn and crush trauma.

In gunshot injuries, tissue is injured primarily via two mechanisms: tissue crush and tissue stretch. These two mechanisms correlate to the permanent and temporary cavitation created by the projectile.

In explosive trauma, health care personnel and other first responders can expect to encounter complex injury matrices, including burns, lacerations, traumatic amputations, head and neck injuries, fractures, impaled materials such as shrapnel, barotrauma from blast overpressures and crush injury.

All primary blast injuries are a result of compressive forces from the blast overpressure wave. While ear injuries are the most common injury seen in post-detonation incidents, lung damage is a major cause of mortality among bombing victims.

The lung damage threshold is 30 psi above atmospheric with progressively higher levels of spalling, pulmonary hemorrhage, air embolism and pulmonary contusions at higher levels.

As the blast wave passes through the body, it generates damage via spalling, implosion and inertia. Spalling is created when a shock wave reaches a fluid-gas interface. It causes the surface to fragment.

Implosion is the momentary contraction of an air bubble as a high-pressure blast wave passes through it; and as the overpressure falls, the bubble again expands rapidly.

Inertia is the movement of the body wall in the direction of the blast wave, where solid organs actually vibrate and may collide with adjacent structures, generating tearing and stretching forces.

Air blasts also may cause gastrointestinal (GI) injuries like tearing, internal hemorrhages and perforations. Note: Explosive injuries severe enough to cause injuries to the GI tract, liver or spleen normally produce fatal lung damage.

Secondary blast injuries include abrasions, contusions, punctures and lacerations caused by flying debris and shrapnel. In many explosions, secondary injury is responsible for the majority of casualties.

Tertiary injury occurs when the victim becomes a projectile and is propelled through the air by blast forces and impacts other objects, including other individuals. Blunt trauma and traumatic amputations are likely, as are head injuries and closed and open fractures.

Quaternary injuries involve structural collapse/crush injury, toxic inhalations, thermal burns and inhalational injuries.

Peripheral injuries caused by panic and subsequent stampeding/mass egress are always a possibility and add to the casualty load.

In terms of immediate life-threatening conditions seen in mass trauma victims, airway compromise, tension pneumothorax, severe hemorrhage and shock are given top priority. Prompt surgical interventions by qualified trauma teams are essential.

In armed assault and energetic materials-related tactical ultraviolence, clinicians must focus initially on airway, breathing and circulation, followed by the secondary survey and ongoing monitoring of appropriate physiological parameters.

Appropriate initiation and maintenance of oxygenation and mechanical ventilatory support utilizing strategies to minimize iatrogenic pulmonary injury are part of the mainstays of critical care for mass trauma-related casualties.

Clinicians must base medical decision-making on accepted triage and resource allocation protocols.

Be Prepared

In mass trauma-related events generated by tactical ultraviolence, an essential component of incident management and crisis resolution involves forensic investigation and criminal prosecution. This process must involve health care personnel in evidence identification, recovery and preservation.

First and foremost are situational awareness and force protection. The safety of all responders is of paramount importance.

Secondary and multiple devices with or without the presence of armed and active perpetrators are a real possibility. The goal here is to injure, maim and kill responder personnel, including health care providers.

Be on the lookout for the suspicious package and the “victim” turned perpetrator. Be aware of the improvised device hidden under a casualty or the patient with a suicide vest.

Appropriate personal protective equipment and countermeasures such as gloves, face shield, respirators and body substance isolation are essential.

Mass trauma-related casualties are common in various disaster scenarios, whether they are generated by natural or man-made causes. Many scenarios share common pathophysiological mechanisms and clinical interventions.

Our goals and objectives during these precarious times are multifaceted and need to meet the tactical and strategic challenges faced by our health care delivery systems.

Now Online: For more of Frank G. Rando’s articles and references, visit our Online Extras section at

Frank G. Rando is a senior faculty, subject matter expert and a consultant for the Department of Homeland Security and various components of the National Domestic Preparedness Consortium.