Burn injuries from the london suicide bombings: a new classification of blast-related thermal injuries.

In July 2005, four suicide bombers detonated explosive improvised high explosive devices (IEDs) in three separate underground carriages and a double decker bus in London, resulting in 56 deaths and 775 injured. This study aims to understand the mechanisms and patterns of burn injuries from high explosives, and the related factors that determine mortality. The types and patterns of burn injuries in survivors and fatalities in the confined underground train carriages and the bus were analysed, evaluating injury severity score and the victims' relative position from the detonation point. The data were sourced from collated police witness statements, hospital records, forensic post mortem examinations and forensic examinations at the scene. The detonation of an explosive device in a confined space causes complex injuries to the human body, resulting in blast-related direct thermal and radiant burns. Injury patterns and mortality were related to crowd density, enclosure design, position of the victims and proximity to the device. Suicide bombings using IEDs will result in direct thermal burns and radiant burns currently categorised in the quaternary (miscellaneous) blast injury group. We propose a classification of these burns following an analysis of the London bombing data with respect to burns in both the fatalities and survivors. Distance from the device, crowd density and environment influences these burns.

En juillet 2005, 4 kamikazes faisaient exploser leur engin artisanal dans 3 rames de métro et 1 autobus à impériale de Londres, faisant 56 morts et 775 blessés. Cette étude a pour but d'étudier les mécanismes et la physiopathologie des brûlures liées à une explosion ainsi que d'évaluer les facteurs associés de mortalité. Nous avons analysé le type et la localisation des brûlures, l'ISS selon la position des victimes par rapport à l'épicentre. Les données provenaient des témoignages recueillis par les forces de police, des dossiers médicaux, des autopsies et des analyses de site. Une explosion en milieu clos entraînent des lésions complexes parmi lesquelles des brûlures thermiques directes et par radiation. La topographie des lésions et la mortalité étaient en relation avec la densité humaine, la topographie du volume clos, la position des victimes et leur situation par rapport à l'épicentre. Les brûlures directes et par radiation sont actuellement catégorisées dans les blasts quaternaires. A la suite des attentats londoniens, nous proposons une classification de ces brûlures, influencées par la distance à l'épicentre, la densité humaine et l'environnement.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.

INTRODUCTION: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide. METHODS: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed. RESULTS: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%). DISCUSSION/CONCLUSION: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

Prophylaxis for blood-borne diseases during the London 7/7 mass casualty terrorist bombing: a review and the role of bioethics.

The suicide bombings in London on 7 July 2005 resulted in a mass casualty situation. Over 50% of casualties were treated at the Royal London Hospital where clinicians witnessed large numbers of severely injured patients. In some casualties human biological foreign material was found embedded in the soft tissue originating from the suicide bombers or other casualties. This had the potential of placing individuals at risk of transmission of blood-borne diseases. Advances in the fields of medicine and biology have led to increased survivorship in the context of trauma and mass casualty incidents. This has resulted in the emergence of ethical scenarios surrounding patient management. A systematic review of the literature of the 7/7 bombings, and suicide bombings reported globally, where biological implantation is noted, was performed to examine the medicolegal issues arising during such attack. Twelve casualties with human tissue implanted were recorded in the 7/7 bombings. While all patients at risk were given prophylaxis based on recommendations by the Health Protection Agency, several ethical considerations surfaced as a result. In this paper, we compare the sequence of events and the management process of the victims of the 7/7 bombings and the evidence-based research regarding blood-borne infection transmission. Furthermore, it explores the ethical dilemmas, experienced by the senior author on 7/7, surrounding prophylaxis for blood-borne diseases and protocols to avoid confusion over best practice in future bombing incidents.

Heterotopic ossification in victims of the London 7/7 bombings.

Heterotopic ossification (HO) is the formation of bone at extraskeletal sites. Over 60% of amputees injured by improvised explosive devices in the recent conflict in Afghanistan have developed HO, resulting in functional impairment. It is hypothesised that a key aetiological factor is the blast wave; however, other environmental and medical risk factors, which the casualties have been exposed to, have also been postulated. The suicide terrorist bombings in London in 2005 resulted in many blast-related casualties, many of whom were managed by the Royal London Hospital. This cohort of severely injured patients whose injuries also included trauma-related amputations shared some, but not all, of the risk factors identified in the military population. We reviewed these patients, in particular to assess the presence or absence of military-established risk factors for the formation of HO in these casualties.

Human body projectiles implantation in victims of suicide bombings and implications for health and emergency care providers: the 7/7 experience.

INTRODUCTION: On 7 July 2005 four suicide bombings occurred on the London transport systems. In some of the injured survivors, bone fragments were embedded as biological foreign bodies. The aim of this study was to revisit those individuals who had sustained human projectile implantation injuries as a result of the bomb blasts at all scenes, review the process of body parts mapping and DNA identification at the scene, detail the management of such injuries and highlight the protocols that have been put in place for protection against blood borne pathogens. METHODS: We retrospectively reviewed 12 instances of victims who sustained human body projectile implantation injuries. The Metropolitan Police and forensic scientists identified the human projectiles using DNA profiling and mapped these on the involved carriages and those found outside. All human projectiles included were greater than 3 cm(2). RESULTS: Twelve cases had human projectile implantation injuries. Of these, two died at the scene and ten were treated in hospital. Projectiles were mapped at three of the four bomb blast sites. Our findings show that victims within a 2m radius of the blast had human projectile injuries. Eight of the allogenic bony fragments that were identified in the survivors originated from the suicide bomber. All victims with an open wound should have prophylaxis against hepatitis B and serum stored for appropriate action against HIV and hepatitis C infection. CONCLUSIONS: All victims following a suicide bombing should be assumed to have human body projectile implantation injuries with blood products or bony fragments. All immediate care providers should receive prophylaxis against hepatitis B virus and appropriate action should be taken against HIV and hepatitis C infection.

Salvage of right colon interposition by microsurgical venous anastomosis.

Venous insufficiency of a right colon interposition in esophageal reconstruction can be a fatal complication resulting in total failure. A case is presented of the salvage of the right colon interposition by additional microsurgical venous anastomosis to relieve the problem of venous stasis. The outcome was successful in a young patient with a complicated medical history.