Explosions, Burn Injuries and Adverse Health Effects of Electronic Nicotine Delivery Systems: A Review of Current Regulations and Future Perspectives.

PURPOSE: While there is a declining trend in the use of traditional methods of smoking tobacco, electronic nicotine delivery systems (ENDS) have gained popularity worldwide. ENDS are marketed as safe for the primary reason that they do not contain the well-established toxic ingredients found in traditional cigarettes. However, growing concerns over incidences of fire and explosion with specific types of ENDS, as well as their short and long-term effects, remain unaddressed. This review examines the under studied role of customized components such as batteries, e-liquid compositions, and methods of nicotine delivery that result in physical injuries and adverse health effects of ENDS. METHODS: Using online reference databases (Web of Science, PubMed, Medline other, Google scholar, FDA website, FDA register), we analyzed the mechanisms through which ENDS may pose significant risk to human health. RESULTS: An increase in the use and popularity of ENDS has been observed among youth and adults in the United States since 2007. The ENDS devices available to the public allow for custom alterations which can introduce incompatible components, resulting in overheating and explosion related injuries. Heavy metals have been found to leach from some devices into the e-liquid, and the heating of e-liquid ingredients can produce toxic byproducts. CONCLUSIONS: Overall, the current literature demonstrates that ENDS are not a safe alternative to traditional cigarettes due to explosion risks and negative health effects including addiction, adverse respiratory and cardiovascular effects, heavy metal leaching, and toxic byproducts exposure. These risks warrant regulation of ENDS devices and formulations, with urgency underscored by their increasing popularity among youth and adults.

Healthcare system impacts of the 2017 Manchester Arena bombing: evidence from a national trauma registry patient case series and hospital performance data.

INTRODUCTION: In response to detonation of an improvised explosive device at the Manchester Arena on 22 May 2017, we aimed to use detailed information about injured patients flowing through hospital healthcare to objectively evaluate the preplanned responses of a regional trauma care system and to show how routinely collected hospital performance data can be used to assess impact on regional healthcare. METHODS: Data about injury severity, management and outcome for patients presenting to hospitals were collated using England's major trauma registry for 30 days following hospital attendance. System-wide data about hospital performance were collated by National Health Service England's North West Utilisation Management Unit and presented as Shewhart charts from 15 April 2017 to 25 June 2017. RESULTS: Detailed information was obtained on 153 patients (109 adults and 44 children) who attended hospital emergency departments after the incident. Within 6 hours, a network of 11 regional trauma care hospitals received a total of 138 patients (90%). For the whole patient cohort, median Injury Severity Score (ISS) was 1 (IQR 1-10) and median New ISS (NISS) was 2 (IQR 1-14). For the 75 patients (49%) attending a major trauma centre, median ISS was 7.5 (IQR 1-14) and NISS was 10 (IQR 3-22). Limb and torso body regions predominated when injuries were classified as major life threatening (Abbreviated Injury Scale>3). Ninety-three patients (61%) required hospital admission following emergency department management, with 21 (14%) requiring emergency damage control surgery and 24 (16%) requiring critical care. Three fatalities occurred during early resuscitative treatment and 150 (98%) survived to day 30. The increased system-wide hospital admissions and care activity was linked to increases in regional hospital care capacity through cancellations of elective surgery and increased community care. Consequently, there were sustained system-wide hospital service improvements over the following weeks. CONCLUSIONS: The systematic collation of injured patient and healthcare system data has provided an objective evaluation of a regional major incident plan and provided insight into healthcare system resilience. Hospital patient care data indicated that a prerehearsed patient dispersal plan at incident scene was implemented effectively.

Injuries associated with electronic nicotine delivery systems: A systematic review.

BACKGROUND: Since its introduction on the market in 2007, the number of reports on injuries caused by the overheating, ignition, or explosion of electronic nicotine delivery systems (ENDSs) has increased significantly. These injuries appear to have different causes, the most important one being lithium-ion battery overheating to the point of ignition or explosion. METHODS: A literature search for all relevant studies concerning ENDS-related traumatic injuries of all kinds was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol. The search started with the first introduction of ENDSs in 2007 and ended February 2020. Articles included were reports on patients who sustained flame, chemical, or traumatic injuries of the skin, soft tissue, and/or bone, related to the use of ENDSs. RESULTS: This systematic review includes 180 patients from 41 case series and reports, published between 2016 and 2020. The mean age was 30.8 years (range, 17-59 years) with an overall male predominance (168 of 180 patients, 93%). In most injuries, multiple anatomical sites were affected, with the thigh/lower limb being the most commonly injured area (77%) followed by the upper limb/hand (43%). Eighty-two patients (51%) required a surgical treatment, 70 patients (43%) were managed conservatively with dressings or ointments, and 9 patients (6%) underwent enzymatic debridement. Thirty-five percent of all patients underwent skin grafting. CONCLUSION: Injuries from overheating, ignition, or explosion of ENDSs are an emerging, underreported, and underresearched issue. There is a need for increased regulation of ENDSs and improved surveillance of related injuries. Both health care providers and consumers should be made aware of the risks and be advised about how to safely handle these devices. In contrast to other articles, this systematic review includes all types of injuries related to ENDS overheating, ignition, and explosion. To our knowledge, this is the most extensive systematic review performed to date. LEVEL OF EVIDENCE: Review article, level III.

Incidence, casualties and risk characteristics of civilian explosion blast injury in China: 2000-2017 data from the state Administration of Work Safety.

BACKGROUND: Civilian explosion blast injury is more frequent in developing countries, including China. However, the incidence, casualties, and characteristics of such incidents in China are unknown. METHODS: This is a retrospective analysis of the State Administration of Work Safety database. Incidents during a period from January 1, 2000 to April 30, 2017 were included in the analysis. The explosions were classified based on the number of deaths into extraordinarily major, major, serious and ordinary type. Descriptive statistics was used to analyze the incidence and characteristics of the explosions. Correlation analysis was performed to examine the potential correlations among various variables. RESULTS: Data base search identified a total of 2098 explosions from 2000 to 2017, with 29,579 casualties: 15,788 deaths (53.4%), 12,637 injured (42.7%) and 1154 missing (3.9%). Majority of the explosions were serious type (65.4%). The number of deaths (39.5%) was also highest with the serious type (P = 0.006). The highest incidence was observed in the fourth quarter of the year (October to December), and at 9:00-11:00 am and 4:00-6:00 pm of the day. The explosions were most frequent in coal-producing provinces (Guizhou and Shanxi Province). Coal mine gas explosions resulted majority of the deaths (9620, 60.9%). The number of explosion accidents closely correlated with economic output (regional economy and national GDP growth rate) (r = - 0.372, P = 0.040; r = 0.629, P = 0.028). CONCLUSIONS: The incidence and civilian casualties due to explosions remain unacceptabe in developing China. Measures that mitigate the risk factors are of urgently required.

Antibiotic Practice Patterns for Extremity Wound Infections among Blast-Injured Subjects.

INTRODUCTION: We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012). METHODS: Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment. RESULTS: Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones. CONCLUSIONS: Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship.

Evaluation of Blast Overpressure Exposure Effects on Concentration of Antibiotics in Mice.

OBJECTIVE: Infection as sequelae to explosion-related injury is an enduring threat to our troops. There are limited data on the effects of blast on antibiotic pharmacokinetics (PK), pharmacodynamics (PD), and efficacy. The observational study presented here is our Institute's first attempt to address this issue by combining our existing interdepartmental blast, infection modeling, and in vivo PK/PD capabilities and was designed to determine the PK effects of blast on the first-line antibiotic, cefazolin, in an in vivo mouse model. METHODS: A total of 160 male BALB/c mice were divided to sham and blast (exposed to blast overpressure of 19 psi) in two biological replicates. At 1 hour after blast/sham exposure, the animals received IV injection of cefazolin (328 mg/kg). Animals were euthanized at 3 minutes, 10 minutes, 15 minutes, 30 minutes, 1 hour, 3 hours, 6 hours, or 10 hours after the injection. Plasma and liver were analyzed for concentration of cefazolin using mass-spectrometry. RESULTS: We observed increases in the concentration of cefazolin in the plasma and liver of blast exposed animals at later time points and increase in elimination half-life. CONCLUSION: Our results indicate that blast-induced physiologic changes significantly influence cefazolin PK and suggest that efficacy could be affected in the context of the blast; assessment of efficacy and PD effects require further investigation. Metabolic changes resulting from blast may influence other classes of antibiotics and other therapeutics used with these injuries. Therefore, this may have important treatment considerations in other areas of military medicine.

Initial Biphasic Fractional Anisotropy Response to Blast-Induced Mild Traumatic Brain Injury in a Mouse Model.

INTRODUCTION: Blast-induced mild traumatic brain injury was generated in a mouse model using a shock tube to investigate recovery and axonal injury from single blast. METHODS: A supersonic helium wave hit the head of anesthetized male young adult mice with a reflected pressure of 69 psi for 0.2 ms on Day 1. Subsequently, the mice were cardioperfused on Days 2, 5, or 12. The isolated brains were subjected to diffusion tensor imaging. Reduced fractional anisotropy (FA) indicated axonal injury. RESULTS: After single blast, FA showed a biphasic response in the corpus callosum with decrease on Days 2 and 12 and increase on Day 5. CONCLUSIONS: Blast-induced mild traumatic brain injury in a mouse model follows a biphasic FA response within 12 days after a single blast similar to that reported for human subjects.

The Development of a Tympanic Membrane Model and Probabilistic Dose-Response Risk Assessment of Rupture Because of Blast.

INTRODUCTION: There is no dose-response model available for the assessment of the risk of tympanic membrane rupture (TMR), commonly known as eardrum rupture, from exposures to blast from nonlethal flashbangs, which can occur concurrently with temporary threshold shift. Therefore, the objective of this work was to develop a fast-running, lumped parameter model of the tympanic membrane (TM) with probabilistic dose-dependent prediction of injury risk. MATERIALS AND METHODS: The lumped parameter model was first benchmarked with a finite element model of the middle ear. To develop the dose-response curves, TMR data from a historic cadaver study were utilized. From these data, the binary probability response was constructed and logistic regression was applied to generate the respective dose-response curves at moderate and severe eardrum rupture severity. RESULTS: Hosmer-Lemeshow statistical and receiver operation characteristic analyses showed that maximum stored TM energy was the overall best dose metric or injury correlate when compared with total work and peak TM pressure. CONCLUSIONS: Dose-response curves are needed for probabilistic risk assessments of unintended effects like TMR. For increased functionality, the lumped parameter model was packaged as a software library that predicts eardrum rupture for a given blast loading condition.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion.

OBJECTIVE: The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE). METHODS: Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge. RESULTS: The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands. CONCLUSION: Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

Social Media Usage During Disasters: Exploring the Impact of Location and Distance on Online Engagement.

Social media play an important role in emergency management. The location of citizens and distance from a disaster influence the social media usage patterns. Using the Tianjin Port Explosion, we apply the correlation analysis and regression analysis to explore the relationship between online engagement and location. Citizens' online engagement is estimated by social media. Three dimensions of the psychological distance - spatial, temporal, and social distances - are applied to measure the effects of location and distance. Online engagement is negatively correlated to such 3 kinds of the distance, which indicates that citizens may pay less attention to a disaster that happens at a far away location and at an area of less interaction or at a relatively long period of time. Furthermore, a linear model is proposed to measure the psychological distance. The quantification relationship between online engagement and psychological distance is discussed. The result enhances our understanding of social media usage patterns related to location and distance. The study gives a new insight on situation awareness, decision-making during disasters.

Application of fuzzy fault tree analysis based on modified fuzzy AHP and fuzzy TOPSIS for fire and explosion in the process industry.

This study aimed at establishing fault tree analysis (FTA) using expert opinion to compute the probability of an event. To find the probability of the top event (TE), all probabilities of the basic events (BEs) should be available when the FTA is drawn. In this case, employing expert judgment can be used as an alternative to failure data in an awkward situation. The fuzzy analytical hierarchy process as a standard technique is used to give a specific weight to each expert, and fuzzy set theory is engaged for aggregating expert opinion. In this regard, the probability of BEs will be computed and, consequently, the probability of the TE obtained using Boolean algebra. Additionally, to reduce the probability of the TE in terms of three parameters (safety consequences, cost and benefit), the importance measurement technique and modified TOPSIS was employed. The effectiveness of the proposed approach is demonstrated with a real-life case study.

Association between prenatal exposure to a 1-month period of repeated rocket attacks and neuropsychiatric outcomes up through age 9: a retrospective cohort study.

Exposure to gestational stress is implicated in increased risk for neuropsychiatric disorders in offspring. We assessed association between prenatal exposure to a 1-month period of repeated rocket attacks during the 2006 Second Lebanon War in Northern Israel and emergence of childhood neuropsychiatric disorders from birth through 9 years of age. Children born to women who were pregnant during the war (N = 6999) were identified and compared to children in the same district born a year later (N = 7054), whose mothers were not exposed to rocket attacks during pregnancy. Multivariable regression models assessed risk for attention deficit hyperactivity disorder, autism, epilepsy, depression and/or anxiety, or any of these disorders (composite outcome) in offspring. Models controlled for multiple confounders including parents' demographics, parity, maternal use of psychotropic medications during pregnancy, post-partum depression and parental psychiatric history. Results show that exposed and comparison groups did not differ with respect to demographics, parity or psychiatric history. Exposed and comparison groups were similar with regard to gestational age and weight at birth. Multivariable models did not demonstrate an association between exposure to rocket attacks during pregnancy and neuropsychiatric outcomes by age 9. No interactions were found between exposure and gestational trimester at exposure or child's sex. Our findings suggest that in utero exposure to isolated, 1-month repeated rocket attacks on a civilian population was not associated with major neuropsychiatric outcomes in children by age 9. Future studies should evaluate whether this exposure is associated with psychiatric and/or other health-related outcomes later in life.

The Burden of Dental Emergencies, Oral-Maxillofacial, and Cranio-Maxillofacial Injuries in US Military Personnel.

INTRODUCTION: High numbers of dental emergencies (DE) in military service members (approximately 15% per annum) prompted the inclusion of Dental Readiness as one of six conditions that determine service members' Individual Medical Readiness (IMR). Additionally, even with the advances in body armor and helmet design, Cranio- and Oral-maxillofacial (CMF, OMF) injuries continue to occur in hostile environments. The objectives of this report are (1) to provide a comprehensive review of the incidence of DE and CMF/OMF injuries in US military personnel deployed in multiple environments and (2) to compare the rates of DE and CMF/OMF injuries occurring in the 20th century with the rates observed in the early 21st century. MATERIALS AND METHODS: Published and unpublished studies, as well as military reports of DE, OMF, and CMF injuries occurring in US military personnel were evaluated. Study publication dates included 1955 to 2017, with data collection periods from 1941 through 2014. RESULTS: The results of 30 investigations were reviewed. Overall, the reported annual DE rates varied widely among US military personnel between 1966 and 2012, ranging from 26 to 324 (mean 152.2) DE per 1,000 personnel per year (PPY). The average annual incidence of DE for personnel in hostile environments was 125.1 per 1,000 PPY. Thirteen studies reported rates of OMF-CMF injuries from 1941 to 2014. The overall mean OMF injury rate in Operation Enduring Freedom (OEF) was 2.8 per 1,000 PPY, while the mean rate during Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) was 3.2 per 1,000 PPY. A mean of 22.3 CMF injuries per 1,000 PPY was calculated from two reports during OIF. CONCLUSIONS: The percentage of DE and OMF casualties that can be expected in hostile environments is approximately 12%. Using the most recent data since 2000, the mean DE rate was 118.2 per 1,000 PPY and the OMF rate was 3.0 per 1,000 PPY. Future research should yield information which is representative of the evolving military environment. This information should be used to enhance military-specific dental therapies and to guide protection of the craniofacial region. More importantly, quality data are necessary (1) to enable the accurate prediction of DE, CMF, and OMF casualties to insure that troop levels are sufficient for mission success and (2) to insure that all outcome variables are available to measure policy success or failure.

New Trends in Terrorism-Related Injury Mechanisms: Is There a Difference in Injury Severity?

STUDY OBJECTIVE: The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set. METHODS: This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes. RESULTS: Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks. CONCLUSION: Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

Fireworks: boon or bane to our eyes?

Fireworks are an integral aspect of national, cultural and religious festivals globally, featuring in a vast range of celebrations including Diwali in India and New Year's Eve in the USA. We have seen a trend in eye injuries related to the use of fireworks, with millions of people, of which a large proportion comprising children, are injured annually-and rather than falling, as one would hope, this number is remaining stable. A comprehensive study of the impact of firework-related injuries to the eye is not available, and the efforts to mitigate this are not widely discussed in the literature. This literature review therefore focusses on studying the impact of firework-related eye injuries, the effect of legislation on mitigating these injuries and their associated morbidity.

Prominent Injury Types in Vehicle Underbody Blast.

BACKGROUND: To fully understand the injury mechanisms during an underbody blast (UBB) event with military vehicles and develop new testing standards specific to military vehicles, one must understand the injuries sustained by the occupants. METHODS: Injury data from Service Members (SM) involved in UBB theater events that occurred from 2010 to 2014 were analyzed. Analysis included the investigation of prominent skeletal and visceral torso injuries. Results were categorized by killed-in-action (n = 132 SM) and wounded-in-action (n = 1,887 SM). RESULTS: Over 90% (553/606 SM) of casualties in UBB events with Abbreviated Injury Scale (AIS) 2+ injury sustained at least one skeletal fracture, when excluding concussion. The most frequent skeletal injuries from UBB were foot fractures (13% of injuries) for wounded-in-action and tibia/fibula fractures (10% of injuries) for killed-in-action. Only 1% (11/1037 SM) of all casualties with AIS 2+ injuries had visceral torso injuries without also sustaining skeletal fractures. In these few casualties, the coded injuries were likely due to trauma from a loading path other than direct UBB loading. CONCLUSION: Skeletal fractures are the most frequent AIS 2+ injury resulting from UBB events. Visceral torso injuries are infrequent in individuals that survive and they generally occur in conjunction with skeletal injuries.

Low-Level Primary Blast Induces Neuroinflammation and Neurodegeneration in Rats.

OBJECTIVE: Mild blast traumatic brain injury is commonly prevalent in modern combat casualty care and has been associated with the development of neurodegenerative conditions. However, whether primary lower level blast overpressure (LBOP) causes neurodegeneration and neuroinflammation remains largely unknown. The aim of our present study was to determine whether LBOP can cause neuroinflammation and neurodegeneration. METHODS: Anesthetized rats were randomly assigned to LBOP group (70 kPa, n = 5) or sham group (without blast, n = 5). Histopathological and cytokine changes in brain tissue at 5 days post-injury were evaluated by hematoxylin-eosin staining and Bioplex assay, respectively. RESULTS: Histopathological assessment revealed neuronal degeneration and increased density of inflammatory cells in frontal and parietal cortex, hippocampus and thalamus in rats exposed to LBOP. LBOP exposure significantly elevated levels of pro-inflammatory cytokines (EPO, IL-1ß, IL-6, IL-12, IL-18, and TNF-α) and chemokines (GRO and RANTES) as well as of an anti-inflammatory cytokine (IL-13) in the frontal cortex. CONCLUSIONS: This study reveals a role of neuroinflammation in neurodegeneration after mild blast traumatic brain injury. Therapies that target this process might in warfighters might function either by attenuating the development of post-traumatic stress disorder, chronic traumatic encephalopathy and Alzheimer's disease, or by slowing their progression.

Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings.

Terrorist incidents that target hospitals magnify morbidity and mortality. Before a real or perceived terrorist mass casualty incident threatens a hospital and its providers, it is essential to have protocols in place to minimize damage to the infrastructure, morbidity, and mortality. In the years following the Boston Marathon bombings, much has been written about the heroic efforts of survivors and responders. Far less has been published about near misses due to lack of experience responding to a mass casualty incident resulting from terrorism. After an extensive review of the medical literature and published media in English, Spanish, and Hebrew, we were unable to identify a similar event. To the best of our knowledge, this is the first reported experience of a bomb threat caused evacuation of an emergency department in the United States while actively responding to multiple casualty terrorist incidents. We summarized the chronology of the events that led to a bomb threat being identified and the subsequent evacuation of the emergency department. We then reviewed the problematic nature of our response and described evidence-based policy changes based on data from health care, law enforcement, and counterterrorism. (Disaster Med Public Health Preparedness. 2019;13:791-798).