Primary Blast Injury After a Bomb Explosion in a Civilian Bus

Abstract

A 6-kg explosive charge detonated under a seat in the center of a crowded city bus in Jerusalem, killing three passengers immediately. Of the 55 survivors, all of whom were transferred to two major medical centers, 29 were hospitalized. Among those admitted, a high rate of primary blast injuries was found, including perforated ear drums (76%), blast lung (38%), and abdominal blast injuries (14%). Two of the latter patients suffered bowel perforations, which were diagnosed with considerable delay. Eight patients (31%) had sustained life-threatening trauma, consisting of a combination of primary, secondary, and tertiary blast injuries. The overall mortality rate was 10.3%. The large number of primary blast injuries, including the unexpected finding of bowel perforations, is explained by the high amplitude of the air pressure wave (3.8-5.2 atm) and its relatively long duration (2-3 msec) resulting from the detonation of the high-energy explosive charge in the small, enclosed space of the bus. Besides the usual wounds sustained by victims of an explosion that occurs in a confined space, the possibility of primary blast injury to the abdomen and to the lungs should be taken into account by the treating surgeon.

Clinical Features and Management of Blast Injuries

“…This leads to an instantaneous rise in temperature and pressure (the blast wave), which is followed by a massive negative suction effect (the blast wind) [2]. Contrary to popular perception, the blast wave can travel around objects, is faster in water and can penetrate body armour.…”

Disaster Medicine: Conventional Terrorist Bombings

“…An overpressure of 5 psi causes tympanic membrane (TM) rupture, 16 psi results in pulmonary blast injury, and 30-42 psi is defined as the lethality threshold pressure. 12,15,16 Water transmits blast waves more efficiently than air. Compared to air blasts, underwater explosions send out compressive shock waves at much higher speeds (up to 5000 fps).…”

“…5,3233,35 In one report of 55 ' casualties in a civilian bus bombing, 11 suffered lung injuries and 4 had gastrointestinal trauma. 15 Ina review of 200 bombing incidents worldwide involving 3357 casualties, Frykberg and Tepas found that the immediate on-scene fatality rate was 13%. 4 The mean number of casualties per bombing was 15.…”

“…Of 104 passengers on two civilian buses that were bombed in Israel, 7 were killed immediately, 51 were admitted to the hospital, 16 had pulmonary blast injury, and 7 complained of significant abdominal pain, with 4 having intestinal perforations. 15,23 All of the severely injured also had perforated tympanic membranes. At least 42 of the 80 Americans injured in the 1986 LaBelle Disco terrorist bombing in Berlin had ruptured tympanic membranes.…”

Challenges Faced by the Intensive Care Unit during a Terrorist Attack: The Riyadh Experience

“…Reflection of the short-lived incident shock waves in confined spaces results in a complex blast wave pattern amplifying both the blast energy and lifetime [3,8]. Amplifications up to 8-9 times are possible in reflected blast wind usually with more devastating consequences resulting both from amplification effect and longer exposure to the generated complex HE blast waves [9][10][11]. The London trains and bus bombings of 2005, with 50 casualties and 700 injuries, are an example of how confinement significantly enhances the blast wind [6].…”