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Role of Radiology in Evaluation of Terror Attack Victims

Ofer Benjaminov1, Miriam Sklair-Levy2, Avraham Rivkind3, Maya Cohen1, Gabi Bar-Tal4 and Michael Stein5

1 Department of Diagnostic Imaging, Rabin Medical Center, Beilinson Campus, Zabotinsky St., Petah-Tikva 49100, Israel.
2 Department of Radiology, Hadassah University Hospital, Jerusalem, Israel.
3 Department of General Surgery, Hadassah University Hospital, Hebrew University, Jerusalem, Israel.
4 Department of Diagnostic Imaging, Meir Hospital, Kfar Saba, Israel.
5 Department of General Surgery and Trauma, Rabin Medical Center, Beilinson Campus, Petah-Tikva 49100, Israel.


Figure 1
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  		Fig. 1A —62-year-old man with primary blast injuries. Some patients injured by primary blast may appear unharmed and cannot be assessed by naked eye or physical examination. Gas-filled organs such as ears, lungs, and gastrointestinal tract are most vulnerable to blast effect. Injury to lungs is cause of greatest morbidity and mortality from blast effect. Chest radiograph shows bilateral perihilar pulmonary infiltrates in butterfly pattern.

 

Figure 2
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  		Fig. 1B —62-year-old man with primary blast injuries. Some patients injured by primary blast may appear unharmed and cannot be assessed by naked eye or physical examination. Gas-filled organs such as ears, lungs, and gastrointestinal tract are most vulnerable to blast effect. Injury to lungs is cause of greatest morbidity and mortality from blast effect. Further deterioration causes complete whitening of lungs.

 

Figure 3
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  		Fig. 2A —Shrapnel used by terrorists. Bizarre material includes nails, screws, and screw nuts embedded within explosive.

 

Figure 4
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  		Fig. 2B —Shrapnel used by terrorists. Bizarre material includes nails, screws, and screw nuts embedded within explosive.

 

Figure 5
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  		Fig. 3 —14-year-old girl with compound fracture of femur caused by multiple shrapnel fragments. Circles indicate odd pieces of shrapnel.

 

Figure 6
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  		Fig. 4A —19-year-old woman with multiple shrapnel wounds. Patient suffered extensive tissue damage from multiple shrapnel fragments. With multiple shrapnel wounds, dilemma for clinicians is whether to perform débridment and further imaging. In most cases, surgery is not indicated because metals often remain inert and do not cause damage. Indications for removal are proximity to neurovascular structures, intraarticular involvement, or possibility of toxic effects of metal such as lead. Late indications include infections.

 

Figure 7
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  		Fig. 4B —19-year-old woman with multiple shrapnel wounds. In this case, CT revealed penetrating rectal injury (arrow, B) with extravasation of air (curved arrow, C) and contrast material (straight arrows, C) administered rectally during triple-contrast study.

 

Figure 8
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  		Fig. 4C —19-year-old woman with multiple shrapnel wounds. In this case, CT revealed penetrating rectal injury (arrow, B) with extravasation of air (curved arrow, C) and contrast material (straight arrows, C) administered rectally during triple-contrast study.

 

Figure 9
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  		Fig. 5A —23-year-old woman with multiple nail projectile injuries. Patient underwent surgery for burn wound excision (tangential excision) and slowly regained consciousness. Localizer (A) and axial (B) CT images show nail (arrow) located within head of patient. Point of entry was not identified before CT, and nail was not included in field of view of initial radiographs.

 

Figure 10
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  		Fig. 5B —23-year-old woman with multiple nail projectile injuries. Patient underwent surgery for burn wound excision (tangential excision) and slowly regained consciousness. Localizer (A) and axial (B) CT images show nail (arrow) located within head of patient. Point of entry was not identified before CT, and nail was not included in field of view of initial radiographs.

 

Figure 11
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  		Fig. 6A —28-year-old man with abdominal shrapnel injury. Patient was initially thought to be only slightly injured because he walked unassisted into emergency department complaining of mild tinnitus and superficial burns. Radiography results raised suspicion of foreign body in abdomen. CT confirmed suspicion. Nail (arrow) was in upper abdomen with its tip within peritoneum between liver and stomach.

 

Figure 12
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  		Fig. 6B —28-year-old man with abdominal shrapnel injury. Patient was initially thought to be only slightly injured because he walked unassisted into emergency department complaining of mild tinnitus and superficial burns. Radiography results raised suspicion of foreign body in abdomen. Three tiny gas bubbles (circle) were noted in right peritoneal cavity. On sonography (focused abdominal sonography for trauma) performed in emergency department, fluid was not detected in peritoneal cavity.

 

Figure 13
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  		Fig. 6C —28-year-old man with abdominal shrapnel injury. Patient was initially thought to be only slightly injured because he walked unassisted into emergency department complaining of mild tinnitus and superficial burns. Radiography results raised suspicion of foreign body in abdomen. Nail within gluteus muscle (circle) was also noted. At surgery, rectal perforation was found and repaired.

 

Figure 14
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  		Fig. 7A —17-year-old boy with shrapnel injuries from screw nuts who presented with cold hand and weak pulse. Angiogram shows shrapnel (arrow) in forearm with comminuted fracture-induced vasospasm.

 

Figure 15
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  		Fig. 7B —17-year-old boy with shrapnel injuries from screw nuts who presented with cold hand and weak pulse. Digital subtraction angiogram shows thin vessels consistent with vasospasm (arrows). There was no evidence of vascular rupture.

 

Figure 16
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  		Fig. 8A —32-year-old-man injured by bone fragments. Bone fragments may become projectiles themselves and cause severe penetrating injury. They can become necrotic debris and serve as nidus for infection. Bone fragments may test positive for hepatitis B virus (HBV) and HIV. Axial (A) and coronal (B) reconstruction CT images show bone fragment injuries in right neck (arrow, A).

 

Figure 17
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  		Fig. 8B —32-year-old-man injured by bone fragments. Bone fragments may become projectiles themselves and cause severe penetrating injury. They can become necrotic debris and serve as nidus for infection. Bone fragments may test positive for hepatitis B virus (HBV) and HIV. Axial (A) and coronal (B) reconstruction CT images show bone fragment injuries in right neck (arrow, A).

 

Figure 18
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  		Fig. 8C —32-year-old-man injured by bone fragments. Bone fragments may become projectiles themselves and cause severe penetrating injury. They can become necrotic debris and serve as nidus for infection. Bone fragments may test positive for hepatitis B virus (HBV) and HIV. Foreign body in neck proven by bone fragment and by DNA testing as belonging to terrorist, who tested positive for HBV. This case prompted Ministry of Health to instruct all hospitals in country to immunize all victims of suicide bombing incidents against HBV.

 

Figure 19
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  		Fig. 9A —14-year-old girl with shrapnel injury. Chest radiograph shows nails overlying cardiac silhouette.

 

Figure 20
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  		Fig. 9B —14-year-old girl with shrapnel injury. Echocardiogram performed in emergency department shows pericardial effusion (straight arrows). There was uncertainty whether this shrapnel was located in chest wall or within heart (curved arrow).

 

Figure 21
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  		Fig. 9C —14-year-old girl with shrapnel injury. After patient was stable, CT showed nail located within left ventricle. Heart tamponade (circle, C) was drained, and nail was removed (arrow, D) at surgery.

 

Figure 22
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  		Fig. 9D —14-year-old girl with shrapnel injury. After patient was stable, CT showed nail located within left ventricle. Heart tamponade (circle, C) was drained, and nail was removed (arrow, D) at surgery.

 

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