DOI:10.2214/AJR.05.0591
AJR 2006; 187:609-616
© American Roentgen Ray Society
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.
Received April 19, 2005;
accepted after revision July 10, 2005.
Address correspondence to O. Benjaminov
(obenjami{at}netvision.net.il).
Abstract
OBJECTIVE. Terrorism is the war of our time, and terrorists push
their demands in many ways, leading to great diversity in the number and type
of injuries and casualties. Between September 2000 and January 2005, Israel
experienced 136 suicide attacks.
CONCLUSION. We have reviewed the imaging procedures performed on
victims of suicide bomber terror attacks that occurred during this period. We
have studied the injury patterns encountered in such attacks, their
mechanisms, and the dilemmas arising from them. To deal with such multiple
trauma events more efficiently, we have established a multidisciplinary trauma
team in which radiologists play a major role.
Keywords: emergency radiology • trauma • X-ray technology
Introduction
Understanding the different mechanisms used by terrorists and types of
injuries they can cause helps in approaching victims properly.
Types of Explosives
The two types of explosives that are usually involved in such attacks are
remotely controlled explosives and suicide bombers. Remotely controlled bombs
are generally prepared within a lead pipe and placed in crowded areas, usually
within an enclosed space. Suicide bombers carry explosives worn on belts.
These explosives can be activated by the individual carrying them, usually as
close as possible to the victims. To increase the damage, the explosives are
usually activated in an enclosed space
[1]. Such explosives contain
metal fragments, nails, screws, and screw nuts.
Injuries caused by explosives are classified into three categories
[2-4].
Primary blast injuries are caused by the formation of a shock wave and
movement of air, which is referred to as the blast wind. As the shock wave
passes through the body and through air, crash injuries are created, causing
tissue damage such as that seen with blunt injuries: pulmonary hemorrhage
(Figs. 1A and
1B) and edema; gastrointestinal
hemorrhage; and auditory injuries, with the most common being perforation of
eardrums [4,
5]. Secondary injuries are
caused by objects propelled outward by the explosion. They include penetrating
and mainly orthopedic injuries similar to the secondary impacts encountered in
patients who are involved in motor vehicle crashes. Tertiary blast injuries
occur when the victims themselves are displaced by the blast wind and
subsequently collide with nearby objects. This action results in a wide range
of both penetrating and blunt trauma injuries.
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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.
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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.
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In addition to the injuries mentioned, other forms include burns,
inhalation of toxic substances, and crush injuries caused by falling debris
and collapsing buildings.
The majority of victims that we have seen suffered from secondary injuries
and were not critically injured. The critically injured who died on the site
mainly died from primary blast injuries, and the noncritical victims were the
ones to arrive first at the hospital.
Terror and Medicine
Terrorist attacks frequently cause a multiple-casualty situation and
therefore overwhelm the medical system and pose a challenge
[6]. On a daily basis, civilian
medical centers are not accustomed to managing multiple casualties. The
medical approach in such events is somewhat different from cases of a single
multiple-trauma victim. The initial assessment and management within a short
period of time in an overwhelmed emergency department are complicated tasks
even for experienced personnel.
Staff performance and decision making are greatly influenced if previous
exercises and drills have taken place and if proper principles and guidelines
are set [5,
7,
8]. However, in contrast to
scheduled exercises and drills in which all of the staff and facilities are
prepared, a true incident occurs when no one is expecting it. In such cases,
when a large staff is needed in the hospital, key personnel are not always
available, traffic is being detoured, roads are blocked, and telephone lines
are loaded. The staff on call must cope with the situation as best they
can.
Role of Radiology
Multiple-casualty situations, as is the case with terrorist attacks,
require the presence of multidisciplinary teams in the emergency department.
Traumatologists, surgeons, and radiologists should be an essential part of
that team
[8-10].
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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.
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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.
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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.
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The shrapnel used by terrorists consists of metal fragments embedded within
the explosive material (Figs.
2A and
2B). Because of their elongated
and bizarre shape, shrapnel fragments are propelled outward by the explosion
with a kinetic energy smaller than that produced by a conventional bullet.
They cause penetrating and mainly orthopedic injuries
(Fig. 3). Tissue damage at the
site of entry is usually extensive for each particle
(Fig. 4A); however, at times it
may go unrecognized (Figs. 5A
and 5B). The site of entry is
slit-like (Figs. 6A,
6B, and
6C). Survivors may suffer a
combination of injuries at numerous sites with varying degrees of severity.
Bizarre shrapnel may cause damage to viscera
(Fig. 4B) and vascular
structures (Figs. 7A and
7B). Bone fragments of victims
and the terrorists themselves become projectiles that may cause severe tissue
damage and may serve as carriers of infectious disease (Figs.
8A,
8B, and
8C).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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).
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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).
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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.
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With time and periodic drills, we have learned that the radiologic
assessment and needs in such attacks are different than with a multiple-trauma
single victim. The number of casualties is hard to predict. The radiology
facilities must meet the demands of multiple victims referred to the emergency
department regarding quality of service, and consequently the number of staff
should be set appropriately. Imaging is performed during two early phases of
the event: primary evaluation, when patients are seen in the admitting area or
trauma room or directed to the operating room to receive initial treatment.
The main techniques used are conventional radiography and sonography. Next is
the reassessment phase, in which additional techniques are used for definitive
treatment planning. Those techniques include CT and angiography.
Once an event occurs, hospitals within the closest range are placed on
alert. All elective procedures are postponed. Radiologists on call from all
subspecialties are called in to the hospital through an automated emergency
pager system. One sonography radiologist is stationed in the emergency
department together with the radiology resident on call (our sonography is
performed by physicians). A neuroradiologist and a body imager are stationed
in the CT room with at least three experienced technologists. Two or three
radiographers are stationed in the emergency department performing
conventional radiography with two portable machines. The angiographers are
also called to the hospital in case there is a request for a procedure. MRI is
not included in the system and is performed only on special request. Two
general radiographers are available to interpret radiographs.
Many of the conventional films are interpreted by the clinicians, and
radiologists are called on when there are doubts concerning interpretation,
such as uncertainty regarding the presence of a pneumothorax or a fracture, or
location of bizarre shrapnel (Figs.
9A,
9B,
9C, and
9D). All films are reviewed
again after the event. We have no studies comparing the interpretation skills
among the different professional groups. Our expertise mainly applies to
performing sonography in the emergency department (focused abdominal
sonography for trauma [FAST]), CT, and angiography.
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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).
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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.
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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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Conclusion
Radiology plays an essential role in the initial evaluation of victims in a
multitrauma event such as a terror attack. Radiologists should be part of the
trauma team. Hospitals should organize emergency plans for a mass-casualty
event and organize periodic drills. Most of the radiology studies performed
initially are conventional radiography followed later by CT. Injuries caused
by bizarre shrapnel pose dilemmas and a challenge for the surgeons and should
raise suspicion of additional internal injuries.
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Abstract
Introduction
