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An Introduction to Asymmetric War (Terrorism) and the Epidemiology of Blast Trauma. Timothy E. Davis, MD, MPH Lt. Commander, USPHS Commissioned Corps CDC/NCIPC/DIDOP/OD Asst. Professor of Emergency Medicine, Emory University.

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An introduction to asymmetric war terrorism and the epidemiology of blast trauma l.jpg

An Introduction toAsymmetric War (Terrorism)and theEpidemiology of Blast Trauma

Timothy E. Davis, MD, MPH

Lt. Commander, USPHS Commissioned CorpsCDC/NCIPC/DIDOP/OD

Asst. Professor of Emergency Medicine, Emory University

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Rules of Engagement (ROE)“… directives … under which military forces initiate engagement with belligerent forces…”

1. Presentations developed from domestic and foreign open source information (OSINF) including health, engineering, intelligence, national security, and military.

2. This area of study is problematic

a. Lack of data standards - definitions, analyses, reporting

b. Prone to misinformation & propaganda

3. The opinions are those of the cited sources, and does not constitute an endorsement by the CDC, DHHS, or Emory University.

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ObjectivesBlast Epidemiology

1. Discuss terrorism and asymmetric war

2. Review the limits of epidemiologic data

3. Examine why conventional weapon terrorism (blast trauma) is both a public health and healthcare system problem

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Weapons of Mass Destruction

Make-shift bombs are WMD

“… any explosive, incendiary, or poison gas - (i) bomb, (ii) grenade, (iii) rocket ..., (iv) missile ..., (v) mine, or (vi) ... similar ... devices” – U.S. Code, Title 18, Part I, Chapter 113b, Sections 2332a and 921a

Alternative terms for WMD

CBRNE – chemical, biological, radiological, nuclear, explosive

BNICE – biological, nuclear, incendiary, chemical, explosive

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17,579 criminal bombings in U.S, 1988-1997 (FBI)

  • Average of 5 bombings per day

  • Bombings doubled over the 10-year period

    214 U.S. Embassy bombings, 1988-1997 (State) - Average ~ 2 per month

  • 830 bomb-related deaths, 1988-1997 (CDC/NCHS)

  • US bombing death counts exceed deaths for most US disasters - floods, hurricanes, lightening. (NOAA)

  • 4,063 bomb-related injuries (FBI)

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Selected Causes of Deaths, United States, 1988-1997

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2001 Worldwide Terror Against U.S. Concerns

Bombs were used in ¾ of the 348 terror attacks in 2001

98% of terror attacks used conventional weapons.

Almost one terror attack per day in 2001.

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2001 Total U.S. Worldwide Terror Casualties

Majority of casualties in 2001 occurred at non-Gov. sites

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5 Billion Pounds Produced Each Year in U.S.

Explosive matter

From Explosives, R. Meyer – 5th Edition

Chemicals for non-explosive purpose


Fertilizer gradeammonium nitrate Chlorates as weed killers

Gas generating for foam plastics

Organic peroxides as catalysts

NTG and PETN-soln for pharmaceuticals

Salts of nitrated organic acids for pest-control

High explosives(HE)


Pyrotechnic (LE)

Flashes, FlaresFume generators

Optical/acoustic signals, fireworks


  • 1

  • 2

Lead azideHg fulminateTetrazene

Black powder


Double base; composites; liquid fuels; oxidizers



Gelatins; powders; permitted; ANFO; slurries, emulsions

Singles = TNT; RDX; PETN; Mixes = CB; RDX-based plastics; Torpex

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Explosives areTerrors’ Perfect Storm

1. Available – 5 billion pounds legally made in U.S.

2. Low tech – Literacy helpful

3. Scalable – 1 kilogram to 1 kiloton TNT-equivalents

4. Simple delivery - hand-carried, truck, plane, train, ship

5. Simple Guidance system – placed, thrown, or suicide

6. Human factors – available financing and volunteers

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Understanding Terrorism

1. Intent to induce fear in someone other than its victims, with the goal to change an entity’s political behavior.

2. Independent of the cause that motivates it– can be unjust or righteous – the end justifies the means.

3. Neither spontaneous nor random– it is a staged psychological act conducted for its impact on an audience.

4. Not aimed at personal gain– it can be motivated by political, religious, or ideological objectives.

5. Requires ever escalating “shock and awe” to remain effective – maintain sense of helplessness

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Who Gets Targeted?

  • Almost all terror campaigns target free-press countries

    • Representative governments are especially vulnerable

  • Russia

    • Chechens used suicide tactics against free-press Russia, but not U.S.S.R.

  • Kurds – “Kurdistan” – parts of Iran, Iraq, and Turkey

    • Used terrorism against Turkey, only as Turkey moved toward more representative government in the 1980s

    • Never used terror tactics against Iran or Iraq, yet where severely repressed by Saddam Hussein

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Terror Tactics are EscalatingCivilians now more than collateral damage

The 1980s – The “IRA era”

  • Placement / stationary bombs - package, culvert, or car bombs targeted against government or rivals

  • “Gentlemen’s agreement” - advanced warning limits casualties

    –>evacuations, & staging of medical resources

  • The 1990s – The Suicide bomber era

    • – Human “smart bomb” for precise placement

    • – Used only against “soft” civilian targets

  • The 2000s – Complex tactics era

    • – couples mega-bombs with multiple synchronized attacks

    • – often suicide – pioneered in 1983 Beirut

    • – large or multiple suicide “smart” bombs against “soft” targets

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Intifada II

Kobar Towers

Israelis Lv Lebanon

Desert Storm

Marine Barracks

What’s The Trend?

IRA era

Solo Suicide era

Complex tactic era

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Succeeded despite military raids to kill or arrest terrorist leaders

Why Is Terror Growing?Because it works

  • In 6 of the 11 suicide campaigns successful (55%)

    • terrorists achieved at least partial victory

    • airpower or economic sanctions < 15% success

  • Targeted states

    • Fully or partially withdrew from territory

    • Began negotiations

    • Released a terrorist leader

  • Suicide campaigns - successful against even hawkish governments

    • Reagan

    • Netanyahu

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“We couldn’t stay there and run the risk of another suicide attack on the Marines.”

-- Ronald Reagan, An American Life

Why Is Terror Growing?Because it works

  • Democratic leaders publicly confirmed suicide attacks pushed them to make concessions

  • Examples

    • U.S. left Lebanon in 1983 - Marine barracks bombing

    • Israel followed in 1985 after > 800 IDF deaths / 18 mo.

    • Spain left Iraq after March 2004 Madrid bombings

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Bomb-Injury Threat Model suicide attack on the Marines.”



Size & weightExplosive choice

Purpose & Source

Delivery system




Age, sex, & weight

Fitness, PPE

Nutrition, health

Access to care

Open Space, Confined Space,Structural Collapse

Reflecting or Shielding surfaces

Building and non-structural debris

Air and liquid hazards

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Military Combatant suicide attack on the Marines.”



Mostly male, healthy, athletic, 18-35 years

More young, older, female, poor health

Personal Protective Equipment (PPE)

Helmet, armored vest, armored vehicles

No PPE or armor


(weapon type)

Manufactured high-order (HE) military ordnance

Makeshift low- and high-order bombs

Injury Patterns

Well-studiedHigh tech shrapnel

Poorly studied

Nails, bolts, glass



Organized trauma care - long-term rehab., comp., life-long assist.,

Pres.-Cabinet advocate

Variable access to care, rehabilitation, and assistance. Ad hoc advocacy

Military Data Less Helpful

TE Davis, CY Lee

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J Trauma. 2004;56: 1033-1041 suicide attack on the Marines.”

27% of trauma surgeonsnot prepared to treat

blast trauma

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Objectives suicide attack on the Marines.”Blast Epidemiology

a. coercion of a strong state by a weak stateless entity

1. Discuss terrorism and asymmetric war

2. Review the epidemiologic data and the limits

3. Examine why conventional weapon terrorism (blast trauma) is both a public health and healthcare system problem

a. bombings occur daily in the U.S. b. terrorists use bombs > 98%

c. No standard terms, analyses, reporting

a. An unanticipated event that adversely affects of a large segment of the population and potentially overwhelms regional health infrastructure.

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The Basics of Explosives suicide attack on the Marines.”andBomb-blast Trauma

Timothy E. Davis, MD, MPH

Lt. Commander, Commissioned Corps, USPHSCDC/NCIPC/DIDOP/OD

Asst. Professor of Emergency Medicine,

Emory University

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Objectives suicide attack on the Marines.”Basics of Bomb Blast Trauma

1. Recognize how injuries and casualty mix are affected by

a. bomb type

b. terrorist tactic

c. bombing environment

2. Anticipate casualty severity profile, and identify common, occult, and high risk injuries following

a. open space bombing

b. confined space bombing

c. bombing with structural collapse

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Explosives Are Ubiquitous suicide attack on the Marines.”

  • 1. Legally made – illegally obtained explosives from commercial and military sources

    • 5 billion poundsproduced legally

  • Explosive “recipes”available in libraries, bookstores, www

    • - ANFO fertilizer, acetone-H2O2, Molotov cocktail

  • 3. Commandeered fuel-laden commercial vehicles

    • Plane, train, fuel oil truck, LNG fuel super tanker ship

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Explosives Classified by the suicide attack on the Marines.”Speed of ExplosionHigh-order (HE) versus Low-order (LE)

  • High-explosives(HE) = detonation

    • Supersonic – Explosion is faster than the speed of sound

    • Blast over-pressurization impulse wave

    • HE does not mean “large” – a hand grenade is a HE

    • HE blast injuries are characterized as a) Primary, b) Secondary, c) Tertiary, d) Quaternary

    • E.g., all military bombs, TNT, Dynamite, Semtex, ANFO

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Idealized blast overpressure waveform suicide attack on the Marines.”seen only in high-order explosives (HE)





0 ATM Zero

Atmosphere Pressure

Zero ATM




Horrocks, CL. Blast Injuries: Biophysics, Pathophysiology and Mnaagement Principles.

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Explosives Classified by the suicide attack on the Marines.”Speed of Explosion

Low-order explosives (LE) = deflagration – not detonation

  • Subsonic – explosion occurs < the speed of sound

  • NO blast over-pressurization wave

  • LE does not mean “small” – 9-11 attacks involved LE

  • LE injuries can be characterized as a) shrapnel, b) blunt, c) crush, d) burn

  • E.g., Napalm, gunpowder, Molotov cocktail, many petroleum-based (but ANFO is HE)

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Bombs can be suicide attack on the Marines.”

Classified by Size and Weight

  • Small Arms – 1-person carry - hand grenades, rocket propelled grenades (RPG), also machine guns, assault rifles

  • Light Arms – 1 or 2-person carry - makeshift bombs < 10 kg gross weight, mortars, shoulder-held missile launchers, and some landmines, surface mines, grenades

  • Heavy Weapons – mechanized- makeshift car, truck, plane, train, or ship bombs, also air bombs, rockets, tanks, artillery

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Black Powder suicide attack on the Marines.”












Bombs can be

Classified by TNT-equivalents

TNT-eq = the amount of TNT needed to create the same blast effect

TNT-eq calculations – 7 different formulas with differing results

A measure of energy – not of raw weight

- a 10 kg (TNT-eq) backpack bomb has 2 kg of explosives

Shock waves and heat waves decrease rapidly – 1 / radius2

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Bombs can be Classified by suicide attack on the Marines.”

Source and Original Purpose

  • Original Purpose

  • Military-grade– government sanctioned

  • Civilian-grade– legally manufactured assault-lite - Uzi, Glock, Mauser, Berretta, Bushmaster AR-15

  • Source

  • Mass-produced– “manufactured” by arms industry

  • Makeshift– Improvised, small assembly line

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Bombs can be Classified suicide attack on the Marines.”based onAdulterants

  • “Dirty Bomb” - addition of bio-chem-rad agents

    • Cyanide, Warfarin, Hepatitis have been used

      • Exothermic reaction may alter biologics and chemicals

      • Radiologicals are not affected by heat

  • Shrapnel

    • Criminals lack access to high tech shrapnel or canisters

      • Use less efficient bolts, nails, glass

      • Compensate with excess bulk explosives

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Suicide bomber suicide attack on the Marines.”

1– 5 kg

5 meters

10-30 meters

Compact car








Passenger van

1,180 (~ OKC)



Panel truck

4,545 (~ Khobar)



Fuel truck

13,636 (~ Beruit)




27,273 kg



Size Does Matter

Explosives Lethal Blast Serious Injury

in Kg TNT-eq. Range (meters)Range (meters)

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Environment can Protect or Harm suicide attack on the Marines.”Open, Confined, and Enclosed space explosions

  • Open Space– street corner, open market, stadium

  • Blast impulse weakens rapidly ~ 1 / radius2

  • 10% fatalities, straight-forward rescue and transport

  • Confined space– inside bus, train, or auditorium

    • Blast pressures intensified x2-9,

    • 20% fatalities, 70% DOS, complicated rescue

  • Structural collapse (Enclosed space)

  • – inside a reinforced multi-story building

  • - Complex reflections, blast pressure up x2-9,structural collapse, complicated rescue,

  • delayed care, 20% fatalities, 90% DOS

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Environment Characteristics suicide attack on the Marines.”Confined & Enclosed Space

Surrounding structures can either

shield, dampen, or amplify the

blast over-pressure wave.

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Blast-Injury Vocabulary suicide attack on the Marines.”Specific for High-order Explosives (HE)

1. Primary (1°)Blast Injury (e.g. blast lung)– over-pressurization impulse wave – often fatal

  • Secondary (2°) Blast Injury(e.g. glass shards)– penetrating shrapnel and debris

  • Tertiary (3°)Blast Injury (e.g. traumatic amputation)– blunt - blast wind throws the individual

4. Quaternary (4°)Blast Injury (miscellaneous)– burns, fume poisonings, suffocation, building collapse,

crush injuries, chronic disease flare, mental health

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Blast Injuries Do Not Occur suicide attack on the Marines.”in Isolation

A Casualty with “Blast Lung” (1°) will also have

1. Penetrating glass shards (2°)

2. Traumatic amputation (3°)

3. Burns, inhalation injury, deafness (4°)

The Injury Severity Score (ISS) does not accurately measure complexity, or resource utilization

Other Typical confined space (bus) injuries

  • (1°) Blast lung, bowel rupture, TM rupture

  • (2°) Penetrating foreign body to globe, chest, abdomen

  • (3°) Traumatic amputations, Fx to face, pelvis, ribs, spine

  • (4°) crush injuries, 1° & 2°burns

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Primary Blast Injury suicide attack on the Marines.”associated exclusively with high-order (HE) explosives

1. Caused by the over-pressure blast wave

  • Invisible, supersonic

    2. Lethal radius rapidly diminishes with distance

  • 1 / radius3 . Lethal radius is 3x in water

    3. Affects most air filled structures

  • Lungs, GI tract, Sinuses, Middle ear (TM rupture)

  • But also brain – “shell shock”

Courtesy: Battlefield Wounds, JR Mechtel, RN, MSN – DMRTI

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“White Butterfly Sign” suicide attack on the Marines.”

  • Blast Lung – 70% fatal

  • A clinical diagnosis, confirmed with X-ray

  • A severe pulmonary contusion from air compression – re-expansion

  • Symptoms – exposure plus SOB, cough, hemoptysis, retrosternal pain

  • Signs – Tachypnea, cyanosis, decrease BS, dull to percussion, rales / crackles, hemo/pneumo-thorax, subcutaneous emphysema, retro-sternal crunch, air emboli, retinal artery emboli

  • Management – Similar to severe pulmonary contusion

  • – complex fluid management

  • – mechanical ventilation further increases chance of air emboli

CL Horrocks, Wounds of Conflict

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Blast Abdomen suicide attack on the Marines.”

  • Delayed onset> 8-36 hours – more common in submersion

  • 1. Intestinal intra-wall hemorrhages

  • 2. Shearing of local mesenteric vessels

  • 3. Sub-capsular and retroperitoneal hematomas,

  • Fracture of liver and spleen, and testicular rupture

  • Zero in Madrid (?)

  • Symptoms – exposure plus abdominal pain, nausea, vomiting, hematemesis (rare), rectal pain and tenesmus, testicular pain

  • Signs – abdominal tenderness, rebound, guarding, absent bowel sounds, signs of hypovolemia

  • Management – Rescect small bowel contusions > 15 mm, and large bowel contusions > 20 mm

  • CL Horracks, Wounds of Conflict, 2001

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Blast Brain suicide attack on the Marines.”concussion, TBI, shell shock, misdiagnosed behavioral disorder

  • Blast over-pressure wave – not always a straight path

    • Dampened, reflected, or amplified off solid surfaces

    • Helmets, Kevlar stop shrapnel, but magnify blast waves

  • Do not assume all dysfunctional actions are behavioral

  • Future treatment for IC bleed may be rF VIIa

    • Animal studies promising

    • Human recombinant Factor VIIa used in Israel under a humanitarian protocol

    • Not U.S.-FDA approved or recommended

J Neurosurgery Jan 2002

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Secondary Blast Injury suicide attack on the Marines.”“Secondary” applied exclusively to high-order (HE) injuries

1. Penetrating injury from shrapnel or debris.

2. Open-space bombings – nails out to 100 meters- from 5 kg bomb

3. Makeshift bomb shrapnel unpredictable path- high use of CT and X-ray in Israel

4. Treat as dirty grossly contaminated – delayed primary closure

Courtesy: Battlefield Wounds, JR Mechtel, RN, MSN – DMRTI

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Glazed Glass Retrofitting suicide attack on the Marines.”

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Tertiary Blast Injury suicide attack on the Marines.””Tertiary” applied exclusively for high-order (HE) injuries

1. Caused by displacement of body, or body parts, by force of blast wind – includes traumatic amputations

2. Blunt trauma – solid object strikes, or victim is thrown against solid object, includes impalement

3. Care follows standard blunt trauma protocols

Courtesy: Battlefield Wounds, John R. Mechtel, RN, MSN – DMRTI

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Quaternary Blast Injury suicide attack on the Marines.”“Quaternary” applied exclusively for high-order (HE) injuries

Classified by some disciplines as “miscellaneous”

1. Crush injuries

2. Suffocation and Fume poisonings

3. Burns

4. Exacerbation of chronic disease

  • Asthma, COPD, diabetes, hypertension, CAD, PUD, alcohol and drug abuse, mental health

    5. New behavioral problems

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Low-order Explosives (LE) suicide attack on the Marines.”uses “clear text” mechanism descriptions – differ from HE

Low-order explosives (LE) differ in mechanism:

1. Deflagration not detonation (HE)

2. Subsonic “slow burn” versus supersonic explosion

3. No over-pressurization and blast wave impulse

  • Ballistic effect – shrapnel and debris

  • Thermal effect – burns from the heat generation

  • Suffocation – all oxygen is consumed

    Also ->fume poisonings, crush injuries, exacerbation of chronic disease (asthma, COPD, diabetes, hypertension, MI, PUD, mental health)

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Low-order Explosives (LE) suicide attack on the Marines.”versusHigh-order Explosives

HE and LE produce dirty contaminated wounds in devitalized tissue.

Survivability largely depends on proximity to the explosion, building construction, evacuation proficiency, and luck.

70-90% of fatalities are DOS.

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Trauma Patterns suicide attack on the Marines.”Small (5 kg) Open Space Suicide Bombing

Casualties – 1-30(Israel - average 23, range 1-99)


– killed 1-5

– admitted 5-10

– treat & release 20

Injury patterns

- 1° Blast trauma < 5 meters

- occult nails < 100 meters

- temporary deafness

- risk of Hepatitis, Tetanus, HIV

}1/3rdkilled or admitted

} 2/3rd outpatient treatment

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Trauma Patterns suicide attack on the Marines.” Small (10 kg) Confined Space Backpack Bomb

Casualties – 20-50 bus and 150-200 train / bomb - 70% of fatalities are Dead on Scene (DOS)


– killed 20%

– admitted 20%

– treat and release 60%

Injury patterns

- 1° Blast trauma – anywhere within bus or train cabin

- temporary deafness, risk of Hepatitis, Tetanus, HIV

Complicated train rescue


Simplified Severity Predictor = 1/3rd killed or admitted > 24°.

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Structural collapse bombing suicide attack on the Marines.”(100-1,000 kg TNT-eq)

Casualties – 100 – 3,000

– largely based on bomb size, time of day, warning, building structure, and evacuation proficiency

– 90% of fatalities are DOS

Severity – follows pattern of Earthquake or structural collapse

– killed if in the wake

– treat and release if nearby, but not in direct path

– small percentage admitted (<1-5%)

Injury patterns

- respiratory problems, temporary deafness

Rescue must weigh risk versus benefit of rapid ingress

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Bomb-Injury Threat Model suicide attack on the Marines.”


Size & weightExplosive choice

Purpose & Source

Delivery system




Age, sex, & weight

Fitness, PPE

Nutrition, health

Access to care

Open Space, Confined Space,Structural Collapse

Reflecting or Shielding surfaces

Building and non-structural debris

Air and liquid hazards

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Questions ? suicide attack on the Marines.”

Tim Davis, MD, MPH Catherine Y. Lee, MPH Sherlita Amler, MD

[email protected]@[email protected]

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Questions ? suicide attack on the Marines.”

Sherlita Amler, MD

Medical Epidemiologist


[email protected]

Tim Davis, MD, MPH

Medical Epidemiologist

CDC/NCIPC/DIDOP [email protected]

Catherine Y. Lee, MPH

Research Analyst, Emory

Rollins School of Public [email protected]