Skip to main content

Terrorist attacks: common injuries and initial surgical management

Abstract

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient’s condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. Kulla M, Maier J, Bieler D, Lefering R, Hentsch S, Lampl L, Helm M. Civilian blast injuries: an underestimated problem?: Results of a retrospective analysis of the TraumaRegister DGU(R). Unfallchirurg 2015.

  2. Bieler D, Hentsch S, Franke A, Kollig E. Current strategies for the treatment of blast injuries to the extremities. In: A survey of blast injury across the full landscape of military science. Canada: Halifax; 2011.

  3. Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C. The first aid and hospital treatment of gunshot and blast injuries. Dtsch Arztebl Int. 2017;114:237–43.

    PubMed  PubMed Central  Google Scholar 

  4. Franke A, Bieler D, Wilms A, Hentsch S, Johann M, Kollig E. Treatment of gunshot fractures of the lower extremity: Part 1: incidence, importance, case numbers, pathophysiology, contamination, principles of emergency and first responder treatment. Der Unfallchirurg. 2014;117(11):975–84.

    CAS  PubMed  Google Scholar 

  5. Edwards DS, McMenemy L, Stapley SA, Patel HD, Clasper JC. 40 years of terrorist bombings—a meta-analysis of the casualty and injury profile. Injury. 2016;47(3):646–52.

    CAS  PubMed  Google Scholar 

  6. Friemert B, Franke A, Bieler D, Achatz A, Hinck D, Engelhardt M. Treatment strategies for mass casualty incidents and terrorist attacks in trauma and vascular surgery: presentation of a treatment concept. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2017;88(10):856–62.

    CAS  PubMed  Google Scholar 

  7. Rao PP, Singh DV. Combat surgery: Status of tactical abbreviated surgical control. Med J Armed Forces India. 2017;73(4):407–9.

    PubMed  PubMed Central  Google Scholar 

  8. Service, Médical. du, RAID: Tactical emergency medicine: lessons from Paris marauding terrorist attack. Crit Care. 2016;20:37.

    Google Scholar 

  9. Ling GS, Rhee P, Ecklund JM. Surgical innovations arising from the Iraq and Afghanistan wars. Annu Rev Med. 2010;61:457–68.

    CAS  PubMed  Google Scholar 

  10. Mayo A, Kluger Y. Terrorist bombing. World J Emerg Surg. 2006;1:33–8.

    PubMed  PubMed Central  Google Scholar 

  11. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. JTrauma. 2008;64(2):295–9.

    Google Scholar 

  12. Bumbasirevic M, Lesic A, Mitkovic M, Bumbasirevic V. Treatment of blast injuries of the extremity. J Am Acad Orthop Surg. 2006;14(10):S77–S81.

    PubMed  Google Scholar 

  13. Gawande A. Casualties of war–military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004;351(24):2471–5.

    CAS  PubMed  Google Scholar 

  14. Plurad DS. Blast injury. MilMed. 2011;176(3):276–82.

    Google Scholar 

  15. Weil YA, Mosheiff R, Liebergall M. Blast and penetrating fragment injuries to the extremities. J Am Acad Orthop Surg. 2006;14(10):S136–S139139.

    PubMed  Google Scholar 

  16. Turner CD, Lockey DJ, Rehn M. Pre-hospital management of mass casualty civilian shootings: a systematic literature review. Crit Care (Lond Engl). 2016;20(1):362.

    Google Scholar 

  17. Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma. 1997;42(6):1018–21.

    CAS  PubMed  Google Scholar 

  18. Johansson J, Blomberg H, Svennblad B, Wernroth L, Melhus H, Byberg L, Michaelsson K, Karlsten R, Gedeborg R. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims. Resuscitation. 2012;83(10):1259–64.

    PubMed  Google Scholar 

  19. Mohammad A, Branicki F, Abu-Zidan FM. Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses: a systematic review. World J Surg. 2014;38(2):322–9.

    PubMed  Google Scholar 

  20. Navarro S, Montmany S, Rebasa P, Colilles C, Pallisera A. Impact of ATLS training on preventable and potentially preventable deaths. World J Surg. 2014;38(9):2273–8.

    PubMed  Google Scholar 

  21. Dayan L, Zinmann C, Stahl S, Norman D. Complications associated with prolonged tourniquet application on the battlefield. Mil Med. 2008;173(1):63–6.

    PubMed  Google Scholar 

  22. Asensio JA, Petrone P, O'Shanahan G, Kuncir EJ. Managing exsanguination: what we know about damage control/bailout is not enough. Proceedings (Baylor University Medical Center). 2003;16(3):294–6.

    Google Scholar 

  23. Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2013;3:CD007438.

    Google Scholar 

  24. Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. Br J Anaesth. 2014;113(2):242–9.

    CAS  PubMed  Google Scholar 

  25. Mody RM, Zapor M, Hartzell JD, Robben PM, Waterman P, Wood-Morris R, Trotta R, Andersen RC, Wortmann G. Infectious complications of damage control orthopedics in war trauma. J Trauma. 2009;67(4):758–61.

    PubMed  Google Scholar 

  26. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, Stelfox HT. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg. 2015;78(6):1187–96.

    PubMed  Google Scholar 

  27. Schwab R, Gusgen C, Hentsch S, Kollig E. Terrorism–a new dimension in trauma care. Chirurg. 2007;78(10):902–9.

    CAS  PubMed  Google Scholar 

  28. Centers, for, Disease, Control, and, Prevention: Explosions and Blast Injuries. A primer for clinicians. https://www.btcdcgov/masscasualties/explosionsasp. 2006.

  29. Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma. 2009;66(5):1468–77.

    PubMed  Google Scholar 

  30. Leibovici D, Gofrit ON, Stein M, Shapira SC, Noga Y, Heruti RJ, Shemer J. Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41(6):1030–5.

    CAS  PubMed  Google Scholar 

  31. Horrocks CL. Blast injuries: biophysics, pathophysiology and management principles. J Roy Army Med Corps. 2001;147(1):28–40.

    CAS  PubMed  Google Scholar 

  32. Josey T, Ouellet S, Bieler D, Cernak I, Franke A, Gupta R, Kirkman E, Leggieri MJ, Jr., Orru H, Philippens M, et al. Guidelines for reproducing blast exposures in the laboratory. J R Army Med Corps. 2018.

  33. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005;352(13):1335–422.

    CAS  PubMed  Google Scholar 

  34. Bieler D, Kollig E, Achatz G, Friemert B, Franke A. Typische Verletzungen durch terrorassoziierte Ereignisse und ihre Implikationen für die Erstversorgung. Trauma und Berufskrankheit. 2018;20(3):177–87.

    Google Scholar 

  35. Ritenour AE, Baskin TW. Primary blast injury: update on diagnosis and treatment. Crit Care Med. 2008;36(7 Suppl):S311–S317317.

    PubMed  Google Scholar 

  36. Hull JB, Cooper GJ. Pattern and mechanism of traumatic amputation by explosive blast. J Trauma. 1996;40(3 Suppl):S198–S205.

    CAS  PubMed  Google Scholar 

  37. Leibner ED, Weil Y, Gross E, Liebergall M, Mosheiff R. A broken bone without a fracture: traumatic foreign bone implantation resulting from a mass casualty bombing. J Trauma. 2005;58(2):388–90.

    PubMed  Google Scholar 

  38. Wong JM, Marsh D, Abu-Sitta G, Lau S, Mann HA, Nawabi DH, Patel H. Biological foreign body implantation in victims of the London July 7th suicide bombings. J Trauma. 2006;60(2):402–4.

    PubMed  Google Scholar 

  39. Arnold JL, Halpern P, Tsai MC, Smithline H. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med. 2004;43(2):263–73.

    PubMed  Google Scholar 

  40. Kluger Y, Nimrod A, Biderman P, Mayo A, Sorkin P. The quinary pattern of blast injury. Am J Disaster Med. 2007;2(1):21–5.

    PubMed  Google Scholar 

  41. Maiden N. Ballistics reviews: mechanisms of bullet wound trauma. Forensic Sci Med Pathol. 2009;5(3):204–9.

    PubMed  Google Scholar 

  42. Ordog GJ, Wasserberger J, Balasubramaniam S. Shotgun wound ballistics. J Trauma. 1988;28(5):624–31.

    CAS  PubMed  Google Scholar 

  43. Baechler MF, Groth AT, Nesti LJ, Martin BD. Soft tissue management of war wounds to the foot and ankle. Foot Ankle Clin. 2010;15(1):113–38.

    PubMed  PubMed Central  Google Scholar 

  44. Ramasamy A, Hill AM, Clasper J. Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps. 2009;155(4):265–72.

    CAS  PubMed  Google Scholar 

  45. Rispoli DM, Horne BR, Kryzak TJ, Richardson MW. Description of a technique for vacuum-assisted deep drains in the management of cavitary defects and deep infections in devastating military and civilian trauma. J Trauma. 2010;68(5):1247–52.

    PubMed  Google Scholar 

  46. Taylor CJ, Hettiaratchy S, Jeffery SL, Evriviades D, Kay AR. Contemporary approaches to definitive extremity reconstruction of military wounds. J R Army Med Corps. 2009;155(4):302–7.

    CAS  PubMed  Google Scholar 

  47. Holle G, Germann G, Sauerbier M, Riedel K, Von Gregory H, Pelzer M. Vacuum-assisted closure therapy and wound coverage in soft tissue injury: clinical use. Unfallchirurg. 2007;110(4):289–300.

    CAS  PubMed  Google Scholar 

  48. Machen S. Management of traumatic war wounds using vacuum-assisted closure dressings in an austere environment. US Army Med Dep J. 2007;1:17–23.

    Google Scholar 

  49. Dissemond J, Gerber V, Kramer A, Riepe G, Strohal R, Vasel-Biergans A, Eberlein T. A practice-oriented recommendation for treatment of critically colonised and locally infected wounds using polihexanide. J Tissue Viability. 2010;19(3):106–15.

    CAS  PubMed  Google Scholar 

  50. Eberlein T, Assadian O. Clinical use of polihexanide on acute and chronic wounds for antisepsis and decontamination. Skin Pharmacol Physiol. 2010;23:45–51 (Epub 2010 Sep 8).

    CAS  PubMed  Google Scholar 

  51. Hubner NO, Kramer A. Review on the efficacy, safety and clinical applications of polihexanide, a modern wound antiseptic. Skin Pharmacol Physiol. 2010;23:17–27.

    PubMed  Google Scholar 

  52. Przybilski M, Deb R, Erdmann D, Germann G. New developments in skin replacement materials. Chirurg. 2004;75(6):579–87.

    CAS  PubMed  Google Scholar 

  53. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma. 2009;67(4):752–7.

    PubMed  Google Scholar 

  54. McGuigan FX, Forsberg JA, Andersen RC. Foot and ankle reconstruction after blast injuries. Foot Ankle Clin. 2006;11(1):165–82.

    PubMed  Google Scholar 

  55. Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR. The mangled foot and leg: salvage versus amputation. Foot Ankle Clin. 2010;15(1):63–75.

    PubMed  Google Scholar 

  56. Sheridan GW, Matsen FA. Fasciotomy in the treatment of the acute compartment syndrome. J Bone Joint Surg Am. 1976;58:112–5.

    CAS  PubMed  Google Scholar 

  57. Breederveld RS, Tuinebreijer WE. Incidence, cause and treatment of burn casualties under war circumstances. Eur J Trauma Emerg Surg. 2009;35:240–3.

    PubMed  Google Scholar 

  58. Ennis JL, Chung KK, Renz EM, Barillo DJ, Albrecht MC, Jones JA, Blackbourne LH, Cancio LC, Eastridge BJ, Flaherty SF, et al. Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties. J Trauma. 2008;64(2 Suppl):S146–S151151.

    PubMed  Google Scholar 

  59. Wolf SE, Kauvar DS, Wade CE, Cancio LC, Renz EP, Horvath EE, White CE, Park MS, Wanek S, Albrecht MA, et al. Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom. Ann Surg. 2006;243(6):786–92.

    PubMed  PubMed Central  Google Scholar 

  60. Butler FK. Tactical combat casualty care: update 2009. J Trauma. 2010;69(1 Suppl):S10–S1313.

    PubMed  Google Scholar 

  61. Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193–211.

    PubMed  Google Scholar 

  62. Hinck D, Gatzka F, Debus ES. Surgical combat treatment of vascular injuries to the extremities. American experiences from Iraq and Afghanistan. Gefässchirurgie. 2011;16:93–9.

    Google Scholar 

  63. Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM Jr. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006;60(2):432–42.

    PubMed  Google Scholar 

  64. Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, Propper BW, Rasmussen TE. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg. 2010;52(1):91–6.

    PubMed  Google Scholar 

  65. Taller J, Kamdar JP, Greene JA, Morgan RA, Blankenship CL, Dabrowski P, Sharpe RP. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at Echelon II facilities? J Trauma. 2008;65(3):595–603.

    PubMed  Google Scholar 

  66. Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. Lancet. 2009;374(9687):405–15.

    PubMed  Google Scholar 

  67. Tonus C, Preuss M, Kasparek S, Nier H. Adequate management of stab and gunshot wounds. Chirurg. 2003;74(11):1048–56.

    CAS  PubMed  Google Scholar 

  68. Wall MJ Jr, Soltero E. Damage control for thoracic injuries. Surg Clin N Am. 1997;77(4):863–78.

    PubMed  Google Scholar 

  69. Wölfl CG, Vock B, Wentzensen A, Doll D. Stop the bleeding—damage control surgery vs definitive treatment. Trauma und Berufskrankheit. 2009;11(3):183–91.

    Google Scholar 

  70. Karmy-Jones R, Jurkovich GJ, Nathens AB, Shatz DV, Brundage S, Wall MJ Jr, Engelhardt S, Hoyt DB, Holcroft J, Knudson MM. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg. 2001;136(5):513–8.

    CAS  PubMed  Google Scholar 

  71. Gusgen C, Willms A, Richardsen I, Bieler D, Kollig E, Schwab R. Characteristics and treatment strategies for penetrating injuries on the example of gunshot and blast victims without ballistic body armour in Afghanistan (2009–2013). Zentralbl Chir. 2017;142(4):386–94.

    PubMed  Google Scholar 

  72. Berg RJ, Karamanos E, Inaba K, Okoye O, Teixeira PG, Demetriades D. The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg. 2014;76(2):418–23.

    PubMed  Google Scholar 

  73. Sanei B, Mahmoudieh M, Talebzadeh H, Shahabi Shahmiri S, Aghaei Z. Do patients with penetrating abdominal stab wounds require laparotomy? Arch Trauma Res. 2013;2(1):21–5.

    PubMed  PubMed Central  Google Scholar 

  74. Anjaria DJ, Ullmann TM, Lavery R, Livingston DH. Management of colonic injuries in the setting of damage-control laparotomy: one shot to get it right. J Trauma Acute Care Surg. 2014;76(3):594–8 (discussion 598–600).

    PubMed  Google Scholar 

  75. Müller T, Doll D, Kliebe F, Ruchholtz S, Kühne C. Damage Control bei hämodynamisch instabilen Patienten—Eine Behandlungsstrategie für Schwerverletzte. Anästhesiol Intensivmed Notfallmed Schmerzther. 2010;45(10):626–34.

    PubMed  Google Scholar 

  76. Franke A, Bieler D, Friemert B, Kollig E, Flohe S. Preclinical and intrahospital management of mass casualties and terrorist incidents. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2017;88(10):830–40.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding authors

Correspondence to Dan Bieler or Axel Franke.

Ethics declarations

Conflict of interest

DB, EK, CG and GA are instructors of the TDSC course. AF and BF are directors of the TDSC course. DB, AF, BF and GA developed the TDSC course concept. MM confirms that there is no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bieler, D., Franke, A., Kollig, E. et al. Terrorist attacks: common injuries and initial surgical management. Eur J Trauma Emerg Surg 46, 683–694 (2020). https://doi.org/10.1007/s00068-020-01342-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-020-01342-z

Keywords

  • Blast injuries
  • TASC
  • Damage control surgery
  • Gunshot wounds
  • Terrorist attacks
  • Tactical surgery