Abstract
Background
Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI.
Methods
We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS.
Results
The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo’s grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1–6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h.
Conclusions
Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Aschkenasy-Steuer G, Shamir M, Rivkind A et al (2005) Clinical review: The Israeli experience: conventional terrorism and critical care. Crit Care 9:490–499
Mellor SG (1992) The relationship of blast loading to death and injury from explosions. World J Surg 16:893–898
Leibovici D, Gofrit ON, Stein M et al (1996) Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma 41:1030–1035
Frykberg ER (2002) Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 53:201–212
Peral-Gutierrez de Ceballos J, Turégano-Fuentes F, Pérez-Díaz D et al (2005) Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 33:S107-S112
Pizov R, Oppenheim-Eden A, Matot I et al (1999) Blast lung injury from an explosion on a civilian bus. Chest 115:165–172
Gustillo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg 58A:453–458
Kuhn F, Morris R, Witherspoon CD et al (1996) Standardized classification of ocular trauma. Ophthalmology 103:240–243
Cushman JG, Pachter HL, Beaton HL (2003) Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 54:147–155
Kirschenbaum L, Keene A, O’Neill P et al (2005) The experience at St. Vincent’s hospital, Manhattan, on September 11, 2001: preparedness, response, and lessons learned. Crit Care Med 33:S48–S52
Aylwin ChJ, König ThC, Brenan NW et al (2006) Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 368:2219–2225
Lockey DJ, MacKenzie R, Redhead J et al (2005) London bombings July 2005: the immediate pre-hospital medical response. Resuscitation 66:ix–xii
Wong JM, Marsh D, Abu-Sitta G et al (2006) Biological foreign body implantation in victims of the London July 7th suicide bombings. J Trauma 60:402–404
Peleg K, Aharonson-Daniel L, Michael M et al (2003) Patterns of injury in hospitalized terrorist victims. Am J Emerg Med 21:258–262
Peleg K, Aharanson-Daniel L, Stein M et al (2004) Gunshot and explosion injuries: characteristics, outcomes and implications for care of terror-related injuries in Israel. Ann Surg 239:311–318
Almogy G, Belzberg H, Mintz Y et al (2004) Suicide bombing attacks: update and modifications to the protocol. Ann Surg 239:295–303
Almogy G, Rivkind A (2006) Surgical lessons learned from suicide bombing attacks. J Am Coll Surg 202:313–319
Stein M (2005) Urban bombing: a trauma surgeon’s perspective. Scand J Surg 94:286–292
Stein M, Hirshberg A (1999) Medical consequences of terrorism. The conventional weapon threat. Surg Clin North Am 6:1537–1552
Cooper GJ, Taylor DE (1989) Biophysics of impact injury to the chest and abdomen. J R Army Med Corps 135:58–67
Avidan V, Hersch M, Armon Y et al (2005) Blast lung injury: clinical manifestations, treatment, and outcome. Am J Surg 190:945–950
El-Khoury GY, Whitten CG (1993) Trauma to the upper thoracic spine: anatomy, biomechanics, and unique imaging features. AJR Am J Roentgenol 160:95–102
Koizumi M, Ueda Y, Lida J et al (2002) Upper thoracic spinal cord injury without vertebral bony lesions: a report of two cases. Spine 27:E467–E470
Hamilton-Farrell M, Bhattacharyya A (2004) Barotrauma. Injury 35:359–370
DePalma RG, Burris DG, Champion HR et al (2005) Blast injuries. N Engl J Med 352:1335–1342
Zwimpfer TJ, Bernstein M (1991) Spinal cord concussion. J Neurosurg 72:894–900
Katz E, Ofek B, Adler J et al (1989) Primary blast injury after a bomb explosion in a civilian bus. Ann Surg 209:484–488
Born CT (2005) Blast trauma: the fourth weapon of mass destruction. Scand J Surg 94:279–285
Miguel-Tobal JJ, Cano-Vindel A, Gonzalez-Ordi H et al (2006) PTSD and depression after the Madrid March 11 train bombings. J Traumatic Stress 19:69–80
Einav S, Aharonson-Daniel L, Weissman Ch et al (2006) In-hospital resource utilization during multiple casualty incidents. Ann Surg 243:533–540
Acknowledgment
The authors thank Dr. Michael Stein for his very helpful discussion of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Turégano-Fuentes, F., Caba-Doussoux, P., Jover-Navalón, J.M. et al. Injury Patterns from Major Urban Terrorist Bombings in Trains: The Madrid Experience. World J Surg 32, 1168–1175 (2008). https://doi.org/10.1007/s00268-008-9557-1
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-008-9557-1