Evaluation and Treatment of Blast Injuries Charles Stewart MD FACEP, FAAEM Jacarta Hotel bombing
Objectives – • Describe the basic physics, mechanisms of injury, and pathophysiology of blast injury • List the four types or categories of blast injuries • List the factors associated with increased risk of primary blast injury
Objectives…cont. • Recognize the key diagnostic indicators of serious primary blast injury • State the most common cause of death following an explosion
Why? • Combat • Terrorism • Accidents
Combat: Iraq
Combat: Iraq
Combat: Viet Nam • Dong Ha ammunition dump explosion September 3, 1967 • 20, 000 tons of explosives
Terrorism: NYC
Terrorism: USS Cole
Terrorism: Dhahran Khobar Towers in Dhahran, Saudi Arabia, after a terrorist bomb exploded and killed 19 Air Force members.
Terrorism: ? ? ?
Terrorism • Bombings are clearly the most common cause of casualties in terrorist incidents. • Recent terrorism has shown increasing numbers of suicidal bombers wearing or driving the explosive device • A poor man’s guided missile!
Texas City Texas • USS Grandcamp was loading ammonium nitrate fertilizer. 2, 300 tons were already onboard. • A fire was discovered in the hold of the ship. • At 0912 hrs the ammonium nitrate exploded
Ship’s Anchor Fragments can travel… …a long distance….
Accidents Grain elevator
Accidents Gasoline tanker: I-95
Accidents Fireworks Plant Explosion
First… a little theory …What is an explosive? There are four types… • High explosive • Low explosives • Fuel-Air explosives • Nuclear Explosives We won’t talk about nuclear explosions…
Explosives • High order • Detonation • Blast wave formation (supersonic) • Low order • Deflagration • No blast wave formation (always subsonic)
High order explosives “HE” • Nitroglycerine • Dynamite • TNT – the “classic” • PETN – ‘det’ cord. • C-4 – familiar to all military • Semtex (Warsaw pact version of C-4) • ANFO • Ammonium nitrate, fuel oil mixture
High order explosives “HE” • When a high explosive detonates, it is converted instantaneously into a gas at high pressure and temperature. • The expansion of these gases creates the blast wave. • Brisance is the shattering effect of the blast wave
The blast wave… A shock wave
High Speed Photography of Blast Wave
Low order explosives (propellants) • Gunpowder • Nitrocellulose • Smokeless powder • (This is also is a high explosive under certain conditions) • Match heads • Multiple other compounds
Deflagration Low-order explosive combustion Deflagration is very rapid burning…. The speed is increased by confinement
Fuel-air explosives (Thermobaric weapons) • Neither a high explosive nor a low order explosive • Has features of both • Most often has deflagration • May have supersonic detonation • May have much longer, broader blast wave than high explosive
Thermobaric explosives Fuel-air mixtures
Thermobaric weapons Fuel-air mixtures • Optimized to produce heat and blast • Secondary effects through flying fragments • Toxic detonation gases • Anoxia
Thermobaric weapons Fuel-air mixtures • Particularly effective in enclosed spaces • Fireball and blast can travel around corners • Blast waves are intensified when reflected by walls and other surfaces.
Fuel-air explosives Thermobaric weapons
Fuel-Air Mixtures (not just military explosives) • Grain/dust explosions • BLEVE • Slow escape of natural or LP gas
IED (A very, very bad terminology) • Improvised Explosive Device • ANY device that doesn’t have a military issue number…somewhere • Ranges from • crude match-head pipe bombs Low explosive • Experimental professional munitions that don’t yet have issue numbers Often high explosives
IED Has many shapes
Issued munitions …can be part of an IED But are not IED’s themselves M-79/M-203 155 mm Artillery M-18 “Claymore mine” C-4
Issued munitions …can be part of an IED Roadside IED… 155 mm Artillery shells linked with detonation cord
Blast effects
Injuries from blast Definitions • Primary • The direct effect of the blast • Secondary • Due to projectiles from the blast • Tertiary • The victim is thrown by the blast wind • Quaternary • All other effects – burns, building collapse, etc.
Primary Blast Injury • Primary Blast Injury (PBI) is caused directly by the sudden increase in air pressure after an explosion • Blast wave or shock front that travels faster than the speed of sound • How will this injure tissue? ? ?
Primary Blast Injury • Compression of surrounding air or water • Differential pressures at interfaces • Differential pressures in tissues • Organ distortion • Tensile strength of the tissue is exceeded • Tissue tearing
Variables Affecting Severity Primary Blast Injury • Distance is the most important • Intensity varies by the third power of the distance… • Double the distance from the explosion and reduce the injury by a factor of 8 • The most effective way to minimize injury from primary blast injury is to increase the distance from the center of the explosion (stand-off distance)
“Stand-off” distance Distance works….
Stand-off distance
Variables Affecting Severity Primary Blast Injury • "Blast Environment" is a very important factor determining the extent of injuries. • Nearby structures may either act as a shield or may reflect the blast wave onto a casualty. • Confined environment increases damage • Foxhole or shelter is a confined environment • Inside the bus is bad… • Orientation of body relative to blast wave – end-on orientation minimizes injury
Blast inside of a closed space Reflected Blast Waves • A blast wave that is reflected can create a peak pressure 10 X greater than that of the incident wave. • Blast waves inside buildings are repeatedly reflected creating a “complex blast wave” • Marked increase in injuries related to primary blast effects when explosion occurs in a closed space
Blast inside of a closed space In the Foxhole • Blast occurring over simple foxholes can readily generate complex blast waves. • The static overpressure from an explosion directly over a foxhole causes a wave to propagate into the foxhole and reverberate. • Depending upon the size and shape of the foxhole and the location of soldier in it, the effective overpressure loading can be much greater than the incident blast wave itself.
Variables Affecting Severity Primary Blast Injury • Peak of the initial positive wave • Overpressure >60 -80 PSI potentially lethal • Duration of the overpressure • Longer is bad – See thermobaric weapons • Medium in which it travels • Water is a special case
Potential for Occult Injury Primary Blast Injury • Blast shock waves may pass through a solid structure (hull of a ship or wall of a tank) and produce serious injury • Multiple fractures, • Disruption of major blood vessels, • Damage to internal organs without disruption of the solid structure itself. • These injuries may occasionally occur without damage to the skin.
Primary blast injury • Direct trauma • Amputations • Death • Hollow organ damage • Ear • Lung • GI tract
Primary blast injury • Organs most sensitive to blast effects are air filled (damage is produced at the interface between air and water) • middle ear: ear drum rupture @ 5 psi • the respiratory system – • lungs and bronchi: lung damage at 15 psi • upper airways (trachea, pharynx and larynx) • nasal passages and sinuses • the bowels. • LD 50 is around 50 psi. • Air embolism is 1 o cause of sudden death due to blast
Primary Blast Injury Death Amputation
Primary blast injury Traumatic amputation • Blast wave creates stress wave through skin and muscles • Stress wave shatters solid bone • Landmines • Expanding gases enter and expand tissues while ripping off distal part
Primary blast injury Pulmonary injury • Hemorrhage: • Pulmonary contusion • Hemoptysis • Hemothorax • Escape of Air: • • Pneumothorax Pneumomediastinum Pulmonary pseudocyst Arterial gas embolism (AGE) • Apnea
Primary blast injury Pulmonary injury Bruises on lungs produced when primary blast wave rapidly accelerates ribs into underlying lung tissue • Blood vessels stretched and torn causing pulmonary contusion • Mild interstitial hemorrhage with minor oxygen diffusion problems
Primary blast injury Pulmonary injury • Blood vessels stretched and torn causing pulmonary contusion (bruising) • Severe interstitial and alveolar blood and fluid with major oxygenation and ventilation problems
Primary blast injury Pulmonary injury • Respiratory difficulty • With exertion • At rest !! • Asymmetrically or patchy decreased breath sounds or inspiratory crackles • Decreased Sa. O 2 on ambient air or 100% oxygen therapy • Pulmonary infiltrates on chest radiograph Blood & Fluids in lungs
Primary blast injury Pulmonary injury • Signs of blast lung are usually present at the time of the initial evaluation. • Presentation may be delayed by 48 hours. • In one series, all patient with blast lung required ventilation support within 6 hours of presentation • All were in enclosed space (bus bomb) • Wheezing or SOB on arrival should be presumed to be blast lung
Primary blast injury Pulmonary injury • Alveoli disrupted • Asymmetrically decreased breath sounds • Pneumothorax • Tension pneumothorax • Tracheal deviation • JVD • Shock if enough pressure in hemithorax to cause mediastinal shift (tension pneumothorax)
Primary blast injury Cardiac problems • Arrhythmias • Bradycardia • Thought to be vagal • Hypotension
Primary Blast Injury Brain Injury • • Concussion TBI Arterial gas embolism Signs and symptoms include headache, fatigue, poor concentration, lethargy, anxiety, and insomnia
Primary blast injury Arterial Gas Embolism • Arterial gas embolism (AGE) – [air bubbles enter blood stream and travel to brain and/or heart causing stroke and/or heart attack] • Cerebral circulation • Stroke • Seizures • Altered mental status • Coronary circulation • Dysrhythmias • Ischemia or infarction • Cardiogenic shock Arterial gas embolism in liver
Primary blast injury Ear injury • Middle ear: • Ruptured tympanic membrane (TM) • Temporary conductive hearing loss • Inner ear: • Temporary sensory hearing loss • Permanent sensory hearing loss
Primary blast injury Ear injury • TM rupture thought to be marker for pulmonary injury? • Good study showed that this is NOT true • Earplugs/hearing protection • In water? • Ruptures at 5 psi
Primary blast injury Gastrointestinal injury • More common in underwater blasts • Acute/Delayed perforation of the bowel • No obvious external wound – easily missed • Early hemorrhage • Delayed sepsis • Pathology • • Mesenteric tears Hematomata in bowel wall Intraluminal hemorrhage Delayed perforation up to 8 days after injury
Primary blast injury Identifying Abdominal Injury • Serial abdominal examinations • Serial hematocrit determinations • Diagnostic studies • Ultrasonography • Peritoneal lavage • Computed tomography
Primary Blast Injury Identifying Abdominal Injury Sometimes, you can see it on the CXR.
Primary blast injury Repeated injury • Larynx is most sensitive nonauditory structure to repeated blast followed by GI and lungs. • Repeated exposure to blast waves significantly increases severity of injury/likelihood of death
Underwater Blast & Blast Injury Inside Ships
Underwater Blast Injury • More devastating at a greater distance • Pressure wave travels much faster in water • Force does not dissipate as quickly • If vertically oriented in the water at/near the surface • significantly greater amount of blast energy imparted on the abdomen than on the lungs.
Underwater Blast Injury • During WWII Sir Zachary Cope observed that: “…if the person were floating on the back so that neither the abdomen nor the chest were directly opposed to the blast, no serious injury was sustained. ” • Underwater exposure to the explosion of a 1 lb. charge causes death at 23 ft. This is 3 X farther than the lethal range in air
Underwater Blast Injury If underwater explosion is expected get as horizontal and as close to the surface as possible
Underwater blast injury • Eliat Destroyer Sunk by torpedo • 32 sailors exposed to underwater blast survived to be rescued. • 31 suffered primary blast injury (PBI) • 27 had blast lung with 5 requiring ventilation support • 24 had abdominal signs and underwent laparotomy – • 22 had bowel perforations • 4 of the 32 rescued died – • 3 expired during or shortly after general anesthesia (Arab-Israeli 1967 War)
Underwater Blast Injury • 13 soldiers swimming for recreation were exposed to a nearby underwater explosion • • • All quickly got out of the water Within a minute 2 had cardiac arrest Within 10 minutes 2 more died Within 30 minutes 2 more died. The remaining 7 were evacuated by helicopter Only 3 survived.
Primary blast injury is lethal…. But SECONDARY blast injuries are the real killer of explosions.
Secondary Blast Injury #1 source of injury/death from explosions • Fragments from munitions (design) • Fragments from “spiked” terrorist bomb (Nails, Glass, Unique IED’s…) • Fragments from blast environment • Glass fragments are a common cause of injury/death related to blast in civilian settings • From the bomber… • At least one paper reports infections from bomber fragments…. Fragments are often (erroneously) called shrapnel…
Fragments can travel… …a long distance…. It is not clinically possible to determine if the explosive was HE or LE from the fragment patterns. Remember the anchor?
Fragments kill! Normally, if the victim is close enough to be seriously injured by blast wave…. victim is killed by fragments (Not true for enhanced blast weapons)
Fragments • Travel at HIGH velocity • Conventional military explosives create fragments with initial velocity > 8000 fps. • M 16 round travels at 2800 fps!
Bomb fragment damage Terrorist bomb Parts of the bomber can be fragments that strike victims
Fragments…. Come from many sources The real shrapnel…. Terrorist devices Munitions (design)
Fragments A car bomb
Fragments • Glass causes up to 50% of secondary blast injuries • 88% of Khobar Towers patients were injured by flying glass • Occur most often in exposed areas such as head, neck and extremities
Fragments Eye injuries • 10% of blast victims will have significant eye injuries.
EFP… a special kind of fragment
EFP Explosively formed projectile A special case of the shaped charge explosive
EFP Vehicle Damage Entry Hole
EFP Entry Hole
EFP Vehicle Damage
EFP The results of the fragment
EFP Results…cont.
EFP Another…
EFP The hardware Often paired with another device that simply uses fragments to increase the number/severity of injuries
EFP • Explosively formed projectiles are professionally designed and manufactured munitions…even if they are labeled as IED’s. • These are NOT the work of the amateur.
Body Armor Mixed blessing • Use of body armor significantly increases primary blast injury • May magnify primary blast injury when the explosion is focused or close. • However, the over all risk of death is higher from secondary blast injury. • Body armor markedly decreases number of fragment wounds (secondary blast trauma)
Tertiary Blast Injuries The blast wind pushes/throws the victim onto something else. The trauma is due to the impact. Blast wind occurs with both HE and LE explosions
Quaternary blast injury • The building collapses • The products of the blast are poisonous • Nitrogen oxides (NOx) are poison • Depleted uranium • The patient is burned • White phosphorous • Exacerbation of underlying COPD, CAD, etc.
Crush and compartment syndrome • Structural collapse may cause extensive blunt trauma • Crush syndrome • Damage to muscles and subsequent release of myoglobin, urates, potassium, and phosphates • Oliguric renal failure • Compartment syndrome • Edematous muscle in an inelastic sheath promotes local ischemia, further swelling, increased compartment pressures, decreased tissue perfusion, and further ischemia
Medical Management Issues In Blast Injury
EMS Providers… • BE WARY OF SECONDARY DEVICES • Device command detonated or timed to occur 30 -100 minutes after the first device • BE WARY of sniper coverage • The sniper may also have control of the secondary device
Management of secondary, tertiary, and quaternary blast injuries is unchanged from usual principles of care. • There may be LOTS of casualties…. • They may have LOTS of injuries…
Open Space Suicide Bombing Small (5 kg TNT-eq) • Casualties – 1 -30 • (Israel - average 23, range 1 -99) • Severity • Killed 1 -5 • Admitted 5 -10 • Treat & release 20 • Injury patterns • • } 1/3 rd killed or admitted } 2/3 rd outpatient treatment 1° Blast trauma < 5 meters Fragment wounds < 100 meters Temporary deafness Risk of Hepatitis, Tetanus, HIV (Fragments of the bomber)
Open Space Suicide Bombing Moderate - Car (50 -100 kg TNT-eq) • Casualties – 1 -50 • (Israel - average 23, range 1 -99) • Severity • Killed 5 -10 • Admitted 10 -20 • Treat & release 40 • Injury patterns • • } 1/3 rd killed or admitted } 2/3 rd outpatient treatment 1° Blast trauma < 25 meters Fragment wounds < 500 meters Temporary deafness Risk of Hepatitis, Tetanus, HIV (Fragments of the bomber) This is an upscale of the backpack suicide bomb…
Confined Space Backpack Bomb Small (10 kg TNT-eq) • Casualties – • 20 -50 bus and • 150 -200 train / bomb • 70% of fatalities are Dead on Scene (DOS) • Severity • Killed 20% • Admitted 20% • Treat and release 60% Simplified Severity Predictor = 1/3 rd killed or admitted > 24°. • Injury patterns • 1° Blast trauma – anywhere within bus or train cabin • Temporary deafness • Risk of Hepatitis, Tetanus, HIV (From fragments of the bomber) • Rescue may be complicated
Structural collapse bombing (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 collapse • 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
Triage • Dead…stays dead • CPR has no place in the MASCAL • Confined space explosions will have FAR more injuries and higher incidence of primary blast injury. • Structure collapse markedly increases mortality
Triage • Do NOT do definitive care in TRIAGE… • Rapid evacuation increases the chance of survival
EMS Providers • Airway control - minimize airway pressures as much as possible. • Positive pressure ventilation only when necessary • Pulse oximetry if possible
EMS Providers • Identify and treat hemorrhage at once • Tourniquet is the appropriate treatment • Good IV access – • Monitor fluid administration carefully • Avoid overhydration/ARDS! • Frequent vital signs
EMS Providers • MANDATORY LITTER PATIENT – • Left lateral decubitus position w/head lower than feet (AGE position), if possible • Don’t allow the patient to assist in own rescue or exert him/her self in any way
Evacuation • Casualties with pneumothorax and AGE will get worse with altitude • Consider field chest tube • Avoid initial evacuation by longdistance high-altitude flights • Bad oxygenation will get worse with altitude
Evacuation Civilian/Mass Casualty variant • Minor injuries skip EMS and go to hospital • Expect LEAST injured to arrive first in hospital • Double first hour’s count for a rough prediction of the ‘first wave’ of casualties
History Important historical questions… • Can you hear me? Do you have ear pain • Tympanic membrane rupture • Hearing loss • Ear injuries do not need special care in the field
History Important historical questions… • Are you short of breath? • First subjective complaints of pulmonary contusion, pneumothorax, hemothorax, or shock. • The more exertion required to elicit dyspnea… the better your patient is • Do you have chest pain?
History Important historical questions… • Do you have nausea, abdominal pain, urge to defecate, or blood in your stools • Early markers for GI injuries • May be absent/altered with other trauma
History Important historical questions… • Do you have eye pain or problems with your vision? • Markers for blunt and penetrating eye trauma • 10% of explosion victims will have eye trauma • This doesn’t take into account military protective eyewear.
Examination Important physical findings… • Respiratory system • Ecchymosis or petechiae in hypopharynx • This is more sensitive than ear findings • Cough • Tachypnea • Dyspnea
Examination Important physical findings… • Respiratory, cont… • Hemoptysis • Rales or crepitations • Wheezes • Chest pain • Asymmetric chest movement • Subcutaneous emphysema
Examination Important physical findings… • Cardiovascular • Tachycardia • Stress, hemorrhage, hypoxia, exertion • Bradycardia • Vasovagal • Delayed capillary refill • Hypotension • Hemorrhage, AGE, vasovagal reaction • Arrhythmias • Shock, coronary AGE
Examination Important physical findings… • Gastrointestinal • Nausea/vomiting • Abdominal tenderness • Hematochezia • Hematemesis
Examination Important physical findings… • Neurologic • Vertigo • • Vertigo is NOT usually due to auditory trauma Coma Altered sensorium Focal numbness Paresthesias Seizures Retrograde amnesia
Examination Important physical findings… • Eye • Difficulty focusing • Blindness • Fundoscopic findings of retinal artery air embolism • Loss of red reflex on fundoscopic examination
Examination Important physical findings… • Auditory system • Blood oozing from mouth or nose • Hyperemia, hemorrhage or rupture of TM • Deafness • Tinnitus
Diagnostic studies • Chest X-ray • Should be done on almost all patients • Pulse oximetry • With multiple casualties consider intermittent monitoring • FAST ? • CT of head, chest, or abdomen if HX and PE suggest • NOT optional in comatose • CT is often biggest bottleneck in MASCAL
Diagnostic studies • CBC • Serial hemoglobin / hematocrit measurements • Stool occult blood • Other labs may be helpful… but order on case-by-case basis
Treatment • Pulmonary • High flow oxygen • Consider intubation • Respiratory distress • Hemoptysis • Use lowest airway pressure possible − PEEP and high ventilation pressures cause POP • If intubated, consider chest tube(s).
Treatment • Hypotension • Blood loss from wounds • Blood loss due to GI hemorrhage • Blood loss due to intra-abdominal organ rupture • Pneumothorax • Air embolism • Vagal reflex
Treatment • Hypotension • Volume support • ? ? Keep dry? ? • Consider blood products – early • LOOK for the CAUSE!
Treatment • Auditory • • Most resolve spontaneously Avoid irrigating or probing the auditory canal Avoid swimming Refer to ENT if no healing or complications occur • Complications include ossicle disruption, cholesteatoma, perilymphatic fistula, and permanent hearing loss (1/3) • Steroids may be helpful in sensorineural hearing loss
Treatment • Wound management • Avoid primary closure • Use delayed primary closure • Consider all wounds to be puncture wounds and have an imbedded FB. • Carefully explore every wound. • Consider CT, US, or MRI to look for radiolucent foreign bodies
Air Embolism • High flow oxygen • Position patient • Injured lung in dependent position • Left lateral recumbent position • head down ? ? ? • Hyperbaric oxygenation • Navy dive table 6
Air Embolism • Aspirin may be helpful in AGE • May reduce inflammation-mediated injury in pulmonary barotrauma • Weigh bleeding risk in acute trauma setting
Eye injury • 28% of blast survivors sustain eye injuries • This may not be true with military eyewear • Objects penetrating eye (or any other body part) should not be removed in an emergency setting • Cover affected eye with a paper cup that will not exert pressure on the globe • Remove object in operating room under controlled conditions • Refer patient to ophthalmology for definitive treatment
Anesthesia • ? Increased morbidity when anesthesia given • ? Unrecognized primary blast injury • ? Barotrauma • Consider spinal anesthesia • Consider bilateral chest tubes
Burns • WP burns require special management • Copious lavage and removal or particles and debris • Rinse with 1% copper sulfate solution • Combines with phosphorous particles and impedes further combustion • Cardiac monitor • Hypokalemia and hyperphsophatemia common • Consider moistened face masks to protect from phosphorous pentoxide gas exposure • Avoid use of flammable anesthetic agents and excessive oxygen
Disposition • Depends on the injury • Don’t be hasty to discharge • Consider observation for 8 -24 hours
Disposition • Limited data prevent establishing optimal duration of observation • Low risk and may be discharged with strict precautions after 6 -8 hours of observation: • Persons exposed to open-space explosions with no apparent significant injury, normal vital signs and unremarkable lung and abdominal examination • Moderate risk and should be observed for longer periods of time for delayed complications: • Persons exposed to confined area explosion or in-water explosions • Persons with TM rupture ? • Persons with intra-oral petechiae
Transportation • Remember primary blast injury may have a little delay in presentation… • Air transport • Repeat CXR? • Bilateral chest tubes?
No problem…? ? ? We got 50 walking wounded in the last 20 minutes from that explosion three blocks away… “Boy, I’m glad nobody got hurt badly in this explosion!”
No problem…? ? ? The trooper was wearing issue body armor. The mortar round exploded about 10 feet away. She was in a foxhole and had overhead cover. She had some injuries on her extremities, but had no torso injuries from the bomb fragments. She developed pulmonary blast injury?
No problem…? ? ? The SEAL had no evidence of ear injury, had no cough, hemoptysis, shortness of breath, or frag wounds… Now you tell me that he had an abdominal blast injury with a perforated colon? There weren’t any markers for blast injury, were there?
Summary • Explosions cause familiar trauma • There may be LOTS of casualties with LOTS of injuries • Secondary blast trauma is the biggest killer • Primary blast injuries of the lung • Leads to pulmonary contusion with possible arterial gas embolism to the brain or heart • May rapidly worsen if casualty exercises (including walking) • May affect evacuation decisions (air vs. ground) – air evac only at LOW altitude • Management of other injuries adjusted • Spontaneous breathing or low airway pressures • Highest level of oxygen supplementation • Just enough fluid or blood to restore perfusion • May help to position differently than supine
Bomb injury, threat model Bomb Size & weight Explosive choice Purpose & Source Delivery system Adulterants Tactic Model courtesy of CDC Human 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 Within water Air and liquid hazards
Casualties – 100 – 3, 000 – largely based on bomb size, time of day, warning, building structure, and evacuation proficiency – 90% of fatalities are DOS
The end. • I’ve covered chaos, mayhem, destruction and disaster! • My work here is complete.
How to Reach Me Military email. charles. stewart@usafa. af. mil Civilian email cstew@storysmith. net Website www. storysmith. net Posted on website • Handout (complete) • Complete slide set of this lecture • Chapter from European Master’s in Disaster Medicine text on blast injuries
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