Public Health Emergency Preparedness

Chapter 7. Blast Terrorism (continued)

Trauma Systems

The medical response to blast terrorism is built on the foundation of the regional trauma system. About 98% of all terrorist events worldwide involve physical trauma, and approximately 75% of all terrorist events are due to blast trauma. Therefore, regional emergency management, public safety, and public health agencies should include not only regional child health care experts, but also regional pediatric trauma professionals in planning for mass casualty events that could affect children. Blast terrorism, like all other mass casualty events, needs to be directed with an Incident Command Structure (Chapter 2, Systems Issues).

Trauma Hospitals

Most trauma hospitals are full-service general hospitals that provide the highest level of health care service in their communities. However, modern trauma system design does not rely solely on such hospitals but integrates all health facilities within the region to the level of their resources and capabilities. Thus, the complete trauma system should consist of an integrated network of health care facilities within a region, designed for safe and rapid transport of injured patients to the health care facilities that best meet their medical needs. As of April 2002, 35 States had formally designated or certified trauma centers, while the remaining States had at least one verified trauma center, which is the key element recognized as essential to trauma systems. Many stand-alone pediatric hospitals also serve as "pediatric trauma centers."

Trauma Centers

Trauma centers are general hospitals that are committed, both institutionally and financially, to priority care of injured patients. Emergency medicine physicians and emergency trauma surgeons are the primary care providers within the context of the trauma center, and they provide appropriate information and followup to each patient's usual primary health care provider. Emergency medicine physicians begin evaluation and management and immediately involve emergency trauma surgeons whenever injuries meet any of the following criteria:

• Are multiple or severe.
• Require support of a full trauma team, based on previously established trauma triage criteria or scores.
• Would benefit from trauma consultation with an emergency trauma surgeon

Trauma centers should have the following attributes:

• Designated as such by emergency medical and public health authorities within the region, based on self categorization according to established standards.
• Followed by on-site peer verification by impartial trauma experts.
• Subject to ongoing review of performance and participation in the regional trauma system.

All trauma centers have key organizational characteristics in common:

• All trauma services should be led by a properly qualified and credentialed emergency trauma surgeon who has education, expertise, and experience in trauma care.
• This emergency trauma surgeon, together with a trauma nurse program manager and trauma registrar, should maintain active programs of continuing education and performance improvement for all members of the trauma service.
• Trauma care should be provided by properly qualified and credentialed physician specialists in general or pediatric emergency medicine, general or pediatric trauma surgery, anesthesiology, radiology, pathology, and the three core surgical subspecialties (critical care, neurologic surgery, and orthopedic surgery).
• This physician team should work in collaboration with properly qualified and credentialed nursing personnel.
• Appropriate physical resources should include properly equipped emergency departments, operating suites, intensive and acute-care units, imaging capabilities, laboratory facilities, and blood bank.
• The in-house trauma team should be available immediately, 24 hours per day, 7 days per week.
• Appropriate and culturally competent mental health, social work, pastoral care, injury prevention programs, and ideally, professional education and trauma research programs should be in place to serve both patients and the community.

Level One Trauma Centers

Level One Trauma Centers offer comprehensive care of seriously injured patients that includes specialists and services for resuscitation, recovery, and rehabilitation. They usually are located in full-service general or university hospitals or, in the case of children, in full-service children's hospitals in which comprehensive care of the trauma patient is part of the institutional mission. The key issue is comprehensive, readily available, and consistent care of injured patients by all needed specialists and services.

Level Two Trauma Centers

Level Two Trauma Centers provide most specialists and services that are available in Level One Trauma Centers, but typically they are located in full-service general hospitals that do not support medical or nursing educational programs (e.g., residency training) or trauma research. Patient care remains exemplary, and community outreach activities are a key part of the hospital's mission. Most Level Two Trauma Centers are located in large urban areas that are served by an academic medical center but with a sufficiently large population to require a second full-service trauma center, or they are in mid-sized urban areas that are not served by an academic medical center. In the latter situation, the Level Two Trauma Center acts as the regional trauma center, serving as the tertiary referral center for Level Three and Four Trauma Centers, as well as for non-trauma centers and other facilities within the region.

Level Three Trauma Centers

Level Three Trauma Centers provide most trauma care in the United States. They typically are located in community hospitals that serve small urban or large suburban areas. Key specialists and services are available, suitable for managing patients with injuries of a single system and few comorbidities. However, medical and surgical subspecialist coverage may be limited, and patients with multiple or severe injuries, with complex comorbidities, or who are very young or very old are usually transferred to a nearby Level One or Level Two Trauma Center after initial stabilization. Most Level Three Trauma Centers play an integral role in the regional trauma system and collaborate with a Level One or Level Two Trauma Center within the region. Again, patient care is exemplary, within the resources of the hospital and the community. Community outreach is essential, particularly in terms of support for the typically volunteer local emergency medical service agencies that serve the area.

Non-Trauma Centers

All facilities that receive emergency patients, including hospitals and free-standing diagnostic and treatment clinics, should have the capabilities for resuscitating and stabilizing injured patients of all ages. Therefore, protocols should be in place for sustentative trauma care (including education of medical and nursing staff in early care of injured patients) and for identification of patients in need of transfer to hospitals capable of providing definitive trauma care (which should be known to all urgent care personnel through prior development of formal transfer agreements). All such facilities should be:

• Considered part of the regional trauma system.
• Prepared to provide, within their communities, anticipatory guidance related to injuries that is consistent with programs advocated by regional experts in injury prevention.
• Participants in regional programs for performance improvement of community trauma care, with special emphasis on the outcomes of patients transferred to local trauma centers.

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Treatment

Treatment of blast trauma involves full integration of the regional emergency medical services (EMS) system and the regional trauma system, in accordance with plans developed in collaboration with regional public safety and emergency management agencies. Although most blast trauma is caused by explosive or incendiary agents, the possibility of other weapons of mass destruction (WMD), such as biological, chemical, or nuclear weapons, should always be considered (Chapter 4, Biological Terrorism; Chapter 5, Chemical Terrorism; and Chapter 6, Radiological and Nuclear Terrorism).

Trauma

The treatment of victims of major trauma, including blast trauma, follows well-established protocols. The American College of Surgeons Committee on Trauma has developed and disseminated such protocols through its support of the Advanced Trauma Life Support® for Doctors Course (Table 7.3). The Emergency Nurses Association and the Society of Trauma Nurses have undertaken like responsibilities for nurses through the Trauma Nursing Core Course and the Advanced Trauma Care for Nurses Course. All three courses focus on a practical approach to the initial care and management of the injured patient, assuming no special knowledge of trauma care, including the steps to be taken during the "golden hour" of trauma care—the critical first hour after injury has occurred.

Burns

Major burns and major trauma are often seen together in victims with injuries caused by explosive or incendiary devices. The treatment of victims of major burns also follows well-established protocols. Specific education on the initial resuscitation of these victims is included in both the Advanced Trauma Life Support® for Doctors course (American College of Surgeons Committee on Trauma) and the Advanced Burn Life Support course (American Burn Association) (Table 7.3, Table 7.4).

Multiple Casualties

The strict definition of a multiple casualty incident is an incident involving more than one casualty that overwhelms the capacity of emergency medical providers at the scene. In general, this happens when a local EMS system must care for five or more victims who have the same illness or injury at the same place and time. Because local hospital emergency departments may also be overwhelmed by such events, EMS systems usually attempt to transport multiple victims to several hospitals in the vicinity of the event when feasible. In such circumstances, attempts are usually made to transport members of the same family to the same hospital, particularly if ill or injured children are involved. However, the availability of specialized pediatric health care resources, such as children's hospitals, may justify preferential transport of pediatric victims of multiple casualty incidents to these facilities.

Mass Casualties

The strict definition of a mass casualty event is an event involving large numbers of casualties, generally 20 or more, that overwhelms and disrupts the resources and capabilities of the entire regional trauma and EMS systems to provide immediate care for all ill or injured victims. This situation develops when the need for ambulances, hospitals, or both exceeds the emergency resources of the regional health care system.  The definition further implies the following:

• The need to activate regional disaster plans that mobilize all available ancillary resources to assist with providing emergency medical care. This includes using the surge capability of both the regional EMS system to deploy extra ambulances (via mutual aid agreements) and of the regional hospital system to maximize the number of victims who can be cared for by opening spare beds, discharging stable patients, canceling elective procedures, and conscripting off-duty staff.
• The need to prioritize care such that those at greatest risk of loss of life or limb are treated first (unless they are unlikely to survive). The most widely used pediatric resource is JumpSTART, modified by Romig (http://www.jumpstarttriage.com) from the Simple Triage and Rapid Treatment (START) triage system used for adults.

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Planning and Mitigation

The approach to planning for the possibility of blast injury after a terrorist attack should combine knowledge of the epidemiology of blast injury with awareness of the resources available to the regional trauma system. The Federal Government has adopted a similar approach for routine trauma system planning that allies the regional public health system with the regional health care system to form regional partnerships for the purpose of developing and implementing comprehensive injury control strategies at the community level.

Medical disaster planning should fully integrate regional public health agencies, regional health care organizations, EMS, emergency departments, and trauma centers before a disaster occurs. Public health officials and trauma care professionals should collaborate to evaluate, and redesign if needed, each system component for optimal performance.

Current regional trauma system design maintains an artificial separation between the pre-event, event, and post-event phases of injury control. The comprehensive public health approach to regional trauma system design integrates all phases of injury control into a single system. Regional injury control systems that have adopted such an approach (e.g., San Diego County, CA) have seen steady improvement in the quality of their injury prevention programs and the outcomes of their trauma patient care.

Public health reasons to apply this approach to blast terrorism include the documented lack of public health preparedness of most regions for terrorist attacks, despite excellent resources that describe the necessary elements for treatment of victims.

Planning

The enormous variability in the following characteristics hinders comparative analysis, and hence accurate prediction, of needs and resources for victims of blast terrorism:

• Type, quality, quantity, force, and delivery (human, bicycle, motorcycle, car, truck, plane) of explosive.
• Environment (closed space vs. open air).
• Time (day vs. night).
• Distance (proximate vs. distant).
• Circumstances (weather conditions, hazardous materials, etc.).
• Protection (clothes, barriers, etc.).
• Sequelae (structural collapse, structural fire, etc.).
• Victims (ages, number, density).

In general, small, frequent blasts in open air usually result in less serious injury than large, single blasts in closed spaces, which historically have resulted in life-threatening injury.

Regional trauma system planning should also consider the special needs of children who are injured due to blast terrorism and the special resources needed to care for them. Children and young adults are at higher risk of serious injury than adults for several reasons (Children Are Not Small Adults, Chapter 1). Specific to blast trauma is that while blast tolerances in children are poorly defined, there is good reason to believe that children may absorb more blast energy per unit body mass than adults after blast trauma. This predisposes children to morbidity and mortality rates higher than those of adults as compressive shock waves passing through the body are compacted into a smaller total body mass.

Mitigation

Because most blast terrorism in recent years has involved children, with the notable exceptions of the terrorist airliner attacks on the World Trade Center in New York and the Pentagon in Washington on September 11, 2001, significant personal experience has been gained with pediatric disaster and emergency preparedness and management by child health professionals. Reports in the literature (summarized below) point out the woeful state of emergency preparedness for disasters that involve children. They also describe the common problems in pediatric disaster planning and management such that pediatric professionals involved in disaster planning will be knowledgeable about these problems and thus can seek to anticipate and thereby avoid them in future disasters.

In the Avianca jetliner crash in New York in January 1990, 22 of 25 (80%) children survived versus 70 of 132 (50%) adults, despite the fact that pediatric patients were inadequately treated and transported (State, regional, and county disaster plans did not address pediatrics). Only three children died, and only seven survivors sustained high-risk injuries. The spectrum of injuries resulting from this event were as follows:

• A 3-month-old boy with intracranial bleeding and aortic rupture (died).
• A 5-year-old boy with massive hemothorax (died).
• A 7-year-old boy with severe traumatic brain injury (died).
• Six children with traumatic brain injury.
• Five children with hypotensive shock.
• Three children with femur fractures with either hypotensive shock or traumatic brain injury.

Triage and transport of pediatric patients:

• Of seven children with a pediatric trauma score (PTS) <8, only one was taken to a Level I Pediatric Center.
• Of five high-risk children (greater risk of death) initially taken to a Level III Pediatric Center, only two were subsequently transported to a higher level Pediatric Center.
• Two high-risk patients and one low-risk patient (low risk of death) were transported by helicopter.

After the bomb blast that destroyed the Alfred P. Murrah Federal Building in Oklahoma City, OK, in April 1995, there were 816 casualties, including 66 children. Of these, 19 children died, and 47 survived. Of the 20 children in the day care center who were seated by windows, 16 died and 4 survived. The spectrum of injuries resulting from this event was as follows:

Of the 19 children who died:

• 90% had skull fractures, most with skull capping.
• Associated injuries: 37% trunk, 31% amputations, 47% arm fractures, 26% leg fractures, 21% burns, 100% soft-tissue injuries.

Of the children who survived:

• 15% required hospitalization.
• Documented injuries: two open depressed skull fractures with partially extruded brain, two closed head injuries, three arm fractures, one leg fracture, one arterial injury, one splenic injury, five tympanic membrane perforations, four burns (one burn >40% total body surface area [BSA]).

No children were injured in the terrorist airliner attack on the Pentagon on September 11, 2001, because the Pentagon daycare center was located on the opposite side of the building from the location of attack. However, as a result of the attack, issues were raised about children's hospital disaster preparedness. Immediately after the disaster, the hospital disaster plan was invoked, resulting in the discharge of more than 50 patients and the cessation of all nonurgent activities. Although hospital staff had conducted disaster drills in preparation for Y2K, hospital leaders continued to question their actual state of readiness. Emergency preparations were complicated by the fact that all of their news came not from official sources, but from local television, leaving hospital leaders unsure about what to expect.

These experiences highlight a number of vitally important issues regarding blast terrorism mitigation in children.

• After a blast, injuries in children are to be expected with most children injured in closed or confined spaces, which greatly increases the magnitude of forces of injury.
• As with blast injuries in adults, most children will either die at the scene or sustain minor injuries. Only a small number of children in the "penumbra" of the blast wind who sustain major injuries will survive to require hospital care, but typically they will not begin to arrive at the trauma center until 30-60 minutes after the blast event.
• Most surviving children with major injuries will require early surgery and subsequent care in a pediatric critical care unit, followed by lengthy hospitalization and rehabilitation, both physical and psychological.

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