Public Health Emergency Preparedness
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Chapter 7. Blast Terrorism (continued)
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).
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
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
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
- 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
- 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
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
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 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).
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.
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
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.
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
- 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
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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.
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
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).
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
- 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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