3. Diseño Experimental
3.2. Diseño general de los experimentos
The vast majority of casualties, as well as health care personnel, typically sustain psychological damage as the result of their ordeal. Reactions range from acute stress reaction to acute stress disorder to posttraumatic stress disorder. All casualties exhibiting decreased awareness, acute anxiety, dissociative symptoms (including a sense of time distortion), or other stress-related symptoms must be provided with survivor counseling, utilizing social work, chaplain, and psychiatric resources as needed.
Evidence
Personnel who secure the scene of an explosion and manage casualties often need to realize that they are working within a crime scene where evidence must be collected. Multidisciplinary rehearsals with security and medical care personnel should optimize the functions of both responders.
Explosive devices are the most common source of injury in both military and terrorist settings and can produce devastating casualties in small and large numbers. Mass- casualty blast events, once the sole province of the battlefi eld hospital, now threaten the urban hospital, the civilian trauma surgeon, and health systems throughout the world. All medical providers need to bear the burden of preparing for infl uxes of overwhelming numbers of
casualties with primary blast and penetrating wounds, as well as burns and crush injuries. It is important that prehospital care providers and medics (1) understand the nature of the explosive weapons that are causing death and serious injuries with increasing frequency, (2) recognize the physiologic consequences of these weapons of war and terror, and (3) be prepared to provide care that will save lives and reduce morbidity.
SUMMARY
References
1. Staten CL: A comparison of the Afghan Mujahideen (1979-89)
and the Iraqi insurgency (2003): a review of the tactics, weapons, training, and composition, 2004, Emergency Response and
Research Institute (ERRI), www.blackwaterusa.com/btw2004/ downloads/afghan.ppt (accessed October 2004).
2. Karmy-Jones R, Kissinger D, Golocovsky M, et al: Bomb-related injuries, Mil Med 159:536, 1994.
3. Federal Bureau of Investigation, Bomb Data Center: 1999
bombing incidents, Pub No 0367, Washington, DC, 1999, US
Department of Justice.
4. Davis TE: Asymmetric war (terrorism) and the epidemiology of
blast trauma, 2004, www.bt.cdc.gov/coca/ppt/masstrauma.ppt
(accessed October 2004).
5. Signifi cant terrorist incidents, 1961-2003: a brief chronology, Washington, DC, 2004, Offi ce of the Historian, Bureau of Public Affairs, US Department of State, http://www.state.gov/r/pa/ho/ pubs/fs/5902.htm (accessed October 2004).
6. Arnold JL, Tsai M-C, Halpern P, et al: Mass-casualty, terrorist bombings: epidemiological outcomes, resource utilization, and time course of emergency needs. Part I, Prehosp Disaster Med 18:220, 2003.
7. Explosive blast. In Primer to design safe school projects in
case of terrorist attacks: providing protection to people and buildings, FEMA 428, Washington, DC, 2003, US Department of
Homeland Security, Federal Emergency Management Agency, p 4-4, http://www.fema.gov/pdf/fi ma/428/fema428.pdf (accessed October 2004).
8. Bean JR: Enhanced blast weapons and forward medical treat- ment, Army Med Dept J, April-June 2004, p 48, http://das. cs.amedd.army.mil/PDF/ J04_4_6.pdf (accessed October 2004). 9. Wilson J: Weapons of the insurgents, Popular Mechanics, March 2004, http://www.popularmechanics.com/science/military/2004/ 3/weapons_of_ insurgents/ (accessed November 2004). 10. Dugdale-Pointon T: Terrorist weapons; bombs (IEDs). In Antill P,
Dugdale-Pointon T, Rickard J: Military history encyclopedia on
the Web, August 2004, http://www.rickard.karoo.net/articles/
weapons_terrorbomb.html (accessed October 2004).
11. Médecins du Monde: Israeli and Palestinian civilians: victims
of an endless confl ict, Press conference, July 2003, http://www.
medecinsdumonde.org/2missions/palestine/publications/rapp ort%20Attentats%20eng.pdf (accessed October 2004).
12. Halpern P, Tsai M-C, Arnold JL: Mass-casualty, terrorist bombings: Implications for emergency department and hospital emergency response. Part II, Prehosp Disaster Med 18:235, 2003.
13. Prendergast J: Oklahoma City aftermath, Civil Eng 65:42, 1995, http://www.wai.com/AppliedScience/Blast/blast-okcity.html (accessed October 2004).
14. Stein M, Hirshberg A: Medical consequences of terrorism: the conventional weapon threat, Surg Clin North Am 79:1537, 1999. 15. Arnold L, Halperin P, Tsai MC, Smithline H: Mass casualty
terrorist bombings: a comparison of outcomes by bombing type,
Ann Emerg Med 43:263, 2004.
16. Mallonee S, Shariat S, Stennies G, et al: Physical injuries and fatalities resulting from the Oklahoma City bombing, JAMA 276:382, 1996.
17. Quenemoen LE, Davis YM, Malilay J, et al: The World Trade Center bombing: injury prevention strategies for high-rise building fi res, Disasters 20:125, 1996.
18. Phillips YY, Richmond DR: Primary blast injury and basic research: a brief history. In Bellamy RF, Zajtchuk R, editors: Con-
ventional warfare: ballistic, blast, and burn injuries, Washington,
DC, 1989, Offi ce of the Surgeon General, Department of the Army.
19. Frykberg ER, Tepas JJ III: Terrorist bombings: lessons learned from Belfast to Beirut, Ann Surg 208:569, 1988.
20. Abarbanell NR: Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols, Am J Emerg Med 19:137, 2001.
21. Wood SP, Vrahas M, Wedel SK: Femur fracture immobilization with traction splints in multisystem trauma patients, Prehosp
Emerg Care 7:241, 2003.
22. Hill PF, Edwards DP, Bowyer GW: Small fragment wounds: biophysics, pathophysiology and principles of management,
J R Army Med Corps 147:41, 2001.
23. Bowyer GW: Management of small fragment wounds: experience from the Afghan border: J Trauma 40:S170, 1996.
24. Coupland RM: War wounds of limbs: surgical management, Oxford, 1993, Butterworth-Heinemann Medical.
25. Explosions and blast injuries: a primer for clinicians, CDC Emergency Preparedness and Response, at http://www.bt.cdc. gov/masstrauma/explosions.asp (accessed October 2004).
CHAPTER 25 Injuries from Explosives
581
26. Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center—New York City, September 11, 2001, MMWR 51(1), 2002, http://www.mipt.org/pdf/ mmwrvol51no1_01112002.pdf (accessed October 2004). 27. Trimble K, Clasper J: Anti-personnel mine injury: mechanism
and medical management, J R Army Med Corps 147:73, 2001. 28. Coupland RM, Korver A: Injuries from antipersonnel mines:
the experience of the International Committee of the Red Cross,
BMJ 303:1509, 1991.
29. Dalinchuk MM, Lalzoi MN: [Eye injuries in explosive mine wounds (in Russian)], Voen Med Zh, August 1989.
30. Horrocks CL: Blast injuries: biophysics, pathophysiology and management principles, J R Army Med Corps 147:28, 2001. 31. Guy RJ, Kirkman E, Watkins PE, Cooper GJ: Physiologic responses
to primary blast, J Trauma 45:983, 1998.
32. Guy RJ, Glover MA, Cripps NP: The pathophysiology of primary blast injury and its implications for treatment. Part I. The thorax, J R Nav Med Serv 84:79, 1998.
33. Owen-Smith M: Bomb blast injuries: in an explosive situation.
Nurs Mirror 149:35, 1979.
34. Mellor SG, Cooper GJ: Analysis of 828 servicemen killed or injured by explosion in Northern Ireland 1970−84: the Hostile Action Casualty System, Br J Surg 76:1006, 1989.
35. Mellor SG: The relationship of blast loading to death and injury from explosion, World J Surg 16:893, 1992.
36. Caseby NG, Porter MF: Blast injury to the lungs: clinical presentation, management and course, Injury 8:1, 1976. 37. Coppel DL: Blast injuries of the lungs, Br J Surg 63:735, 1976. 38. Cohn SM: Pulmonary contusion: review of the clinical entity,
J Trauma 42:973, 1997.
39. Oppenheim A, Pizov R, Pikarsky A, et al: Tension pneumo- peritoneum after blast injury: dramatic improvement in ventila- tory and hemodynamic parameters after surgical decompression,
J Trauma 44:915, 1998.
40. Leibovici D, Gofrit ON, Shapira SC: Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury?
Ann Emerg Med 34:168, 1999.
41. Katz E, Ofek B, Adler J, et al: Primary blast injury after a bomb explosion in a civilian bus, Ann Surg 209:484, 1989.
42. Kerr AG: Blast injury to the ear: a review, Rev Environ Health 7:65, 1987.
43. Chandler DW, Edmond CV: Effects of blast overpressure on the ear: case reports, J Am Acad Audiol 8:81, 1997.
44. Kerr AG, Byrne JE: Concussive effects of bomb blast on the ear,
J Laryngol Otol 89:131, 1975.
45. Miller IS, McGahey D, Law K: The otologic consequences of the Omagh bomb disaster, Otolarygol Head Neck Surg 126:127, 2002.
46. Yelverton JT et al: Final report, Contract DAMD17-88-C-8141, Ft Detrick, Md, US Army Medical Research and Materiel Command.
47. Stuhmiller LM, Ho KH, Stuhmiller JH: Analysis of blast over- pressure injury data, Technical Report, Contract No DAMD17- 93-C-3005, Fort Detrick, Md, US Army Medical Research and Materiel Command.
48. Paran H, Neufeld D, Shwartz I, et al: Perforation of the terminal ileum induced by blast injury: delayed diagnosis or delayed perforation? J Trauma 40:472, 1996.
49. Harmon JW, Haluszka M: Care of blast-injured casualties with gastrointestinal injuries, Mil Med 148:586, 1983.
50. Cripps NP, Cooper GJ: Risk of late perforation in intestinal contusions caused by explosive blast, Br J Surg 84:1298, 1997. 51. Huller T, Bazini Y: Blast injuries of the chest and abdomen,
Arch Surg 100:24, 1970.
52. Rossle R: Pathology of blast effects. In German aviation medicine
in World War II. VOL 2, Washington, DC, 1950, US Government
Printing Offi ce.
53. Cernak I, Wang Z, Jiang J, et al: Ultrastructural and functional characteristics of blast injury–induced neurotrauma, J Trauma 50:695, 2001.
54. Guy RJ, Glover MA, Cripps NP: Primary blast injury: patho- physiology and implications for treatment. Part III. Injury to the central nervous system and the limbs, J R Nav Med Serv 86:27, 2000.
55. Trudeau DL, Anderson J, Hansen LM, et al: Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion, J Neuropsychiatry Clin Neurosci 10:308, 1998.
56. Hadden WA, Rutherford WH, Merrett JD: The injuries of terrorist bombing: a study of 1532 consecutive patients, Br J Surg 65:525, 1978.
57. Marshall TK: Injury by fi rearms, bombs, and explosives: ex- plosion injuries. In Tedeschi CG, Eckert WG, editors: Forensic
medicine: a study in trauma and environmental hazards.
VOL 1. MECHANICAL trauma, Philadelphia, 1977, Saunders. 58. Brumback RJ: Traumatic rupture of the superior gluteal artery,
without fracture of the pelvis causing compartment syndrome of the buttock, J Bone Joint Surg Am 72:134, 1990.
59. Su WT, Stone DH, Lamparello PJ, Rockman CB: Gluteal com- partment syndrome following elective unilateral iliac artery embolization, J Vasc Surg 39:672, 2004.
60. O’Mara MS, Semins H, Hathaway D, Caushaj PF: Abdominal compartment syndrome as a consequence of rectus sheath hematoma. Am Surg 69:975, 2003.
61. Hessman M, Rommens P: Does the intrapelvic compartment syndrome exist? Acta Chir Belg 98:18, 1998.
62. Bittenbender C: Compartment syndrome vs. crush syndrome. Presented at National Collegiate Emergency Medical Services Foundation (NCEMSF) 10th Annual Conference, Washington, DC, February 2003, http://www.ncemsf.org/about/conf2003/ lectures/bittenbender_crush.pdf (accessed November 2004). 63. Abassi ZA, Hoffman A, Better OS: Acute renal failure com-
plicating muscle crush injury, Semin Nephrol 18:558, 1998. 64. Lein B, Holcomb J, Brill S, et al: Removal of unexploded
ordnance from patients: a 50-year military experience and current recommendations, Mil Med 164:163, 1999.
65. Leibovici D, Gofrit ON, Stein M, et al: Blast injuries: bus versus open-air bombings: a comparative study of injuries in survivors of open-air versus confi ned-space explosions, J Trauma 41:1030, 1996.
66. Frykberg ER: EAST Presidential Address.
67. Levi L, Michaelson M, Admi H, et al: National strategy for mass casualty situations and its effects on the hospital, Prehosp
Medical
Medical
Support
Support
of Urban
of Urban
Operations
Operations
The future of warfare lies in the streets, sewers, high- rise buildings, industrial parks and the sprawl of houses, shacks and shelters that form the broken cities of our world.
—Ralph Peters1
Warfare in cites is inevitable. Historically, military planners have sought to avoid combat in cities, preferring to isolate, bypass, or avoid them. Urban combat places tremendous demands on resources and personnel, often resulting in large numbers of casualties. Some of the most pitched battles in recent history have occurred in and around urban areas: Stalingrad, Achen, Manila, Hue, Sarajevo, Mogadishu, Grosny, and Fallujah; the very names of these cities conjure images of brutal, house-to-house combat.
Since the fall of the Berlin Wall and the end of the Cold War, many new and different threats have emerged. Global terrorism, international criminal activity, the illegal drug trade, and regional despotisms such as Iran and North Korea have replaced the monolithic Soviet military as challenges to our security. Rogue nations and shadowy international terrorists groups such as Al-Queda, lacking the resources to fi ght a conventional war against the United States or other Western powers, instead seek battles that exploit weaknesses in conventional military power while emphasizing their own strengths. During these “asymmetric” confl icts, terrorism, insurgency, and unconventional guerilla warfare are tactics often used by a weaker opponent against a stronger conven- tional force. The rapidly urbanizing developing world will likely be the setting for many of these future confl icts.
Cities have historically been “centers of gravity” during war. They serve as control points, centers of fi nance, popu- lation, and industry. If current demographic trends continue, by 2015 more than 500 cities will have populations greater than 1 million. By 2025, more than 85% of the world’s popu- lation will live in and around cities. U.S. military forces must be prepared to fi ght a determined enemy in the urban environment.
General Charles Krulak, former Commandant of the U.S. Marine Corps, described a “three block war” where we would conduct humanitarian assistance, peacekeeping operations, and intense, highly lethal urban combat in separate parts of the same city.2
This chapter provides an overview of planning considera- tions for health care providers supporting urban operations. Characteristics of the urban battlefi eld, an overview of likely types of casualties, and training and planning considerations are discussed. It is diffi cult to develop specifi c tactics, techniques, and procedures (TTPs) applicable to all combat medics and corpsmen who may fi ght in a city. No “one size fi ts all” solution is presently available. In future urban battles, combatants and medical providers alike will be required to adapt quickly to the current mission, terrain, and situation.