1 in 6 children lives in a conflict zone, exposed to ERWs (Explosive Remnants of War) or UXO (UneXploded Ordinance). Hargrave et al. (2019) trawled through over 70 papers and found that mortality from bomb and blast injuries in children is around 8%. Children have been dying in Iraq, Afghanistan, Syria, Gaza and most recently, Ukraine.
Data from the Joint Theatre Trauma Registry in Afghanistan reveals the extent of the problem. In the six years between 2009 and 2016, 3746 children died and 7904 were injured as a result of explosive devices. 76% of these were boys. Most had more than one body region affected, with lower limb and pelvic injuries predominating, then head and neck injuries and finally chest wounds. The mortality was 7.8%. The mortality of a US military casualty in the same conflict was around 3%. Non-combatants still bear the significant burden of morbidity and mortality in combat zones.
Children can suffer both as collateral damage in armed conflicts and in domestic tragedies. These may be deliberate acts of terrorism, such as in Manchester in 2017, or accidental, such as when a warehouse storing ammonium nitrate exploded next to a fireworks factory in Beirut, Lebanon (2020). Over 200 people were killed, including six children.
A timeline of key civilian terror incidents
- Halifax Harbour (1917) – 2000 dead, 900 injured
- Wall Street Bombing (1920) – 38 dead, 400 injured
- The Buffalo police station bombing (1975) – 1 died, 4 injured
- World Trade Centre Bombing (1993) – 6 died, over 1000 injured
- Oklahoma City bombing (1995) – 168 dead, 680 injured
- The Atlanta Olympics bombing (1996) – 1 dead, 111 injured
- Madrid. (2004) – 191 deaths, 2000 injured
- London (2005) – 56 deaths, 784 injured
- Boston Marathon (2013) – 3 dead, 264 injured
- Manchester Arena (2017) 22 died, 160 injured
And despite legislation trying to prevent it, children are harmed in low-energy fireworks incidents every year. 95% of the children in the US that are injured by fireworks are injured in the three weeks around Independence Day. Again, risk-taking boys exceed girls 3:1. These injuries effect hands (30%) predominantly, heads (22%) and eyes (21%).
The physics of an explosion
Low order vs high order
Low-order explosives, such as gunpowder and improvised pipe bombs, are designed to burn and release energy slowly. They create a sub-sonic explosion characterised by a slow blast front – around 1000km/h. Fragmentation and the heat from the blast cause most injuries, as there is no shock wave.
High-order explosives – like C4, TNT, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil – produce a supersonic over-pressurisation wave. The solid fuel is rapidly converted to a rapidly expanding ball of hot gas that can travel at a velocity of 2000km/h. This blast front may be visible as a distinct line that precedes the debris and dust.
High-order explosives generate immense energy, released in a swift, intense pulse. This is termed brisance. This leads to a sudden rise in pressure and temperature near the detonation site. The power of this pressure wave is inversely proportional to the distance from point of detonation cubed. This blast front is rapidly followed by the blast wind of super-heated air. The blast wind carries debris and dust and causes more damage than the shock wave.
Open-space vs closed-space
The farther away a person is from the source of the explosion, the less likely they are to suffer damage. In an enclosed space, the blast’s energy can reflect, rebound and ricochet off walls and other surfaces, leading to a heightened risk of injury. Victims found between a blast and a building experience 2-3 times more injuries than those in open spaces.
Blasts in enclosed spaces – buildings or buses, for example – are also more likely to cause secondary blast injuries, propel fragments, ignite fires, and lead to entrapment and subsequent crush injuries.
Underwater explosions are significantly deadlier than in air. The pressure waves caused by explosions in water travel further and take longer to dissipate than those in air, resulting in a lethal radius that is up to three times larger.
According to scientists from the Lovelace Foundation in Albuquerque, New Mexico, mortality is a function of both the maximal incident overpressure and inversely proportional to the duration of that pressure. Short, sharp explosions are more lethal.
Primary blast injuries
Primary blast injuries are due to the direct effect of a blast wave, primarily on air-filled organs – the middle ear, the lungs and the intestines. High-frequency stress waves and lower-frequency shearing forces do the damage.
Blast ear presents with tinnitus, hearing loss, vertigo and blood in the ear canal. It only takes about 5 psi to perforate the membrane and disrupt the ossicular chain. 25 of the 30 children involved in the Oklahoma City bombing had ruptured eardrums.
80% of traumatic ruptures heal spontaneously within three months.
If the child does not have a ruptured TM, then other primary blast injuries are less likely. However, of the 17 victims of the Madrid train bombing that had blast lung, four did not have ruptured eardrums. Patients with signs of a ruptured TM should probably go on to have a chest x-ray to look for signs of blast lung.
The majority of patients exposed to a blast may have temporary hearing changes, though these typically return to normal within a few hours. For some return to normality may take a few weeks.
As the pressure waves hit the lungs, they propagate differently in the more-solid capillaries and the air-filled alveoli. The resulting compression and shear forces cause localised microhaemorrhages – blast lung. AThe alveolar wall can be torn, resulting in blood-filled emphysematous changes. Symptoms, depending on the severity of the tear, can range from pulmonary contusion to air embolism if the pulmonary trunk is affected. Damage is especially pronounced at the interface between the lung and mediastinum, the costophrenic angles, and the lung periphery, potentially leading to the formation of traumatic pneumoceles.
DePalma et al. (2005) suggest that patients with potential blast lung should have serial pulse oximetry measurements taken over a period of eight hours; a decrease in SpO2 points to a poor outcome. Symptoms may still develop up to 48 hours after exposure with cough and haemoptysis being the most common presenting complaints.
Up to 80% of patients with blast lung will require respiratory support using a lung-protective ventilation strategy though PEEP may increase the risk of alveolar rupture resulting in pneumothorax or air embolism. They need limited peak inspiratory pressures, and permissive hypercapnia.
Circulatory support is more tricky. Patients with catastrophic limb injuries may well need fluid resuscitation, but the risk of transfusion-related lung injury (TRALI) and transfusion-associated circulatory overload (TACO) is high.
Signs of blast lung injury
Rapid changes in pressure between the cerebrospinal Fluid (CSF) and brain within the skull can lead to bubble formation, cavitating injuries, microvascular damage, and axonal injuries, collectively known as “blast brain“.
It may be challenging to assess preverbal children for the presence of a blunt traumatic brain injury (bTBI). The key to management, as with all causes of TBI is the prevention of secondary injury by avoiding hypotension, hypoxia, hypoglycaemia and hyperpyrexia (fever).
Blast waves can also cause damage to the eyes – so-called blast eye – leading to hyphaema (accumulation of red blood cells and exudates in the anterior chamber of the eye), serous retinitis (retinal vascular damage due to shock waves causing inflammation and bleeding, resulting in blurred vision or blindness) and, in extreme cases, globe rupture. 28% of blast survivors may have eye injuries though most of these are due to shattered glass.
Shockwaves passing through solid organs create pressure differences that lead to tissue shearing and micro- and macrovascular damage, resulting in hypoperfusion and consequent ischaemia. This can then cascade into abdominal compartment syndrome, hypotension, shock, organ dysfunction and potentially death. Areas of ischaemia that don’t perforate immediately (5%) may still suffer necrosis and perforate within 3 to 5 days.
Signs of blast intestinal injury
- Abdominal pain
- Rectal pain
- Testicular pain
- Unexplained hypovolemia
Primary blast injuries are more common in children with evidence of skull fracture, >10% TBSA burns or penetrating thoraco-abdominal injuries.
As the distance from a site of detonation grows, the risk of primary blast injury decreases, while the threat of secondary blast injury rises.
Secondary Blast injuries
Secondary blast injuries account for the majority of deaths. They are injuries caused by debris thrown from the blast site at a high speed. The debris may include fragments of bomb casing, things placed in the bomb (such as ball bearings or nails) and flying glass. Eyelid lacerations account for 20-60% of blast-related eye injuries.
High-energy blasts can lead to massive tissue destruction or loss. Whilst tourniquets may prove life or limb-saving, there is little evidence for the benefit of pelvic binders in children.
All children that suffer penetrating shrapnel injuries should receive an accelerated course of hepatitis B vaccination as well as broad-spectrum antibiotics. Penetrating injuries of biological material – such as bone fragments – may also contaminate wounds. Like gunshot wounds, the visible wound often belies the degree of underlying damage and devitalised or contaminated tissue. Primary closure increases the risk of infection by around 80%.
Tertiary blast injuries
Tertiary blast injuries result from the victim being thrown by the blast. As with falls, it is not the distance that causes the damage but the sudden stop at the end. Someone thrown into a wall at 28 kph will have a mortality rate of about 50%.
Victims tend to suffer from closed head injuries, fractured bones and dislocated joints.
Quaternary blast injuries
Quaternary blast injuries are a type of traumatic injury that can result from exposure to a blast. They may include inhalation of toxins, and rhambomyolysis as a result of crush injuries as well as the exacerbation of pre-existing medical problems such as asthma.
They also include psychological conditions, such as post-traumatic stress disorder (PTSD), anxiety, and depression.
Quinary blast injuries
These are the sort of injuries that Jacks Bauer and Ryan worry about – those caused by a ‘dirty bomb’. A contaminated explosive device leads to a hyper-inflammatory state.
What injuries are more likely in children than in adults?
Unfortunately, head and facial injuries are much more common in children as they are more likely to pick up the unexploded ordinance.
In a study of adults exposed to UXO, 30% of fatalities were caused by shrapnel penetration of the brain, whereas in children, this was only 8%. On the other hand, rupture of the middle ear without secondary complications was much more common in children (17%) than adults (3%)
Proportionally, children have bigger heads than adults, and their immature skulls and unfused fontanelles increase the risk of intracranial injury.
Their near-plastic ribs mean the chest wall is more likely to deform and spring back rather than break, damaging underlying tissues.
A shallower pelvis and thinner abdominal wall make liver, spleen and bladder images more common. Intra-abdominal injuries in children can cause an exaggerated vagal response resulting in severe bradycardia, apnoea, and, ultimately, death.
The commonest causes of death are head injuries, airway burns and internal haemorrhage.
Long term consequences
Surprisingly, children with traumatic or penetrating brain injuries often recover well. Data from conflict zones suggest that retained shrapnel is best managed conservatively. There is a low long-term infection rate, and attempts to remove it may worsen neurological recovery. However, they should receive broad-spectrum antibiotics to reduce the risk of cerebral abscess formation.
It goes without saying that patients with penetrating brain injuries should NOT undergo MRI. The ferromagnetic torque force generated can move particles that are not visible to the naked eye. This can have devastating consequences.
There is a high incidence of post-traumatic epilepsy following a penetrating brain injury.
- 30-50% vs 4-42% in non-penetrating TBI
- 10% suffer seizures within the first week
- 80% suffer seizures within the first two years
In keeping with other forms of intracranial catastrophe, there is little evidence for continuing anti-epileptic treatment beyond the first week.
Long-term psychological and behavioural problems can arise after an explosive event, especially in children. Survivors of an explosive event report significantly higher levels of post-traumatic stress disorder (PTSD), anxiety and depression. Symptoms can range from nightmares, flashbacks and avoidance behaviours to hyper-arousal and panic attacks. There is a significant overlap between the symptoms of traumatic brain injury and PTSD.
Following the Beirut port explosion in 2020, in which over 1000 children were injured, 64% screened positive for anxiety, 52% for probable PTSD and 33% for depression. The further away they were from the blast, the less likely they were to suffer from anxiety or PTSD. Adults, who had been children at the time of the Oklahoma City bombing were still reporting symptoms of PTSD some 25 years later.
Shrapnel – those dangerous flying pieces of debris – was named after British artillery officer Major-General Henry Shrapnel. In 1784, he developed a type of shell with a pre-filled charge of shot and pellets that could spread out when the shell exploded. Victims of flying glass were scattered up to two kilometers from the U.S. Embassy after the 1998 bombing in Nairobi.
Non-terror events are more likely to cause extremity injuries as children either accidentally step on, or handle, unexploded ordnance.
In contrast with adults, children are likely to suffer a traumatic amputation rather than a crush injury. This is because their bones are softer and more pliable and their epiphyseal plates are more likely to separate. This can lead to lifelong consequences.
Children (and their families) are likely to need ongoing support for many years after the event. The blast continues to have a reverberating effect on all children.
According to the International Committee of the Red Cross this is:
“not directly caused by an explosive weapon but are nevertheless a product thereof. Notably, incidental destruction of civilian housing and essential civilian infrastructure – which often leads to a disruption of essential services – can result in civilian death and injury that may far outweigh the immediate civilian casualties caused by an attack.”
In Syria, explosive devices destroyed vital food and health infrastructure, leading to malnutrition and poor health. Paul Reavley spoke about the global burden of bomb and blast injuries in London at DFTB19.
Paul Reavley works as a consultant at the Bristol Royal Infirmary. In this talk he uses his experience in the armed forces to talk about blast injuries. According to Save the Children, one in five children worldwide is living in a conflict zone. We heard from Nat Thurtle about the crisis in Syria and the bombing of those places which should be safe havens for all. It is a public health problem. And unfortunately, as we have seen recently in Manchester, no one is immune.
This post is based on a presentation I gave to ATMA – the Australian Tactical Medical Association.
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