IED’s in AmericaKeynote Presentation from James Phillips MD, Harvard Disaster Medicine

IEDs in America:Is this our future?

James Phillips MD

Health & Safety Institute Conference

San Antonio, Texas

November 1st, 2013

Disclosure

I have no financial relationships to disclose regarding the companies or

products discussed in this presentation.

I will not discuss off label use or investigational use in my presentation.

Purpose

• What is Disaster Medicine?

• What is an IED?

• What are Blast Injuries?

• Discuss the future of IEDs in America.

Disaster Medicine

Medical specialists trained to care for

injuries and illnesses associated with

both natural and man-made disasters,

and who provide education,

consultation, and leadership at all levels

of government and private industry

during all aspects of the disaster cycle.

The Disaster Cycle

Disaster Medicine

• Marriage of emergency preparedness and disaster

management

• A systems oriented specialty – no “disaster clinic”

• Multiple disciplines– Infectious Disease, Trauma, Public Health,

International and Austere Medicine, Counter Terrorism

• EMS Training and Management

• Public Health Focus and Research

April 15th, 2013

Types of Explosives

• Divided into 2 major categories

– HE (High Explosives)

– LE (Low Explosives)

• Are differentiated based on speed of

decomposition of the explosive material

– Greater than speed of sound = High

Explosive

• Military or Industrial Grade Explosives

• Explode by DETONATION

• Creates Blast Wave (Shock Wave)

• Inflict Primary Blast Injury (PBI)

Examples: TNT, C4, Symtex, TATP, Dynamite, Det Cord, ANFO, Nitroglycerin

500 Ton TNT Explosion

Blast Wind

Low Explosives

• Explode by Deflagration

– They do not detonate

• Slower than speed of sound

• No Blast Wave (Shock Wave)

• Used as Propellants

– Black Powder (Gunpowder), Fireworks

Low Explosives

• It IS possible to dramatically increase the

blast pressure of low explosives by

containing them tightly during deflagration.

• By allowing the pressure and heat to build in

an enclosed space, there is a vastly

increased release of energy/time.

Low Explosive Containment

Low Explosive Containment

What is an IED?

• Improvised Explosive Device

– Fabricated in an improvised manner from

chemicals

– designed to destroy, incapacitate, harass, or

distract

– normally devised from nonmilitary components

Roadside IED

Anatomical IEDs

History of IED Use• First saw extensive use in WWII

• “Belarusian Rail War”

“The Troubles”

Worldwide IED Data

IEDs in US Wars

Vietnam War

– Booby Traps

– Tripwires

–Rubber Band Grenades

–Mines

IEDs in US Wars

Global War on Terror

- Primary cause of death and injury to

coalition forces in both Iraq and Afghanistan

theaters.

Roadside IED

Roadside IED

Roadside IED

Notable International IEDs

• “The Troubles”

• Mujahadeen vs Soviets during invasion of

Afghanistan

• Israel

• US Embassies in Beirut, Tanzania, Kenya, Yemen,

Pakistan

• USS Cole (Boat-borne IED)

Notable IEDs on US soil

• Ted Kaczynski (Unabomber)

• Weathermen

• Abortion Clinic Bombings

• 1993 World Trade Center

• 1995 OKC Bombing

• 1996 Olympic Park Bombing

• 2001 9/11 attacks

• 2013 Boston Marathon Bombing

IED Components

• PIES

– Power Supply

– Initiator – “fuse”

– Explosive (HE or LE)

– Switch - both arms and triggers the blast)

From: (EMRTC) Incident Response to Terrorist Bombing

Power Sources

Types of Switches

• Direct Wire

• Timer (e.g. alarm clock, watch, egg timer)

• Remote Control (e.g. garage door opener)

• Radio

• Infrared

• Cell Phone

Blasting Caps

High Explosives

• Dynamite/TNT

• Plastic Explosives (Semtex, C4)

• ANFO/ANMN

• Military artillery shells, mines, etc

High Explosive IEDs

• Detonation

• Damage is mostly due to the primary blast wave

itself, shrapnel, and structural collapse

• Very high energy, supersonic wave

• Shrapnel not necessary

Alfred P. Murrah Building

2000 lbs Ammonium Nitrate and Nitromethane

• Truck parked 6.5 feet from building wall

• AMMN in barrels, initiated by dynamite,

and triggered by a timer.

• Caused near-total structural collapse,

and damaged 300 surrounding buildings

2000 lbs Ammonium Nitrate and Nitromethane

Low Explosive IEDs

• Frighteningly easy to make

• If contained, can be very deadly

• Injuries differ from HE, as no true blast wave is

generated.

• Shrapnel and Incendiaries can enhance effect

Boston Marathon Bombing

• Low Explosive Bomb - Used fireworks from

NH

– Placed in a high integrity blast container to

amplify

• Greatly enhanced blast force

• Subsonic, but ? Primary Blast Injury

– Added metal nails, ball bearings

• Shrapnel added for lethality by Secondary

Blast Injury

• Caused vast majority, if not all, deaths and

injuries

Pressure Cooker Bomb

Where Did They Learn?

• Jihadi Literature

• Internet

Blast Physics

• Pressure caused by a blast wave over and above

normal atmospheric pressure – the cause of HE

primary blast injury

Blast Wave Overpressure

Blast Wave

Fireball

• High energy waves that travel through the

organs and tissues of the body at variable

speeds and cause direct injury by shearing.

Shockwaves

Fragmentation vs. Shrapnel

Blast Wind

Blast Injuries

• Types of injuries caused by explosions

• Depend on type of explosive used

– HE vs LE (Blast wave causes Primary Blast

Injury)

– Addition of incendiaries (Time Square attempt)

– Addition of shrapnel

Blast Injuries

Blast Injuries

• Primary

– Primary Blast Wave

• Secondary

– Fragmentation and shrapnel

• Tertiary

– Thrown against walls or ground

• Quaternary

– Burns, structural collapse, other medical problems

• Quinternary

– Addition of CBR (theoretical)

Blast Injuries

• Special Considerations

– Distance from blast is most important

• Primary blast injury

• Shrapnel/Frags

– Location indoors vs outdoors

• Blast waves reflect off walls at 3-10 times strength

– Underwater blasts are much more powerful

• Fluid physics

Primary Blast Injury• Primary Blast Injury

– Affect is caused by supersonic wave of

compressed gas and its effects on air filled

organs.

– Middle Ear is most commonly affected

– Blast Lung Injury is the killer

– Bowel injury is more rare but possible

– Traumatic Brain Injury

– HE may cause traumatic amputations

Middle Ear

• Tympanic Membrane Rupture

• Occurs at pressures as low as 5 psi

• May cause temporary or permanent conductive

or sensorineural hearing loss

• 80% heal nonsurgically

Middle Ear

Blast Lung Injury• Major damage due to massive shearing forces due to

implosion beyond tensile strength of alveoli and pulmonary

capillaries

• ARDS like picture with dyspnea, wheezing, hypoxia,

hemoptysis, PTX, or tension PTX.

• Most common cause of immediate PBI death

– Massive arterial air embolus

Blast Lung Injury

Blast Lung Injury

• May present up to 48 hours after

• Unlikely if no TM rupture, but possible

• Observe for at least 4 hours for

deterioration

• Most are dead or symptomatic on arrival

• Lung protective ventilator strategies if

intubation required.

Blast Abdominal Injuries

• May have delayed presentation up to 8

days

– Small area of severe damage -> perforation

• May present with acute abdomen initially

• More common than blast lung if

underwater

Blast Abdominal Injuries

CNS Injuries

• Unclear mechanism

• Likely coup-contrecoup

• Effects of small air emboli?

Secondary Blast Injuries

• Majority of LE IED injuries

• Fragmentation and Shrapnel

– Includes structural shrapnel

• Soft tissue and bony injuries

– Amputations

• Eye Injuries

– Abrasions

– Globe ruptures

Secondary Blast Injury

Secondary Blast Injury

Tertiary Blast Injuries

• Blast wave pushes person

against walls or thrown to

ground.

• Blunt trauma

– Broken bones, CHI, skull fractures

Tertiary Blast Injuries

Quaternary Injuries

• Thermal burns

– must be close to blast, only likely to see on survivors from LE

• Dust/particulate inhalational injuries

• Death from other medical causes

– Myocardial Infarction, etc

• Structural collapse

– Primary cause of quaternary death and injury

• OKC Bombing Structural Collapse

Quinternary Injuries• Due to radioactive exposure/fallout

• Due to dispersion of toxin/biological agent

• Due to chemical agent

Why “the future?”

• Easy to make in your mom’s kitchen

• Very difficult to predict builders/users

• Compact, transportable, and

powerful

• Easily created with numerous trigger

options

• Bad guys love to copycat

Summary

• What is Disaster Medicine?

• What is an IEDs?

• What are Blast Injuries?

• The future of IEDs in America.

Bibliography

• References can be provided at

request.

Thank you