Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 5  |  Issue : 4  |  Page : 296-298
Explosive attack: Lessons learned in Seyed Al Shohada mosque attack, April 2008, Shiraz, Iran


1 Department of General Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Neurology, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
3 Department of Internal Medicine, Urology Nephrology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Submission02-Sep-2011
Date of Acceptance10-Aug-2011
Date of Web Publication15-Oct-2012
 

   Abstract 

Introduction: The threat of explosive attacks has become a worldwide problem. Bombing is the preferred method of attacks. These attacks result in specific physical and psychiatric trauma. In this paper, we present an epidemiologic description of the physical injuries of patients who survived the explosive attack in Seyed Al Shohada mosque April 2008 Shiraz, Iran. Materials and Methods: All medical records of the patients admitted at Shiraz Hospitals on April 2008 due to Seyed Al Shohada mosque bombing attacks, Shiraz, Iran, were reviewed. Results: A total of 202 patients were referred to the hospitals over 24 h following the terrorist attack. One hundred sixty-four patients were admitted for short periods of observation (<24 h). Thirty-eight patients needed more than 1 day of hospitalization. The mean age of the patients was 26.2 (range 2 to 51) years. One hundred thirty-five (66.8%) patients were males. Twenty-six (12.8%) were children. Burn was the most prevalent cause of admission. Five (13.5%) patients needed chest tube insertion and eight (21%) needed skin grafts due to burn. Overall, 12 patients expired (5%). Three (25%) of them were children (2 and 6, and 11 years old). Mortality rate was significantly higher among the children than adults (P value <0.05). The most important cause of death was head trauma which was seen in five (41.6%) of the expired patients followed by burn (including air way burn) in four (33%), and internal bleeding in three (25%). Patients with head trauma had significantly a higher rate of mortality than other patients (P value <0.05). Discussion: Following a bombing attack, numerous victims were brought to the emergency unit suffering from a combination of multi-organ injuries caused by the blast, penetrating injuries caused by shrapnel and other debris, and burns. It is important for a physician to be familiar with the clinical features and treatments of explosive attacks victims. Early management of patients at the scene and hospital may save their life.

Keywords: Explosive attack, Seyed Al Shohada mosque, trauma, Iran

How to cite this article:
Paydar S, Sharifian M, Parvaz SB, Abbasi HR, Moradian Mj, Roozbeh J, Nikghbalian S, Sagheb MM, Ghaffarpasand F, Salehi O, Dehghani J. Explosive attack: Lessons learned in Seyed Al Shohada mosque attack, April 2008, Shiraz, Iran. J Emerg Trauma Shock 2012;5:296-8

How to cite this URL:
Paydar S, Sharifian M, Parvaz SB, Abbasi HR, Moradian Mj, Roozbeh J, Nikghbalian S, Sagheb MM, Ghaffarpasand F, Salehi O, Dehghani J. Explosive attack: Lessons learned in Seyed Al Shohada mosque attack, April 2008, Shiraz, Iran. J Emerg Trauma Shock [serial online] 2012 [cited 2018 Aug 20];5:296-8. Available from: http://www.onlinejets.org/text.asp?2012/5/4/296/102363



   Introduction Top


The threat of explosive attacks has become a worldwide problem. Bombing is the preferred method of attacks. These attacks result in specific physical and psychiatric trauma. [1]

Following a bombing attack, the scores of victims suffering from a combination of blast injury, penetrating injury, and burns are brought to physicians and local hospitals. [2] Explosive materials cause injuries in four mechanisms; primary blast injury is caused by the rapid outward spread of the shock wave, the energy of which is inversely proportional to the distance from the explosion's epicenter. Gas-containing organs such as the lungs, tympanic membranes, and bowel are the most susceptible parts to injury. [3] Secondary blast injury is caused by penetrating missiles components of bomb-based material (shrapnel) and debris that are propelled by the shock wave. [4],[5] Tertiary blast injuries result from a victim's body being displaced by expanding gasses and high winds; trauma then occurs from the tumbling and impacting objects. [6],[7]

Burns and associated injuries from the collapse of buildings are defined as quaternary injuries and are also common among survivors of explosions. [8],[9] It will become increasingly important for trauma surgeons, emergency physicians, and psychiatrists to be familiar with the special needs and treatment of these patients. [10]

In this paper, we present an epidemiologic description of the physical injuries of patients who survived the bombing attack in Seyed Al Shohada mosque, April 2008, Shiraz, Iran. This explosion occurred during prayers at the Seyed al-Shohada Mosque in Shiraz, southern Iran on April 12, 2008, and 9:14 p.m. local time. Around 800 people, which were mostly youth, had congregated at the Mosque. Twelve people were killed and 202 were injured.


   Materials and Methods Top


All medical records of the patients admitted at Shiraz Hospitals on April 2008 due to Seyed Al Shohada mosque bombing attacks, Shiraz, Iran, were reviewed. The patients who were admitted as a direct result of the attack were included.

Hospital records and trauma registry records were reviewed from the 12 different hospitals in which the victims were treated. The records were reviewed for demographic data such as age, sex, attack setting, and survival; the presence and location of penetrating injuries; the presence and extent of burns; the presence and location of fractures and trauma, and any aspects of internal injuries. Statistical analysis was performed using SPSS version 13 (Statistical Package for the Social Sciences, Chicago, Ill) and presented as median and range.


   Results Top


202 patients were referred to the hospitals over 24 h following the attack of Seyed Al Shohada mosque, April 2008. Despite aggregation of thousands of people in the site of explosion, all the patients were sent to the medical center with Emergency medical services (EMS) ambulances within 1 h. One hundred sixty-four patients were admitted for short periods of observation (<24 h) and released on the first 24 h. All the patients referred to the Nemazi hospital as a referral center in southern Iran and then after primary resuscitations the patients referred to the specialties' hospitals.

On admission the patients were visited by a general surgeon, with the aid of nurses, first evaluated and resuscitated as needed. The patients who needed emergency surgical intervention or any other emergency care were selected and transferred to an appropriate ward immediately; then, they were prepared for the operating room, while others received the appropriate and required cares such as wound care, IV antibiotics, and tetanus vaccinations.

In the second step, the patients were evaluated by a neurosurgeon and an orthopedic surgeon respectively was then guided to the radiology unit. The laboratory samples were collected and sent for analysis.

At this time, an internist, a gynecologist, an urologist, and a pediatrician were invited to examine the patients who needed their respective consultation.

Tertiary screening was done 2 h later by the general surgery team where the primary plan for each of the patients was determined according to the physical examinations and laboratory and radiologic findings. The patients who needed the specialty care such as orthopedic care were referred to the specialty hospitals after ruling out all other surgical or internal complications.

Overall 38 patients needed more than 1 day of hospitalization. The mean age of the patients was 26.2 (range 2 to 51) years. One hundred thirty-five patients (66.8%) were males. Twenty-six of patients (12.8%) were children. Burn was the most prevalent cause of admission. Other causes of hospitalization are shown in [Table 1]. Many patients had multiple complaints.
Table 1: Causes of Hospitalization

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Nine patients (23.6%) needed ICU (intensive care unit) admission. Six of the patients (15.7%) developed spleen laceration and internal bleeding.

We hydrated all of the patients with standard fluid hydration method; none of them developed renal failure during hospitalization course and after discharge.

Eleven patients (28.9%) with air way burn were incubated. One of them was not incubated as he decided, he expired 3 h later due to severe airway edema and intubation wasn't possible at that time.

The pelvic was the most prevalent site of fracture. Orthopedic operation was done on six patients (15.6%). Five patients (13.5%) needed chest tube insertion and eight (21%) needed skin grafts due to burn.

Overall, twelve patients expired (5%). Three (25%) of them were children (2, 6 and 11 year old). Mortality rate was significantly higher among the children than adults (P < 0.05).

The most important cause of death was head trauma which was seen in 5 (41.6%) of the expired patients followed by burn (including air way burn) 4 (33%) and internal bleeding 3 (25%). The patients with head trauma had a significantly higher rate of mortality than other patients (P < 0.05).


   Discussion Top


Following an explosive attack, numerous victims were brought into the emergency unit suffering from a combination of multi-organ injuries caused by the blast, penetrating injuries caused by shrapnel and other debris, and burns.

EMS plays an important role in patients' survival. The distance of the medical centers to the scene has a vital role in management of the patients. Non-urgent patients should be referred to a hospital close to the scene of the event, but not the closest. The nearest medical center should be prepared to treat fully urgent patients, as well as a large number of self-evacuated patients. [2],[11] On the other hand, aggregation of people in the scene causes several problems for primary resuscitation of patients and then transfer to the hospitals. In the present study, medical centers were near to the scene and EMS rapidly referred the patients, it may have an important role in patients' survival.

When there is only one center with advanced medical facilities such as what happened in other case, admission capacity of the main hospital should be considered in the referral of the patients by EMS. In our case, the number of the patients was more than available facilities of the referral hospital (Nemazi hospital). In such conditions, we suggest that the patients be screened at the scene. This can reduce the rate of the admission in the main hospital, and un-urgent patients who need especial cares such as orthopedic cares can refer to the hospitals with focus facilities. However, in this condition the rule of tertiary screening is more prominent and the patients should be re-examined to identify any missed problems.

Mortality and morbidity among the children in this study similar to other studies was significantly higher than adults. Moreover, psychiatric problems after terroristic attacks among children are considerable. The children in such situations should be evaluated carefully, and physical and psychiatric long-term follow up is recommended. [12]

Regarding several physical traumas in such situations, during explosion and after that when the crowd aggregate and run out of the doors, we suggest hydrating all of the patients with the standard fluid hydration method. This may reduced the rate of renal failure due to crash injury and rhbdomyolisis in these conditions.

Older individuals, children and females were more affected by terror events. Early diagnosis, long-term follow up, and early medical and psychological help to the victims are important. [2],[13]

The Pelvis was the most prevalent site of fracture in our study while it was different from Zafer et al.'s study who reported calcaneal fractures as the most common site of fracture among their patients. [14]

Airway burn is an important sign and needs urgent management. Delayed intubation may be fatal. Patients with head trauma, burn, and internal bleeding in this study had a higher rate of mortality and morbidity, so external signs of trauma should be considered to triage victims to the appropriate level of care both at the scene and in the hospital. [15],[16]

Overall, it is important for a physician to be familiar with the clinical features and treatment of explosion victims. Early management of such patients might save their life.

 
   References Top

1.Almogy G, Mintz Y, Zamir G, Bdolah-Abram T, Elazary R, Dotan L, et al. Suicide bombing attacks: Can external signs predict internal injuries? Ann Surg 2006;243:541-6.  Back to cited text no. 1
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2.Hall RC, Hall RC, Chapman MJ. Medical and psychiatric casualties caused by conventional and radiological (dirty) bombs. Gen Hosp Psychiatry 2006;28:242-8.  Back to cited text no. 2
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3.Iremonger MJ. Physics of detonations and blast-waves. In: Cooper GJ, Dudley HA, Gann DS, Nikels S, Patrik T., editors. Scientific Foundations of Trauma. Oxford, England: Butterworth-Heinemann; 1997.p. 189-99.  Back to cited text no. 3
    
4.Cooper GJ, Maynard RL, Cross NL, Hill JF. Casualties from terrorist bombings. J Trauma 1983;23:955-67.  Back to cited text no. 4
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5.Karmy-Jones R, Kissinger D, Golocovsky M, Jordan M, Champion HR. Bomb-related injuries. Mil Med 1994;159:536-9.  Back to cited text no. 5
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6.Phillips YY. Primary blast injuries. Ann Emerg Med 1986;15:1446-50.  Back to cited text no. 6
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7.Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med 2001;37:664-78.  Back to cited text no. 7
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8.Katz E, Ofek B, Adler J, Abramowitz HB, Krausz MM. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg 1989;209:484-8.  Back to cited text no. 8
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9.Leibovici D, Gofrit ON, Shapira SC. Eardrum perforation in explosion survivors: Is it a marker of pulmonary blast injury? Ann Emerg Med 1999;34:168-72.  Back to cited text no. 9
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10.Mekel M, Bumenfeld A, Feigenberg Z, Ben-Dov D, Kafka M, Barzel O, et al. Terrorist suicide bombings: Lessons learned in Metropolitan Haifa from September 2000 to January 2006. Am J Disaster Med 2009;4:233-48.  Back to cited text no. 10
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11.Bloch YH, Schwartz D, Pinkert M, Blumenfeld A, Avinoam S, Hevion G, et al. Distribution of casualties in a mass-casualty incident with three local hospitals in the periphery of a densely populated area: Lessons learned from the medical management of a terrorist attack. Prehosp Disaster Med 2007;22:186-92.  Back to cited text no. 11
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12.Baker DR. A public health approach to the needs of children affected by terrorism. J Am Med Womens Assoc 2002;57:117-8,121.  Back to cited text no. 12
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13.Jehel L, Duchet C, Paterniti S, Consoli SM, Guelfi JD. Prospective study of post-traumatic stress in victims of terrorist attacks. Encephale 2001;27:393-400.  Back to cited text no. 13
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14.Zafar H, Rehmani R, Chawla T, Umer M, Mohsin-e-Azam. Suicidal bus bombing of French nationals in Pakistan: Physical injuries and management of survivors. Eur J Emerg Med 2005;12:163-7.  Back to cited text no. 14
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15.Almogy G, Luria T, Richter E, Pizov R, Bdolah-Abram T, Mintz Y, et al. Can external signs of trauma guide management?: Lessons learned from suicide bombing attacks in Israel. Arch Surg 2005;140:390-3.  Back to cited text no. 15
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16.Almogy G, Rivkind AI. Surgical lessons learned from suicide bombing attacks. J Am Coll Surg 2006;202:313-9.  Back to cited text no. 16
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Correspondence Address:
Maryam Sharifian
Department of Neurology, Student Research Committee, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.102363

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