ORIGINAL ARTICLES Abdominal Trauma After Terrorist Bombing Attacks Exhibits a Unique Pattern of Injury Miklosh Bala, MD, Avraham I. Rivkind, MD, FACS, Gideon Zamir, MD, Tal Hadar, MD, Iryna Gertsenshtein, MSc, Yoav Mintz, MD, Alon J. Pikarsky, MD, Dalit Amar, MD, Noam Shussman, MD, Mahmoud Abu Gazala, MD,and Gidon Almogy, MD Background: The recent growth in the volume of civilian blast trauma caused by terrorist bombings warrants special attention to the specific pattern of injury associated with such attacks. Objective: To characterize the abdominal injuries inflicted by ter- rorist-related explosions and to compare the pattern of injury with civilian, penetrating and blunt, abdominal trauma. Methods: Retrospective analysis of prospectively collected data from 181 patients with abdominal trauma requiring laparotomy, who were admitted to the Hadassah Hospital, Jerusalem, Israel, from October 2000 to December 2005. Patients were divided into 3 groups according to mechanism of injury: terror-related blast injury (n = 21), gunshot wounds (GSW) (n = 73) and blunt trauma (n = 87). Results: Median injury severity score in the blast group was signif- icantly higher compared with GSW and blunt groups (34, 18, and 29, respectively, P  0.0001). Injury to multiple body regions (3) occurred in 85.7% of blast group, 28.8% of GSW group, and 59.7% of blunt group (P  0.001). The pattern of intra-abdominal injury was different between the groups. Bowel injury was found in 71.4% of blast victims, 64.4% of GSW, and 25.3% of blunt group (P  0.001). Parenchymal injury was found in one third of patients in blast and GSW groups versus 60.9% of patients in blunt group (P = 0.001). Penetrating shrapnel was the cause of bowel injury in all but 1 patient in the blast group (94.4%). Conclusions: Terrorist attacks generate more severe injuries to more body regions than other types of trauma. Abdominal injury inflicted by terrorist bombings causes a unique pattern of wounds, mainly injury to hollow organs. Shrapnel is the leading cause of abdominal injury following terrorist bombings. (Ann Surg 2008;248: 303–309) M ass casualty events caused by suicide bombings have become a threat to civilians all over the world and physicians treating trauma victims need to have the medical and logistic knowledge to handle casualties of such attacks. 1 Trauma after explosions has traditionally been categorized into primary, secondary tertiary, and quaternary injury. 2 Pri- mary blast injury occurs as a direct effect of changes in atmospheric pressure caused by the blast wave and affects air-containing organs such as the lung, middle ear, and bowel. Secondary blast injury is caused by missiles composed of bomb-related material (shrapnel) and debris that are propelled by the shock wave. The energy content of shrapnel decreases inversely with the cube of the distance. Tertiary blast injury includes injury from collapsing buildings and displacement of the victims. 3 Burns and associated injuries such as inhalation of dust and smoke are termed quaternary injuries. The charac- teristics of trauma after terrorist attacks are multidimensional injury caused by a combination of these mechanisms. 4 The victims of terrorist attacks are younger, more severely injured, require more surgical interventions, and have a 3-fold higher mortality rate compared with victims of other forms of trauma. 5 Abdominal injury associated with terrorist explosions has been shown to occur in 10% of victims admitted to a tertiary care hospital. 6 The most common mechanisms were penetrating wounds caused by shrapnel and flying debris. Abdominal injury caused by the blast wave after terrorist attacks is uncommon and only a handful of cases have been reported. 7–8 We hypothesized that abdominal injury after terror- ist-related explosions is associated with a different abdom- inal and systemic injury pattern and severity compared with penetrating and blunt abdominal trauma not related to an explosive insult. These differences may significantly impact the therapeutic decision making and resource use in such mass casualty events. Our center is the prime level I trauma center in Israel dealing with terrorism-related injuries and we have gained a vast experience in the medical as well as logistic management aspects. We therefore sought to charac- terize indications for laparotomy, and pattern of intra-abdom- inal injury, and describe the role of damage control and negative laparotomy after terrorist bombing attacks at the Hadassah Hospital level I trauma center in Jerusalem, Israel. The secondary objective was to compare abdominal injury caused by terrorist bombing attacks with injury caused by civilian trauma, mainly penetrating gunshot wounds (GSW) and blunt abdominal trauma. From the Department of General Surgery and Trauma Unit, Hadassah- Hebrew University Medical Center, Jerusalem, Israel. Reprints: Gidon Almogy, MD, Department of General Surgery, Hadassah University Hospital, PO Box 12000, Jerusalem, Israel. E-mail: almogyg@ yahoo.com. Copyright © 2008 by Lippincott Williams & Wilkins ISSN: 0003-4932/08/24802-0303 DOI: 10.1097/SLA.0b013e318180a3f7 Annals of Surgery • Volume 248, Number 2, August 2008 303