Fast Response, Imaging Aided Boston Marathon Bombing Victims

Laurie Barclay, MD

August 19, 2013

In the Boston Marathon bombing, radiologic imaging of blast injuries played a key role in emergency response, with findings illustrating optimal timing and use of modalities and techniques, according to a study published online August 19 in Arthritis Care and Research (AC&R).

"In an era of terrorism, even clinicians serving non-military patients need to understand the spectrum of injuries caused by bomb explosions," lead author Ali Guermazi, MD, professor of radiology at Boston University School of Medicine in Massachusetts, said in a news release. "Critically ill bomb-blast patients needed quick assessments of their injuries, which had the most devastating effects to the lower limbs."

Rheumatologists who are not routinely involved in acute trauma care may be recruited as first responders in similar incidents and may also treat victims later in the course of their recoveries from complex musculoskeletal injuries.

Dr. Guermazi and several of his colleagues who treated victims of the April 15 Boston bombing independently submitted their article to AC&R.

"AC&R was interested in the topic, given the long-term sequelae of traumatic joint and muscle injuries that often require treatment by rheumatologists, healthcare providers, nurses, and physical therapists who specialize in rheumatic diseases," AC&R Editor-in-Chief Marian T. Hannan, DSc, MPH, senior scientist, Institute for Aging Research, and associate professor of medicine at Harvard Medical School in Boston, told Medscape Medical News. "As a Boston-area resident with many ties [to] Boston hospitals, [I] was personally concerned with the many persons involved in the Boston Marathon bombing incident. Any good that could come from this tragic event, such as the information contained in the article, will help overcome the overwhelming sense of loss and sadness."

Injury Mechanism and Types

As extremely compressed air in the blast wave moves away from the explosion, it can damage the lungs, bowel, and ears, and it also creates a vacuum, known as the blast wind, that pulls debris back toward the explosion source. The Centers for Disease Control and Prevention estimate that traumatic amputation occurs in up to 3% of bombing survivors with soft tissue and musculoskeletal blast injury.

"This article highlights the important information that can help in any future situation with overwhelming trauma, both for immediate responders, emergency personnel, and those treating the trauma patients long-term, especially those requiring rehabilitation of lower extremity injuries," said Dr. Hannan, who is also codirector of musculoskeletal research at Hebrew SeniorLife in Boston. "In any traumatic situation, there are insights to be gained for the medical community and those healthcare providers for long-term benefit and understanding for the trauma patients as long as we document the findings with an aim to improve future situations."

The explosion of 2 pressure-cooker bombs at the finish line of the Boston Marathon resulted in 3 deaths and 264 casualties, including soft tissue damage, limb fractures, and amputations. Victims closest to the blasts incurred the most severe injuries to the lower extremities from shrapnel including metal, nails, and ball bearings.

"The level of response from the Boston area responders, both immediately at the scene and in the hospital settings, was key to the treatment success and the ability to minimize long-term damage to many of the Boston Marathon bombing patients," Dr. Hannan said.

Prompt imaging was critical for assessing these injuries. Many patients underwent one or more operations, and rehabilitation from the injuries for many patients will be prolonged and difficult.

Use of Imaging

The authors recommend systematically examining each extremity for open wounds and musculoskeletal, neurological, and vascular injury. These should be documented and photographed. As suggested by earlier studies, liberal use of radiography and computed tomography can detect foreign objects, define basic penetration patterns, and evaluate bony and soft tissue damage.

Urgent surgical intervention is needed for large foreign body removal, penetrating blood vessels, hemostasis, damaged tissue debridement, and amputation. When the patient is stable postoperatively, radiography and more detailed imaging are recommended.

Magnetic resonance imaging and ultrasound are not useful in the acute phase because of their long acquisition times and the possible movement of embedded metallic shrapnel. If vascular injury is suspected, computed tomography angiography is recommended, as well as conventional angiography in some cases for vascular intervention under fluoroscopic guidance.

"For the many lower extremity injuries from the Boston Marathon bombing, medical imaging and noting the elements of the soft tissue injuries were key aspects that should be highlighted for future treatments and understanding of the injuries and outcomes," Dr. Hannan concluded. "There is also a tremendous impetus to gain the positive insights amidst the sadness and loss that prevail in many of these traumatic events, both for patients and their providers of rehabilitation."

The study authors and Dr. Hannan have disclosed no relevant financial relationships.

Arthritis Care Res. Published online August 19, 2013.

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