Terrorist bombings. Lessons learned from Belfast to Beirut.

Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall "critical mortality" rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.