Statistics – Hostile and Terror Incidents

25th September 2020 updated 18th May 2021

In recent years Catastrophic Haemorrhage, once the preserve of military medicine, has become a standard feature on all First Aid courses.   Tourniquets, once frowned upon, are now an essential part of every First Aid kit when preparing for hostile or higher risk environments.   Why is this?

The modern management of catastrophic haemorrhage originated on the battlefields of Iraq and Afghanistan post 9/11.   The seminal work by Bellamy (1) yielded the often cited phrase that ‘exsanguination is one of the leading causes of preventable deaths on the battlefield’ which, whilst based on data from WWII and Vietnam, still holds true in recent conflicts in Iraq and Afghanistan (2-5)    

Following the withdrawal of troops from Iraq the Golden Age of Private Military Contractors (PMCs) emerged:  For former military contractors, their Principals were typically military leaders, diplomats and engineers and the threats they were exposed to were classically military in nature, typically Improvised Explosive Devices (IEDs) and gunshot wounds (GSWs) – the standard incidents of which combat casualty care is built around.  The Hostile PMC industry has all but disappeared, but the mystique lives on and so does the obsession with tourniquets.

With increased media attention on terrorism activities and a revival in the training and education in Catastrophic Haemorrhage, do tourniquets actually warrant their place in medic bag or First Aid kit if one is preparing for terrorist or hostile incidents?

What are we preparing for?

Terrorism in Europe

Terrorism is not a new thing.  Since the second World War European history has been littered with terrorist attacks, peaking in frequency in the 70’sand 80’s with incidents involving IEDs, vehicle bombs and mortar attacks from groups such as the IRA and Hamas.   Since 2011, large scale, coordinated attacks utilising explosives have been replaced by lone-wolf attacks in Europe using vehicles and knives; easier to fly under the radar and easier to procure than firearms and explosives whilst still producing a large number of casualties and as much disruption.

Terrorism in the UK

It would be easy for any Millennial to believe that Terrorism started with the 9/11 attacks on New York but that view would be challenged by anyone brought up in the UK throughout the 70s and 80s.

From 1970 to 2018 there were 3,411 deaths from terror activities recorded with the majority (84%) between 1970 and 1990 occurring in Northern Ireland (6).   Since that time terrorism in the United Kingdom has declined massively with a few isolated incidents:

• 1972 was a particularly bloody year in Northern Ireland with 344 killings in Northern Ireland despite a brief ceasefire declared by the IRA.

• 271 people were killed Scotland in the Lockerbie bombing in 1988

• The 7th July Bombings in London in 2005 resulted in 52 civilian deaths.

• 2017 included multiple attacks:

  • Westminster Bridge – 4 deaths

  • Manchester Arena – 23 deaths

  • London Bridge – 11 deaths

Injury Patterns of Terrorism Attacks

Blast Injuries

From a historical perspective, bombings were the modus operandi of many terror organisations but heightened security means that these large-scale attacks are becoming increasing rare.

Designed to cause as much disruptions and with as many casualties as possible they are predicable in their location; centred on public events such as the Boston Marathon (2013) and the Manchester Arena or financial districts; In the US In the period from 1983 to 2002 there were more than 36,000 explosive incidents, causing almost 6,000 injuries and 699 deaths. (7)

Injuries from blasts are predictable to a degree (8):

• Primary blast injuries are uncommonly seen in a hospital setting, because they usually result in immediate death.

• Primary blast injuries from improvised explosive do not usually yield a large enough overpressure to cause primary injuries over a wide distance compared to military grade explosives.  As such fatalities and those with injuries not compatible with life tend to only be found in close proximity to the blast.

• Low order explosives used in improvised explosive devices tend to be augmented with shrapnel to increase their damaging effect (such as the Manchester Arena and Boston marathon bombing).  Most casualties sustain minor injuries, which may be treated on scene.

• Injuries predominantly affect the head and neck and the periphery, which suggests that clothing plays a major role in protection from secondary injuries.

• Injuries to the chest and abdomen are relatively uncommon but have a high mortality, also associated with head injury.

Despite the comparative rarity of Blast injuries as a result of terrorist activities, of the survivable injuries sustained, the majority tend to be on limbs which can be managed with the use of tourniquets however in a major incident you will need more than two tourniquets so understand how to improvise a tourniquet which actually works.

Further Reading: Blast Injuries

Vehicular injuries

The use of vehicles against pedestrians is a relatively new means of terrorism and still comparatively rare, that said pedestrian versus vehicle accidents represent a significant proportion of accidental deaths worldwide. 

Notable incidents in the UK include:

• 22nd March 2017 - Westminster Bridge. 5 deaths caused by knife injuries.

• 3rd June 2017 - London Bridge. 2 deaths due to vehicle impact, 6 deaths due to knife injuries.

• 19th June 2017 - Finsbury Park. 1 death due to vehicle impact.

• 14th August 2018 - Westminster Bridge. 0 deaths.

An analysis of injury patterns utilising the Abbreviated Injury Score reveals predictable patterns in the most serious injuries (9):

• The most common injuries being to lower limbs –the typical point of impact - but the most serious, non-preventable, being to the head and thorax.

• There are some variations on injury patterns due to age and gender; adults, being taller, are more likely to receive lower limb injuries than children and women are almost twice as prone to serious pelvic injuries than males.

• The majority of injuries are musculoskeletal and internal organ damage which are difficult to manage in a pre-hospital setting. 

Despite the high incidence of limb injuries, uncontrollable external bleeding, however, is comparatively rare.  These casualties need surgery as soon as possible with few interventions being available to the responder in a pre-hospital setting.

Knife injuries.

Knife crime is considerably more common than terror events but the geographical spread is not uniform with certain regions experiencing significantly higher incidents than others, even down to certain regions within one city.  If you look at the murder rate in London, the geographical distribution is notably polarised around certain regions (10).   Across all murders, knives were used in approximately 39% of all cased. (11)

One analysis of wounding patterns from knife attacks reveals that the most life-threatening injuries occur in the chest (45.5%), followed by the abdomen (21.2%) and neck (5.8%).  Life threatening wounds which may warrant application of a tourniquet (arms and legs) account for just 20.7% of injures. (12)

These casualties are therefore more likely to benefit from wound packing and chest seals.

Further Reading: Open Chest Injury

Further Reading: Haemostatic Agents

Firearms Incidents

Firearms incidents are much less common in the UK than compared to knives due to greater restrictions in place.  In the US there is an unfortunately large amount of data available for analysis on injury patterns.  in 2016/17 there were 31 fatal shootings in the UK – one for every 1.9 million people.   In the US there were 11,000 murders or manslaughters, or one death for every 30,000 people.

Firearms used illegally in the UK are either smuggled in from abroad or start off as legal guns (ceremonial or deactivated) but become illegal be reactivating or modifying them.  Alternatively they are simply stolen from licence holding gun owners as was the case in the murder of MP Jo Cox.

Where knife crime and isolated shooting events are more prevalent in some areas than others, Civilian Public Mass Shootings (CPMSs) data suggests that almost any community is at risk (13) although CPMSs have common characteristics amongst them. (15, 15)

A recent review of 139 gunshot fatalities consisting of 371 wounds from 12 civilian, public, mass shooting events found: (16)

• Victims had an average of 2.7 gunshots.

• Relative to military reports, the case fatality rate was significantly higher and incidence of potentially survivable injuries was significantly lower.

• Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds.

• The probable site of fatal wounding was the head or chest in 77% of cases.

• Only 7% of victims had potentially survivable wounds.

• The most common site of potentially survivable injury was the chest (89%). 

• No head injury was potentially survivable.

• There were no deaths due to exsanguination from an extremity.

More recent data from Sarani et al (17) suggest that revised EMS response and triage criteria should concentrate on rapidly extricating and treating victims who have sustained a gunshot to the chest as the most salvageable cohort following a CPMS event.

These casualties with survival injuries are most likely to need a chest seal rather than a tourniquet.

Acid Attacks

Common misunderstanding is that this is a predominantly Asian crime where a male attacker carries out an ‘honour’ punishment on a female victim, typically for rejecting his sexual advantages, refusal to marry or for bringing shame on the family.  While this may be true in certain regions this is not the case in the UK. (18)

• Data from the period 2002-2016 show Just 6% of all suspects in London over the last 15 years were Asian while White Europeans comprised 32% of suspects and African Caribbean 38% of suspects.

• Of the 2,196 victims in the 15 year period almost half (987) were White Europeans and a quarter (557) African Caribbean.

• Over a 15 year period, the attacker was male in 74% of cases and the victim was also male in 67% cases.

• The figures also show that after a 10 year decline attacks surged by more than 500% between 2012 (73 attacks) and 2016 (469 attacks).

Combined with a decreasing average age of the attacker being towards 21 years old, Acid attacks are the modus operandi of gang crime for theft and muggings.  Only 32 incidents appear to be racially motivated.

Tourniquets are no use in acid attacks or the use of chemical agents.  The primary need here is for dilution and irrigation with clean water.   There is mixed evidence over the efficacy of Diphoterine® compared to 20 minutes of running water for the treatment of chemical buns – it’s real benefit is the ability to carry Diphoterine® in a medic bag for initial treatment when 20 minutes of cold running water is not always available.

Further Reading - Burns Part 2: Special Cases

Summary

• Terrorist and hostile activities in the UK and Europe are still incredibly rare compared to other violent criminal activity including knife crime.

• Our perception of both Hazard and Risk may not match the reality of high-profile events such as bombings, vehicular incidents and other organised activities.

• An analysis of patterns of injury reveals that:

  • Many casualties will sustain injuries which are not compatible with life, regardless of interventions which may be able to be applied at the scene.

  • Of those with survivable injuries, uncontrollable external haemorrhage which may be managed with a tourniquet is exceptionally rare.

    • Blast injuries affect the whole body. Head, chest and abdominal injuries have a lower chance of survival but where survivable injuries occur in these instances, tourniquets are not warranted. Tourniquets may be warranted where casualties have sustained life threatening haemorrhage from limbs.

    • Vehicular injuries cause blunt force trauma resulting in musculoskeletal injuries and internal bleeding. Death from external bleeding is rare.

    • Knife, gun and acid attacks are targeted towards the head for lethality as well as the chest and abdomen due to the size of the ‘target’. Injuries to limbs tend to be superficial and caused by the casualty attempting to protect more vulnerable areas. Where death from haemorrhage occurs, it is likely to be abdominal or junctional (neck, armpit or groin) which cannot be managed with a tourniquet.

Tourniquets have their place in the management of life threatening haemorrhage but are not a panacea for all trauma. The contents of your medic bag should be commensurate with your Risk Assessment and that should be based on available data rather than tradition and media coverage.

References

1. Bellamy RF.  (1995)  “Combat Trauma Overview”. In: Zajtchuk R, Grande C, eds. Textbook of Military Medicine, Anesthesia, and Perioperative Care of the Combat Casualty. Falls Church, VA: Office of the Surgeon General of the Army; 1995:1-42.

2. Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF.  (2006)  “Understanding combat casualty care statistics”.  Journal of Trauma.60(2):397-401

3. Holcomb JB, McMullin NR, Pearse L,  et al.  (207)  “Causes of death in US Special Operations Forces in the global war on terrorism: 2001-2004”.  Annals of Surgery.  245(6):986-991

4. Kelly JF, Ritenour AE, McLaughlin DF,  et al.  (2008)  “Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006”.  Journal of Trauma.  64(2):(suppl)  S21-S27

5. Kotwal RS, Montgomery HR, Kotwal BM, et al. (2011)  “Eliminating Preventable Death on the Battlefield”.  The Archives of Surgery.  146(12):1350–1358

6. UK Parliament  (2020)  "Research Briefing: Terrorism in Great Britain: the Statistics.”  Published Friday, 27 March, 2020.  https://commonslibrary.parliament.uk/research-briefings/cbp-7613/

7. Kapur GB, Hutson HR, Davis MA, Rice PL.  (2005)  “The U.S. twenty-year experience with bombings: implications for terrorism preparedness and medical response.”  Journal of Trauma. 59(6):1436-1444.

8. Boffard KD, Macfarlane CA.  (1993)  “Urban bomb blast injuries: patterns of injury and treatment.”  Surgery Annual 25 Pt 1: 29-47 .

9. Martin, J. L., Lardy, A., & Laumon, B. (2011).  “Pedestrian injury patterns according to car and casualty characteristics in France”.  Annals of advances in automotive medicine. Association for the Advancement of Automotive Medicine.  Annual Scientific Conference. 55, 137–146.

10. Homocide rates in London - Metroplitan Police crime Dash Board: https://www.met.police.uk/sd/stats-and-data/met/crime-data-dashboard/

11. Knife Crime Statistics – https://commonslibrary.parliament.uk/research-briefings/sn04304/

12. Bleetman A, Watson CH, Horsfall I, Champion SM.  (2003)  “Wounding patterns and human performance in knife attacks: optimising the protection provided by knife-resistant body armour”.  Journal of Clinical Forensic Medicine. 2003;10(4):243‐248.

13. American College of Surgeons. (2015)  “See Something, Do Something: Improving Survival Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium”.  Bulletin of the American College of Surgeons.  100(15).

14. Blair JP, Martaindale MH, Nichols T. Active shooter events from 2000 to 2012. FBI Law Enforcement Bulletin. January 2014. Available at: https://leb.fbi.gov/articles/featured-articles/active-shooter-events-from-2000-to-2012 Accessed June 22, 2015.

15. Blair JP, Schweit KW. (2014) “A Study of Active Shooter Incidents, 2000–2013”. Texas State University and Federal Bureau of Investigation. U.S. Department of Justice, Washington, DC.

16. Smith ER, Shapiro G, Sarani B. (2016)  “The profile of wounding in civilian public mass shooting fatalities”.  Journal of Trauma and Acute Care Surgery.  81(1):86‐92.

17. Sarani B, Smith ER, Shapiro G, et al. (2021) “Characteristics of survivors of civilian public mass shootings”. Journal of Trauma and Acute Care Surgery. 2021;90(4)

18. https://www.bbc.co.uk/bbcthree/article/5d38c003-c54a-4513-a369-f9eae0d52f91