Article, Traumatology

The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks

a b s t r a c t

As terrorist actors revise their tactics to outmaneuver increasing counter-terrorism Security measures, a recent trend toward less-sophisticated attack methods has emerged. Most notable of these “low tech” trends are the Targeted Automobile Ramming MAss Casualty (TARMAC) attacks. Between 2014 and November 2017, 18 TARMAC attacks were reported worldwide, resulting in 181 deaths and 679 injuries. TARMAC attack-related in- juries are unique compared to accidental pedestrian trauma and other causes of Mass casualty incidents (MCI), and therefore they require special consideration. No other intentional mass casualty scenario is the result of a blunt, non-penetrating trauma mechanism. Direct vehicle impact results in high-power injuries including blunt trauma to the central nervous system (CNS), and thoracoabdominal organs with Crush injuries if the vic- tims are run over. Adopting new strategies and using existing technology to diagnose and treat MCI victims with these injury patterns will save lives and limit morbidity. Point-of-care ultrasound is one such tech- nology, and its efficacy during MCI response is receiving an increasing amount of attention. ultrasound machines are becoming increasingly available to emergency care providers and can be critically important during a MCI when access to other imaging modalities is limited by patient volume. By taking ultrasound diagnostic techniques validated for the detection of life-threatening cardioThoracic and abdominal injuries in individuals and applying them in a TARMAC mass casualty situation, physicians can improve triage and allocate resources more effectively. Here, we revisit the high-yield applications of POCUS as a means of enhanced prehospital and hospital-based tri- age, improvED resource utilization, and identify their potential effectiveness during a TARMAC incident.

(C) 2018

Introduction

A Mass Casualty Incident (MCI) exists when a sufficiently large num- ber of injured are present and overwhelm the normal functioning of a system such as an emergency department (ED). Additional resources are required to fully manage the number and/or injury severity of arriv- ing patients. Prototypical causes of MCI include natural disasters like tornadoes and earthquakes, technological disasters such as a bridge col- lapse or a chemical plant explosion, and also intentional events like

? Funding information: Non-funded study, No compensation for consulting, No conflict of interest.

* Corresponding author at: 2120 L Street, NW Suite 450, Washington DC 20037, United States.

E-mail address: [email protected] (H. Shokoohi).

bombings and mass shootings. Differing injury patterns result from each type of incident (penetrating, crush, burn, etc.). While an all- hazards approach to Disaster preparedness improves efficiency, emer- gency medicine and trauma surgery specialists must remain mindful that terrorism-related injuries are different compared to accidental trauma, and therefore, require distinctive consideration [1,2].

In recent years, there has been a dramatic increase in the frequency of Targeted Automobile Ramming MAss Casualty (TARMAC) attacks in traditionally Western countries. Recent high-profile TARMAC attacks have occurred in France, Spain, Germany, Sweden, the UK, Canada, Australia, and the United States, signifying that TARMAC has become the tactic of choice for both “lone wolf” actors and terrorist cells [3,4,5,6]. Understanding a Diagnostic approach to different injury pat- terns helps medical providers reduce morbidity and mortality. Adopting new technologies and medical techniques to treat the survivors of

https://doi.org/10.1016/j.ajem.2018.05.058

0735-6757/(C) 2018

intentional trauma has historically saved the lives of patients injured by unintentional causes as well. A prime example of this concept has been the rapid expansion of tourniquet use as a primary means of prehospital Hemorrhage control, championed by the Committee on Tactical Combat Casualty Care for the military, and widely accepted into civilian EMS practice following the Boston Marathon bombing [7]. The use of POCUS for patients injured in natural disasters, terrorist attacks, and during military events has been studied [8,9,10]. Ultrasound machines now exist that are suitable for use in the prehospital environment and could be used during a MCI as they are portable, feature more user- friendly interfaces, and can transmit images wirelessly. Trained emer- gency responders can easily and rapidly obtain high quality images to determine the presence or absence of life threatening injuries such as pneumothorax, cardiac tamponade, and intraabdominal bleeding [11,12]. This noninvasive method of imaging can be repeated multiple times as a means of re-triaging survivors and detecting responses to medical interventions without the concerns of radiation or intravenous contrast exposure inherent in CT imaging. In a setting of scarce re- sources and capabilities, this will improve resource allocation. The au- thors propose the use of POCUS by well-trained first-receiver physicians as a primary means of enhanced triage and injury detection during a TARMAC response.

A unique concern

TARMAC attacks result in a Surge of patients who may require resus- citation, computed tomographic (CT) imaging, surgical subspecialty consultation, and immediate operative intervention. This type of MCI can easily exceed the normal working resources of even the best pre- pared emergency department. There has been a very significant in- crease in the frequency of TARMAC attacks in Europe, Australia, and the United States in recent years [13-16]. A US Government report states that from 2014 through November 2017, terrorists carried out

18 known vehicle-ramming attacks worldwide, resulting in 181 fatali- ties and 679 injuries [17]. Table 1 highlights some of the most high- profile events.

TARMAC attacks are unique among MCIs in that the vast majority of

the injuries to patients are the result of blunt trauma to the head and torso. These injuries are unique not only because of their mechanisms, but also because of their types and severity of injuries. The intentional nature of a TARMAC increases the associated morbidity and mortality as compared to an accident. A 2016 study supported the hypothesis that victims of an intentional vehicular ramming suffered significantly more severe injuries than those injured accidentally, and the authors concluded that CNS injury was the leading cause of death [15].

Point-of-care ultrasound in TARMAC

One proven method for screening victims of blunt trauma is the use of POCUS by trained emergency physicians. Studies have shown its util- ity in detecting occult life-threatening injuries in penetrating, crush, and blunt Trauma victims individually [19]. The Focused assessment with sonography in trauma (FAST) examination has become the standard of care for the diagnosis of post-traumatic Pericardial tamponade and hemoperitoneum [20,21,22]. POCUS is also useful in diagnosis of chest, extremity trauma, evaluation of shock states and intravascular volume depletion [23,24,25]. Integration of POCUS in the emergency response to a TARMAC attack has potential to assist medical response team in pri- oritizing initial transport from the scene, prioritize the use of imaging modalities in the hospital, appropriately devote operating tables for life- saving interventions, and identify injuries in cases who may need to be transferred to the accessory hospitals.

We surmise that appropriate application of prehospital ultrasound, emergency receiving triage ultrasound, and continuous repeat POCUS of patients undergoing stabilization in the ED will help the MCI medical responses in the following categories.

Table 1

List of high profile TARMAC attacks in Western countries in the recent years.

Year

Country

Location

Vehicle

Deaths

Injured

Motive

2018

Germany

Munster

Camper Van

3

20

Mental illness [1]

2017

Australia

Melbourne

SUV

1

19

Mental Illness [2]

2017

USA

New York City, NY

Pickup truck

8

12

Terrorism [3]

2017

Spain

Barcelona/Cambrils

Vans (2)

14

100+

Terrorism [4]

2017

USA

Charlottesville, VA

Car

1

40+

Terrorism [5]

2017

England

London Bridge

Truck, 7.5 tons

8 (5 stabbed)

48

Terrorism [6]

2017

Sweden

Stockholm

Truck, 30 tons

5

14

Terrorism [7]

2017

USA

Times Square, New York City, NY

Car

1

20

Intoxication/mental illness [8]

2016

Germany

Berlin

Truck, 25+ tons

12

56

Terrorism [9]

2016

France

Nice

Truck, 9 tons

87

434

Terrorism [10]

2015

USA

Stillwater, OK

Car

4

46

Mental illness [11]

2015

Austria

Graz, Austria

Car

3

36

Terrorism [12]

1https://www.thenational.ae/world/europe/germany-car-ramming-kills-three-1.719560

2“Suspect in Australian car ramming ‘spoke about voices’: Authorities” http://abcnews.go.com/International/deliberate-car-ramming-injures-[14-]people-melbourne/story?id= 51925440, Retrieved: January 10, 2018

3“Terror Attack Kills 8 and Injures 11 in Manhattan” https://www.nytimes.com/2017/10/31/nyregion/police-shooting-lower-manhattan.html, Retrieved: November 19, 2017

4Zoli, C. (2017, October 06). Is There Any Defense Against Low-Tech Terror? Retrieved October 24, 2017, from http://foreignpolicy.com/2017/10/02/terror-has-gone-low-tech/

5Charlie Savage And Rebecca R. Ruiz. (2017, August 14). Sessions Emerges as Forceful Figure in Condemning Charlottesville Violence. Retrieved October 24, 2017, from https://www. nytimes.com/2017/08/14/us/politics/domestic-terrorism-sessions.html

6Evans, M. (2017, June 10). London Bridge terrorists were thwarted in attempt to hire a 7.5 t truck on day of atrocity. Retrieved October 24, 2017, from http://www.telegraph.co.uk/news/

2017/06/09/london-bridge-terrorists-tried-hire-truck-earlier-day/.

7Johnson, S., Pollard, N., & Roos, R. (2017, April 10). Uzbek suspect in Swedish attack sympathized with Islamic State: police. Retrieved October 24, 2017, from https://www.reuters.com/ article/us-sweden-attack/uzbek-suspect-in-swedish-attack-sympathized-with-islamic-state-police-idUSKBN17B089.

8Barbara Demick, Alexandra Zavis, Vera Haller. (2017, May 19). One killed and 22 injured when a car plows into pedestrians in New York’s Times Square. Retrieved October 24, 2017, from

http://www.latimes.com/nation/nationnow/la-na-times-square-car-pedestrians-20170518-story.html.

9Eddy, M. (2016, December 21). Germany Seeks Tunisian Tied to Berlin Christmas Market Attack. Retrieved October 24, 2017, from https://www.nytimes.com/2016/12/21/world/europe/

berlin-christmas-market-attack.html. 10Birnbaum, M., & McAuley, J. (2016, July 16). Attacker in Nice is said to have radicalized ‘very rapidly’. Retrieved October 24, 2017, from https://www.washingtonpost.com/world/islamic- state-claims-responsibility-for-france-attack-in-nice/2016/07/16/4327456e-4ab9-11e6-8dac-0c6e4accc5b1_story.html?utm_term=.bbd9a2a44945

11Reports, T. W. (2015, November 14). Proving mental fitness in Oklahoma State homecoming parade trial could prove difficult. Retrieved October 24, 2017, from http://www. chicagotribune.com/news/nationworld/ct-oklahoma-state-homecoming-parade-crash-20151114-story.html.

12Office of Security Policy and Industry, Engagement Surface Division – Highway and Motor Carrier Section. Vehicle Ramming Attacks. 2017: 1-7. https://info.publicintelligence.net/TSA- VehicleRamming.pdf.

Determine patterns of injury severity and need for immediate med- ical intervention (Prehospital)
  • Enhance triage accuracy at the scene and Triage of EMS Resources
  • (Prehospital)

    Guide hospital-based Delivery of care and triaging Hospital resources including Operating rooms and imaging capacity (Hospital- based)

    Ultrasound Use in Prehospital Setting.

    Like any other auto versus pedestrian incident, the pattern and se- verity of the injuries are a result of several factors, including the type of vehicle (size and bumper height), vehicle speed, and point of impact on the victim. The preferential use of a heavy, large truck with a high bumper at high speed, ramming in different directions creates a pattern in which most injuries arise from ground impacts to the head resulting in fatal Traumatic brain injuries, and injuries to the legs and pelvis resulting in significant morbidity and mortality. The survivors of the first impact suffer from intraabdominal and intrathoracic injuries, for which POCUS is the optimal initial imaging modality in detecting life- threatening injuries. POCUS enables the identification of patients who may have a higher chance at survival with rapid intervention – those with blunt trauma to the chest, abdomen and pelvis. POCUS evidence of internal bleeding in pleural, peritoneal, or pericardial space may trig- ger the decision to transport immediately to a trauma center; the dis- covery of a lack of Lung sliding and pneumothorax may lead to the decision to decompress a pneumothorax in the appropriate clinical set- ting. The use of POCUS in cases with blunt abdominal and chest trauma has long been established in the ED and trauma literature [26,27]. In a systematic review by O’Dochartaigh and Douma, the authors provided three studies in which the use of prehospital ultrasound positively changed patient management. The authors concluded that there is moderate evidence that supports prehospital physician use of ultra- sound for trauma patients; management was changed based on the re- sults of the prehospital POCUS; the benefit of ultrasound use in non- physician services is unclear [28].

    In European countries in which EP evaluating victims at the scene there is better success reported in the literature. In a study by German prehospital physicians, they performed 144 POCUS using handheld US in 971 patients (14.8%) on various applications including FAST, thorax, cardiac and renal US. The study resulted in a sensitivity of 85% and spec- ificity of 100% with no occurrence of false positive findings. They have concluded that use of POCUS is a useful imaging modality for triage in multi-casualty scenarios [29].

    In another study in France, 302 ultrasound exams done out of hospi- tal by French SAMU physicians, in which they found that the diagnostic accuracy was improved (i.e., positive USS) in 181 (67%) cases, decreased it (i.e., negative USS) in 22 (8%) cases, and was not contributive (i.e., USS was 0) in 67 (25%) cases [30]. In a recent study by O’Dochartaigh et al. in a Canadian Critical Care Helicopter Emergency Medical Service, prehospital POCUS was used in 455 missions, 318 by non-physician crew and 137 by physicians. In combined trauma and Medical patients, in the non-physician group interventions were supported by prehospital ultrasonography in 26% of cases (95% CI [18-34]). For trans- port physicians, the percentage support was found to be significantly greater at 45% of cases (95% CI [34-56]) [31].

    There are many more good examples of using POCUS in different natural and manmade disasters as well. For example, in the wake of the Boston Marathon Bombing, FAST was indicated in the imaging algo- rithm for unstable patients with blast injuries [32]. Based on these appli- cations a few protocols have been suggested including portable ultrasonography in mass casualty incidents. The CAVEAT examination (chest, abdomen, vena cava, and extremities in acute triage) during multi-casualty incidents is one such example [33].

    In a military use of POCUS, FAST examinations performed by trained emergency physicians using portable equipment at a large military com- bat hospital in Iraq had very high sensitivity (100%), specificity (99%), and negative predictive value (100%), as confirmed by subsequent

    operative reports and computed tomography (CT) imaging [34]. In that particular experience, ultrasonography was performed in patients who sustained blunt, blast, and penetrating trauma [34].

    It is important to note that there are no data demonstrating im- proved patient outcomes (survivability, morbidity, rates of surgery) on patients in TARMAC where POCUS is applied. Even though the use of POCUS in prehospital evaluation of MCI victims has been demonstrated in a few scenarios, the feasibility of prehospital POCUS application in TARMAC attack yet to be determined.

    We realize that there is no evidence-based standard for POCUS inte- grated MCI triage including those that resulted from TARMAC attacks. Even we assume that the field triage might not even occur for the major- ity of injured patients considering the typical Inner city location of at- tacks and self-referral of patients to the closest hospitals.

    As such we believe there is, yet, no clear evidence of benefit and fea- sibility to integrate POCUS as part of a prehospital triage protocol in the United States. While there is no evidence of improved patient outcomes, one can still surmise that there is the potential for improved patient out- comes if one is able to properly identify an life-threatening traumatic in- jury early during the course of the MCI encounter. However, the current consensus seems to support that deploying emergency physicians with a POCUS skill may serve well at the screening zones and more impor- tantly at smaller hospitals which may not necessarily have POCUS capa- bility in place.

    Ultrasound Use in Hospital Setting. Ultrasound Enhanced Triage Accuracy and Triage of Hospital Resources. Typically, a TARMAC attack results in a rapid influx of severely in-

    jured patients in need of resuscitation, computed tomographic (CT) im- aging, surgical subspecialty evaluation and intervention, and can easily overwhelm the resources of any emergency department. An efficient EMS system prepared to distribute patients equally among hospitals can be foiled by geography, with victims making their own way to the closest hospital and quickly overwhelming resources as well [35]. This rapid surge of victims typically occurs within minutes and is dramati- cally different from the typical surge from a gradual influx of patients [36]. For example in similar blast injury scene in the Madrid bombings the closest hospital received 272 patients in 2.5 h [37].

    After victims have been triaged, effectively delivering the appropri- ate medical care requires detailed plans for the flow of each patient cat- egory through the ED. Without appropriate resource allocation and management, such situations can lead to an emergency response failure and adversely impact patients’ outcomes. Given the nature of injuries related to TARMAC attacks the most victims will undergo multiple im- aging studies. The number of patients who need emergent CT scans may lead to a bottleneck and hinder the capacity of the trauma center in providing adequate care. In a similar Scenario of Madrid bombing 350 radiology imaging studies and interventions had been performed in the day of bombing [37].

    Accurate re-triaging is necessary to match hospital resources with patient load. POCUS provides an optimal imaging technology to rapidly bridge the gap between patient load and available resources. When faced with a large number of casualties, the goal is to first care for those patients who will benefit the most from basic interventions (e.g. tube thoracostomy) and rapid surgical or angiographic interventions. To accomplish this, emergency physicians and trauma surgeons can uti- lize POCUS to provide dynamic re-triaging of patients and allocation of hospital resources including OR, CT scan, blood bank, and critical care services. Considering the severity of poly trauma related to TARMAC, it is predicted that these patients will have an increased need for critical care/ICU services, which in turn can exceed ICU capacity with a limited capability to divert or transfer critically ill patients. In this case, the ED will automatically function as an Emergency mass critical care unit. By repeating the noninvasive POCUS, the emergency team can continu- ously monitor patients and interactively feed patient capacity informa- tion to a decision support system. This re-triaging process and the accurate estimate of the number and severity of casualties are critical

    at this stage for management to mobilize backup resources effectively. In a recent MCI event, Kimberly et al. reported a similar use in reassessing casualties from the Boston Marathon Bombing MCI [32].

    Additionally, in the aftermath of TARMAC, the capacity to provide optimal trauma care is highly challenging and will be unpredictable. Therefore, the normal trauma protocols are replaced by a minimum ac- ceptable care (MAC) strategy aimed at rapid assessment and limited to lifesaving procedures using minimal resources, including use of CT scans which mainly will be restricted to the cases with traumatic brain injuries. Considering the high number of cases with head injury during a TARMAC attack, little imaging capacity will be remained to al- locate for cases with torso injuries. This will dictate the high utilization of POCUS based protocols including FAST, and Rapid US in Hypotension (RUSH) protocols in evaluating patients with blunt abdominal and tho- racic injuries.

    Historically, POCUS has been used to dedicate hospital resources in trauma cases. In a randomized controlled trial john et. al. investigated the use of point-of-care, limited ultrasonography (PLUS) for trauma in two level 1 trauma centers to assess its effects on time to operative care. It was determined that a protocol that included PLUS significantly decreased the time to operative care for patients with suspected torso trauma. This was also found to improve resource utilization and lower cost [38,39].

    In a recent article by Young et al. [40] they described the use of radi- ology in the emergency department (ED) in a trauma center during a mass casualty incident of the two terrorist attacks on 22 July 2011 in Norway, using a minimum acceptable care (MAC) strategy in which CT was restricted to potentially Severe head injuries. Nine patients from the explosion and 15 from the shooting were included. During the first 15 h, 22/24 patients underwent imaging in the ED. All 15 gun- shot patients had plain films taken in the ED, compared to three from the explosion. A CT was performed in 18/24 patients; ten of these were completed in the ED [40]. This study highlights the need for alter- native resources as such only 10 people could get CT scans in the ED in the first 15 h.

    Operational aspects of ultrasound application in TARMAC

    POCUS has a wide range of applications in diagnostic imaging and procedural guidance that can be utilized in prehospital and hospital care of patients involved in TARMAC attacks. However, certain consider- ations should be noted in this application while planning POCUS inte- gration in the response protocol (Table 2).

    Many modern ultrasound units are battery-powered and store im- ages digitally, which allows for electronic and/or wireless data trans- fer. However, in the setting of a TARMAC attack, a lack of sufficient battery and source of power will limit their continuous use. Handheld US machines also will get a heated battery with prolonged use, limit- ing their utilization to a shorter time of utilization.
  • Throughout areas in which a terrorist attack has occurred, the exces- sive use of wireless devices may prevent a robust transmission of im- ages wirelessly, which may limit the digital use and transmission of images. Additionally, to limit energy consumption, it is desirable for US machines to minimize their transmit power.
  • Considering multiple zones of operation and the need for multiple US machines for re-triaging in the ED, Trauma bay and ICU, there may be a need for central control of the devices and their accessories.
  • In disaster planning, we suggest prioritizing US as a standard method to be dispatched to the scene and available in the point of triage in the hospital setting. We suggest considering and maintaining adequate US machines with battery capability and additional backup batteries in the ED, trauma bay and ICU.
  • The most proper implementation model for deploying US and sonographers is yet to be determined. However, the following models may be considered based on the local capability and arrangements.
  • Table 2

    Proposed Implementation of POCUS in the prehospital and hospital-based emergency ser- vices during MCI.

    Prehospital-Implementation

    Prioritization of patients in need of emergent/urgent interventions using POCUS

    a) Pneumothorax, hemoperitoneum, pericardial effusion

    Re-triaging of patients with concerning mechanisms of injuries but lack of objective injuries by POCUS

    Prehospital-Barriers

    Competing with other wireless access/bandwidth during time of crisis in sending images for interpretation if acquired but not interpreted at the scene
  • Need for transmission of a signal in an area where wireless access is not available or permitted
  • Limited battery power
  • Environmental conditions — excessive heat/cold/rain
  • Access to qualified personnel to acquire imaged
  • Hospital-based-Implementation

    POCUS triage team in the emergency department to assist in patient triage

    Confirm the diagnosis requiring emergent or urgent operative intervention

    Globe rupture
  • vascular injuries
  • Solid organ hemorrhage
  • Pulmonary/Cardiac injuries
  • Confirm the absence of above diagnoses
  • POCUS as a force multiplier to cross sectional imaging evaluation of patients

    Reserve the use of CT scanning for high morbidity/mortality injuries

    Assess for intracranial operative intervention injury

  • POCUS to reassess patients

    Reassess patients to enhance tertiary trauma reevaluation

    Hospital-based-Barriers

    A disproportional availability of POCUS in a higher volume and higher acuity ED during TARMAC response

  • Limited time and resources required to document the POCUS results to be available to the other treating providers
  • Limited number of well-trained Emergency physician sonographers

    Local POCUS experts should fill a dedicated role in disaster response.

  • Local POCUS expert(s) in hospital with US machine(s)
  • Sending US machines with untrained people for just-in-time train- ing or remote image transmission/interpretation
  • Including wireless networks in transmitting images will significantly improve communication and planning in the use of POCUS. However, proper documentation is essential in sharing medical information with other medical professionals, so developing a backup documenta- tion plan is necessary.
  • Conclusions

    The increased frequency of TARMAC attacks in the recent years indi- cates a paradigm shift in terrorism tactics against civilians. In a world where automobile vs. pedestrian Mass casualty events are not only a re- ality, but extremely difficult to prevent, emergency departments and emergency managers must consider this modality when planning and drilling disaster scenarios. Evidence demonstrating the effectiveness of POCUS performed during a mass casualty response continues to grow and deserves further investigation. TARMAC, an intentional MCI caused by blunt trauma alone, is a new phenomenon, and one that results in a unique pattern of injuries for which POCUS can be very helpful. While prehospital POCUS requires further study to determine its reliability, it may prove useful for on-scene triage of blunt torso trauma. In the ED, ac- cess to real-time clinical information from POCUS allows for low-risk se- rial imaging of patients that may change their triage priority and

    thereby improve the allocation of sparse hospital resources in the most appropriate order. POCUS is safe, accurate, and fast. In trained hands, it can diagnose and evaluate for appropriate treatment. Therefore, in the resource-limited aftermath of a TARMAC incident, we propose that mass casualty incident plans implemented by hospitals should rely heavily upon POCUS during the initial response.

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