Characteristics of Improvised Explosive Device Trauma Casualties in the Gaza Strip and Other Combat Regions: The Israeli Experience

Objective. Low-intensity conflict is characterized in asymmetrical conventional and nonconventional warfare. The use of improvised explosive devices (IEDs) in the Israeli-Palestinian conflict has evolved over the past few decades to include the addition of diesel, biological agents, shrapnel, and nitroglycerin to the explosive content. Due to its nature and mechanism, an IED injury might present as a multidimensional injury, impairing numerous systems and organs. Materials and Methods. The authors present a case series of 5 Israeli Defense Forces (IDF) soldiers wounded by an IED presenting a typical and similar pattern of burns to their faces, trunks, and limbs, in addition to ocular, ear/nose/throat, and orthopedic injuries. An analysis of the experience in treating the aforementioned injuries is included. Results. Improvement in casualties’ burns and traumatic tattoos was observed following debridement, aggressive scrubbing with or without dermabrasion, and conservative local dressing treatment protocol. The authors found a positive correlation between improvement degree and treatment timing. Injury pattern was correlative to the protective gear worn by the soldiers. Wearing protective eye gear and wearing ceramic vests can diminish the extent of IED injuries, while creating typical patterns of injuries to be treated. Conclusion. Based on these experiences, such injuries should be brought to a trauma center as soon as possible. Treating multidimensional trauma should be done in a facility with abilities to treat head injuries, eye injuries, penetrating injuries, blast injuries, and burns. Such specialized disciplines and facilities that have past experience with IEDs and war injuries are able to assess and treat these injuries in a more dedicated manner, resulting in better long-term rehabilitation.

In recent decades, improvised explosive devices (IEDs) have become a frequently used weapon in the Israeli-Palestinian conflict. These devices are typically comprised of explosives, shrapnel, dirt, and may also be designed with diesel, lighting fuel, nitric oxide, or biological materials such as blood infected with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus.¹ Five different mechanisms of explosives injuries have been described: primary blast injuries are caused by an overpressurization shock wave followed by an underpressurization wave, which travels through the body. This mechanism is responsible for traumatic brain injury, tympanic membrane rupture, and lung injury.² Secondary injuries are caused by bomb fragments, along with other fragments propelled by the explosion. This mechanism is the most common cause of explosion-related injury and death.^2,3 Tertiary injuries are caused by wind of the blast propelling and displacing victims and causing surrounding structures to collapse.^2,3 Quaternary injuries are all other injuries, including inhalation injuries and burns.^2,3 Quinary injuries are caused by additional bomb components, such as metals, bacteria, fuel, and radiation.² It is important to note that each mechanism is not a solitary event, and numerous body systems may be affected by an explosion.

The face is a region commonly affected by blast injury by way of secondary injury. The winds carry ground elements, sand, shrapnel, and other components, resulting in penetrating injuries, deep abrasions, lacerations, and shredding and puncturing of the skin. Areas most susceptible to injury are those composed of flexible soft tissue, such as lips, cheeks, and eyelids. It is not uncommon for traumatic tattooing to occur if deposits are not extracted from affected layers of the skin. Another frequent mechanism of injury to the facial region is thermal injury. Eyelids are commonly affected, as are eyebrows and lips.3 Other types of craniomaxillofacial injuries due to IEDs include fractures, mostly to midfacial bones, and open wounds, particularly of the scalp, forehead, jaw, cheek, and lip.⁴

Various studies have been conducted in the past decades garnering statistical data and attempting to analyze typical injury patterns among IED casualties, mostly in Iraq and Afghanistan. One study investigated burns in combat and found more than 70% of burns were due to IED explosions (stationary or vehicle borne), with the hands and head most frequently burned (80% and 77%, respectively).⁵ Another study found that among soldiers who were evacuated to a medical facility after a combat explosion, 78% of the mechanisms reported were IED blasts. The extremities were the body region most often injured (41.3%), followed by the head and neck (37.4%), and torso (8.8%)².

During autumn of 2013, 4 patients were referred to the burn unit at Sheba Medical Center, Tel Hashomer, Israel, following an injury caused by an IED explosion sustained during routine army activity in the Gaza Strip. The IED was hidden in an underground smuggling tunnel, several meters below ground, adjacent to barrels of diesel. The soldiers were standing above the tunnel at the time of detonation. None of the soldiers was wearing protective goggles or ceramic vests during the explosion, which took place at nighttime. It should be noted all patients were provided with both a ceramic vest and protective goggles by the army, but did not use them at the time of injury as their task and location at the time were deemed as low-risk, not necessitating the use of protective gear. Due to the explosion, all 4 patients were propelled and lifted off the ground, landing in the vicinity of the explosion. All patients lost consciousness and could not provide the treating clinicians with additional details regarding their immediate injuries. All injured personnel were triaged at the scene, treated by field medics and physicians, and transported to a nearby level 1 trauma medical center, Soroka Medical Center, Be’er Sheva, Israel, where they were treated for multiple injuries. A fifth patient was injured by an IED detonated in Northern Israel, resulting in similar injuries. This patient was brought to a nearby level 1 trauma medical center as well, in this case, Rambam Health Care Campus, Haifa, Israel). All 5 patients were healthy, and between 21 and 34 years of age. Patients were transferred to the authors’ care 3-15 days after initial injury. All patients presented with facial burns, in addition to other injuries (Table 1). The burn severity varied from first-degree to third-degree burns. All patients underwent aggressive scrubbing with or without dermabrasion under sedation, as well as treatment with threolone (chloramphenicol 3% and prednisolone 0.5%), an enzyme alginogel (Flaminal, Flen Pharma, Moshav Gimzo, Israel), or silver sulfadiazine, depending on the severity of their burns (Table 1). 

Upon arrival, the remainder of dark particles, such as sand and other components, underneath the patients’ facial skin were visible to the naked eye. Following debridement, scrubbing, and a conservative local dressing treatment protocol, improvement in burns and traumatic tattoos was observed. The authors found a positive correlation between the degree of improvement and treatment timing: patient A, who underwent debridement 15 days after injury, had limited improvement in traumatic tattooing in comparison with patients B-E, who underwent debridement within 3 or 5 days postinjury (Figures 1 and 2). The authors also noted injury patterns were correlative to the protective gear used by the patients: penetrating ocular injury due to lack of protective eyewear, as well as abdominal, scrotal, and limb involvement in exposed areas where a ceramic vest was not present. 

Patient A was discharged to a rehabilitation facility due to other injuries before being discharged home,while patients B-E were discharged directly home. All wounds debrided achieved complete closure. 

An IED injury brings the potential for grave results, such as limb amputation, blindness, severe burns, internal injury, and death. A number of measures can be taken to minimize injury and increase survival. One such measure is the use of personal protective equipment (PPE) such as helmets, gloves, flak jackets, ceramic plates, or eye protection.^2,5

The field of combat eye protection (CEP) has evolved over the years, in part due to wars such as the Vietnam war where penetrating ocular injury led to blindness in nearly 50% of casualties. A solution in the form of effective protective eyewear needed to be designed. It has been suggested that the ideal eye armor must be lightweight, scratch-proof, comfortable, easily maintained, lack a tendency to fog, be resistant to high impact, and should not impair visual performance. Currently, different types of CEP devices are provided to soldiers worldwide with the main focus of providing ballistic and UVA/UVB protection. The main problem, however, is soldiers’ variable compliance in wearing CEP.⁶ A British study found service personnel were 9.9 times more likely to sustain an eye injury if they were not wearing CEP compared to those wearing it (P < 0.01). Still, while a ballistic helmet and CEP cover the upper two-thirds of the face, the lower third remains poorly protected and accounts for the location of 60% of facial injuries.⁷ It is recommended that any individual exposed to a blast be examined by an ophthalmologist to exclude any ocular injury.8 Another type of armor for which compliance is unknown is neck-protecting gear, such as tactical vests, helmet nape pads, and detachable body armor modular systems. In contrast with neck-protecting gear, whose compliance rates are unknown, studies show that wearing body armor vests among British and American service personnel has a compliance rate of more than 90%.⁹

Nevertheless, it is not merely enough to provide soldiers with proper PPE. In the described cases, they were provided with PPE, but failed to wear it during the event. Educating soldiers about the importance of using PPE, and the possible ramifications of not using it, should be implemented to a higher degree. This should include all personnel, regardless of rank, and be enforced through example by commanders in the field. Furthermore, as described in these cases, an IED may go off during seemingly low-risk routine tasks and even at assembly points. Routine protocols of when to use PPE should be examined. Following an analysis of the events, the IDF has refreshed its preventive measures and guidelines and is also purchasing additional PPE equipment and improving protocols for its use.

For patients with evidence of possible traumatic tattooing, surgical action in the form of debridement, scrubbing, or dermabrasion should be taken as soon as possible to extract damaging particles and decrease the likelihood of a permanent traumatic tattoo. Ideal debridement timing should be within the first 24 hours of injury, although satisfactory results have also occurred with treatment performed 16 days postinjury.10 In cases of traumatic tattooing due to deeply embedded pigment, a possible solution is the use of Q-switched lasers (ie, ruby, alexandrite, and neodymium-doped yttrium aluminium garnet).10 Laser therapy has been demonstrated to be efficacious in treating traumatic tattoos up to 15 years after the incident.11 It should be noted that laser treatment works best for carbon-based pigment, while its effect on metallic or mineral particles is often unsatisfactory.¹⁰

In summary, wearing protective eye gear and ceramic vests can diminish the extent of IED injuries while creating typical patterns of injuries to be treated. Based on the authors’ experience, patients with such injuries should be brought to a trauma center as soon as possible. Multidimensional trauma should be treated in a facility with the ability to treat head and eye injuries, penetrating and blast injuries, and burns. Specialized disciplines and facilities with past experience treating IED and war injuries are able to assess and treat these injuries in a more dedicated manner, resulting in better outcomes and long-term rehabilitation.

Affiliations: Department of Plastic and Reconstructive Surgery and the Burn Unit, Sheba Medical Center, Tel Hashomer, Israel; Department of Plastic Surgery, Assaf Harofeh Medical Center, Zerifin, Israel; and Department of Surgery, A. Meir Medical Center, Kfar Saba, Israel

Correspondence:
Liran Barzilai, MD
liran.barzilai@gmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.