It’s all about the Blast: Psychological Health Consequences of Combat Blast Exposure
Alan Peterson, PhD1,2,3
1Professor, Department of PsychiatryUniversity of Texas Health Science Center at San Antonio
2Research Health ScientistSouth Texas Veterans Health Care System
3Professor, Department of PsychologyUniversity of Texas at San Antonio
Disclosures
• The presenter has no financial relationships to disclose.• This continuing education activity is managed and accredited by
Professional Education Services Group in cooperation with AMSUS.• Neither PESG, AMSUS, nor any accrediting organization support or
endorse any product or service mentioned in this activity.• PESG and AMSUS staff has no financial interest to disclose.• Commercial support was not received for this activity.
Funding SourcesDepartment of Defense
Army Medical Research and Materiel CommandMilitary Operational Medicine Research Program
Congressionally Directed Medical Research ProgramsPsychological Health and Traumatic Brain Injury Research Program
Tri-Service Nursing Research ProgramAir Force Medical Support Agency
711th Human Performance Wing, USAF School of Aerospace MedicineUSAF Operational Medicine Research Program
Department of Veterans AffairsRobert Wood Johnson Foundation
Disclaimer: The views expressed in this presentation are solely those of the author and do not reflect an endorsement by or the official policy/position of the U.S. Army, the U.S. Air Force, the Department of Defense, the
Department of Veterans Affairs, or the U.S. Government. 3
Learning Objectives
At the conclusion of this activity, the participant will be able to: 1. understand how blast explosions are the primary cause of
morbidity and mortality in military personnel who have deployed to Iraq and Afghanistan.
2. describe the development of Improvised Explosive Devices (IEDs) in the wars in Iraq and Afghanistan.
3. describe the symptoms, causes, and factors contributing to combat-related psychological health conditions after blast exposure.
Overview• Blast explosions have been the primary cause of morbidity and mortality in military personnel deployed in and around Iraq and Afghanistan (Eastridge et al., 2012)
• Amputations • Burns• Traumatic Brain Injury (TBI) • Posttraumatic stress disorder (PTSD)• Other related injuries
Overview
• Explosive blasts can cause multiple forms of damage that are more complex than any other wounding agent (Champion et al., 2009)• Recent reports indicate that almost 80% of all combat-related injuries in US military personnel deployed to Iraq and Afghanistan have been from blasts• This is the highest proportion seen in any large-scale conflict (Murray et al., 2005; Owens et al., 2008)
Much of the blast data reported in this presentation are from the IOM Report on Long-Term Effects of Blast
Exposures (2014 )
Overview• What causes explosive blasts?• The human impact of blasts• Research on blast-related injuries• Blast protection and prevention• Evidence-based treatments for PTSD and TBI
Complex Injurious Environment Due to BlastInstitute of Medicine Committee on Long-Term Consequences of Blast Exposures (2014)
The Multi-System Response to BlastInstitute of Medicine Committee on Long-Term Consequences of Blast Exposures (2014)
Acute Blast: VulnerableOrgans/Systems
Long-termSecondary Effects
Deaths in Major U.S. Wars
War Duration(Years) Deaths Deaths per
DayDeaths per Population
Deaths per 100,000
Civil War 4 625,000 599 1.988% 1988 WW I 2 116,516 279 0.110% 110 WW II 4 405,399 416 0.307% 307 Korea 3 36,516 45 0.02% 20 Vietnam 8 58,151 26 0.03% 30Afghanistan 13? 2356 0.5 0.00075% 0.75 Iraq 9? 4489 1.4 0.0014% 1.4
Worldwide Terrorist and IED Attacks(National Counterterrorism Center, 2012)
• In 2011, there were over 10,000 terrorist attacks• Average of 27 terrorist attacks per day• Nearly 45,000 victims in 70 countries• Over 12,500 deaths
• In 2011, there were 3747 IED attacks• Average of 10 IED attacks per day• Countless number of victims• Over 6,350 deaths
Worldwide Terrorist Attacks(National Counterterrorism Center, 2012)
What causes battlefield explosions?MortarsRocketsRPGsMinesIEDs
VBEDs
Weaponry Cause of Death
IED
Gunshot
Mortar/Rocket
Bomb
0
200
400
600
800
1000
1200
U.S. Military Deaths in Iraq
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
700
800
900
1000
486
849 846 822904
314
14960 54
1 0 3
U.S. Military Deaths in Afghanistan
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140
100
200
300
400
500
600
700
800
900
1000
12 49 48 5299 98 117 155
317
499418
310
12755
Lethality of Combat Injuries(Gawande, 2004)
Revolutionary War
Civil War
WW IWW II
KoreaVietnam
Persian Gulf War
OIF/OEF
05
1015202530354045
Increased Ratio of Wounded to DeceasedInstitute of Medicine Committee on Long-Term Consequences of Blast Exposures (2014)
What is an IED?• An IED attack is the use of a "homemade" bomb and/or destructive
device to destroy, incapacitate, harass, or distract• IEDs are used by criminals, vandals, terrorists, suicide bombers, and
insurgents• Because they are improvised, IEDs can come in many forms, ranging
from a small pipe bomb to a sophisticated device capable of causing massive damage and loss of life
• IEDs can be carried or delivered in a vehicle; carried, placed, or thrown by a person; delivered in a package; or concealed on the roadside
• November 14, 2003, first IED death in Iraq
Immediate Health Effects of an IED• Explosions create a high-pressure blast that sends debris flying and
lifts people off the ground• Type and number of injuries will vary depending on
• Physical environment• Size of the blast• Amount of shielding between victims and the blast• Fires• Resulting structural damage• Whether the explosion occurs in a closed space or an open area
Immediate Health Effects of an IED• Injuries common to explosions include:
• Overpressure damage to the lungs, ears, abdomen, and other pressure-sensitive organs
• Blast lung injury, a condition caused by the extreme pressure of an explosion, is the leading cause of illness and death for initial survivors of an explosion
• Fragmentation injuries caused by projectiles thrown by the blast• Impact injuries caused when the blast throws a victim into another object• Thermal injuries caused by burns to the skin, mouth, sinuses, and lungs• Other injuries including exposure to toxic substances, crush injuries, and
aggravation of pre-existing conditions
Signature Injuries of OIF/OEF/OND• Amputations• Burns• Traumatic Brain Injury (TBI)• Posttraumatic Stress Disorder (PTSD)
Amputations•Center for the Intrepid at BAMC•65,000 square feet•Built from $55 million in donations (Intrepid Fallen Heroes Fund)
Ten Years at War: Comprehensive Analysis of Amputation Trends.Krueger, Wenke, & Ficke, (2012) . J Trauma Acute Care Surg. 73(6) Sup 5:S438-S444
Figure 1 . The number of amputations per month for the US Military during OEF, OIF, and OND 2001-2011
Ten Years at War: Comprehensive Analysis of Amputation Trends.Krueger, Wenke, & Ficke, (2012) . J Trauma Acute Care Surg. 73(6) Sup 5:S438-S444
• Number of amputations performed at each body location• Percentages show the percent of total amputations that each location represented
• 42% Transtibial (below-knee amputation)
• 35% Transfemoral (above-knee amputation)
• 30% sustained multiple amputations
Burns
• Institute of Surgical Research (ISR) Burn Center on BAMC Campus
• ISR Mission• Optimizing Combat Casualty Care
• ISR Vision• To be the nation's premier joint research organization planning
and executing registry-based and translational research providing innovative solutions for burn, trauma, and combat casualty care from the point of injury through rehabilitation
• Treated over 800 OEF/OIF/OND burn patients
TBI
•Defense and Veterans Brain Injury Center (DVBIC)•National Intrepid Center of Excellence (NICoE)•Mission Connect• INTRuST Consortium•Chronic Effects of Neurotrauma Consortium (CENC)
TBI Severity (VA/DOD)
Criteria Mild Moderate SevereLOC 0 - 30 mins 31 mins - 24 hrs >24 hoursAOC Moment - 24 hrs >24 hours. Severity based on other criteria
PTA 0 - 1 Day 2 – 7 Days >7 DaysGCS 13 - 15 9 – 12 <9
StructuralImaging
Normal Normal or Abnormal Normal or Abnormal
TBI Diagnostic Challenges• TBI is a historic event• What may persist are postconcussive symptoms• Diagnostic criteria are based largely on patient self-report, particularly
for mild TBI • Possible threats to diagnostic accuracy:
• Recall bias• Cognitive difficulties• Overlap of symptoms in co-morbid conditions• Other factors
Epidemiology of TBI• Estimated prevalence of TBIs in OEF/OIF/OND veterans between
10% and 20% (e.g., Hoge et al., 2008; Tanielian & Jaycox, 2008)• Armed Forces Health Surveillance Center (2014) studied 307,283
cases of TBI across all US service branches between 2000-2014• 82.4% of all TBIs were classified as mild• 8.3% as moderate• 1.0% as severe• 1.5% penetrating injuries• 6.8% could not be classified
TBI and PTSD Symptom OverlapTBI• Insomnia• Memory Problems• Poor concentration• Depression• Anxiety• Irritability• Headache• Dizziness• Fatigue• Noise/light intolerance
PTSD• Insomnia• Memory problems• Poor concentration• Depression• Anxiety• Irritability• Re-experiencing• Avoidance• Emotional numbing
Management of Concussion/mTBI• VA/DoD Clinical Practice Guideline (2009)• The vast majority of patients will improve with no lasting clinical
sequelae • Patients should be reassured and encouraged that the
condition is transient and full recovery is expected• The term 'brain damage' should be avoided• A risk communication approach should be applied
Management of Concussion/mTBI• Treatment of somatic complaints (e.g. sleep,
dizziness/coordination problems, nausea, numbness, smell/taste, vision, hearing, fatigue, appetite problems) should be based upon individual factors and symptom presentation
• Headache is the single most common symptom associated with concussion/mTBI
• Assessment/management of headaches should parallel those for other causes of headache
• Medication for ameliorating the neurocognitive effects attributed to concussion/mTBI is not recommended
Effects of Hyperbaric Oxygen Therapy (HBOT) on Postconcussion Symptoms in Military Members
Miller et al., (2014), JAMA Internal Medicine, 175:43-53.
• DESIGN, SETTING, AND PARTICIPANTS:• Multicenter, double-blind, sham-controlled clinical trial of 72 military
service members with ongoing symptoms at least 4 months after mild TBI
• Enrolled at military hospitals in Colorado, North Carolina, California, and Georgia between 2011-2012
• Assessments occurred before randomization, at the midpoint, and within 1 month after completing the interventions.
Effects of HBOT on Postconcussion Symptoms in Military MembersMiller et al., (2014), JAMA Internal Medicine, 175:43-53.
• INTERVENTIONS:• Routine care• 40 HBOT sessions administered at 1.5 atmospheres absolute (ATA)• 40 sham sessions consisting of room air at 1.2 ATA, or no supplemental
chamber procedures.• MAIN OUTCOMES AND MEASURES:
• Rivermead Post-Concussion Symptoms Questionnaire (RPQ) served as the primary outcome measure
• Secondary measures included additional patient-reported outcomes and automated neuropsychometric testing
Effects of HBOT on Postconcussion Symptoms in Military MembersMiller et al., (2014), JAMA Internal Medicine, 175:43-53.
• RESULTS:• On average, participants had 3 lifetime mTBIs• Most recent occurred 23 months before enrollment• No differences were observed between groups for improvement of at least 2
points on the RPQ-3 subscale• Compared with the no intervention group, both groups undergoing
supplemental chamber procedures showed improvement in symptoms on the• No difference between the HBOT group and the sham group was observed (P
= .70)• Chamber sessions were well tolerated.
Effects of HBOT on Postconcussion Symptoms in Military MembersMiller et al., (2014), JAMA Internal Medicine, 175:43-53.
• CONCLUSIONS AND RELEVANCE:• Among service members with persistent PCS, HBOT
showed no benefits over sham compressions• Both intervention groups demonstrated improved outcomes
compared with PCS care alone• Finding suggests that the observed improvements were not
oxygen mediated but may reflect nonspecific improvements related to placebo effects.
What is it?• Results from exposure to one or
more extreme traumatic events• Military Combat• Motor Vehicle Accidents• Physical or Sexual Assault• Terrorist Attacks• Natural Disasters• Other traumatic events
• Symptoms include• Distressing memories, dreams,
flashbacks• Avoidance of trauma reminders• Negative changes in thought
processes, mood• Heightened arousal (e.g., irritable,
startle easily, difficulty concentrating, sleep disturbance)
PTSD
How Common is PTSD?
• Affects 7% of Americans• 4% adult males• 10% adult females
• Percentage is twice as high in military service members and veterans (14%)
PTSD Prevalence0
2
4
6
8
10
12
14
16
Males
Females
General Popu-lation
Service Members & Veterans
Who is at Greatest Risk for PTSD?
• Those with most significant or frequent traumas
• Tip-of-the spear military warriors• Those in blast explosions resulting in
horrific and mutilating injuries and death
• Those who experience significant risk of personal injury or death
• Those who experience things no humans should have to experience
Posttraumatic Stress Disorder
• Since 9-11-2001 over 2.5 million U.S. military have deployed in support of OIF/OEF/OND
• Risk of PTSD upon redeployment (PDHA) and 3-6 months later (PDHRA):
Milliken Auchterlonie, & Hoge, (2007)
PDHA PDHRA
Active 11.8% 16.7%
Guard/Reserve 12.7% 24.5%
Comorbidities of PTSD
• PTSD has many related or comorbid conditions• Depression• Traumatic Brain Injury (TBI)• Sleep Disorders• Chronic Pain• Substance Use Disorders• Suicide
Impact of PTSD
• Homelessness• About 13% of adult homeless population in
U.S. are veterans• About two-thirds of homeless veterans who
served in Iraq/Afghanistan have PTSD• Disability
• Service-connected PTSD costs an estimated $500,000 in lifetime disability payments
• PTSD has a significant impact on individuals, families, communities, and our nation
Evidence-Based Treatments for PTSD(DoD/VA CPG)
• Medication• Sertraline (Zoloft) - FDA indication in 1999• Paroxetine (Paxil) - FDA indication in 2001
• Cognitive Behavior Therapy• Exposure Therapy • Stress Inoculation Training• Cognitive Therapy• EMDR• Combination of Cognitive and Exposure Therapy
IOM Report (2008)
Evidence-Based Treatments for PTSD (IOM, 2008)
•The committee concludes that the current scientific evidence is:•Sufficient to conclude the efficacy of exposure therapies• Inadequate to determine the efficacy of EMDR, cognitive restructuring, coping skills training, and group format psychotherapy
• Inadequate to determine the efficacy in the treatment of PTSD with pharmacotherapy
Evidence-Based Cognitive-Behavioral Treatments for PTSD in Civilians
• Prolonged Exposure (PE)• Involves repeated exposure to:
• Memories of the trauma• Trauma-related situations
• Cognitive Processing Therapy (CPT)• Involves exposure to trauma through:
• Writing and reading accounts of the trauma• Challenging and modifying maladaptive thoughts and beliefs
related to trauma
Loss of PTSD Diagnosis in Civilians after Treatment with PE and CPT
0
20
40
60
80
100
Pre 5+ Years
Perc
ent w
ith P
TSD
Cognitive Processing Therapy (n = 63)
Prolonged Exposure (n = 64)
Resick et al., 2012
Shalev et al., 2011
• Participants (N = 289)• Adult survivors of a traumatic event• Hadassah Univ Hospital, Israel (2003-07)• Contacted by telephone & interviewed
• Inclusion criteria:• Experienced a “Criterion A Event”• Met criteria for full or partial ASD
Prevention of PTSD by Early Intervention
Shalev et al., 2011
Percent with PTSD at 5-Month Follow-Up (N = 289)
0
10
20
30
40
50
60
70
PE CPT SSRI Med Placebo Wait List
Prevention of PTSD in Civilians with Early Treatment
STRONG STAR• South Texas Research Organizational Network Guiding Studies on Trauma And
Resilience• Headquartered at the UT Health Science Center• Largest PTSD Research Consortium in world
• Over 100 of the world’s leading investigators• Over 30 collaborating institutions including partnership with VA’s National
Center for PTSD• Over 25 ongoing research studies
• Conducting most important military-relevant clinical trials and translational research in DoD
• Results will have direct impact on best clinical practices in military and VA treatment facilities
STRONG STAR Projects• 16 Projects ($25M direct costs)• All funded through original STRONG STAR Multidisciplinary
PTSD Research Consortium funding• Multiple partnering principal investigators (PIs)
• Treatment Studies• Biological Studies• Epidemiological Studies
STRONG STAR-Affiliated Projects
• 18 Affiliated Projects• All funded through independent peer-review
• Treatment Studies• Biological Studies• Epidemiological Studies• Dissemination and Implementation Studies
www.STRONGSTAR.org
Consortium to Alleviate PTSD (CAP)• September 2012 Program Announcement through a
Collaborative DoD/VA Psychological Health and TBI Research Program Award
• Total award $45M (DoD = $20M; VA = $25M)• Stated Consortium Objectives in Program Announcement
• Advance treatment for PTSD• Identify and confirm clinically relevant biomarkers as
diagnostic and prognostic indicators of PTSD and co-occurring conditions
THE Signature Injury of OIF/OEF/OND
Blast Trauma
Obtaining CME/CE Credit
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