title: The quinary pattern of blast injury.
abstract: OBJECTIVE
  Bombing is the primary weapon of global terrorism, and it results in a complicated, multidimensional injury pattern. It induces bodily injuries through the well-documented primary, secondary, tertiary, and quaternary mechanisms of blast. Their effects dictate special medical concern and timely implementation of diagnostic and management strategies. Our objective is to report on clinical observations of patients admitted to the Tel Aviv Medical Center following a terrorist bombing.
  
  
  RESULTS
  The explosion injured 27 patients, and three died. Four survivors who had been in close proximity to the explosion, as indicated by their eardrum perforation and additional blast injuries, were exposed to the blast wave. They exhibited a unique and immediate hyperinflammatory state, two upon admission to the intensive care unit and two during surgery. This hyperinflammatory state manifested as hyperpyrexia, sweating, low central venous pressure, and positive fluid balance. This state did not correlate with the complexity of injuries sustained by any of the 67 patients admitted to the intensive care unit after previous bombings.
  
  
  CONCLUSIONS
  The patients' hyperinflammatory behavior, unrelated to their injury complexity and severity of trauma, indicates a new injury pattern in explosions, termed the "quinary blast injury pattern." Unconventional materials used in the manufacture of the explosive can partly explain the observed early hyperinflammatory state. Medical personnel caring for blast victims should be aware of this new type of bombing injury.
authors.affiliation: Department of Surgery, Rambam Medical Center, Rappaport School of Medicine, Technion, Haifa, Israel.
authors.forename: Yoram
authors.initials: Y
authors.lastname: Kluger
authors.forename: Adi
authors.initials: A
authors.lastname: Nimrod
authors.forename: Philippe
authors.initials: P
authors.lastname: Biderman
authors.forename: Ami
authors.initials: A
authors.lastname: Mayo
authors.forename: Patric
authors.initials: P
authors.lastname: Sorkin
mesh_terms: D000328:Adult; D001753:Blast Injuries / Q000276:immunology / Q000503:physiopathology*; D054042:Bombs; D004189:Disaster Planning; D005334:Fever; D006801:Humans; D007249:Inflammation / Q000503:physiopathology*; D008297:Male; D010417:Pentaerythritol Tetranitrate / Q000009:adverse effects*; D015599:Trauma Severity Indices
chemical_list: D010417:Pentaerythritol Tetranitrate