title: 40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.
abstract: BACKGROUND
  Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide.
  
  
  METHODS
  Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed.
  
  
  RESULTS
  58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%).
  
  
  CONCLUSIONS
  Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.
authors.affiliation: Royal Centre for Defence Medicine; The Royal British Legion Centre for Blast Injury Studies, Imperial College London. Electronic address: taffedwards100@hotmail.com.
authors.forename: D S
authors.initials: DS
authors.lastname: Edwards
authors.affiliation: Royal Centre for Defence Medicine; The Royal British Legion Centre for Blast Injury Studies, Imperial College London.
authors.forename: L
authors.initials: L
authors.lastname: McMenemy
authors.affiliation: Royal Centre for Defence Medicine.
authors.forename: S A
authors.initials: SA
authors.lastname: Stapley
authors.affiliation: St. Bartholomews Health NHS Trust, London.
authors.forename: H D L
authors.initials: HD
authors.lastname: Patel
authors.affiliation: Royal Centre for Defence Medicine; The Royal British Legion Centre for Blast Injury Studies, Imperial College London; Defence Medical Group (South East), Frimley Park, UK.
authors.forename: J C
authors.initials: JC
authors.lastname: Clasper
mesh_terms: D001753:Blast Injuries / Q000453:epidemiology* / Q000517:prevention & control; D054042:Bombs / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005060:Europe / Q000453:epidemiology; D005107:Explosions / Q000706:statistics & numerical data; D006708:Homicide / Q000706:statistics & numerical data; D006801:Humans; D008877:Middle East / Q000453:epidemiology; D013405:Suicide / Q000706:statistics & numerical data; D023481:Terrorism / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Bombings: Blast Injury; Suicide; Terrorism