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

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