On Behalf of the TeamHealth Emerging Infectious Disease Taskforce
Introduction
The United States has more significant tornadoes than any other country. In lieu of recent events, the TeamHealth Emerging Infectious Disease Taskforce (EIDT) discusses the clinical impacts of tornadoes.
On average the U.S. experiences 800 to 1,500 tornadoes yearly. Those tornadoes result in approximately 1,800 to 2,500 injuries and about 100 to 200 annual fatalities. Almost every acute care clinician practicing in the nation will encounter tornado casualties in their careers.
This article shares information about injuries associated with tornadoes, the injury profiles seen from tornado casualties and best practices for clinicians to care for tornado wounds.
Tornado History and Science
Tornadoes were rarely studied until the late 1970s when a few healthcare professionals applied scientific principles to study them. These studies resulted in advances in tornado classifications, warning and sheltering recommendations. The science also resulted in the development of the Fujita scale and now the Enhanced Fujita Scale (EF-0 through EF-5). This system is directly tied to the risk and nature of tornado damage and injury. The higher the number, the worse the damage and injury risk.
Radical advancements in Doppler radar now provide highly proficient tornado tracking, classification and warning in most high-risk areas. This has improved the mean tornado warning time from a few minutes to well over 30 minutes. Tornado warnings and sheltering activities of the population are the two most critical preventive components to saving lives.
Injuries Associated with Tornadoes
The most common physical injuries associated with tornadoes include – in descending order:
- Soft Tissue Injuries (lacerations, punctures, abrasions, contusions)
- Fractures, sprains, strains, and other related orthopedic injuries
- Head Injuries and Traumatic Brain Injury (TBI)
- Blunt Chest and/or abdominal trauma
- Burns, Drowning, Toxic Exposures
Multiple Tornado Injury Patterns
It is important to note that although we classify various types of injuries, around 50% of casualties will have two or three different classes of injury. In general, the management of tornado-related injuries does not differ greatly from trauma caused by other mechanisms. There are a few qualifications to this statement mostly around the management of lacerations.
Soft Tissue Injuries
The most common injury following a tornado are soft tissue wounds. Lacerations, punctures, abrasions, and contusions account for over 50% of the total injuries. The wounds are almost universally described as deep and significantly contaminated with soil and debris.
Most casualties suffer from multiple wounds with about 10% requiring surgical debridement in the operating room. Most of the soft tissue injuries are in exposed areas of the body not covered by clothing or other shielding. This is why covering up when sheltering from a tornado is recommended.
One interesting soft tissue injury reported with more violent tornadoes is an abrasive effect. This results from wind accelerated particles of soil, sand, and fine debris striking the skin at high velocity. These high velocity particles have a “sandblasting” effect causing superficial to deep abrasion of the dermis. This skin abrasion can be extensive complicating management.
The Nature of Tornado Soft Tissue Wounds
Soft tissue wounds resulting from tornadoes represent a complex and deceivingly difficult issue. These wounds are highly contaminated with soil and environmental debris and have deeply embedded foreign bodies such as grass, tar, glass, wood, and other materials. Some wounds, particularly those sustained inside multi-story buildings, have been contaminated with raw sewage from ruptured drainage pipes. This fact requires clinicians to consider the location of the patient at the time of wounding and the need for extensive decontamination procedures.
Infection Rates of Tornado Wounds
Tornado wounds closed primarily in the ED are reported to have a 30% or greater wound infection rate on follow-up. These high infection rates have been recognized for decades. As early as 1953, a study looked at over 600 tornado wounds. Those closed primarily in the ED were reported to have a “high frequency” of infections while those treated with delayed primary closure had “few” infections. Unfortunately, no specific numbers were given – which was a common practice for medical reports of the time.
Bacteriology of Tornado Wounds
The gross contamination and foreign body retention seen in tornado wounds result in a high incidence of polymicrobial wound infections. Tornado wounds are typically contaminated with aerobic gram-negative organisms such as Escherichia coli, Klebsiella, Serratia, Proteus, and Pseudomonas. There is a lower – but real – incidence of Staph aureus, Bacteroides, and fungi. In addition, tornado wounds are considered “tetanus-prone” wounds and should be managed as such.
Antibiotics after Primary Wound Closure in Tornado Wounds
Antibiotics are reported as ineffective in preventing infections in primarily closed tornado wounds. Unfortunately most tornado wound studies are uncontrolled. There is also a potential risk of antibiotic suppression of normal flora, which can lead to the growth of opportunistic organisms and fungi.
Tornado Wound Care Recommendations
Current guidelines recommend delayed primary closure for complex tornado wounds, with initial cleaning, short-term antibiotics, and a sterile dressing. Follow-up involves further wound exploration and closure after 48-72 hours. This approach is similar to military wound care and shows good outcomes. In addition:
- Fractures are common in tornado injuries, with about 30% of cases and 22% being open fractures, often requiring debridement and irrigation.
- Head injuries account for about 7% of tornado injuries and are the leading cause of death and long-term morbidity. Protective headgear is recommended during tornadoes.
- Blunt trauma, including non-penetrating chest and abdominal injuries, accounts for another 7% of casualties. Management follows established blunt trauma principles, similar to severe motor vehicle crash trauma.
Closing Comments
Tornado injuries involve complex polytrauma and high contamination levels, requiring thorough wound care, including exploration, irrigation, and debridement. While simple wounds are often closed primarily, complex wounds should use delayed primary closure to reduce infection rates. Fractures and head injuries are major concerns, with specialized management needed for effective treatment.
Learn more about TeamHealth’s Emerging Infectious Disease Taskforce (EIDT) and see a full list of references.