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ORIGINAL PAPERS
J R Army Med Corps: first published as 10.1136/jramc-149-01-04 on 1 March 2003. Downloaded from http://jramc.bmj.com/ on 28 April 2019 by guest. Protected by copyright.
The Pipe Bomb: A Modern Terrorist Weapon
AJ Gibbons, JN Farrier, SJ Key
Wg Cdr A J Gibbons
MA(Cantab)
FDS RCS FRCS RAF
Registrar in
Maxillofacial Surgery
e-mail:
andrew_gibbons@hotmail.com
Mr J N Farrier
FDS RCS FRCS RAF
Registrar in
Maxillofacial Surgery
Mr S J Key
FDS RCS FRCS
Staff Grade in
Maxillofacial Surgery
Maxillofacial Unit,
Morriston Hospital,
Swansea, SA6 6NL. Fig 1. Design of a ‘Pipe Bomb’.
24 The Pipe Bomb
J R Army Med Corps: first published as 10.1136/jramc-149-01-04 on 1 March 2003. Downloaded from http://jramc.bmj.com/ on 28 April 2019 by guest. Protected by copyright.
to her face, head and neck (Figure 3). She
also had shrapnel in both feet. In view of
the peri-oral burns and her hoarse voice,
she was intubated and admitted to the
Respiratory Intensive Care Unit. Her blood
gases were normal on admission and her
lung fields were clear. However, a
subsequent fibre-optic laryngoscopy
showed marked oedema of the vocal cords.
She made a slow but uneventful recovery.
Patient 3 was a 25 year-old English
woman, on holiday in Cape Town, who had
shrapnel in both lower legs and a large
fragment in her right heel. This had caused
a laceration to her Achilles tendon. She also
had ruptured tympanic membranes. She
was the least injured of the four patients,
but the most vocal and required a great deal
of reassurance. Her Achilles tendon was
repaired the next day under general
anaesthetic.
Patient 4 was a 55 year-old Afrikaner
woman whose husband died in the
explosion. She had shrapnel injuries to her
face and legs. The wounds were dressed and
physically she made a good recovery.
J R Army Med Corps: first published as 10.1136/jramc-149-01-04 on 1 March 2003. Downloaded from http://jramc.bmj.com/ on 28 April 2019 by guest. Protected by copyright.
are particularly susceptible as illustrated by
cases 1 and 3. Blast winds are rapidly
moving displaced columns of air that follow
the blast wave and can produce a range of
traumatic soft and hard-tissue damage
depending on the distance of the individual
from the explosive source (9,10). Secondary
blast injuries are due to the products of the
explosion. These include the constituents of
the bomb and any associated debris that
may strike the individual causing
fragmentation injuries seen in all the above
cases. Tertiary blast injuries occur when the
individual becomes the missile and is
thrown against a solid object or the ground
(5). Amputations, which are also due to the
blast wind, are included in this group. Flash
burns are usually superficial on exposed
skin, but smoke inhalation can cause
potentially life-threatening problems in
patients who initially have normal airways.
Case 3 illustrates the high index of
suspicion that is needed in patients with
peri-oral burns as they may have inhalation
Fig 4. Shrapnel injury to skull. injuries.
Fragmenting weapons produce a variety
He had no neurological deficits. The of missiles of different sizes (11,12). The
patient was discharged from hospital 2 days crude but effective pipe bomb releases low
postoperatively under police escort. mass, low energy transfer fragments. In a
confined civilian setting it can cause
Discussion multiple casualties making it an ideal
Emergency medical units need to have terrorist weapon as demonstrated in the
staff trained in the management of blast Cape Town bombing.
injuries and a planned response to deal with Pipe bombs have become one of the
most popular 'tools of terror' in the United
major incidents (1). Although the use of
States and are particularly favoured by
pipe bombs has dramatically increased the
white supremacists and far-right political
medical literature contains few reports on
extremists. Between 1980 and 1990 there
the type of injuries they cause (2,3). were 12,216 bombing incidents in the
Clinicians who rarely see blast injuries may United States, the majority involving pipe-
assume that the injuries are due to bomb devices (2). The Oklahoma bombing
commercially manufactured bombs and be in 1995, leading to 167 deaths (13), was
unaware that home- made pipe bombs have caused by a massive pipe bomb whilst the
been used. explosion at the Atlanta Games in 1996
The Cape Town pipe bombing demon- involved a much smaller device but still
strates the successful implementation of a caused one fatality and more than 100
disaster plan. Trained paramedics and casualties (14). Both incidents gained
trauma consultants arrived on site promptly tremendous media publicity, a key aim of
and rapidly triaged and resuscitated terrorist attacks.
patients. The evacuation of patients to six In the 1990s the incidence of pipe bomb
different hospitals that had been warned of explosions around the world has risen
the imminent arrival of casualties meant dramatically. In Germany the pipe bomb
that patients were seen in trauma units has become synonymous with neo-Nazi
within the ATLS ‘Golden Hour’ (4) and groups (15), whilst in Italy a ‘Unibomber’
that no single hospital was overwhelmed has used several pipe bombs in random
with casualties. attacks. Palestinian terrorists routinely use
The bomb exploded on the ground in a pipe bombs against Israeli targets with
confined space. This is associated with a devastating effects (16). In the United
higher incidence of primary blast injuries Kingdom, the Brick Lane and Soho
and therefore more severe injuries than bombings in London were pipe bomb
open-air explosions (5,6). explosions (17). Between July 1997 and
Blast injuries are classified as primary, February 2001 in Northern Ireland, both
secondary and tertiary (7). Primary blast Catholic and Protestant terrorist groups
injuries result from the direct effects of the were involved in over 75 media reported
pressure wave and cause most injuries to gas incidents of sectarian pipe bomb attacks.
26 The Pipe Bomb
J R Army Med Corps: first published as 10.1136/jramc-149-01-04 on 1 March 2003. Downloaded from http://jramc.bmj.com/ on 28 April 2019 by guest. Protected by copyright.
Primary school as children attempted to of on-site care, pre-hospital time and level of in-
hospital care on survival in severely injured
enter it caused the British Government to patients. J Trauma 1993; 34: 252.
be questioned regarding whether the 2. Karmy-Jones R, Kissinger D, Golocovsky M,
Northern Island cease-fire was still intact Jordan M, Champion H R. Bomb-related injuries.
(18). Mil Med 1994; 159(7): 536-539.
The Cape Town bombing was believed to 3. Davies E B, Rollins C E, Reiber G D, Anthony R
M. Suicide by pipe bomb. Am J Forensic Med Pathol
be the work of a Muslim fundamentalist 1999; 20(2): 136-140.
group in response to the American bombing 4. American College of Surgeons Committee on
of Sudan and Afghanistan (19). Over the Trauma. Advanced Trauma Life Support for
past 5 years, pipe bombs have been Doctors. 6th edn. 1997: 9.
5. De Candole C A. Blast injury. Can Med Assoc J
frequently used by vigilante groups and 1967; 96: 207-214.
criminals in the Cape metropolitan area. 6. Leibovici D, Gofrit O N, Stein M, Shapira S C,
A common feature of all these attacks is Noga Y, Heruti RJ, Shemer J. Blast injuries: bus
the difficulty in tracing the bombers due to versus open-air bombings – a comparative study of
lack of forensic evidence. With conventional injuries in survivors of open-air versus confined
space explosions. J Trauma 1996; 41 (6):1030-
bombs much physical evidence can be 1035.
recovered after a blast, such as the 7. Trimble K, Clasper J. Anti-personnel mine injury;
container, trigger or delay mechanisms. Mechanism and medical management. J R Army
Identification and tracing the origin of these Med Corps 2001; 147: 73-79.
8. Huang J Z, Yang Z, Wang Z, Leng H. Study on
components may aid in identifying and characteristics of blast-fragment combined injury
convicting the bomber. However, where the in dogs. J Trauma 1996; 40(3): 63-67.
components have simply been purchased at 9. Hull J B, Bowyer G W, Cooper G J, Crane J.
a hardware store and the detonator is home Pattern of injury in those dying from traumatic
made, tracing the manufacturer of the amputation caused by bomb blast. Br J Surg 1994;
81(8): 132-135.
bomb is difficult. In addition, most pipe 10. Hull J B, Cooper G J. Pattern and mechanism of
bombs are small enough to fit in a carrier traumatic amputation by explosive blast. J Trauma
bag or briefcase and can, therefore, be left 1996; 40(3): 198-205.
inconspicuously. 11. Bowyer G W, Cooper G J, Rice P. Small fragment
wounds: Biophysics and pathophysiology. J Trauma
For terrorists, buying ammunition such as 1996; 40(3): 159-169.
grenades from outside sources represents a 12. Spalding T J W, Stewart M P M, Tulloch D N, et al.
risk. In comparison pipe bombs can be Penetrating missile injuries in the Gulf War 1991.
made in-house at minimum risk. Br J Surg 1991; 78: 1102.
Unsophisticated home-made detonators 13. Mallonee S, Shariat S, Stennies G, et al. Physical
injuries and fatalities resulting from the Oklahoma
and the crude method of manufacture make City bombing. JAMA 1996; 276: 382-387.
pipe bombs unstable during construction 14. Reynolds P. World: Americas Fugitive charged with
and transport (20). Terrorists using these Atlanta bombing. BBC News Online Network
devices are occasionally killed or injured, as 1998; October 14.
15. Boyes R. Berlin Sounds alarm as neo-Nazis hoard
demonstrated in the second case report. arms. The Times 2000; June 22.
The exponential increase in pipe 16. Bamber D. IRA ‘is teaching Palestinians how to
bombings around the world in the past blow up Israeli soldiers’ in West Bank. The Daily
decade indicates the ease of manufacture of Telegraph 2002; April 28.
this type of bomb and the difficulty the 17. Hopkins N, Hall S. Festering hate that turned quiet
son into a murderer. The Guardian 2000; July 1.
police force have in tracing people who use 18. Sharrock D. Blair challenged over ceasefire. The
it. The pipe bomb is proving to be a cheap Daily Telegraph 2001; September 6.
and deadly modern terrorist weapon 19. Russell A. City is a stronghold of Muslim militants.
The Daily Telegraph 1998; August 27.
20. Sharrock D. Loyalist is killed while working on pipe
Acknowledgements bomb. The Daily Telegraph 2002; January 5.
We thank Mr A Nichol, Head of the Trauma
Unit of Groote Schuur Hospital for his
permission to present patients from the
Unit.