Hostname: page-component-848d4c4894-wzw2p Total loading time: 0 Render date: 2024-05-27T14:13:45.043Z Has data issue: false hasContentIssue false

Traumatic Brain Injuries after Mass-Casualty Incidents: Lessons from the 11 September 2001 World Trade Center Attacks

Published online by Cambridge University Press:  28 June 2012

Wesley Rutland-Brown
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Injury Response, Atlanta, Georgia USA
Jean A. Langlois*
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Injury Response, Atlanta, Georgia USA
Leze Nicaj
Bureau of Injury Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York USA
Robert G. Thomas Jr.
CDC, National Center for Injury Prevention and Control, Office of Statistics and Programming, Atlanta, Georgia USA
Susan A. Wilt
Bureau of Injury Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York USA
Jeffrey J. Bazarian
Department of Emergency Medicine, University of Rochester School of Medicine, Rochester, New York USA
Jean A. Langlois, ScD, MPH CDC/NCIPC/DIR, 4770 Buford Highway, NE MS F-41, Atlanta, GA 30341-3724, USA E-mail:



The 11 September 2001 terrorist attacks on the World Trade Center (WTC) resulted in thousands of deaths and injuries. Research on previous bombings and explosions has shown that head injuries, including traumatic brain injuries (TBIs), are among the most common injuries.


The objective of this study was to identify diagnosed and undiagnosed (undetected) TBIs among persons hospitalized in New York City following the 11 September 2001 WTC attacks.


The medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the WTC attacks were abstracted for signs and symptoms of TBIs. Diagnosed TBIs were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons with an undiagnosed TBI were contacted and informed of the diagnosis of potential undetected injury.


A total of 282 records were abstracted. Fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the abstracted records). The leading cause of TBI was being hit by falling debris (22 cases). One-third of the TBIs (13 cases) occurred among rescue workers.More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they currently were experiencing symptoms consistent with a TBI.


Not all of the TBIs among hospitalized survivors of the WTC attacks were diagnosed at the time of acute injury care. Some persons with undiagnosed TBIs reported problems that may have resulted from these TBIs three years after the event. For hospitalized survivors of mass-casualty incidents, additional in-hospital, clinical surveys could help improve pre-discharge TBI diagnosis and provide the opportunity to link patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers deserves re-evaluation.

Original Research
Copyright © World Association for Disaster and Emergency Medicine 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1.Peral-Gutierrez de Ceballos, J, Turegano-Fuentes, F, Perez-Diaz, D, et al. : 11 March 2004: The terrorist bomb explosions in Madrid, Spain–An analysis of the logistics, injuries sustained, and clinical management of casualties treated at the closest hospital. Crit Care 2005;9(1):104111.CrossRefGoogle Scholar
2.Mallonee, S, Shariat, S, Stennies, G, et al. : Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA 1996;276(5):382387.CrossRefGoogle ScholarPubMed
3.Frykberg, ER, Tepas, JJ: Terrorist bombings: Lessons learned from Belfast to Beirut. Ann Surg 1988;208(5):569576.CrossRefGoogle ScholarPubMed
4.Scott, BA, Fletcher, JR, Pulliam, MW, Harris, RD: The Beirut terrorist bombing. Neurosurgery 1986;18(1):107110.CrossRefGoogle ScholarPubMed
5.Buduhan, G, McRitchie, DI: Missed injuries in patients with multiple trauma. J Trauma 2000;49:600605.CrossRefGoogle ScholarPubMed
6.Rizoli, SB, Boulanger, BR, McLellan, BA, Sharkey, PW: Injuries missed during initial assessment of blunt trauma patients. Accid Anal Prev 1994;26(5):681686.CrossRefGoogle ScholarPubMed
7.Centers for Disease Control and Prevention (CDC): Deaths in World Trade Center terrorist attacks–New York City, 2001. MMWR 2002;51(special issue):1618.Google Scholar
8.CDC: Rapid assessment of injuries among survivors of the terrorist attack on the World Trade Center–New York City, September 2001. MMWR 2002;51(1):15.Google Scholar
9.Brackbill, RM, Thorpe, LE, DiGrande, L, et al. : Surveillance for World Trade Center disaster health effects among survivors of collapsed and damaged buildings. In: Surveillance Summaries, 07 April 2006. MMWR 2006;55(No SS-2):118.Google ScholarPubMed
10.Feeney, JM, Goldberg, R, Blumenthal, JA: September 11, 2001, revisited. Arch Surg 2005;140:10681073.CrossRefGoogle Scholar
11.Frykberg, ER: Medical management of disasters and mass casualties from terrorist bombings: How can we cope? J Trauma 2002;53(2):201212.CrossRefGoogle ScholarPubMed
12.Brooks, A, Holroyd, B, Riley, B. Missed injury in major trauma patients. Injury 2004;35(4):407410.CrossRefGoogle ScholarPubMed
13.Soundappan, SVS, Holland, AJA, Cass, DT: Role of an extended tertiary survey in detecting missed injuries in children. J Trauma 2004;57(1):114118.CrossRefGoogle ScholarPubMed
14.Houshian, S, Larsen, MS, Holm, C: Missed injuries in a Level I trauma center. J Trauma 2002;52(4):715719.Google ScholarPubMed
15.Janjua, KJ,Sugrue, M, Deane, SA: Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma 1998;44(6):10001007.CrossRefGoogle ScholarPubMed
16.Enderson, BL, Reath, DB, Meadors, J, et al. : The tertiary trauma survey: A prospective study of missed injury. J Trauma 1990;30(6):666669.CrossRefGoogle ScholarPubMed
17.Hirshberg, A, Holcomb, JB, Mattox, KL: Hospital trauma care in multiplecasualty incidents: A critical view. Ann Emerg Med 2001;37(6):647652.CrossRefGoogle ScholarPubMed
18.Scott, SG, Vanderploeg, RD, Belanger, HG, Scholten, JD: Blast injuries: Evaluating and treating the postacute sequelae. Federal Pract 2005;22(1):6675.Google Scholar
19.Halpern, P, Tsai, MC, Arnold, JL, et al. : Mass-casualty, terrorist bombings: Implications for emergency department and hospital emergency response (Part II). Prehosp Disast Med 2003;18(3):235241.Google Scholar
20.Ponsford, J: Rehabilitation interventions after mild head injury. Curr Opin Neurol 2005;18(6):692697.CrossRefGoogle ScholarPubMed
21.Ponsford, J, Willmott, C, Rothwell, A, et al. : Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry 2002;73(3):330332.Google Scholar
22.Ponsford, J, Willmott, C, Rothwell, A, et al. : Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics 2001;108(6):12971303.CrossRefGoogle ScholarPubMed
23.Chesnut, RM, Carney, N, Maynard, H, et al. : Rehabilitation for traumatic brain injury. Evidence report no. 2 (Contract 290-97-0018 to Oregon Health Sciences University). Rockville, MD: Agency for Health Care Policy and Research. February 1999.Google Scholar
24.McAllister, TW, Sparling, MB, Flashman, LA, et al. : Differential working memory load effects after mild traumatic brain injury. Neuroimage 2001;14(5):10041012.CrossRefGoogle ScholarPubMed
25.Alves, W, Macciocchi, SN, Barth, JT: Postconcussive symptoms after uncomplicated mild head injury. J Head Trauma Rehabil 1993;8(3):4859.CrossRefGoogle Scholar
26.Englander, J, Hall, K, Stimpson, T, Chaffin, S: Mild traumatic brain injury in an insured population: Subjective complaints and return to employment. Brain Inj 1992;6(2):161166.Google Scholar
27.US Department of Health and Human Services: International Classification of Diseases, 9th Revision: Clinical Modification (ICD-9-CM). 3rd ed. Washington, DC: US Department Health and Human Services, 1989.Google Scholar
28.Marr, AL, Coronado, VG (eds): Central Nervous System Injury Surveillance Data Submission Standards–2002. Atlanta: US Department Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2004.Google Scholar
29.Bazarian, JJ, Veazie, P, Mookerjee, S, Lerner, B: Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes. Acad Emerg Med 2006;13:3138.Google ScholarPubMed
30.MacKenzie, E, Sacco, W: ICDMAP-90: A User's Guide. Baltimore: The Johns Hopkins University School of Public Health and Tri-Analytics, Inc, 1997.Google Scholar
31.American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for Doctors (ATLS). 7th ed. Chicago: American College of Surgeons, 2004.Google Scholar
32.Biffl, WL, Harrington, DT, Cioffi, WG: Implementation of a tertiary trauma survey decreases missed injuries. J Trauma 2003;54(1):3844.CrossRefGoogle ScholarPubMed
33.Hirshberg, A, Scott, BG, Granchi, T, et al. : How does casualty load affect trauma care in urban bombing incidents? A qualitative analysis. J Trauma 2005;58(4):686695.CrossRefGoogle Scholar
34.CDC: (2003, July). J., Langlois and W., Rutland-Brown (Eds.). Mild traumatic brain injury in mass trauma events. Unpublished proceedings.Google Scholar
35.Groves, WA, Ramani, RV, Radmosky, MC, Flick, JP: Protecting first responders: Analysis of PPE guidelines distributed at the World Trade Center and Pentagon disaster sites. Professional Safety 2004;49(11):3141.Google Scholar
36.Jackson, BA, Peterson, DJ, Bartis, JT, et al. : Protecting Emergency Responders—Lessons Learned from Terrorist Attacks. Santa Monica: RAND Distribution Services, 2002.Google Scholar
37.Sample, PL, Darragh, AR: Perceptions of care access: The experience of rural and urban women following brain injury. Brain Inj 1998;12(10):855874.CrossRefGoogle Scholar
38.Corrigan, JD,Whiteneck, G, Mellick, D: Perceived needs following traumatic brain injury. J Head Trauma Rehabil 2004;19(3):205216.CrossRefGoogle ScholarPubMed
39.Arnold, JL,Halpern, P, Tsai, MC, Smithline, H: Mass casualty terrorist bombings: A comparison of outcomes by bombing type. Ann Emerg Med 2004;43:263273.Google Scholar
40.Arnold, JL, Tsai, MC, Halpern, P, et al. : Mass-casualty, terrorist bombings: Epidemiological outcomes, resource utilization, and time course of emergency needs (Part I). Prehosp Disast Med 2003;18(3):220234.Google Scholar