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Preparing Our Communities

• Welcome!

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Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Chapter 3 Explosive and Traumatic Events
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Chapter 3 Objectives

• Match each category of blast injury with its
  appropriate characteristics, body parts affected,
  and types of injuries that would occur.
• Apply the Disaster Paradigm and the concepts of
  MASS triage to traumatic and explosive events
• List scene and safety concerns and how to prepare
  and respond appropriately to each.
• Analyze injuries caused by explosives and develop
  strategies for managing these injury types.

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Explosive Events

• Scope of problem
• 38,362 Explosive Events between 1988 - 1997
• Over 50,000 lbs explosives stolen 1993-1997

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Newer Devices

• Enhanced Blast Weapons
• Fuel air explosives
• Munitions
• Newer technology
• Improvised Explosive Devices
• Simple pipe bombs
• Carried devices
• Large-scale vehicle

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Explosive Events

• Explosion- conversion of solid or liquid
  explosive material into gas causing energy
  release
• Low versus High explosive
• Degree of blast injury governed by 3 factors
• Size of charge
• Distance
• Surrounding environment

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Blasts Reflected By A Solid Surface

• Magnified many times
• Anyone between a blast and a wall can have more
  severe injuries
• Body armor may protect from projectiles but could
  also exacerbate the blast effect

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D-I-S-A-S-T-E-R Paradigm

• D Detection
• I Incident Command
• S Safety and Security
• A Assess Hazards
• S Support
• T Triage and Treatment
• E Evacuation
• R Recovery

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D-I-S-A-S-T-E-R ParadigmDetection

• Traumatic and explosive events are typically not
  as predictable as natural disasters
• Most common device utilized by terrorists
• Simultaneous events

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D-I-S-A-S-T-E-R ParadigmIncident Command

• The Incident Commander should manage traumatic
  and explosive events like any other disaster
  incident.
• Law enforcement may have lead

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D-I-S-A-S-T-E-R ParadigmSecurity and Safety

• Scene must be secured and perimeter established
• Typically a law enforcement role.
• Scene security safety hazards must be relayed
  expeditiously to the Incident Commander

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D-I-S-A-S-T-E-R ParadigmAssess Hazards

• Downed power lines?
• Debris?
• Fire?
• Blood and bodily fluids?
• Hazardous materials?
• Chemical, radiological, or biological
  contamination?
• Secondary explosive devices?
• Structural instability?

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D-I-S-A-S-T-E-R Paradigm Support

• May quickly overwhelm a communitys medical
  resources
• Coordination with trauma and burn centers is
  essential

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D-I-S-A-S-T-E-R ParadigmTriage and Treatment

• Injuries caused by blast
• Primary
• Secondary
• Tertiary
• Quaternary
• Quinary
• Triage
• ABCs of treatment

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Primary Blast Injuries

• Unique to explosions with high explosives
• Causes damage to air filled organs
• Causes
• Blast Lung
• TM rupture and middle ear damage (1)
• Not a good marker for more serious injury
• Abdominal injury
• Traumatic brain injury

http//www.defence.gov.au/dpe/dhs
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Primary Blast InjuriesPulmonary

• Pressure Differentials
• Tear Alveolar Walls
• Disrupt Alveolar-Capillary Interface

Discrete Contusions Multi-Focal
Hemorrhage Hemo-Pneumothorax Traumatic
Emphysema Subcutaneous Air Alveolar-Venous
Fistulae (air emboli)
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Primary Blast InjuriesPulmonary

• Signs
• Difficulty in Completing Sentences in One Breath
• Rapid, Shallow Respirations
• Poor Chest Wall Expansion
• Decreased Breath Sounds
• Wheezing and/or Hemoptysis
• Cutaneous Emphysema

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Primary Blast InjuriesPulmonary
CXR Characteristic Butterfly Pattern
www.bt.cdc.gov/masscasualties/ blastlunginjury.asp
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Primary Blast Injuries

• Systemic Air Embolism
• Vascular Obstruction
• referable to location of occlusion
• Chest pain (coronary symptoms)
• Focal Neurological Deficit
• Blindness
• Tongue Blanching
• Cutis Marmorata

www.medscape.com/viewarticle/408472_3
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Primary Blast Injuries

• Also Systemic Air Embolism
• Most Common Cause of PBI - Related Sudden Deaths
  Over the 1st hour
• Direct Leak Between Pulmonary Vasculature
  Bronchial Tree
• Low Venous Pressure and High Airway Pressure
  Creates Pressure Gradient
• Decompensation is Often Immediately after
  Endotracheal Intubation and Use of Positive
  Pressure Ventilation (PPV)

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Treatment Pulmonary Blast Injury / Arterial Gas
Embolism

• Spontaneous Respiration Preferred if Risk for
  Systemic Air Embolism
• Supplemental O2 Also Improves Bubble Resorption
  (nitrogen shift)
• Hyperbaric O2 Rx May Be Effective for AGE
• Airway Pressure lt Vascular Pressure
• Maximize Preload, Minimize Further Barotrauma and
  Keep Injured Lung in Dependent Position
• Lung Isolation Unilateral Intubation
• Delay Any Non-Emergent Surgery

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Secondary Blast Injuries

• Penetrating trauma caused by acceleration of
  shrapnel or blast debris
• Any body part can be affected
• Causes
• Penetrating ballistic fragmentation
• Blunt injuries
• Eye injuries

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Secondary Blast Injuries

• Entrance wounds may be deceptively small and when
  time allows a detailed exam is required

www.divestmentwatch.com/cities/6skull.jpg
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Tertiary Blast Injuries

• Displacement of body or structural collapse
• Body displacement
• Any body part could be affected
• Fracture and traumatic amputation
• Closed and opened brain injury
• Structure Collapse
• Crush injury
• Compartment syndrome

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Compartment Syndrome

• Ecchymosis,Tenderness, Swelling,
• Pain with Passive Motion
• Hypotension and Shock
• Numbness and Flaccid Paralysis
• May Have Loss of Distal Pulses

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Crush Syndrome

• Traumatic Rhabdomyolysis
• Releases Intracellular Toxins
• Sodium, Calcium, Water Shift into Damaged
  Muscle Cells
• Potassium, Phosphate, Lactate, Myoglobin Shift
  Out of Cells
• Potentially Toxic When Circulated through the
  Blood Stream

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Peaked T Waves from Hyperkalemia
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Treatment of Crush Injury / Crush Syndrome

• Treatment of Hyperkalemia.
• If EKG Evidence of Cardiotoxicity, Treat with IV
  Glucose and Insulin (1 ampule D50 with 10 units
  regular insulin)
• Inhaled Beta-2 Agonist
• Consider Exchange Resin
• Calcium Chloride in Critical Collapse
• Dialysis (hemo, peritoneal, CAVH)
• Remember When Choosing Paralytics

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Treatment of Crush Syndrome

• Early Aggressive Management
• Initiate IV Normal Saline ASAP
• (prior to extrication if possible)
• Consider tourniquet for mangled extremity
  (prior to extrication)
• Saline, NOT Lactated Ringers
• May Need 1.0 - 1.5 Liters per hour
• Goal 200 - 300 cc/hr Urine Output
• ?? Bicarbonate, ?? Mannitol
• Refer for (or perform) Fasciotomy
• if Compartment Syndrome Present

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Quaternary Blast Injuries

• All explosion related to
• Burns and burn related injuries
• Environmental toxins
• Exacerbation of underlying illness

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Quinary Blast Injuries

• Purposeful addition of agents
• Chemical
• Biological
• Nuclear

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D-I-S-A-S-T-E-R ParadigmTriage and Treatment

• Difference in the volume of casualties and injury
  patterns
• Accurate triage reduces the acute burden on
  medical facilities and organizations
• Initial treatment focuses on ABCs (CABs for
  patients with exsanguinating hemorrhage!)

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Triage

• Be aware that patients with TM rupture may not be
  able to hear you!
• FAST exam maybe used for rapid triage in field or
  ED for patients that may need OR
• CT of head, thorax, abdomen can triage patients
  that need to go directly to OR

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Treatment ABCs

• A Airway
• Injuries to the airway are first priority unless
  there is exsanguinating hemorrhage.
• Significant airway burns need rapid intubation

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Treatment ABCs

• B Breathing
• Treat pneumothorax
• Consider escharotomy for patients with
  circumferential thoracic (and extremity) burns

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Treatment ABCs (CABs)

• C Circulation
• External hemorrhage should be controlled with
  direct pressure when possible
• Tourniquet may be placed if bleeding not
  controlled with conventional means

Improvised tourniquet
Commercially Available Tourniquet
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Treatment ABCs (CABs)

• C Circulation
• Consider use of advanced hemostatic agents
• Delayed primary closure should be utilized
• Whole blood transfusion maybe life saving

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Treatment ABCs (CABs)

• C Circulation
• Resuscitate controlled hemorrhage to normal BP
• Resuscitate uncontrolled hemorrhage to
• Improved mental status or SBP 90
• Patient needs to get to OR for hemorrhage control
  

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Treatment ABCs Burns

• Parkland Formula
• Adult 2-4 mls LR x kg body weight x TBSA.
• - Give half in the first 8 hours and remainder
  over the next 16 hours
• Children over 10 years Use the same formula as
  for adults
• Children under 10 years Start with 3-4 mls LR x
  kg body weight x TBSA

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Treatment ABCs

• D Disability
• Obtain baseline neurological exam
• Consider AGE in patients with central
  neurological deficits and primary pulmonary blast
  injury
• Consider psychological impact of the disaster

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Treatment ABCs

• E Exposure, Elimination, Environmental Control
• Allow for thorough examination
• hypothermia may develop
• warm intravenous fluids, warm blankets
• removal from the outdoor environment as quickly
  as feasible are important.

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D-I-S-A-S-T-E-R ParadigmE Evacuation

• Casualties will benefit most from rapid, orderly
  scene evacuation and hospital management
• Managing a balanced flow of patients to regional
  facilities is paramount to avoid overwhelming any
  single hospital
• Consider utilization of aeromedical transport

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D-I-S-A-S-T-E-R ParadigmRecovery

• The recovery phase begins once most casualties
  have been removed from the scene
• A thorough analysis of the post-incident
  management is imperative to determine the overall
  successes and shortfalls of the system.
• Psychological Support

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Summary Highlights

• Utilize Good Standard Trauma Care (e.g.,
  BTLS, ATLS)
• Unique Aspects in Blasts Blast Lung, Ears,
  Abdomen Crush Syndrome, Tri-Threat of Blunt,
  Penetrating, Thermal Injuries, Emboli,
  Compartment Syndromes, Contaminants
• High Risk Environment for 2nd Pass Secondary
  Devices, Unstable Structures, Contaminant
  Release, Secondary Fires, etc

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Questions?