Bombings: Injury Patterns and Care. This project was funded by the Centers for Disease Control and...

Bombings: Bombings: Injury Patterns and Injury Patterns and CareCare

This project was funded by the Centers for This project was funded by the Centers for Disease Control and Prevention (CDC) under Disease Control and Prevention (CDC) under Cooperative Agreement U17/CCU524163-01, Cooperative Agreement U17/CCU524163-01, “Linkages of Acute Care and EMS to State and “Linkages of Acute Care and EMS to State and Local Injury Prevention Programs for Terrorism Local Injury Prevention Programs for Terrorism Preparedness and Response.”Preparedness and Response.”

Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 33

American Medical Association (AMA)American Medical Association (AMA) American Trauma Society (ATS)American Trauma Society (ATS) National Association of EMS Physicians (NAEMSP)National Association of EMS Physicians (NAEMSP) National Association of EMT’s (NAEMT)National Association of EMT’s (NAEMT) National Association of State EMS Officials (NASEMSO)National Association of State EMS Officials (NASEMSO) National Native American EMS Association (NNAEMSA)National Native American EMS Association (NNAEMSA)

The The Bombings: Injury Patterns and Care Bombings: Injury Patterns and Care curriculum was curriculum was developed through the Linkages of Acute Care and EMS developed through the Linkages of Acute Care and EMS to State and Local Injury Prevention Programs project to State and Local Injury Prevention Programs project that was funded by the Centers for Disease Control and that was funded by the Centers for Disease Control and Prevention (CDC). The American College of Emergency Prevention (CDC). The American College of Emergency Physicians (ACEP) served as the lead grantee for the Physicians (ACEP) served as the lead grantee for the project along with the following six other organizations:project along with the following six other organizations:


A task force was established with representative experts from A task force was established with representative experts from emergency medicine including physicians, surgeons, nursing,emergency medicine including physicians, surgeons, nursing,and EMS. Core competencies and knowledge objectives were and EMS. Core competencies and knowledge objectives were developed using a consensus approach. A writing group then developed using a consensus approach. A writing group then developed teaching objectives and course content based on the developed teaching objectives and course content based on the core competencies. core competencies.

The The Bombings: Injury Patterns and CareBombings: Injury Patterns and Care curriculum is designed curriculum is designed to be the minimum content that should be included in any all-to be the minimum content that should be included in any all-hazards disaster response training program. This content is hazards disaster response training program. This content is designed to update the student with the latest clinical designed to update the student with the latest clinical information regarding blast related injuries from terrorism. information regarding blast related injuries from terrorism.


American College of Emergency Physicians (ACEP) Grant Staff– Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic

Injuries from Terrorism Task Force (CO-TIFT) – Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle

InvestigatorInvestigator– Marshall Gardner, EMT-P, EMS and Disaster Preparedness ManagerMarshall Gardner, EMT-P, EMS and Disaster Preparedness Manager– Diana S. Jester, EMS and Disaster Response CoordinatorDiana S. Jester, EMS and Disaster Response Coordinator– Cynthia Singh, MS, Grants and Development ManagerCynthia Singh, MS, Grants and Development Manager– Kathryn Mensah, MS, Grants AdministratorKathryn Mensah, MS, Grants Administrator– Mary Whiteside, PhD, Curriculum Development ConsultantMary Whiteside, PhD, Curriculum Development Consultant

Centers for Disease Control and Prevention (CDC) Staff– Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National

Center for Center for Injury Prevention and ControlInjury Prevention and Control– Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response,

National Center National Center for Injury Prevention and Controlfor Injury Prevention and Control– Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response,

National National Center for Injury Prevention and ControlCenter for Injury Prevention and Control– Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, Paula Burgess, MD, MPH, Team Leader, Division of Injury Response,

National Center National Center for Injury Prevention and Controlfor Injury Prevention and Control– Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of

Injury Injury Response, National Center for Injury Prevention and ControlResponse, National Center for Injury Prevention and Control

12/0612/06


DiscussionDiscussion Topics Topics

BackgroundBackground Explosive EventsExplosive Events Blast InjuriesBlast Injuries

– Primary, Secondary, Tertiary, QuaternaryPrimary, Secondary, Tertiary, Quaternary Crush Injuries and Compartment SyndromeCrush Injuries and Compartment Syndrome Military ExperienceMilitary Experience Special ConsiderationsSpecial Considerations Psychological IssuesPsychological Issues


BackgroundBackground



Terrorism can be defined as containing Terrorism can be defined as containing four key elements:four key elements:– PremeditatedPremeditated– PoliticalPolitical– Aimed at civiliansAimed at civilians– Carried out by sub-national groupsCarried out by sub-national groups



Explosive use increasing in terrorist Explosive use increasing in terrorist eventsevents

Result in mass casualty incidentsResult in mass casualty incidents Recent examplesRecent examples

– Mumbai (2006)Mumbai (2006)– Tel Aviv (2006)Tel Aviv (2006)– London subway (2005)London subway (2005)– Madrid subway (2004)Madrid subway (2004)– Tel Aviv (2001)Tel Aviv (2001)


BackgroundBackground: Historical : Historical PerspectivePerspective

1968-19991968-1999– 7000 international terrorist bombings7000 international terrorist bombings

1969-19801969-1980– 187 bombings in Northern Ireland187 bombings in Northern Ireland

1980-20011980-2001– 324 criminal bombing events in the US324 criminal bombing events in the US

2001-20032001-2003– 500 International terrorist bombings500 International terrorist bombings

20052005– 399 International terrorist bombings399 International terrorist bombings

Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre


Background: Blast DevicesBackground: Blast Devices

Photo used with permission of MAJ Benjamin Gonzalez, MD


Background: Blast DevicesBackground: Blast Devices

Improvised explosive devices (IEDs)Improvised explosive devices (IEDs)– Car and truck bombs (Oklahoma City, World Trade Center I)Car and truck bombs (Oklahoma City, World Trade Center I)– Letter and parcel bombs (Idaho “Unabomber”)Letter and parcel bombs (Idaho “Unabomber”)– Pipe bombs (Atlanta Olympics)Pipe bombs (Atlanta Olympics)– Backpack and satchel bombs (Israel, London)Backpack and satchel bombs (Israel, London)

Incendiary bombs Incendiary bombs – Airplane bombs (World Trade Center II, Pentagon)Airplane bombs (World Trade Center II, Pentagon)

Rocket propelled grenades (RPGs)Rocket propelled grenades (RPGs) Surface to air missiles (SAMs)Surface to air missiles (SAMs) Enhanced blast devicesEnhanced blast devices


BackgroundBackground: Blast Devices: Blast Devices

IEDsIEDs Improvised/“homemade” explosive devicesImprovised/“homemade” explosive devices Made from explosives, commercial blasting Made from explosives, commercial blasting

supplies, or fertilizer and household supplies, or fertilizer and household ingredientsingredients

Designed to cause injury and deathDesigned to cause injury and death Often packed with metal objects such as nails Often packed with metal objects such as nails

or ball bearings; could contain toxic chemicals or ball bearings; could contain toxic chemicals or radiological materials (dirty bomb)or radiological materials (dirty bomb)


BackgroundBackground: Blast Agents: Blast Agents

High-order explosive: HEHigh-order explosive: HE Nitroglycerin (NTG)Nitroglycerin (NTG) DynamiteDynamite PlasticPlastic Ammonium nitrate/ Ammonium nitrate/

fuel oil fuel oil (ANFO) (ANFO) Trinitrotoluene (TNTTrinitrotoluene (TNT)) Triacetone triperoxide Triacetone triperoxide

(TAPT) (TAPT)

Low-order explosive: Low-order explosive: LELE

Petroleum productsPetroleum products(“Molotov cocktail”)(“Molotov cocktail”)

Gunpowder Gunpowder (“black” powder)(“black” powder)

Can become HE, if Can become HE, if contained (e.g., contained (e.g., pipe bomb)pipe bomb)


Explosive Explosive EventsEvents


ExplosiveExplosive Events Events

Incident commandIncident command– Entire area = crime scene → evidence Entire area = crime scene → evidence

preservationpreservation– Multi-jurisdictional responseMulti-jurisdictional response

Scene safetyScene safety– Dirty bombs, secondary devices, building Dirty bombs, secondary devices, building

collapse, high dust environment (possibly collapse, high dust environment (possibly contaminated), bomb fragmentscontaminated), bomb fragments


Explosive Events: Explosive Events: Criminal InvestigationCriminal Investigation

Principles of criminal investigation and Principles of criminal investigation and evidence preservationevidence preservation– Indicators for crime sceneIndicators for crime scene– Evidence and chain of custodyEvidence and chain of custody– Avoid disturbing or compromising evidenceAvoid disturbing or compromising evidence– Detection of possible suspects/perpetratorsDetection of possible suspects/perpetrators– Quick identification and note takingQuick identification and note taking– Documentation of statements by victims Documentation of statements by victims

and witnessesand witnesses

SceneScene Safety Safety


Scene Safety: Common HazardsScene Safety: Common Hazards

Secondary devicesSecondary devices ShrapnelShrapnel Building collapseBuilding collapse Air-borne contaminantsAir-borne contaminants Contaminated patientsContaminated patients Contaminated scene/environmentContaminated scene/environment Perpetrators Perpetrators Terrorist patientsTerrorist patients


Scene Safety: Common HazardsScene Safety: Common Hazards

Victims with no soft tissue injuriesVictims with no soft tissue injuries Vehicles coming or leaving scene (out of Vehicles coming or leaving scene (out of

place)place) People acting oddly People acting oddly Packages or containers at scene (out of Packages or containers at scene (out of

place)place) Vehicles not damaged or out of placeVehicles not damaged or out of place Structural damageStructural damage WeatherWeather Possible places for secondary devicesPossible places for secondary devices


Scene Safety:Scene Safety:Appropriate PPE for blastsAppropriate PPE for blasts

CoverallsCoveralls Heavy coatHeavy coat Heavy glovesHeavy gloves Steel-toed bootsSteel-toed boots Hard hatHard hat Eye protectionEye protection Dust particle maskDust particle mask Breathing apparatus for toxic fumesBreathing apparatus for toxic fumes


Scene Safety: Common Scene Safety: Common PrinciplesPrinciples

Contain the incident Contain the incident – Deny entry to all but respondersDeny entry to all but responders– Set up zonesSet up zones

HotHot WarmWarm ColdCold

Contain the peopleContain the people– Do not let anyone leave Do not let anyone leave

scene until checked scene until checked– Decontaminate if necessaryDecontaminate if necessaryPhoto used with permission of Connie Doyle, MD,

FACEP



Cause no further injury or destructionCause no further injury or destruction Protect yourselfProtect yourself Activate command and Activate command and

hazard response (ICS)hazard response (ICS) Limit accessLimit access Contain the incidentContain the incident

Photo used with permission of Kathryn Brinsfield, MD, FACEP



Worker safety Worker safety Protection of uninvolved public and Protection of uninvolved public and

volunteersvolunteers Protection of injuredProtection of injured Treatment of injuredTreatment of injured Surveillance of patients and workers Surveillance of patients and workers

for long-term effectsfor long-term effects


TriageTriage


TriageTriage

Unique patterns, multiple and occult Unique patterns, multiple and occult injuriesinjuries

Death often result of combined blast, Death often result of combined blast, ballistic, and thermal effect injuries ballistic, and thermal effect injuries (multidimensional injury)(multidimensional injury)

Walking wounded Walking wounded Hidden/internal injuriesHidden/internal injuries Many non-critical patients who require Many non-critical patients who require

time intensive workupstime intensive workups


TriageTriage

Nature of injuries may lead to Nature of injuries may lead to overtriageovertriage

Up to 75% of victims self-refer to Up to 75% of victims self-refer to hospital; arrive by private hospital; arrive by private transportationtransportation

Field triageField triage– Dynamic processDynamic process


TriageTriage

Factors that determine when needs Factors that determine when needs exceed resourcesexceed resources– Large number of patients make rapid Large number of patients make rapid

triage impossible triage impossible – Large number of patients cause delay in Large number of patients cause delay in

transport to hospitalstransport to hospitals– Large number of patients exceed Large number of patients exceed

responder treatment capabilitiesresponder treatment capabilities– Surge at local hospitalsSurge at local hospitals


Blast Blast InjuriesInjuries


Blast Injuries: Unique AspectsBlast Injuries: Unique Aspects

Inflict multi-system injuries on large Inflict multi-system injuries on large groups of people groups of people

Cause many simultaneous life-Cause many simultaneous life-threatening injuriesthreatening injuries

Hidden pattern of injuryHidden pattern of injury


Blast Injuries: Blast Physics Blast Injuries: Blast Physics

Rapid chemical conversion of a solid or Rapid chemical conversion of a solid or liquid into highly pressurized gasesliquid into highly pressurized gases

Gases expand rapidly and compress Gases expand rapidly and compress the surrounding airthe surrounding air

Pressure wave and blast wind are Pressure wave and blast wind are generated and spread in all directionsgenerated and spread in all directions

Is affected by the medium through Is affected by the medium through which it travels, i.e., air vs. waterwhich it travels, i.e., air vs. water


Blast Injuries: Blast PhysicsBlast Injuries: Blast Physics

Emergency War Surgery, 3rd Edition

Importance of Injury Types vs. Distance

Diagram used with permission of John-Phillipe Dionne. PhD


Background: Physics of BlastsBackground: Physics of Blasts

Click to view animation.


Blast Injury: SeverityBlast Injury: Severity

Nature of device – agent, amountNature of device – agent, amount Method of delivery – incendiary, Method of delivery – incendiary,

explosiveexplosive Nature of environment – open, closedNature of environment – open, closed Distance from deviceDistance from device Intervening protective barrierIntervening protective barrier Other environmental hazardsOther environmental hazards


Murrah Murrah BuildingBuilding

Photo Courtesy of the City Of Oklahoma City


Murrah Federal Building, Oklahoma City (1993) – distribution of injuries

JAMA, August 1996, 276 (5): 382-387 © 1996 American Medical Association


Russell Square, London bombing, 2005

Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London


Mumbai, India: July 2006Mumbai, India: July 2006

Reuters/Prashanth Vishwanathan


Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology

Proposed mechanisms*Proposed mechanisms* SpallingSpalling

– Caused by shock wave moving through Caused by shock wave moving through tissues of different densities tissues of different densities → → molecular molecular disruptiondisruption

ImplosionImplosion– Caused by entrapped gases in hollow Caused by entrapped gases in hollow

organs compressing then expanding organs compressing then expanding → → visceral disruptionvisceral disruption


Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology

ShearingShearing– Caused by tissues of different densities Caused by tissues of different densities

moving at different speeds moving at different speeds → → visceral tearingvisceral tearing Irreversible WorkIrreversible Work

– Caused by forces exceeding the tensile Caused by forces exceeding the tensile strength of the tissuestrength of the tissue

*Spalling, implosion and shearing are thought to be three*Spalling, implosion and shearing are thought to be three

mechanisms that cause blast injuries. Irreversible work ismechanisms that cause blast injuries. Irreversible work is

currently being researched as a more likely mechanism of currently being researched as a more likely mechanism of injury.injury.


Blast Injuries: CategoriesBlast Injuries: Categories

Primary injuryPrimary injury– Caused by blast wave Caused by blast wave → → over pressure over pressure

Secondary injurySecondary injury– Caused by flying debris Caused by flying debris → shrapnel → shrapnel

woundswounds Tertiary injuryTertiary injury

– Caused by blast wind Caused by blast wind → → forceful impactforceful impact Quaternary injuryQuaternary injury

– Caused by other vectors Caused by other vectors → → heat, radiationheat, radiation


Blast Injuries: PrimaryBlast Injuries: Primary

Blunt trauma from over pressure waveBlunt trauma from over pressure wave– Unique to high-order explosivesUnique to high-order explosives– Results from the impact of the over-Results from the impact of the over-

pressurization wave with body surfacespressurization wave with body surfaces– Blunt force injuriesBlunt force injuries– Produces barotraumaProduces barotrauma


Diagram used with permission of LTC John McManus, Jr., MD, FACEP


Blast Injuries: PrimaryBlast Injuries: Primary

Most common injuries:Most common injuries: – Blast lung—pulmonary barotraumasBlast lung—pulmonary barotraumas– Traumatic brain injury (TBI), concussionTraumatic brain injury (TBI), concussion– Tympanic membrane (eardrum) ruptureTympanic membrane (eardrum) rupture– Middle ear damageMiddle ear damage– Abdominal hemorrhageAbdominal hemorrhage– Abdominal organ perforation Abdominal organ perforation


Blast Injuries: SecondaryBlast Injuries: Secondary

The most common cause of death in a The most common cause of death in a blast event is secondary blast injuries. blast event is secondary blast injuries. These injuries are caused by flying These injuries are caused by flying debris generated by the explosion. debris generated by the explosion. Terrorists often add screws, nails, and Terrorists often add screws, nails, and other sharp objects to bombs to other sharp objects to bombs to increase injuries.increase injuries.



The most common types of secondary The most common types of secondary blast injuries are:blast injuries are:– Trauma to the head, neck, chest, Trauma to the head, neck, chest,

abdomen, and extremities in the form of abdomen, and extremities in the form of penetrating and blunt traumapenetrating and blunt trauma

– FracturesFractures– Traumatic amputationsTraumatic amputations– Soft tissue injuriesSoft tissue injuries



Penetrating trauma (shrapnel wounds)Penetrating trauma (shrapnel wounds)– Foreign bodies follow unpredictable paths Foreign bodies follow unpredictable paths

through bodythrough body– May have only mild external signsMay have only mild external signs– Have a low threshold for imaging studies Have a low threshold for imaging studies

(plain radiographs, computed tomograms)(plain radiographs, computed tomograms)– Consider all wounds contaminatedConsider all wounds contaminated


Secondary Injury

Used with permission of American Journal of Roentgenology 2006; 187:609-616


Blast Injuries: TertiaryBlast Injuries: Tertiary

Tertiary injuries result from individuals being Tertiary injuries result from individuals being thrown by the blast wind. thrown by the blast wind.

The most common types of tertiary blast The most common types of tertiary blast injuries are:injuries are:– Head injuriesHead injuries– Skull fracturesSkull fractures– Bone fracturesBone fractures

Treatment for most tertiary blast injuries Treatment for most tertiary blast injuries follows established protocols for that specific follows established protocols for that specific injury. injury.


Blast Injuries: QuaternaryBlast Injuries: Quaternary

All explosion-related injuries, illnesses, All explosion-related injuries, illnesses, or diseases not due to primary, or diseases not due to primary, secondary, or tertiary mechanisms are secondary, or tertiary mechanisms are considered quaternary blast injuries. considered quaternary blast injuries. This includes exacerbation or This includes exacerbation or complications of existing conditions.complications of existing conditions.


Blast Injuries: QuaternaryBlast Injuries: Quaternary

The most common quaternary blast The most common quaternary blast injuries include:injuries include:– BurnsBurns– Head injuriesHead injuries– AsthmaAsthma– COPDCOPD– Other breathing problemsOther breathing problems– Angina Angina – HyperglycemiaHyperglycemia– Hypertension Hypertension – Crush injuries Crush injuries


Blast Injuries: Blast LungBlast Injuries: Blast Lung

Used with permission of CHEST, December 1999; 116(6): 1683-1688



Reprinted from American Journal of Surgery, V190: 945-950, Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc.



Clinical manifestationsClinical manifestations– TachypneaTachypnea– HypoxiaHypoxia– CyanosisCyanosis– ApneaApnea– WheezingWheezing– Decreased breath soundsDecreased breath sounds– HemoptysisHemoptysis– CoughCough– Chest painChest pain– DyspneaDyspnea– Hemodynamic instability Hemodynamic instability


Blast Injuries: Blast Lung Blast Injuries: Blast Lung

TreatmentTreatment– High flow oxygen sufficient to prevent High flow oxygen sufficient to prevent

hypoxemia via non-rebreather maskhypoxemia via non-rebreather mask– CPAPCPAP– Endotracheal intubationEndotracheal intubation– Judicious fluid administration (similar to Judicious fluid administration (similar to

that of pulmonary contusion)that of pulmonary contusion)


Blast Injuries: HeadBlast Injuries: Head

Primary blast waves can cause Primary blast waves can cause concussions or mild traumatic brain concussions or mild traumatic brain injury (MTBI) without a direct blow to injury (MTBI) without a direct blow to the headthe head


Blast Injuries: HeadBlast Injuries: Head

Consider the proximity of the victim to Consider the proximity of the victim to the blast particularly when given the blast particularly when given complaints of:complaints of:– Loss of consciousnessLoss of consciousness– HeadacheHeadache– FatigueFatigue– Poor concentration, lethargy, amnesia, or Poor concentration, lethargy, amnesia, or

other constitutional symptomsother constitutional symptoms– Symptoms of concussion and post traumatic Symptoms of concussion and post traumatic

stress disorder (PTSD) can be similarstress disorder (PTSD) can be similar


Blast Injuries: TM RuptureBlast Injuries: TM Rupture

Tympanic membrane rupture indicates Tympanic membrane rupture indicates exposure to an over pressurization exposure to an over pressurization wave. It may be found in victims with wave. It may be found in victims with severe pulmonary, intestinal, or other severe pulmonary, intestinal, or other injuries, or it may be found in isolation. injuries, or it may be found in isolation. Its presence does not indicate that Its presence does not indicate that more sinister blast injuries exist. more sinister blast injuries exist.


Blast Injuries: TM RuptureBlast Injuries: TM Rupture

Used with permission of NEJM, April 2005; 352: 1335-1342


Blast Injuries: EarBlast Injuries: Ear

Ear injuries may include not only TM Ear injuries may include not only TM rupture, but also ossicular disruption, rupture, but also ossicular disruption, cochlear damage, and foreign bodies. cochlear damage, and foreign bodies.


Blast Injuries: EarBlast Injuries: Ear

Presentation: acute hearing loss Presentation: acute hearing loss (conductive, sensorineural)(conductive, sensorineural)

Findings: auditory canal debris, Findings: auditory canal debris, tympanic membrane rupture, ossicular tympanic membrane rupture, ossicular disruption, cochlear damagedisruption, cochlear damage

Treatment: observation; 50-80% of Treatment: observation; 50-80% of ruptured tympanic membranes heal; ruptured tympanic membranes heal; sensorineural hearing loss often sensorineural hearing loss often permanentpermanent


Blast Injuries: AbdomenBlast Injuries: Abdomen

Abdominal injuries (also called blast Abdominal injuries (also called blast abdomen) include abdominal abdomen) include abdominal hemorrhage and abdominal organ hemorrhage and abdominal organ perforationperforation


Blast Injuries: AbdomenBlast Injuries: Abdomen

Clinical manifestations include:Clinical manifestations include:– Abdominal or testicular painAbdominal or testicular pain– TenesmusTenesmus– Rectal bleedingRectal bleeding– Solid organ lacerationsSolid organ lacerations– Rebound tendernessRebound tenderness– GuardingGuarding– Absent bowel soundsAbsent bowel sounds– Signs of hypovolemiaSigns of hypovolemia– NauseaNausea– VomitingVomiting


Blast Injuries: Combined Blast Injuries: Combined InjuriesInjuries

Combined injuries, especially blast and Combined injuries, especially blast and burn injury or blast and crush injury, burn injury or blast and crush injury, are common during an explosive are common during an explosive event. event.


Blast Injuries: Combined Blast Injuries: Combined InjuriesInjuries

Avoid tunnel vision during initial assessmentAvoid tunnel vision during initial assessment Treatment protocols are often contradictoryTreatment protocols are often contradictory

– Blast lung vs. burn injury, blast lung vs. crush injuryBlast lung vs. burn injury, blast lung vs. crush injury Judicious fluid administration for adequate Judicious fluid administration for adequate

tissue perfusion without volume overload may tissue perfusion without volume overload may be required in the multiple injured patient with be required in the multiple injured patient with blast lungblast lung– Presence of additional injuries complicates Presence of additional injuries complicates

administration, rate, selection of fluidsadministration, rate, selection of fluids


Blast Injury: Combined InjuriesBlast Injury: Combined Injuries

Typical confined space (e.g., a bus) injuriesTypical confined space (e.g., a bus) injuries Primary—blast lung, intestinal rupture, TM Primary—blast lung, intestinal rupture, TM

rupturerupture Secondary—Secondary—penetrating injury to head, penetrating injury to head,

eye, chest, abdomeneye, chest, abdomen Tertiary—traumatic amputation, fractures Tertiary—traumatic amputation, fractures

to the face, pelvis, ribs, spineto the face, pelvis, ribs, spine Quaternary— Quaternary— crush injuries, superficial crush injuries, superficial

and partial to full thickness burnsand partial to full thickness burns

Military ExperienceMilitary Experience



U.S. Military has significant experience U.S. Military has significant experience in dealing with blast and explosive in dealing with blast and explosive injuriesinjuries

Military has been quick to seek and Military has been quick to seek and adopt new strategies in treating adopt new strategies in treating hemorrhage, the leading cause of hemorrhage, the leading cause of preventable deathpreventable death

Mortality rates dramatically lower for Mortality rates dramatically lower for the current conflict the current conflict


Military Experience Military Experience

Death Rates After WoundingDeath Rates After Wounding– Revolutionary WarRevolutionary War

42%42%– WWIIWWII 30 30– KoreanKorean WarWar

~25~25– Vietnam WarVietnam War

~25~25– Persian Gulf WarPersian Gulf War ~25~25– Global War on Terror (GWOT)Global War on Terror (GWOT) <10<10



Medical Advances from the GWOTMedical Advances from the GWOT– Expanded use of Damage Control SurgeryExpanded use of Damage Control Surgery– Whole bloodWhole blood– TourniquetsTourniquets– Hemostatic agentsHemostatic agents– Hemostatic dressingsHemostatic dressings



Photo used courtesy of Cybernetics International



Damage Control SurgeryDamage Control Surgery– Technique known for 20 years, but slow to Technique known for 20 years, but slow to

be acceptedbe accepted– Central tenet: Avoid the “Deadly Triad”Central tenet: Avoid the “Deadly Triad”

HypothermiaHypothermia CoagulopathyCoagulopathy Metabolic acidosisMetabolic acidosis

Each condition worsens both of the Each condition worsens both of the othersothers



Damage Control SurgeryDamage Control Surgery– Stop the bleedingStop the bleeding– Remove major contaminantsRemove major contaminants– Wounds left open to avoid abdominal Wounds left open to avoid abdominal

compartment syndrome compartment syndrome ““Pack ‘em and wrap ‘em” Pack ‘em and wrap ‘em”

– Transfer to ICUTransfer to ICU



Damage Control SurgeryDamage Control Surgery– Resuscitate in ICU:Resuscitate in ICU:

Normalize blood pressureNormalize blood pressure Normalize body temperatureNormalize body temperature Normalize coagulation factorsNormalize coagulation factors

– Return to OR 12-18 hours for definitive Return to OR 12-18 hours for definitive surgerysurgery



IV HemostasisIV Hemostasis– INR>1.5 on arrival predictive of need for INR>1.5 on arrival predictive of need for

massive transfusion (MT)massive transfusion (MT)– Fresh thawed plasma best resuscitation Fresh thawed plasma best resuscitation

fluid in MTfluid in MT Optimum ratio of plasma to crystalloid 1:1 to Optimum ratio of plasma to crystalloid 1:1 to

avoid clotting factor dilution >50%avoid clotting factor dilution >50%

– Less crystalloid (acidotic, inflammatory, Less crystalloid (acidotic, inflammatory, adverse effects on coagulation)adverse effects on coagulation)

Hextend (a colloid) preferableHextend (a colloid) preferable



IV HemostasisIV Hemostasis– Use of fresh whole bloodUse of fresh whole blood– Early use of cryoprecipitateEarly use of cryoprecipitate– Recombinant Factor VIIa (rFVlla)Recombinant Factor VIIa (rFVlla)



TourniquetsTourniquets– Liberal use encouraged for any significant Liberal use encouraged for any significant

extremity hemorrhageextremity hemorrhage– No adverse events seen in cases when No adverse events seen in cases when

applied inappropriatelyapplied inappropriately– Apply early (“first resort not last resort”)Apply early (“first resort not last resort”)– Every soldier carries at least one at all Every soldier carries at least one at all

timestimes



Hemostatic DressingsHemostatic Dressings– Key to avoiding coagulopathy from MT is Key to avoiding coagulopathy from MT is

to control bleeding in the first placeto control bleeding in the first place– Primarily used for non-extremity Primarily used for non-extremity

hemorrhagehemorrhage– Dressings applied with pressure x 5 Dressings applied with pressure x 5

minutes; patient wrapped and transportedminutes; patient wrapped and transported



HemCon (chitosan)HemCon (chitosan)– Originally available as a bandageOriginally available as a bandage– Now available in roll that can be stuffed Now available in roll that can be stuffed

into woundinto wound QuikClotQuikClot

– Very exothermic (up to 147 deg F)Very exothermic (up to 147 deg F)– Difficult to debrideDifficult to debride– New Advanced Clotting Sponge (ACS)New Advanced Clotting Sponge (ACS)

Gauze sack – easily removed from wound Gauze sack – easily removed from wound

Special ConsiderationsSpecial Considerations


Special ConsiderationsSpecial Considerations

PregnancyPregnancy ChildrenChildren ElderlyElderly DisabledDisabled Language barriersLanguage barriers


Special Considerations: Special Considerations: PregnancyPregnancy

Injuries to the placenta are possible and must Injuries to the placenta are possible and must be detectedbe detected

Second or third trimester of pregnancy Second or third trimester of pregnancy should be admitted for continuous fetal should be admitted for continuous fetal monitoringmonitoring

The placental attachment is at risk for The placental attachment is at risk for primary blast injuryprimary blast injury

Screening test for fetal-maternal hemorrhage Screening test for fetal-maternal hemorrhage in second or third trimester of pregnancyin second or third trimester of pregnancy– Positive test requires mandatory pelvic ultrasound, Positive test requires mandatory pelvic ultrasound,

fetal non-stress test monitoring, and fetal non-stress test monitoring, and obstetrics/gynecology (OB/GYN) consultation. obstetrics/gynecology (OB/GYN) consultation.


Special Considerations: Special Considerations: ChildrenChildren

History of event or patient’s complaints may be History of event or patient’s complaints may be difficult to obtain. difficult to obtain.

Pulmonary contusion is one of the most common Pulmonary contusion is one of the most common injuries from blunt thoracic trauma. The injury injuries from blunt thoracic trauma. The injury may not be clinically apparent initially and should may not be clinically apparent initially and should be suspected when abrasions, contusions, or rib be suspected when abrasions, contusions, or rib fractures are present. A chest x-ray is essential in fractures are present. A chest x-ray is essential in diagnosis especially when blast lung is suspected.diagnosis especially when blast lung is suspected.

Specialized equipmentSpecialized equipment Identification of regional pediatric trauma Identification of regional pediatric trauma

facilitiesfacilities


Special Considerations: ElderlySpecial Considerations: Elderly

May be at a higher risk of mortality and the in-May be at a higher risk of mortality and the in-hospital stay may be longer and more hospital stay may be longer and more complicated complicated

Orthopedic injuries may be more prevalent Orthopedic injuries may be more prevalent Blunt chest trauma should be of special Blunt chest trauma should be of special

considerationconsideration Decontamination methods may need Decontamination methods may need

modification due to limited mobilitymodification due to limited mobility Technical decontamination of medical Technical decontamination of medical

equipment such as wheelchairs, walkers and equipment such as wheelchairs, walkers and other walking aides may be neededother walking aides may be needed


Special Considerations: Special Considerations: DisabledDisabled

Consideration should be given to Consideration should be given to patients with underlying medical patients with underlying medical conditionsconditions

Untreated or inadequately treated Untreated or inadequately treated fractures may lead to severe and long fractures may lead to severe and long lasting disabilitieslasting disabilities


Special Considerations:Special Considerations:Language BarriersLanguage Barriers

Diverse population speaking multiple Diverse population speaking multiple languages may be an unforeseen obstaclelanguages may be an unforeseen obstacle

Interaction with the deaf, hard of hearing, late-Interaction with the deaf, hard of hearing, late-deafened and the deaf-blinddeafened and the deaf-blind

History of the event maybe difficult to obtain History of the event maybe difficult to obtain as well as the individual history for the patient.as well as the individual history for the patient.

TranslationTranslation– On scene resourcesOn scene resources– Pool of medical interpreters including sign languagePool of medical interpreters including sign language– Telephone translation servicesTelephone translation services


Photo used courtesy of Kwikpoint

Psychological IssuesPsychological Issues



Sequelae from an explosive eventSequelae from an explosive event– AngerAnger– FrustrationFrustration– HelplessnessHelplessness– Desire to seek revengeDesire to seek revenge



Events that affect mental health Events that affect mental health – Little or no warningLittle or no warning– Unknown duration of the eventUnknown duration of the event– Potential threat to personal safetyPotential threat to personal safety– Unknown health risksUnknown health risks



Tips for RespondersTips for Responders– Promotion of safetyPromotion of safety– Promote calmPromote calm– Promote connectednessPromote connectedness– Promote self-efficacyPromote self-efficacy– Promote hopePromote hope


Discussion Topics: ReviewDiscussion Topics: Review

BackgroundBackground Explosive EventsExplosive Events Blast InjuriesBlast Injuries

– Primary, Secondary, Tertiary, QuaternaryPrimary, Secondary, Tertiary, Quaternary Crush Injuries and Compartment SyndromeCrush Injuries and Compartment Syndrome Military ExperienceMilitary Experience Special ConsiderationsSpecial Considerations Psychological IssuesPsychological Issues


Discussion TopicsDiscussion Topics

Surge Capacity Issues Surge Capacity Issues Hospital after Madrid bombing saw 312 Hospital after Madrid bombing saw 312

patients in 2.5 hourspatients in 2.5 hours Need to surge: CT, OR suites, staff, Need to surge: CT, OR suites, staff,

and supplies (blood, etc.)and supplies (blood, etc.) Hidden nature of injuries can lead to Hidden nature of injuries can lead to

dangerous overtriage and undertriagedangerous overtriage and undertriage

Bombings: Injury Patterns and Care. This project was funded by the Centers for Disease Control and...

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Transcript of Bombings: Injury Patterns and Care. This project was funded by the Centers for Disease Control and...