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Blast Injuries: Prehospital Assessment and Management

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Blast Injuries: Prehospital Assessment and Management Jeffrey P Salomone, MD, FACS Past President, Eastern Association for the Surgery of Trauma – PowerPoint PPT presentation

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Title: Blast Injuries: Prehospital Assessment and Management


1
Blast InjuriesPrehospital Assessment and
Management
  • Jeffrey P Salomone, MD, FACS
  • Past President,
  • Eastern Association for the Surgery of Trauma

2
Disclosures
  • Editor / Associate Editor, Prehospital Trauma
    Life Support 5e, 6e, 7e
  • Contributor PHTLS 8e
  • NO financial relationships

3
  • Background
  • Explosive agents / Blast devices
  • Blast Physics
  • Scene Management
  • Injury Types
  • Patient Management

4
Blasts and Blast Injuries
  • Bombings / WMDs
  • Terrorism
  • Middle East / Asia
  • IEDs
  • GWOT Iraq / Afghanistan

5
Unintentional Explosions
  • Gas leaks
  • Industry
  • Fertilizer
  • Petroleum
  • Explosives/ fireworks
  • Grain
  • Illicit- drug manufacturing (meth)
  • Deaths- unusual only 150 in US (2004)

6
Worldwide Terrorism
  • Israel- Tel Aviv ( 2001, 2006)
  • Madrid (2004)- bombs on commuter trains
  • London (2005)- 4 bombs on trains / bus
  • Mumbai (2008)- 11 shooting bombing attacks over
    4 days

7
US Bombings
8
Murrah Federal Bldg ( 1995)
  • 168 killed
  • Almost 700 injured

Photo Courtesy of the City Of Oklahoma City
9
Atlanta Olympic Park Bombing July 27, 1996 130
am
10
Olympic Park Bombing
  • 111 victims news reporter
  • All transported to 11 area hospitals within 32
    minutes by 30 EMS units
  • 35 reporter to Grady Memorial Hosp
  • Reporter 1st to arrive, CPR in progress
  • 35 with shrapnel injuries
  • 15 admitted- 10 required surgery in 1st 12 hrs
  • Ortho, vascular, thoracotomy, laparotomy, facial
    expl
  • 19 treated and released

11
Olympic Park Bombing
  • 61 pts to 3 downtown hospitals AMC
  • 4 operations 2 wound closures 2 shrapnel
    removal
  • 15 minor victims to 7 other area hospitals

12
September 11, 2001
  • Commercial aircraft used as bombs
  • Twin towers- World Trade Center
  • Pentagon

13
Boston Marathon Bombing
  • April 15, 2013
  • 3 killed
  • 243 injured
  • 152 presented to ED within 24 hrs of blast
  • All survived

14
Blast Devices
15
Blast Agents
  • High-order explosive HE
  • Nitroglycerin (NTG)
  • Dynamite
  • Plastic
  • Ammonium nitrate/ fuel oil (ANFO)
  • Trinitrotoluene (TNT)
  • Triacetone triperoxide (TAPT)
  • Low-order explosive LE
  • Petroleum products
  • (Molotov cocktail)
  • Gunpowder
  • (black powder)
  • Can become HE, if contained (e.g., pipe bomb)

16
Blast Devices
  • Improvised explosive devices (IEDs)
  • Car and truck bombs (Oklahoma City, World Trade
    Center I)
  • Letter and parcel bombs (Idaho Unabomber)
  • Pipe bombs (Atlanta Olympics)
  • Backpack and satchel bombs (Israel, London)
  • Incendiary bombs
  • Airplane bombs (World Trade Center II, Pentagon)
  • Rocket propelled grenades (RPGs)
  • Surface to air missiles (SAMs)

17
Blast Devices
  • IEDs
  • Improvised/homemade explosive devices
  • Made from explosives, commercial blasting
    supplies, or fertilizer and household ingredients
  • Designed to cause injury and death
  • Often packed with metal objects such as nails or
    ball bearings
  • Could contain toxic chemicals or radiological
    materials (dirty bomb)

18
Blast Physics
  • Rapid chemical conversion of a solid or liquid
    into highly pressurized gases
  • Gases expand rapidly and compress the surrounding
    air

19
Blast Physics
  • Blast wave- causes an almost instantaneous rise
    in atmospheric pressure (barotrauma)
  • Normal is 14.3 psi
  • Overpressure can exceed 4 million psi
  • Underpressure
  • Blast wind
  • Air pushed out of area, creating vacuum
  • Wind speed can be hundreds of mph

20
Blast Physics
Importance of Injury Types vs. Distance
Emergency War Surgery, 3rd Edition
21
Scene ManagementSAFETY / SITUATION
22
Initial Staging
  • Safe Distance
  • Stage upwind / uphill
  • Assess with binoculars
  • Liquids, contaminants, etc
  • Number of victims
  • Need for Incident Command

23
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24
Scene Safety Hazards
  • Secondary devices
  • Shrapnel
  • Building collapse
  • Air-borne contaminants
  • Contaminated patients
  • Contaminated scene/environment
  • Perpetrators
  • Terrorist patients

25
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26
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27
Triage
  • Field triage
  • Safe distance
  • SALT / START
  • Dynamic process
  • Unique patterns
  • Multiple injuries
  • Occult / hidden / internal injuries

28
Triage
  • Walking wounded
  • Many non-critical patients who require time
    intensive workups
  • Up to 75 of victims self-refer to hospital via
    private transportation)

29
Crime Scene
  • Life saving takes precedence
  • Avoid disturbing or compromising evidence (chain
    of custody)
  • Documentation of statements by victims and
    witnesses

30
Blast Injuries
31
Blast Injury Severity
  • Nature of device agent, amount
  • Method of delivery incendiary, explosive
  • Nature of environment open, closed
  • Distance from device
  • Intervening protective barrier
  • Other environmental hazards

32
Blast Injuries Categories
  • Primary injury
  • Caused by blast wave ? over pressure
  • Secondary injury
  • Caused by flying debris ? shrapnel wounds
  • Tertiary injury
  • Caused by blast wind ? forceful impact
  • Quaternary injury
  • Caused by other vectors ? heat, radiation

33
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34
Blast Injuries Primary
  • Blunt trauma from over pressure wave
  • Unique to high-order explosives
  • Results from the impact of the over-pressurization
    wave with body surfaces
  • Barotrauma blunt force injuries

35
Blast Injuries Primary
  • Most common injuries
  • Tympanic membrane (eardrum) rupture
  • Middle ear damage
  • Blast lungpulmonary barotrauma
  • Abdominal organ perforation ( esp. colon)
  • Abdominal hemorrhage (solid organs)
  • Traumatic brain injury (TBI), concussion

36
Blast Injuries Blast Lung
37
Blast Injuries Secondary
  • Most common cause of death in a blast event is
    secondary blast injuries
  • Caused by flying debris generated by the
    explosion
  • Pieces of bomb / environment (glass)
  • Added screws, nails, etc.

38
Blast Injuries Secondary
  • Most common types of secondary blast injuries
    are
  • Penetrating trauma to the head, neck, chest,
    abdomen, and extremities
  • Fractures
  • Traumatic amputations
  • Soft tissue injuries

39
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40
Blast Injuries Secondary
  • Penetrating trauma (shrapnel wounds)
  • Foreign bodies follow unpredictable paths through
    body
  • May have only mild external signs
  • Have a low threshold for imaging studies (plain
    radiographs, computed tomograms)
  • Consider all wounds contaminated

41
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42
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43
Blast Injuries Tertiary
  • Tertiary injuries result from individuals being
    thrown by the blast wind.
  • The most common types of tertiary blast injuries
    are
  • Head injuries
  • Skull fractures
  • Fractures

44
Blast Injuries Quaternary
  • Includes
  • Burns
  • Biologic / radiologic / chemical contamination
  • Crush injuries
  • Exacerbation of chronic health conditions

45
Patient Assessment and Management
46
Airway / Breathing
  • Intubate if necessary
  • Positive pressure ventilation in blast lung can
    result in air emboli

47
Blast Lung
  • Clinical manifestations
  • Tachypnea
  • Hypoxia
  • Cyanosis
  • Apnea
  • Wheezing
  • Decreased breath sounds
  • Hemoptysis
  • Cough
  • Chest pain
  • Dyspnea
  • Hemodynamic instability
  • Treatment
  • High flow oxygen sufficient to prevent hypoxemia
    via non-rebreather mask
  • CPAP
  • Endotracheal intubation
  • Judicious fluid administration
  • Needle decompression

48
Circulation Hemorrhage / Shock
  • Tourniquets
  • Manufacture ( NOT improvised)
  • Topical hemostatic agents
  • IV therapy / fluid resuscitation

49
Tourniquets
50
Abdominal Injuries
  • Clinical manifestations include
  • Abdominal pain
  • Rectal bleeding
  • Rebound tenderness / Guarding
  • Diminished / absent bowel sounds
  • Signs of hypovolemia / unexplained shock
  • Nausea vomiting

51
Blast Injuries Combined Injuries
  • Avoid tunnel vision
  • Treatment protocols are often contradictory
  • Blast lung vs. burn injury
  • Blast lung vs. crush injury
  • Judicious fluid administration

52
Blast Injury Combined Injuries
  • Typical confined space (e.g., a bus) injuries
  • Primaryblast lung, intestinal rupture, TM
    rupture
  • Secondarypenetrating injury to head, eye, chest,
    abdomen
  • Tertiarytraumatic amputation, fractures to the
    face, pelvis, ribs, spine
  • Quaternary crush injuries, superficial and
    partial to full thickness burns

53
Special Considerations
  • Pregnancy- placental injuries
  • Children- pulmonary contusions
  • Evidence of chest injury
  • Elderly- disabilities, medical conditions,
    osteoporosis

54
Transport Destination
  • Trauma Centers capable of managing injuries

55
Summary
  • Scene safety issues
  • Injuries can be very complex
  • Hemorrhage control
  • Support ventilation / oxygen
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