®
“Preparing Our Communities”
Welcome!
V 2.9 04/07
® BDLS is a registered trademark of the American Medical Association
1
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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® BDLS is a registered trademark of the American Medical Association
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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 Paradigm
Detection
• 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 Paradigm
Incident 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 Paradigm
Security 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 Paradigm
Assess 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 community’s
medical resources
• Coordination with trauma and burn
centers is essential
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D-I-S-A-S-T-E-R Paradigm
Triage and Treatment
• Injuries caused by blast
•
•
•
•
•
Primary
Secondary
Tertiary
Quaternary
Quinary
• Triage
• ABC’s 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
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QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
http://www.defence.gov.au/dpe/dhs
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Primary Blast Injuries
Pulmonary
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 Injuries
Pulmonary
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 Injuries
Pulmonary
CXR: Characteristic “Butterfly” Pattern
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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 < 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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Injuries Closed Injuries
ncy Care
Compartment Syndrome
s. Contusion
Ecchymosis
Hematoma
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 Ringer’s
– 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 Paradigm
Triage 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 ABC’s
(CAB’s 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 ABC’s
• 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 ABC’s
• B = Breathing
– Treat pneumothorax
– Consider escharotomy for patients with
circumferential thoracic (and extremity) burns
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Treatment ABC’s (CAB’s)
• C = Circulation
– External hemorrhage should
be controlled with direct
pressure when possible
– Tourniquet may be placed if
bleeding not controlled with
conventional means
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Improvised tourniquet
Commercially Available Tourniquet
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Treatment ABC’s (CAB’s)
• 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 ABC’s (CAB’s)
• 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 ABC’s
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 ABC’s
• 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 ABC’s
• 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 Paradigm
E = 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 Paradigm
Recovery
• 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?
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