10/1/2013
EXPLOSIONS:
BURNS AND CONCOMITANT INJURIES
Nicole S. Gibran MD, FACS
David & Nancy Auth-Washington Research
Foundation Chair in Restorative Burn Surgery
Director, UW Medicine Regional Burn Center
Professor, UW Department of Surgery
ACKNOWLEDGEMENT
This work represented part of a thesis
project of Dr Ricardo Piccolo Daher
EXPLOSION RELATED INJURIES
Multiple etiologies
• Military
• Terrorist
• Civilian
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10/1/2013
MILITARY EXPLOSIONS
• Leading cause of death in the battlefield
• High-Order with over-pressurization shock waves
• Primary injuries
• impact of intense over-pressurization impulse “blast-wave”
• blast lung, tympanic membrane rupture
• Secondary injuries
• flying debris and bomb fragments,
• Tertiary injuries
• Individuals thrown by the blast-wave
• resulting in blunt/penetrating trauma, fractures
• Quaternary injuries
• Burns, inhalation injuries, crush injuries, toxic exposures
• Exacerbations of preexisting conditions
CIVILIAN EXPLOSIONS
Most often low-order (sub-sonic) explosives:
• Propane
• Methamphetamine
• Home O2 (not a true explosion)
• Fireworks
• Mortars, pipe bombs, gunpowder, sparkler bombs
HOME O2 ‘EXPLOSIONS’
Things to think about
• Corneal abrasions
• COPD exacerbation
• NO burn resuscitation
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10/1/2013
PROPANE EXPLOSION INJURIES
Things to think about…
•
•
•
•
Corneal abrasions
Resuscitation requirements
± Inhalation injury
Circumferential extremity burns
METHAMPHETAMINE INJURIES
Things to think about…
•
•
•
•
•
Hazmat precautions
Resuscitation requirements
Inhalation injury
Circumferential extremity burns
Tympanic membrane rupture
FIREWORK AND GUN POWDER INJURIES
Things to think about…
•
•
•
•
•
Corneal abrasions
Globe injuries
Hand & digit avulsions
Black powder tattooing
Very small 3rd, 4th 5th degree burns
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10/1/2013
HIGH ORDER EXPLOSIONS
Things to think about…
•
•
•
•
Limb threatening injuries
Exsanguination
Foreign bodies
Infection
UW MEDICINE REGIONAL BURN CENTER
PHILOSOSPHY
Patients involved in low order
explosions such as with propane or
methamphetamine explosions
do not require extensive medical
workup because significant
concomitant trauma is unusual
DATA SOURCES
• American College of Surgeons National Trauma
Data Bank (NTDB) v.6.2: 2001-5, 2006, 2008
• Harborview Medical Center Burn Registry: 2008
• International Classification of Diseases v.9, ICD-9-CM
• Burn codes 940-949
• E-codes: Explosion related mechanisms of injury
• Analysis included patient & injury characteristics
and injury outcomes
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10/1/2013
CONCURRENT INJURIES
Occult Injuries
Overt Injuries
– Fractures (800-829)
-
Intracranial Injury,
Excluding Skull Fractures (850-854)
-
Internal Injury of Thorax, Abdomen
and Pelvis (860-869)
-
Injury to Blood Vessels (900-904)
-
Crushing Injury (925-929)
-
Effects of Foreign Body Entering
Through Orifice (930-939)
-
Injury to Nerves and Spinal Cord
(950-957)
– Dislocations (830-839)
– Sprains & Strains of Joints &
Adjacent Muscles (840-848)
– Open Wounds (870-897)
– Superficial Injuries (910-919)
– Contusion with Intact Skin
Surface (920-924)
DATA SOURCES
National Trauma Data Bank (2001-5, 2006, 2008):
• 2,489,463 patients
• 53,144 burn patients
• 4,222 patients with burns due to explosions
HMC Burn Data Registry (2008):
• 710 patients
• 90 patients with burns due to explosions
Explosion incidence ranges between 8-13% of burn injuries.
E-code
803
837.1
890.0
891.0
Description
Railway accident involving explosion, fire, or burning
Explosion, fire, or burning in watercraft
Explosion caused by conflagration in private dwelling
Explosion caused by conflagration in unspecified building or structure
921
Accident caused by explosion of pressure vessel
921.0 Boilers
921.1 Gas cylinders
921.8 Other Specified: Aerosol can, Pressure cooker, Auto tire
921.9 Other unspecified pressure vessel
923
Accident caused by explosive material
923.0 Fireworks
923.1 Blasting materials
923.2 Explosive gases
Other Specified Explosive materials: bomb, missile, grenade, mine,
923.8
shell, torpedo, explosion in munitions dump or factory
923.9 Unspecified explosive material
955.5 Suicide and self inflicted injury by explosives
965
Assault by firearms and explosives
965.6 Gasoline bomb
965.8 Other specified: Bomb NOS; Dynamite
965.9 Unspecified explosive
971 Injury due to legal intervention by explosives
Injury by explosives undetermined whether accidentally or purposely
985.5
inflicted
992 Injury due to war operations by explosion of marine weapons
993 Injury due to war operations by other explosion
NTDB (‘02-08) HMC (‘08)
N=4222
N=90
4
53
430
107
0
1
3
3
69
268
369
35
2
9
4
0
511
45
1528
12
3
34
477
17
223
11
2
0
5
5
1
2
0
0
0
0
10
0
2
67
0
0
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10/1/2013
NTDB DATA
890.0/891.0
921
Explosion by Pressure
Conflagration Vessels
N=537
N=741
N (%)
N (%)
Burns Only
Burns with Injuries
Toxic Effects of
Substances,
Nonmedical
Open Wound
Fractures
Superficial Injury
Contusion
Internal Injury
Intracranial Injury
Sprains and Strains
Dislocations
Injury to
Nerve/Spinal Cord
Injury to Blood
Vessel
Other effects of
External Causes
Foreign Body
Crushing Injury
Poisoning
396 (73.8)
141 (26.2)
594 (80.2)
147 (19.8)
923.0
Fireworks
N=511
N (%)
923.2
Explosive
Gases
N=1528
N (%)
318 (62.2)
193 (37.8)
1298 (85.0)
230 (15.0)
923.8/923.9
Other
Specified &
Unspecified
N=700
N (%)
522 (74.6)
178 (25.4)
Table
Total
N=4017
N (%)
p
3128 (77.9)
889 (22.1)
<0.001
<0.001
103 (19.2)
44 (5.9)
13 (2.5)
132 (8.6)
67 (9.6)
359 (8.9)
<0.001
36 (6.7)
21 (3.9)
19 (3.5)
6 (1.1)
22 (4.1)
9 (1.7)
1 (0.2)
2 (0.4)
48 (6.5)
46 (6.2)
31 (4.2)
15 (2.0)
19 (2.6)
5 (0.7)
6 (0.8)
3 (0.4)
137 (26.8)
77 (15.1)
75 (14.7)
22 (4.3)
5 (1.0)
6 (1.2)
9 (1.8)
11 (2.1)
46 (3.0)
52 (3.4)
60 (3.9)
26 (1.7)
17 (1.1)
9 (0.6)
3 (0.2)
4 (0.3)
67 (9.6)
49 (7.0)
56 (8.0)
17 (2.4)
10 (1.4)
8 (1.1)
7 (1.0)
4 (0.6)
334 (8.3)
245 (6.1)
241 (6.0)
86 (2.1)
73 (1.8)
37 (0.9)
26 (0.6)
24 (0.6)
<0.001
<0.001
<0.001
0.003
<0.001
0.169
0.001
<0.001
<0.001
0
5 (0.7)
10 (2.0)
0
3 (0.4)
18 (0.4)
1 (0.2)
4 (0.5)
7 (1.4)
1 (0.1)
4 (0.6)
17 (0.4)
0.002
6 (1.1)
4 (0.5)
0
3 (0.2)
1 (0.1)
14 (0.3)
0.009
0
0
0
3 (0.4)
1 (0.1)
0
1 (0.2)
1 (0.2)
0
1 (0.1)
0
1 (0.1)
3 (0.4)
0
0
8 (0.2)
2 (0.0)
1 (0.0)
0.208
0.326
0.804
NTDB DATA
923.2
923.8/923.9
890.0/891.0
921
923.0
Explosion by Pressure Fireworks Explosive
Other
Conflagration Vessels
N=511
Gases
Specified
N=741
N (%)
N=1528
and
N=537
N (%)
N (%)
N (%)
Unspecified
N=700
N (%)
Burns
Only
Overt
Injuries
Occult
Injuries
396 (73.8)
594 (80.2) 318 (62.2) 1298 (85.0) 522 (74.6)
113 (21.0)
116 (15.6) 168 (32.9)
28 (5.2)
31 (4.2)
25 (4.9)
Total
N=4017
N (%)
p
3128
(77.8)
<0.0001
207 (13.5)
154 (22.0)
758 (18.9) <0.0001
23 (1.5)
24 (3.4)
131 (3.3) <0.0001
NTDB DATA
Isolated
Burn
N=3262
Age (SD) 36.6(19.2)
% Male
82.6
Burn size:
<10% 682 (61.3)
10-19% 237 (21.3)
>20% 194 (17.4)
ISS (SD) 6.3 (9.8)
Mortality (%) 109 (3.7)
LOS (SD) 7.2 (14.0)
ED GCS (SD) 13.6 (3.7)
Inhalation
58 (1.8)
Injury (%)
Overt
N=816
Occult
N=144
Total
N=4222
P
37.1 (17.9)
86.6
39.1 (17.7)
86.1
36.7 (18.9)
83.5
0.32
0.03
90 (61.2)
25 (17.0)
32 (21.8)
13.0 (14.1)
65 (8.5)
10.7 (18.1)
12.2 (4.9)
19 (61.3)
3 (9.7)
9 (29.0)
21.0 (15.9)
15 (10.8)
18.1 (34.8)
10.1 (5.7)
791 (61.3)
265 (20.5)
235 (18.2)
8.1 (11.6)
189 (4.9)
8.2 (16.1)
13.2 (4.1)
<0.0001
<0.0001
<0.0001
<0.0001
254 (31.1)
17 (11.8)
329 (7.8)
<0.0001
0.17
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10/1/2013
HMC DATA
N
Burn Only
Overt
Occult
Total
79
10
1
90
37.1 (±20)
39.6
36.8 (±18)
0.93
70%
100%
84.9
0.45
Age (SD) 36.7 (±18)
% Male
85%
P
Burn size:
<10% 60 (76%)
7 (70%)
0
67 (75%)
0
0
12 (13%)
3 (30%)
1 (100%)
11 (12%)
10-19% 12 (15%)
>20%
Mortality
7 (9%)
0
LOS (SD) 8.67 (±16)
Inhalation Injury (%)
9 (11%)
-
0
0
0
-
6.4 (±6)
28
8.63 (±15)
0.95
2 (20%)
1 (100%)
12 (13%)
0.16
HMC DATA
N
Isolated Burns
N (%)
Overt
N (%)
Occult
N (%)
Total
N (%)
79 (99%)
10 (11%)
1 (1%)
90
Superficial
Injury
0
5 (50%)
0
5 (6%)
Open Wound
0
3 (30%)
0
3 (3%)
Toxic Effects of
Substances,
Nonmedical
0
1
0
1 (1%)
Fractures
0
1
0
1 (1%)
Internal Injury
0
0
1
1 (1%)
HMC DATA
Isolated Burns
N=79
N (%)
None 42 (54%)
CXR only 25 (32%)
Spinal XRays
Cervical
2 (3%)
Thoracic
0
Lumbar
0
Other XRays
4 (5%)
CT total
2 (3%)
CT head/neck
2 (3%)
CT
0
Head/Spine/Pelvis
Radiologic
Workup
Overt
N=10
N (%)
2 (20%)
5 (50%)
Occult
N=1
N (%)
0
0
2 (20%)
2 (20%)
2 (20%)
2 (20%)
2 (20%)
1 (10%)
1 (100)
1 (100)
1 (100)
0
1 (100)
0
Total
N=90
N (%)
44 (48.9)
30 (30.3)
5 (5.6)
5 (5.6)
3 (3.3)
3 (3.3)
6 (6.7)
5 (5.6)
3 (3.3)
1 (10%)
1 (100)
2 (2.2)
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10/1/2013
CIVILIAN LOW ORDER INJURIES
Most patients have isolated burn injuries
21% have concomitant injuries
• Most are overt - easily diagnosed with PE
• 3% are occult
Firework related burns are more likely to be associated
with concomitant injuries
Focused ED radiologic work-up was not associated
with missed injuries
RECOMMENDATIONS
Focused trauma work-up based on mechanism
and PE is likely a safe and cost-effective means
of diagnosing other injuries in patients with burns
due to Low-Order explosions
LIMITATIONS OF ANALYSIS
NTDB is a voluntary data set
• Not representative of the entire burn population
• Total burn size missing in 66.7% of patients
ICD-9 coding is open to misinterpretation
• Superficial injury code and open wound includes
blisters which may represent the burn itself
These data can not be extrapolated to injuries
sustained in an event such as the April 15
Boston Marathon bombing
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10/1/2013
Thank you
Judge of a man by his questions rather than by his answers.
Voltaire (1694 - 1778)
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