Pre-hospital and Emergency Department
Management for Blast Injury
Nat Krairojananan MD FRCST
Department of Trauma and Emergency Medicine
Phramongkutklao Hospital
Physics of the explosive
• Sudden rapid conversion from chemical
component to gas, heat, pressure, light and flame
• Low-order explosive devices < 400 m/sec.
• High-order explosive devices 1400-9000 m/sec.
Type of explosives
Manufactured explosives
• Military:
C4
• Industrial: TNT
Type of explosives
Improvise Explosive Devices (IED)
• Pipe bomb
• ANFO (Ammonium Nitrate Fuel Oil)
Factors influence severity of injuries
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Size and amount of explosive
Distance from the detonation
Media (air VS water)
Detonation in the closed space
Blast injury categorization
Primary blast injury
Secondary blast injury
Tertiary blast injury
Quaternary blast injury
Quinary blast injury
Primary blast injury
• Caused by high order explosive only
• Over pressure to air-filled organs
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Blast lung: PTX, pulmonary contusion, PE
Blast bowel: ruptured hollow viscus  peritonitis
Blast ear: TM perforation
Blast brain: concussion
Blast eye
Secondary blast injury
• Penetrating injury/ laceration
• Fragmentation of case/shell or Shrapnel
• Secondary fragment
Secondary blast injury
Tertiary blast injury
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Blast wave
Propulsion of body onto hard surface
Propulsion of object onto individuals
Structural collapsed
Fall from height
• Blunt injury
• crush syndrome
• compartment syndrome
Quaternary blast injury
Not caused by primary, secondary or tertiary
blast injury
• Fire (burn)
• Inhalation injury
• Asphyxia
Quinary blast injury
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Toxic fume
Chemical injury
Radiation
Biological agents
Part I
Scene Management
For EMS personnel
Scene management
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Scene sized up (scene safety)
Scene triage
Scene treatment
Evacuation
ICS in bombing event
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Commander
Security
Search and rescue
Treatment team
Evacuation team
Scene sized up
Recognition of specific hazards with bombing
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Secondary device
Environmental hazards (fires, toxin)
Structural instability
Other threat; sniper
Safe distance?
Scene Triage
• MASS triage
• START triage
MASS Triage
M: Move
A: Assess
S: Sort
S: Send
• Presence of threat
MOVE
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Quickly evacuate all patients from scene
Move unresponsive patients first
Use of appropriate stabilization and equipment
Stretcher or SKED
MASS triage
ASSESS
• According to Pre-Hospital Trauma Life Support (PHTLS)
protocol by assess life threatening injury first
Abv.
Extend
Action
A
Airway and C-spine protection
Open & clear airway, C-collar
B
Breathing (chest injury)
O2 supplement by face mask
with bag, Rx for tension PTX
C
Circulation (hemorrhagic shock)
Stop bleeding, initiate iv fluid
D
Disability (neurologic status)
Check A-V-P-U
E
Environmental control
Keep warm
MASS triage
SORT
Categorize and tag patients into groups for Rx and evacuation
Color code
RED-immediate
Severity
Life threatening injury
Type of injuries
- Airway obstruction
- Chest injury
- Hemorrhagic shock
YELLOW-delayed - Potential life threatening - Fracture
- Limb threatening injury - mild abdominal
injury
- PTSD*
GREEN-minimal
Minor injury
Wounds
BLACK or BLUE
Expectant
Obvious signs of death
- Severe injury
- Extensive wounds
MASS triage
SEND
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Expedient patients to appropriate resources
Trauma center
En route care: monitors
Proper stabilization
MASS triage
START Triage
Simple Triage And Rapid Treatment
START triage
Scene Sized up
Ask patients to walk to your voice
Unable to walk
Able to walk
Ask patients to raise
hand or leg
GREEN (minimal)
Walk to assigned
area
START Triage (cont.)
Ask patient to
raise hand or leg
No response
Assess breathing
Breathing
5 /min or more
Obey command
No breathing
YELLOW
BLACK or BLUE
RED
Delayed Rx
possibility
Supportive treatment
with limited resources
Immediate AW
treatment
Initial management
• Treat life threatening injuries
• Prevent disability
Abv.
Extend
Action
A
Airway and C-spine protection
Open & clear airway, C-collar
B
Breathing (chest injury)
O2 supplement by face mask
with bag, Rx for tension PTX
C
Circulation (hemorrhagic shock)
Stop bleeding, initiate iv fluid
D
Disability (neurologic status)
Check A-V-P-U
E
Environmental control
Keep warm
START triage
Evacuation
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Expedient patients to appropriate resources
Trauma center
En route care: monitors
Proper stabilization
START triage
Part II
Emergency Department Management
For clinicians, nurses
Emergency department management
• Triage and Patient categorization
• Treatment zones by color code
• follow Advance Trauma Life Support (ATLS) protocol
Primary blast injury treatment
System
Blast lung
CXR in all
cases*
Blast GI
Possible injury
Immediate Rx
consultation
Tension PTX
Needle thoracocentesis,
follow by ICD insertion
and support ventilation
- Trauma surgeon
- CVT surgeon
Air embolism
Support ventilation
Intensivist
Pulmonary contusion Support ventilation
Intensivist
Intra abdominal
bleeding
iv fluid infusion,
investigation
Trauma surgeon
Bowel perforation
Investigation, observe
Trauma surgeon
Blast brain Brain concussion, ICH Check GCS, lateralizing sign
Blast ear
TM perforation
Ear exam in all cases
Blast eye
Globe rupture
Eye examination
Neurosurgeon
ENT
Opthalmologist
Secondary blast injury treatment
Injury
Immediate Rx
Definitive Rx
consultation
Explore lap.
Trauma surgeon
Penetrating
injury
- Bleeding control
- iv fluid replacement
- Film for foreign body
Amputation
- Bleeding control
- Tourniquet if necessary
- iv fluid replacement
Surgical
- Trauma surgeon
debridement
- Orthopedist
and control bleeding
Laceration
- Bleeding control
- iv fluid replacement
- Film for foreign body
Debridement
and suture
Opened fracture
- Immobilization
- Distal neurovascular
check
- Debridement
- Bone realignment
Trauma surgeon
Orthopedist
Tertiary blast injury treatment
Injury
Blunt chest /
abdominal
injury
Immediate Rx
Definitive Rx
consultation
- Bleeding control
- iv fluid replacement
- FAST / DPL
Explore lap.
Trauma surgeon
Crush syndrome - iv fluid load to force diuresis - Alkalinize urine
- ECG monitoring
- Dialysis if necessary
- Looking for compartment
syndrome
Trauma surgeon
Compartment
syndrome
- Trauma surgeon
- Orthopedist
Fasciotomy
Quaternary blast injury treatment
Injury
Immediate Rx
Inhalation injury
- Airway management
- Oxygen supplement
Asphyxia
- Airway management
- Oxygen supplement
Burn
- Keep warm
- Wound care
- iv fluid resuscitation
Definitive Rx
- Wound debridement
- Grafting for skin coverage
Quinary blast injury treatment
Injury
Immediate Rx
Definitive Rx
Toxic fume
Airway and ventilation support
Antidote?
Chemical injury
Decontamination
Wound care
Radiation
Supportive treatment
same
Biological agents
- Isolation
- Medical personnel PPE
Antibiotics ?
Special consideration
• ‘upside down’ or ‘reverse’ triage
• Estimated incoming patient
Total number of patient = Number in first hour x 2
Special consideration
CBRNE event
• Decontamination
• Personal Protective Equipment
EMS personnel
preparation
Decontaminating station
Thank you
Comments and question are welcome
Three suspected