bombings3h.ppt general information for education

Education

1. Bombings: Bombings:
Injury Patterns and CareInjury Patterns and Care

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

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

4. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 44
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.

5. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 55
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 InvestigatorRick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle Investigator
–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 Center for Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National Center for
Injury Prevention and ControlInjury Prevention and Control
–Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, National Center Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, National Center
for Injury Prevention and Controlfor Injury Prevention and Control
–Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, National Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, National
Center for Injury Prevention and ControlCenter for Injury Prevention and Control
–Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National Center Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National Center
for Injury Prevention and Controlfor Injury Prevention and Control
–Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Injury Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Injury
Response, National Center for Injury Prevention and ControlResponse, National Center for Injury Prevention and Control
12/0612/06

6. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 66
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

7. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 77
BackgroundBackground

8. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 88
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

9. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 99
BackgroundBackground

Explosive use increasing in terrorist eventsExplosive use increasing in terrorist events

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)

10. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1010
BackgroundBackground: Historical Perspective: Historical Perspective

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

11. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1111
Background: Blast DevicesBackground: Blast Devices
Photo used with permission of MAJ Benjamin Gonzalez, MD

12. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1212
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

13. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1313
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 ingredientssupplies, or fertilizer and household ingredients

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)

14. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1414
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: LELow-order explosive: LE

Petroleum productsPetroleum products
(“Molotov cocktail”)(“Molotov cocktail”)

Gunpowder Gunpowder
(“black” powder)(“black” powder)

Can become HE, if Can become HE, if
contained (e.g., pipe contained (e.g., pipe
bomb)bomb)

15. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1515
Explosive Explosive EventsEvents

16. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1616
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

17. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1717
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 and Documentation of statements by victims and
witnesseswitnesses

18. SceneScene Safety Safety

19. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 1919
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

20. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2020
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 place)Vehicles coming or leaving scene (out of place)

People acting oddly People acting oddly

Packages or containers at scene (out of place)Packages or containers at scene (out of 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

21. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2121
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

22. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2222
Scene Safety: Common PrinciplesScene Safety: Common Principles

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 checkedscene until checked
–Decontaminate if necessaryDecontaminate if necessary
Photo used with permission of Connie Doyle, MD, FACEP

23. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2323
Scene Safety: Common PrinciplesScene Safety: Common Principles

Cause no further injury or destructionCause no further injury or destruction

Protect yourselfProtect yourself

Activate command and hazard Activate command and hazard
response (ICS)response (ICS)

Limit accessLimit access

Contain the incidentContain the incident
Photo used with permission of Kathryn Brinsfield, MD, FACEP

24. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2424
Scene Safety: Common PrinciplesScene Safety: Common Principles

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 for Surveillance of patients and workers for
long-term effectslong-term effects

25. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2525
TriageTriage

26. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2626
TriageTriage

Unique patterns, multiple and occult injuriesUnique patterns, multiple and occult injuries

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

27. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2727
TriageTriage

Nature of injuries may lead to overtriageNature of injuries may lead to overtriage

Up to 75% of victims self-refer to hospital; Up to 75% of victims self-refer to hospital;
arrive by private transportationarrive by private transportation

Field triageField triage
–Dynamic processDynamic process

28. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2828
TriageTriage

Factors that determine when needs Factors that determine when needs
exceed resourcesexceed resources
–Large number of patients make rapid triage Large number of patients make rapid triage
impossible 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 responder Large number of patients exceed responder
treatment capabilitiestreatment capabilities
–Surge at local hospitalsSurge at local hospitals

29. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 2929
Blast Blast InjuriesInjuries

30. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3030
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

31. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3131
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 the Gases expand rapidly and compress the
surrounding airsurrounding 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 which Is affected by the medium through which
it travels, i.e., air vs. waterit travels, i.e., air vs. water

32. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3232
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

33. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3333
Background: Physics of BlastsBackground: Physics of Blasts
Click to view animation.

34. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3434
Blast Injury: SeverityBlast Injury: Severity

Nature of device – agent, amountNature of device – agent, amount

Method of delivery – incendiary, explosiveMethod of delivery – incendiary, explosive

Nature of environment – open, closedNature of environment – open, closed

Distance from deviceDistance from device

Intervening protective barrierIntervening protective barrier

Other environmental hazardsOther environmental hazards

35. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3535
Murrah Murrah
BuildingBuilding
Photo Courtesy of the City Of Oklahoma City

36. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3636
Murrah Federal Building, Oklahoma City (1993) – distribution of injuries
JAMA, August 1996, 276 (5): 382-387 © 1996 American Medical Association

37. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3737
Russell Square, London bombing, 2005
Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London

38. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3838
Mumbai, India: July 2006Mumbai, India: July 2006
Reuters/Prashanth Vishwanathan

39. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 3939
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 organs Caused by entrapped gases in hollow organs
compressing then expanding compressing then expanding visceral
→
visceral
→
disruptiondisruption

40. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4040
Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology

ShearingShearing
–Caused by tissues of different densities moving Caused by tissues of different densities moving
at different speeds 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.

41. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4141
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 wounds
→
shrapnel wounds
→

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

42. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4242
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

43. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4343
Diagram used with permission of LTC John McManus, Jr., MD, FACEP

44. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4444
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

45. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4545
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 debris These injuries are caused by flying debris
generated by the explosion. Terrorists generated by the explosion. Terrorists
often add screws, nails, and other sharp often add screws, nails, and other sharp
objects to bombs to increase injuries.objects to bombs to increase injuries.

46. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4646
Diagram used with permission of LTC John McManus, Jr., MD, FACEP

47. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4747
Blast Injuries: SecondaryBlast Injuries: Secondary

The most common types of secondary The most common types of secondary
blast injuries are:blast injuries are:
–Trauma to the head, neck, chest, abdomen, Trauma to the head, neck, chest, abdomen,
and extremities in the form of penetrating and extremities in the form of penetrating
and blunt traumaand blunt trauma
–FracturesFractures
–Traumatic amputationsTraumatic amputations
–Soft tissue injuriesSoft tissue injuries

48. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4848
Blast Injuries: SecondaryBlast Injuries: Secondary

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

49. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 4949
Secondary Injury
Used with permission of American Journal of Roentgenology 2006; 187:609-616

50. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5050
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 injuries The most common types of tertiary blast injuries
are:are:
–Head injuriesHead injuries
–Skull fracturesSkull fractures
–Bone fracturesBone fractures

Treatment for most tertiary blast injuries follows Treatment for most tertiary blast injuries follows
established protocols for that specific injury. established protocols for that specific injury.

51. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5151
Diagram used with permission of LTC John McManus, Jr., MD, FACEP

52. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5252
Blast Injuries: QuaternaryBlast Injuries: Quaternary

All explosion-related injuries, illnesses, or All explosion-related injuries, illnesses, or
diseases not due to primary, secondary, diseases not due to primary, secondary,
or tertiary mechanisms are considered or tertiary mechanisms are considered
quaternary blast injuries. This includes quaternary blast injuries. This includes
exacerbation or complications of existing exacerbation or complications of existing
conditions.conditions.

53. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5353
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

54. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5454
Blast Injuries: Blast LungBlast Injuries: Blast Lung
Used with permission of CHEST, December 1999; 116(6): 1683-1688

55. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5555
Blast Injuries: Blast LungBlast Injuries: Blast Lung
Reprinted from American Journal of Surgery, V190: 945-950,
Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc.

56. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5656
Blast Injuries: Blast LungBlast Injuries: Blast Lung

Clinical manifestationsClinical manifestations
–TachypneaTachypnea
–HypoxiaHypoxia
–CyanosisCyanosis
–ApneaApnea
–WheezingWheezing
–Decreased breath soundsDecreased breath sounds
–HemoptysisHemoptysis
–CoughCough
–Chest painChest pain
–DyspneaDyspnea
–Hemodynamic instability Hemodynamic instability

57. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5757
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 that Judicious fluid administration (similar to that
of pulmonary contusion)of pulmonary contusion)

58. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5858
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 the injury (MTBI) without a direct blow to the
headhead

59. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 5959
Blast Injuries: HeadBlast Injuries: Head

Consider the proximity of the victim to the Consider the proximity of the victim to the
blast particularly when given complaints of:blast particularly when given complaints of:
–Loss of consciousnessLoss of consciousness
–HeadacheHeadache
–FatigueFatigue
–Poor concentration, lethargy, amnesia, or other Poor concentration, lethargy, amnesia, or other
constitutional symptomsconstitutional symptoms
–Symptoms of concussion and post traumatic Symptoms of concussion and post traumatic
stress disorder (PTSD) can be similarstress disorder (PTSD) can be similar

60. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6060
Blast Injuries: TM RuptureBlast Injuries: TM Rupture

Tympanic membrane rupture indicates Tympanic membrane rupture indicates
exposure to an over pressurization wave. exposure to an over pressurization wave.
It may be found in victims with severe It may be found in victims with severe
pulmonary, intestinal, or other injuries, or pulmonary, intestinal, or other injuries, or
it may be found in isolation. Its presence it may be found in isolation. Its presence
does not indicate that more sinister blast does not indicate that more sinister blast
injuries exist. injuries exist.

61. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6161
Blast Injuries: TM RuptureBlast Injuries: TM Rupture
Used with permission of NEJM, April 2005; 352: 1335-1342

62. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6262
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.

63. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6363
Blast Injuries: EarBlast Injuries: Ear

Presentation: acute hearing loss Presentation: acute hearing loss
(conductive, sensorineural)(conductive, sensorineural)

Findings: auditory canal debris, tympanic Findings: auditory canal debris, tympanic
membrane rupture, ossicular disruption, membrane rupture, ossicular disruption,
cochlear damagecochlear 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

64. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6464
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

65. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6565
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

66. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6666
Blast Injuries: Combined InjuriesBlast Injuries: Combined Injuries

Combined injuries, especially blast and Combined injuries, especially blast and
burn injury or blast and crush injury, are burn injury or blast and crush injury, are
common during an explosive event. common during an explosive event.

67. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6767
Blast Injuries: Combined InjuriesBlast Injuries: Combined Injuries

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 Blast lung vs. burn injury, blast lung vs. crush
injuryinjury

Judicious fluid administration for adequate Judicious fluid administration for adequate
tissue perfusion without volume overload tissue perfusion without volume overload
may be required in the multiple injured may be required in the multiple injured
patient with blast lungpatient with blast lung
–Presence of additional injuries complicates Presence of additional injuries complicates
administration, rate, selection of fluidsadministration, rate, selection of fluids

68. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 6868
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, eye, penetrating injury to head, eye,
chest, abdomenchest, abdomen

Tertiary—traumatic amputation, fractures to Tertiary—traumatic amputation, fractures to
the face, pelvis, ribs, spinethe face, pelvis, ribs, spine

Quaternary— Quaternary— crush injuries, superficial and crush injuries, superficial and
partial to full thickness burnspartial to full thickness burns

69. Crush InjuryCrush Injury

70. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7070
Crush Injury: DefinitionCrush Injury: Definition

An injury sustained when a body part is An injury sustained when a body part is
subjected to a high degree, or prolonged subjected to a high degree, or prolonged
presence, of force or pressurepresence, of force or pressure
–Usually applied to both regional (e.g. body part) Usually applied to both regional (e.g. body part)
effects and systemic effects.effects and systemic effects.

Acute traumatic ischemia, with or without Acute traumatic ischemia, with or without
associated injuries, describes actual insult to associated injuries, describes actual insult to
tissuestissues

71. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7171
Crush Injury: Crush SyndromeCrush Injury: Crush Syndrome

Term used to describe the systems Term used to describe the systems
manifestations of crush injury after manifestations of crush injury after
reperfusion of affected body part(s)reperfusion of affected body part(s)
Reprinted with permission of OrthoWorld.com

72. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7272
Crush Injury:Crush Injury:
Compartment SyndromeCompartment Syndrome

Is a collection of localized signs and Is a collection of localized signs and
symptoms that result when the perfusion symptoms that result when the perfusion
pressure falls below the tissue pressure in pressure falls below the tissue pressure in
a closed anatomic space for sufficient a closed anatomic space for sufficient
time that compromise of circulation and time that compromise of circulation and
function of tissues involved occursfunction of tissues involved occurs

73. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7373
Crush Injury: IncidenceCrush Injury: Incidence

5-15% of mass casualty situations5-15% of mass casualty situations
–Natural disasters, especially earthquakes and Natural disasters, especially earthquakes and
tornadoestornadoes
–Structural collapse, with or without victim Structural collapse, with or without victim
entrapmententrapment
–Industrial, farm or transportation accidentsIndustrial, farm or transportation accidents
–Blast injury (all types)Blast injury (all types)
–CombatCombat
–Prolonged immobilization with major vascular Prolonged immobilization with major vascular
or microvascular circulation compromiseor microvascular circulation compromise

74. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7474
Crush Injury: Examples of eventsCrush Injury: Examples of events

Tyre, Lebanon (1982)Tyre, Lebanon (1982)
–Building collapseBuilding collapse

Beirut, Lebanon (1983)Beirut, Lebanon (1983)
–Marine barracks bombedMarine barracks bombed

Oklahoma City (1995)Oklahoma City (1995)
–Murrah Federal Building Murrah Federal Building
bombedbombed

Khobar, Saudi Arabia Khobar, Saudi Arabia
(1996) (1996)
–Khobar Towers bombedKhobar Towers bombed
Used with permission of AP Photo/KM Chaudhry

75. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7575
Crush Injury: PathophysiologyCrush Injury: Pathophysiology

Areas most affectedAreas most affected
–Lower extremitiesLower extremities
–Upper extremitiesUpper extremities
–PelvisPelvis
–Gluteal regionGluteal region
–Abdominal musclesAbdominal muscles
Reprinted with permission of OrthoWorld.com

76. Crush SyndromeCrush Syndrome

77. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7777
Crush SyndromeCrush Syndrome

May occur in absence of trauma and evolve May occur in absence of trauma and evolve
in the absence of early signs or symptomsin the absence of early signs or symptoms
–Arterial thrombosis or embolismArterial thrombosis or embolism
–Severe anemiaSevere anemia
–ToxinsToxins
–Legitimate medications and drugs of abuseLegitimate medications and drugs of abuse

Systemic effects due to rhabdomyolysis and Systemic effects due to rhabdomyolysis and
reperfusion of hypoxic and damaged tissues reperfusion of hypoxic and damaged tissues
and is the major cause of early mortalityand is the major cause of early mortality

78. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7878
Crush Syndrome: PathophysiologyCrush Syndrome: Pathophysiology
Rhabdomyolysis Rhabdomyolysis

Efflux from damaged muscle cells of:Efflux from damaged muscle cells of:
–PotassiumPotassium
–PurinesPurines
–Lactic AcidLactic Acid
–PhosphatePhosphate
–MyoglobinMyoglobin
–ThromboplastinThromboplastin
–CreatineCreatine

79. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 7979
Crush Syndrome : PathophysiologyCrush Syndrome : Pathophysiology

Reperfusion Reperfusion
–Skeletal muscle damage greatest after reperfusionSkeletal muscle damage greatest after reperfusion
–Superoxide radicals produced during reperfusion Superoxide radicals produced during reperfusion
attacks free fatty acids, producing cellular edema, attacks free fatty acids, producing cellular edema,
death, and necrosisdeath, and necrosis
–Na-K-ATP pump exchanges intracellular sodium for Na-K-ATP pump exchanges intracellular sodium for
calcium with further derangement of intracellular calcium with further derangement of intracellular
metabolismmetabolism

80. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8080
Crush Syndrome: PathophysiologyCrush Syndrome: Pathophysiology

Resultant effects of derangements due to rhabdomyolysis Resultant effects of derangements due to rhabdomyolysis andand reperfusion reperfusion

PotassiumPotassium  HyperkalemiaHyperkalemia  ArrhythmiasArrhythmias

CalciumCalcium HypocalcemiaHypocalcemia  ArrhythmiasArrhythmias

PhosphatePhosphate  HyperphosphatemiaHyperphosphatemia  Renal Renal
damage damage

MyoglobinMyoglobin  MyoglobinemiaMyoglobinemia  Renal damageRenal damage

Fluid shiftsFluid shifts  HypovolemiaHypovolemia  Renal failureRenal failure

ReperfusionReperfusion  Free radicalsFree radicals  Renal damageRenal damage

PurinesPurines HyperuricemiaHyperuricemia  Renal damageRenal damage

HypoxemiaHypoxemia  Lactic acidLactic acid  AcidosisAcidosis

ThromboplastinThromboplastin  Complement systemComplement system  DICDIC

CreatinineCreatinine  Elevated serum levelsElevated serum levels

SodiumSodium Azotemia Azotemia

81. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8181
Crush Syndrome: Clinical PresentationCrush Syndrome: Clinical Presentation

General condition of a patient with crush General condition of a patient with crush
injury dictated by other injuries, delay in injury dictated by other injuries, delay in
extrication, environmental conditionsextrication, environmental conditions

Common presentationsCommon presentations
–Hypothermia or hyperthermiaHypothermia or hyperthermia
–Dehydration/shockDehydration/shock
–Mental status varies from alert to comatoseMental status varies from alert to comatose

82. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8282
Crush Syndrome: Clinical PresentationCrush Syndrome: Clinical Presentation

Affected part (usually limb)Affected part (usually limb)
–Tense edema and decreased sensationTense edema and decreased sensation
–Overlying skin may be shiny, contused, Overlying skin may be shiny, contused,
necroticnecrotic

May have penetrating wounds (worse May have penetrating wounds (worse
diagnosis)diagnosis)

83. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8383
Crush Syndrome: Crush Syndrome:
Potential ComplicationsPotential Complications

HyperkalemiaHyperkalemia

HypocalcemiaHypocalcemia

HyperphosphatemiaHyperphosphatemia

Metabolic acidosisMetabolic acidosis

HypothermiaHypothermia

Acute Renal failure Acute Renal failure

84. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8484
Crush Syndrome: TreatmentCrush Syndrome: Treatment

Greatest initial danger is after release of Greatest initial danger is after release of
crushed limb from entrapment with crushed limb from entrapment with
restoration of circulationrestoration of circulation

Mainstay of treatment is aggressive fluid Mainstay of treatment is aggressive fluid
resuscitation and brisk diuresisresuscitation and brisk diuresis

Amount of tissue damage correlates with Amount of tissue damage correlates with
need for dialysisneed for dialysis
–Cannot determine actual tissue damage Cannot determine actual tissue damage
based on area of affected body partbased on area of affected body part

85. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8585
Crush Syndrome: TreatmentCrush Syndrome: Treatment

Delay in treatment associated with Delay in treatment associated with
greater morbidity and mortalitygreater morbidity and mortality
–50% renal failure at 6 hours50% renal failure at 6 hours
–100% renal failure at 12 hours100% renal failure at 12 hours
–Rhabdomyolysis induced renal failure has Rhabdomyolysis induced renal failure has
40% mortality 40% mortality

86. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8686
Crush Syndrome: TreatmentCrush Syndrome: Treatment
PrehospitalPrehospital

Primary survey and initial stabilization Primary survey and initial stabilization
(ABCs)(ABCs)

Fluid resuscitation before patient is Fluid resuscitation before patient is
extricated with severe or prolonged extricated with severe or prolonged
entrapment of limb or pelvis (more than a entrapment of limb or pelvis (more than a
hand or foot) hand or foot)

87. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8787
Crush Syndrome: TreatmentCrush Syndrome: Treatment
HospitalHospital

Fluid resuscitationFluid resuscitation

Brisk diuresisBrisk diuresis

Diagnose and treat other metabolic derangementsDiagnose and treat other metabolic derangements
–HyperkalemiaHyperkalemia
–HypocalcemiaHypocalcemia

Treat tissue damageTreat tissue damage

Pain controlPain control

AgitationAgitation

88. Compartment SyndromeCompartment Syndrome

89. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 8989
Compartment SyndromeCompartment Syndrome

Is a collection of localized signs and Is a collection of localized signs and
symptoms that result when the perfusion symptoms that result when the perfusion
pressure falls below the tissue pressure in pressure falls below the tissue pressure in
a closed anatomic space for sufficient a closed anatomic space for sufficient
time that compromise of circulation and time that compromise of circulation and
function of tissues involved occursfunction of tissues involved occurs

90. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9090
Compartment SyndromeCompartment Syndrome

Can lead to crush syndrome systemic Can lead to crush syndrome systemic
effects if left untreated or inadequately effects if left untreated or inadequately
treated.treated.
Photo used with permission of The Institute for Foot
and Ankle Reconstruction at Mercy, Baltimore, MD

91. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9191
Compartment SyndromeCompartment Syndrome
Suggestive clinical findings Suggestive clinical findings

Similar settings to crush injury, but may also Similar settings to crush injury, but may also
occur with subacute traumaoccur with subacute trauma

Bone fractures Bone fractures

High velocity penetrating injury to muscles in High velocity penetrating injury to muscles in
closed compartment with extensive tissue closed compartment with extensive tissue
disruptiondisruption

Can also occur in subacute fashion due to Can also occur in subacute fashion due to
prolonged immobilization on hard surfaceprolonged immobilization on hard surface

92. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9292
Compartment Syndrome: Compartment Syndrome:
PathophysiologyPathophysiology

Significance of muscle mass damageSignificance of muscle mass damage

Typically occurs in major muscle groups Typically occurs in major muscle groups
enclosed by inelastic, fibrous sheathsenclosed by inelastic, fibrous sheaths

Tissue/muscle damage results in edema Tissue/muscle damage results in edema
in a closed volume spacein a closed volume space
–Progressive cycle of edema, perfusion Progressive cycle of edema, perfusion
compromise, tissue hypoxia and cellular compromise, tissue hypoxia and cellular
derangement, further edema, etc.derangement, further edema, etc.
–Untreated, will produce same effects as crush Untreated, will produce same effects as crush
injuryinjury

93. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9393
Compartment Syndrome: Compartment Syndrome:
Clinical PresentationClinical Presentation

The 5 P’sThe 5 P’s
–PainPain
–PallorPallor
–ParesthesiaParesthesia
–ParalysisParalysis
–PressurePressure

Progression of symptomsProgression of symptoms
– (sometimes the 6(sometimes the 6
thth
P) P)

94. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9494
Compartment Syndrome: Compartment Syndrome:
TreatmentTreatment
Prehospital Prehospital

Primary survey and initial stabilization Primary survey and initial stabilization
(ABC’s)(ABC’s)

Suspect compartment syndromeSuspect compartment syndrome

Immobilize affected partImmobilize affected part

Treat other injuriesTreat other injuries

95. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9595
Compartment Syndrome: Compartment Syndrome:
TreatmentTreatment
HospitalHospital

Primary survey, stabilization and Primary survey, stabilization and
resuscitation, secondary surveyresuscitation, secondary survey

Diagnosis through examinationDiagnosis through examination

Treat systemic effects of compartment Treat systemic effects of compartment
syndrome similar to crush injury syndrome similar to crush injury
treatmenttreatment

96. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9696
Compartment Syndrome:Compartment Syndrome:
Extremity InjuriesExtremity Injuries

Management of extremity injuries Management of extremity injuries
–Indication for field amputationIndication for field amputation
–Appropriate use of tourniquet applicationAppropriate use of tourniquet application
–Appropriate use of hemostatic dressingsAppropriate use of hemostatic dressings
–Appropriate anesthesia/analgesicAppropriate anesthesia/analgesic

97. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9797
Compartment Syndrome: Compartment Syndrome:
Procedural SkillsProcedural Skills

Measuring compartment pressuresMeasuring compartment pressures

Use of KetamineUse of Ketamine

FasciotomiesFasciotomies
Photo used with permission of Immediate Action Services

98. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9898
Compartment Syndrome: Compartment Syndrome:
Procedural SkillsProcedural Skills

Fasciotomies are a definitive Fasciotomies are a definitive
treatment, but tissue pressure at treatment, but tissue pressure at
which it is required is controversial.which it is required is controversial.

Varying views include:Varying views include:
–Early fasciotomy when pressures >45 mm Hg Early fasciotomy when pressures >45 mm Hg
or when within 20 mm Hg of diastolic pressureor when within 20 mm Hg of diastolic pressure
–Delayed fasciotomy (beyond 48-72 hours) Delayed fasciotomy (beyond 48-72 hours)
increases risk of sepsis and death due to increases risk of sepsis and death due to
extensive necrotic tissues extensive necrotic tissues

99. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 9999
Compartment Syndrome: Compartment Syndrome:
Procedural SkillsProcedural Skills

FasciotomyFasciotomy
–Provide adequate analgesia and anesthesiaProvide adequate analgesia and anesthesia
–Pre-operative broad spectrum antibioticsPre-operative broad spectrum antibiotics
–Ensure ALL compartments in extremity checked Ensure ALL compartments in extremity checked
for pressures (multiple compartments may be for pressures (multiple compartments may be
affected)affected)
–Check compartment pressures before and after Check compartment pressures before and after
fasciotomyfasciotomy
–Ensure adequate hemostasisEnsure adequate hemostasis
–Pack wound open and use large bulky Pack wound open and use large bulky
dressings dressings

100. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 100100
Entrapped Patient TreatmentEntrapped Patient Treatment

Treatment Treatment
–Fluid resuscitation before victim extricatedFluid resuscitation before victim extricated

1 L NS bolus, followed by 1-1.5 L per hour infusion1 L NS bolus, followed by 1-1.5 L per hour infusion
–Limb stabilizationLimb stabilization
–Minimize potential systemic effects of reperfusionMinimize potential systemic effects of reperfusion

Consider use of tourniquets prior to releaseConsider use of tourniquets prior to release
–Consider alkalinization by giving 1 ampule of Consider alkalinization by giving 1 ampule of
sodium bicarbonate (50 mEq) immediately prior sodium bicarbonate (50 mEq) immediately prior
to extrication, followed by adding 1 ampule of to extrication, followed by adding 1 ampule of
sodium bicarbonate to each liter of NS infused at sodium bicarbonate to each liter of NS infused at
1-1.5 L per hour as above; keep second IV line 1-1.5 L per hour as above; keep second IV line
open without sodium bicarbonateopen without sodium bicarbonate

101. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 101101
Field AmputationField Amputation

Indications:Indications:
–Unable to safely extricateUnable to safely extricate
–Continued environmental toxins pose hazard Continued environmental toxins pose hazard
to victim and rescuersto victim and rescuers
–Grossly prolonged time until definitive Grossly prolonged time until definitive
treatment even after extricationtreatment even after extrication

102. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 102102
Field AmputationField Amputation

Best performed by trauma or orthopedic Best performed by trauma or orthopedic
surgeonsurgeon

Few EMS systems have protocolsFew EMS systems have protocols

Ensure adequate analgesia and anesthesiaEnsure adequate analgesia and anesthesia
–Ketamine (dissociative anesthetic)Ketamine (dissociative anesthetic)

Decreases or only minimally increases serum Decreases or only minimally increases serum
potassium levelspotassium levels

Patient maintains airway despite adequate Patient maintains airway despite adequate
anesthesiaanesthesia

103. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 103103
Photo used with permission of Immediate Action Services

104. Military ExperienceMilitary Experience

105. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 105105
Military ExperienceMilitary Experience

U.S. Military has significant experience in U.S. Military has significant experience in
dealing with blast and explosive injuriesdealing with blast and explosive injuries

Military has been quick to seek and adopt Military has been quick to seek and adopt
new strategies in treating hemorrhage, new strategies in treating hemorrhage,
the leading cause of preventable deaththe leading cause of preventable death

Mortality rates dramatically lower for the Mortality rates dramatically lower for the
current conflict current conflict

106. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 106106
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

107. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 107107
Military Experience Military Experience

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

108. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 108108
Military Experience Military Experience
Photo used courtesy of Bio Cybernetics International

109. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 109109
Military Experience Military Experience

Damage Control SurgeryDamage Control Surgery
–Technique known for 20 years, but slow to be Technique known for 20 years, but slow to be
acceptedaccepted
–Central tenet: Avoid the “Deadly Triad”Central tenet: Avoid the “Deadly Triad”

HypothermiaHypothermia

CoagulopathyCoagulopathy

Metabolic acidosisMetabolic acidosis
Each condition worsens both of the othersEach condition worsens both of the others

110. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 110110
Military ExperienceMilitary Experience

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

111. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 111111
Military ExperienceMilitary Experience

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

112. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 112112
Military ExperienceMilitary Experience

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 fluid Fresh thawed plasma best resuscitation fluid
in MTin MT

Optimum ratio of plasma to crystalloid 1:1 to avoid Optimum ratio of plasma to crystalloid 1:1 to avoid
clotting factor dilution >50%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

113. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 113113
Military ExperienceMilitary Experience

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)

114. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 114114
Military ExperienceMilitary Experience

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 timesEvery soldier carries at least one at all times

115. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 115115
Military ExperienceMilitary Experience

Hemostatic DressingsHemostatic Dressings
–Key to avoiding coagulopathy from MT is to Key to avoiding coagulopathy from MT is to
control bleeding in the first placecontrol bleeding in the first place
–Primarily used for non-extremity hemorrhagePrimarily used for non-extremity hemorrhage
–Dressings applied with pressure x 5 minutes; Dressings applied with pressure x 5 minutes;
patient wrapped and transportedpatient wrapped and transported

116. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 116116
Military ExperienceMilitary Experience

HemCon (chitosan)HemCon (chitosan)
–Originally available as a bandageOriginally available as a bandage
–Now available in roll that can be stuffed into Now available in roll that can be stuffed into
woundwound

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

117. Special ConsiderationsSpecial Considerations

118. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 118118
Special ConsiderationsSpecial Considerations

PregnancyPregnancy

ChildrenChildren

ElderlyElderly

DisabledDisabled

Language barriersLanguage barriers

119. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 119119
Special Considerations: PregnancySpecial Considerations: Pregnancy

Injuries to the placenta are possible and must be Injuries to the placenta are possible and must be
detecteddetected

Second or third trimester of pregnancy should Second or third trimester of pregnancy should
be admitted for continuous fetal monitoringbe admitted for continuous fetal monitoring

The placental attachment is at risk for primary The placental attachment is at risk for primary
blast injuryblast injury

Screening test for fetal-maternal hemorrhage in Screening test for fetal-maternal hemorrhage in
second or third trimester of pregnancysecond 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.

120. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 120120
Special Considerations: ChildrenSpecial Considerations: Children

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 facilitiesIdentification of regional pediatric trauma facilities

121. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 121121
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 complicated hospital stay may be longer and more 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 modification Decontamination methods may need modification
due to limited mobilitydue to limited mobility

Technical decontamination of medical equipment Technical decontamination of medical equipment
such as wheelchairs, walkers and other walking such as wheelchairs, walkers and other walking
aides may be neededaides may be needed

122. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 122122
Special Considerations: DisabledSpecial Considerations: Disabled

Consideration should be given to patients Consideration should be given to patients
with underlying medical conditionswith underlying medical conditions

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

123. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 123123
Special Considerations:Special Considerations:
Language BarriersLanguage Barriers

Diverse population speaking multiple languages Diverse population speaking multiple languages
may be an unforeseen obstaclemay 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 as History of the event maybe difficult to obtain as
well as the individual history for the patient.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

124. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 124124
Photo used courtesy of Kwikpoint

125. Psychological IssuesPsychological Issues

126. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 126126
Psychological IssuesPsychological Issues

Sequelae from an explosive eventSequelae from an explosive event
–AngerAnger
–FrustrationFrustration
–HelplessnessHelplessness
–Desire to seek revengeDesire to seek revenge

127. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 127127
Psychological IssuesPsychological Issues

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

128. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 128128
Psychological IssuesPsychological Issues

Tips for RespondersTips for Responders
–Promotion of safetyPromotion of safety
–Promote calmPromote calm
–Promote connectednessPromote connectedness
–Promote self-efficacyPromote self-efficacy
–Promote hopePromote hope

129. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 129129
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

130. Bombings: Injury Patterns and CareBombings: Injury Patterns and Care 130130
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, and Need to surge: CT, OR suites, staff, and
supplies (blood, etc.)supplies (blood, etc.)

Hidden nature of injuries can lead to Hidden nature of injuries can lead to
dangerous overtriage and undertriagedangerous overtriage and undertriage