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This project was funded by the Centers forThis project was funded by the Centers for
Disease Control and Prevention (CDC) underDisease Control and Prevention (CDC) under
Cooperative Agreement U!"CCU#$%&'*Cooperative Agreement U!"CCU#$%&'*
+,in-ages of Acute Care and ./0 to 0tate and+,in-ages of Acute Care and ./0 to 0tate and
,ocal 1njury Prevention Programs for Terrorism,ocal 1njury Prevention Programs for Terrorism
Preparedness and 2esponse34Preparedness and 2esponse34
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American /edical Association (A/A)American /edical Association (A/A) American Trauma 0ociety (AT0)American Trauma 0ociety (AT0) 5ational Association of ./0 Physicians (5A./0P)5ational Association of ./0 Physicians (5A./0P) 5ational Association of ./T6s (5A./T)5ational Association of ./T6s (5A./T) 5ational Association of 0tate ./0 78cials (5A0./07)5ational Association of 0tate ./0 78cials (5A0./07) 5ational 5ative American ./0 Association (55A./0A)5ational 5ative American ./0 Association (55A./0A)
TheThe Bombings: Injury Patterns and CareBombings: Injury Patterns and Care curriculum wascurriculum was
developed through the Linkages of cute Care and !"#developed through the Linkages of cute Care and !"#
to #tate and Local Injury Prevention Programs projectto #tate and Local Injury Prevention Programs project
that was funded by the Centers for $isease Control andthat was funded by the Centers for $isease Control and
Prevention %C$C&' The merican College of !mergencyPrevention %C$C&' The merican College of !mergencyPhysicians %C!P& served as the lead grantee for thePhysicians %C!P& served as the lead grantee for the
project along with the following si( other organi)ations:project along with the following si( other organi)ations:
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task force was established with representative e(perts from task force was established with representative e(perts from
emergency medicine including physicians* surgeons* nursing*emergency medicine including physicians* surgeons* nursing*
and !"#' Core competencies and knowledge objectives wereand !"#' Core competencies and knowledge objectives were
developed using a consensus approach' writing group thendeveloped using a consensus approach' writing group then
developed teaching objectives and course content based on thedeveloped teaching objectives and course content based on thecore competencies'core competencies'
TheThe Bombings: Injury Patterns and CareBombings: Injury Patterns and Care curriculum is designedcurriculum is designed
to be the minimum content that should be included in any all+to be the minimum content that should be included in any all+
ha)ards disaster response training program' This content isha)ards disaster response training program' This content is
designed to update the student with the latest clinicaldesigned to update the student with the latest clinical
information regarding blast related injuries from terrorism'information regarding blast related injuries from terrorism'
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merican College of !mergency Physicians %C!P& ,rant #ta-9 .athryn /' Brins0eld* "$* "P/* 1C!P* Chair* Curriculum on Traumatic
Injuries from Terrorism Task 1orce %C2+TI1T&9 3ick "urray* !"T+P* !"# and $isaster Preparedness $irector* Principle3ick "urray* !"T+P* !"# and $isaster Preparedness $irector* Principle
InvestigatorInvestigator9 "arshall ,ardner* !"T+P* !"# and $isaster Preparedness "anager"arshall ,ardner* !"T+P* !"# and $isaster Preparedness "anager
9 $iana #' 4ester* !"# and $isaster 3esponse Coordinator$iana #' 4ester* !"# and $isaster 3esponse Coordinator9 Cynthia #ingh* "#* ,rants and $evelopment "anagerCynthia #ingh* "#* ,rants and $evelopment "anager9 .athryn "ensah* "#* ,rants dministrator.athryn "ensah* "#* ,rants dministrator9 "ary 5hiteside* Ph$* Curriculum $evelopment Consultant"ary 5hiteside* Ph$* Curriculum $evelopment Consultant
Centers for $isease Control and Prevention %C$C& #ta-9 3ichard C' /unt* "$* 1C!P* $irector* $ivision of Injury 3esponse* 6ational3ichard C' /unt* "$* 1C!P* $irector* $ivision of Injury 3esponse* 6ational
Center forCenter for Injury Prevention and ControlInjury Prevention and Control9 #cott "' #asser* "$* 1C!P* Consultant* $ivision of Injury 3esponse*#cott "' #asser* "$* 1C!P* Consultant* $ivision of Injury 3esponse*
6ational Center6ational Center for Injury Prevention and Controlfor Injury Prevention and Control9 !rnest !' #ullivent* III* "$* "edical 27cer* $ivision of Injury 3esponse*!rnest !' #ullivent* III* "$* "edical 27cer* $ivision of Injury 3esponse*
6ational6ational Center for Injury Prevention and ControlCenter for Injury Prevention and Control9 Paula Burgess* "$* "P/* Team Leader* $ivision of Injury 3esponse* 6ationalPaula Burgess* "$* "P/* Team Leader* $ivision of Injury 3esponse* 6ational
CenterCenter for Injury Prevention and Controlfor Injury Prevention and Control9 4ane "itchko* "!d* C/!#* /ealth Communications #pecialist* $ivision of4ane "itchko* "!d* C/!#* /ealth Communications #pecialist* $ivision of
InjuryInjury 3esponse* 6ational Center for Injury Prevention and Control3esponse* 6ational Center for Injury Prevention and Control
89;
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Bombings: Injury Patterns 6
$iscussion$iscussionTopicsTopics
:ac-ground:ac-ground
.;plosive .vents.;plosive .vents
:last 1njuries:last 1njuries9 Primary* 0econdary* Tertiary*
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BackgroundBackground
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BackgroundBackground
Terrorism can be de=ned as containingTerrorism can be de=ned as containing
four -ey elements>four -ey elements>
9 PremeditatedPremeditated9 PoliticalPolitical
9 Aimed at civiliansAimed at civilians
9 Carried out by subnational groupsCarried out by subnational groups
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BackgroundBackground
.;plosive use increasing in terrorist.;plosive use increasing in terrorist
eventsevents
2esult in mass casualty incidents2esult in mass casualty incidents 2ecent e;amples2ecent e;amples
9 /umbai ($&)/umbai ($&)
9 Tel Aviv ($&)Tel Aviv ($&)
9 ,ondon subway ($#),ondon subway ($#)
9 /adrid subway ($%)/adrid subway ($%)
9 Tel Aviv ($)Tel Aviv ($)
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BackgroundBackground: /istorical: /istorical
PerspectivePerspective
?&@????&@???9 ! international terrorist bombings! international terrorist bombings
?&??@?&??@9 @! bombings in 5orthern 1reland@! bombings in 5orthern 1reland
?@$?@$9 '$% criminal bombing events in the U0'$% criminal bombing events in the U0
$$'$$'9 # 1nternational terrorist bombings# 1nternational terrorist bombings
$#$#9 '?? 1nternational terrorist bombings'?? 1nternational terrorist bombings
0ources> ry-berg .2* Tepas BB U0 Departments of 0tate* Bustice Terrorism 2esearch
Centre
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Background: Blast $evicesBackground: Blast $evices
Photo used with permission of "4 Benjamin ,on)ale)* "$
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Background: Blast $evicesBackground: Blast $evices
1mprovised e;plosive devices (1.Ds)1mprovised e;plosive devices (1.Ds)9 Car and truc- bombs (7-lahoma City* orld Trade Center 1)Car and truc- bombs (7-lahoma City* orld Trade Center 1)
9 ,etter and parcel bombs (1daho +Unabomber4),etter and parcel bombs (1daho +Unabomber4)
9 Pipe bombs (Atlanta 7lympics)Pipe bombs (Atlanta 7lympics)
9 :ac-pac- and satchel bombs (1srael* ,ondon):ac-pac- and satchel bombs (1srael* ,ondon)
1ncendiary bombs1ncendiary bombs9 Airplane bombs (orld Trade Center 11* Pentagon)Airplane bombs (orld Trade Center 11* Pentagon)
2oc-et propelled grenades (2PEs)2oc-et propelled grenades (2PEs) 0urface to air missiles (0A/s)0urface to air missiles (0A/s)
.nhanced blast devices.nhanced blast devices
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Bombings: Injury Patterns 13
BackgroundBackground: Blast $evices: Blast $evices
1.Ds1.Ds
1mprovised"+homemade4 e;plosive devices1mprovised"+homemade4 e;plosive devices
/ade from e;plosives* commercial blasting/ade from e;plosives* commercial blastingsupplies* or fertiliFer and householdsupplies* or fertiliFer and household
ingredientsingredients
Designed to cause injury and deathDesigned to cause injury and death
7ften pac-ed with metal objects such as nails7ften pac-ed with metal objects such as nailsor ball bearings could contain to;ic chemicalsor ball bearings could contain to;ic chemicals
or radiological materials (dirty bomb)or radiological materials (dirty bomb)
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BackgroundBackground: Blast gents: Blast gents
Gighorder e;plosive> G.Gighorder e;plosive> G.
5itroglycerin (5TE)5itroglycerin (5TE)
DynamiteDynamite PlasticPlastic
Ammonium nitrate"Ammonium nitrate"
fuel oil fuel oil(A57)(A57)
Trinitrotoluene (T5TTrinitrotoluene (T5T)) Triacetone tripero;ideTriacetone tripero;ide
(TAPT) (TAPT)
,oworder e;plosive>,oworder e;plosive>
,.,.
Petroleum productsPetroleum products(+/olotov coc-tail4)(+/olotov coc-tail4)
EunpowderEunpowder
(+blac-4 powder)(+blac-4 powder)
Can become G.* ifCan become G.* if
contained (e3g3*contained (e3g3*
pipe bomb)pipe bomb)
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Bombings: Injury Patterns 15
!(plosive!(plosive !vents!vents
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!(plosive!(plosive!vents!vents
1ncident command1ncident command
9 .ntire area H crime scene I evidence.ntire area H crime scene I evidence
preservationpreservation9 /ultijurisdictional response/ultijurisdictional response
0cene safety0cene safety
9 Dirty bombs* secondary devices* buildingDirty bombs* secondary devices* building
collapse* high dust environment (possiblycollapse* high dust environment (possiblycontaminated)* bomb fragmentscontaminated)* bomb fragments
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Bombings: Injury Patterns 17
!(plosive !vents:!(plosive !vents:
Criminal InvestigationCriminal Investigation
Principles of criminal investigation andPrinciples of criminal investigation and
evidence preservationevidence preservation
9 1ndicators for crime scene1ndicators for crime scene9 .vidence and chain of custody.vidence and chain of custody
9 Avoid disturbing or compromising evidenceAvoid disturbing or compromising evidence
9 Detection of possible suspects"perpetratorsDetection of possible suspects"perpetrators
9
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#cene#cene#afety#afety
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Bombings: Injury Patterns 19
#cene #afety: Common /a)ards#cene #afety: Common /a)ards
0econdary devices0econdary devices
0hrapnel0hrapnel
:uilding collapse:uilding collapse Airborne contaminantsAirborne contaminants
Contaminated patientsContaminated patients
Contaminated scene"environmentContaminated scene"environment
PerpetratorsPerpetrators Terrorist patientsTerrorist patients
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#cene #afety: Common /a)ards#cene #afety: Common /a)ards
Jictims with no soft tissue injuriesJictims with no soft tissue injuries Jehicles coming or leaving scene (out ofJehicles coming or leaving scene (out of
place)place) People acting oddlyPeople acting oddly Pac-ages or containers at scene (out ofPac-ages or containers at scene (out of
place)place) Jehicles not damaged or out of placeJehicles not damaged or out of place
0tructural damage0tructural damage eathereather Possible places for secondary devicesPossible places for secondary devices
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Bombings: Injury Patterns 21
#cene #afety:#cene #afety:
ppropriate PP! for blastsppropriate PP! for blasts
CoverallsCoveralls
Geavy coatGeavy coat
Geavy glovesGeavy gloves 0teeltoed boots0teeltoed boots
Gard hatGard hat
.ye protection.ye protection Dust particle mas-Dust particle mas-
:reathing apparatus for to;ic fumes:reathing apparatus for to;ic fumes
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Bombings: Injury Patterns 22
#cene #afety: Common#cene #afety: Common
PrinciplesPrinciples
Contain the incidentContain the incident
9 Deny entry to all but respondersDeny entry to all but responders
9 0et up Fones0et up Fones GotGot armarm
ColdCold
Contain the peopleContain the people
9 Do not let anyone leaveDo not let anyone leave
scene until chec-ed scene until chec-ed
9 Decontaminate if necessaryDecontaminate if necessaryPhoto used with permission of Connie $oyle* "$*1C!P
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Bombings: Injury Patterns 23
#cene #afety: Common#cene #afety: Common
PrinciplesPrinciples
Cause no further injury or destructionCause no further injury or destruction
Protect yourselfProtect yourself
Activate command andActivate command andhaFard response (1C0)haFard response (1C0)
,imit access,imit access
Contain the incidentContain the incident
Photo used with permission of .athryn Brins0eld* "$* 1C!P
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Bombings: Injury Patterns 24
#cene #afety: Common#cene #afety: Common
PrinciplesPrinciples
or-er safetyor-er safety
Protection of uninvolved public andProtection of uninvolved public and
volunteersvolunteers Protection of injuredProtection of injured
Treatment of injuredTreatment of injured
0urveillance of patients and wor-ers0urveillance of patients and wor-ersfor longterm eKectsfor longterm eKects
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Bombings: Injury Patterns 25
TriageTriage
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Bombings: Injury Patterns 26
TriageTriage
UniLue patterns* multiple and occultUniLue patterns* multiple and occult
injuriesinjuries
Death often result of combined blast*Death often result of combined blast*ballistic* and thermal eKect injuriesballistic* and thermal eKect injuries
(multidimensional injury)(multidimensional injury)
al-ing woundedal-ing wounded
Gidden"internal injuriesGidden"internal injuries /any noncritical patients who reLuire/any noncritical patients who reLuire
time intensive wor-upstime intensive wor-ups
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Bombings: Injury Patterns 27
TriageTriage
5ature of injuries may lead to5ature of injuries may lead to
overtriageovertriage
Up to !#M of victims selfrefer toUp to !#M of victims selfrefer tohospital arrive by privatehospital arrive by private
transportationtransportation ield triageield triage
9 Dynamic processDynamic process
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Bombings: Injury Patterns 28
TriageTriage
actors that determine when needsactors that determine when needs
e;ceed resourcese;ceed resources
9 ,arge number of patients ma-e rapid,arge number of patients ma-e rapidtriage impossibletriage impossible
9 ,arge number of patients cause delay in,arge number of patients cause delay in
transport to hospitalstransport to hospitals
9 ,arge number of patients e;ceed,arge number of patients e;ceedresponder treatment capabilitiesresponder treatment capabilities
9 0urge at local hospitals0urge at local hospitals
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Bombings: Injury Patterns 29
BlastBlast InjuriesInjuries
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Bombings: Injury Patterns 30
Blast Injuries: =ni>ue spectsBlast Injuries: =ni>ue spects
1nNict multisystem injuries on large1nNict multisystem injuries on large
groups of peoplegroups of people
Cause many simultaneous lifeCause many simultaneous lifethreatening injuriesthreatening injuries
Gidden pattern of injuryGidden pattern of injury
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Bombings: Injury Patterns 31
Blast Injuries: Blast PhysicsBlast Injuries: Blast Physics
2apid chemical conversion of a solid or2apid chemical conversion of a solid or
liLuid into highly pressuriFed gasesliLuid into highly pressuriFed gases
Eases e;pand rapidly and compressEases e;pand rapidly and compressthe surrounding airthe surrounding air
Pressure wave and blast wind arePressure wave and blast wind are
generated and spread in all directionsgenerated and spread in all directions
1s aKected by the medium through1s aKected by the medium through
which it travels* i3e3* air vs3 waterwhich it travels* i3e3* air vs3 water
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Bombings: Injury Patterns 32
Blast Injuries: Blast PhysicsBlast Injuries: Blast Physics
Emergency War Surgery, 3rd Edition
1mportance of 1njury Types vs3Distance
$iagram used with permission of 4ohn+Phillipe $ionne' Ph$
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Bombings: Injury Patterns 33
Background: Physics of BlastsBackground: Physics of Blasts
Clic- to viewanimation3
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Bombings: Injury Patterns 34
Blast Injury: #everityBlast Injury: #everity
5ature of device 9 agent* amount5ature of device 9 agent* amount
/ethod of delivery 9 incendiary*/ethod of delivery 9 incendiary*
e;plosivee;plosive 5ature of environment 9 open* closed5ature of environment 9 open* closed
Distance from deviceDistance from device
1ntervening protective barrier1ntervening protective barrier 7ther environmental haFards7ther environmental haFards
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Bombings: Injury Patterns 35
"urrah"urrah
BuildingBuilding
Photo Courtesy of the City 2f 2klahoma City
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Bombings: Injury Patterns 36
"urrah 1ederal Building* 2klahoma City %8??@& A distribution ofinjuries
4"* ugust 8??
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Bombings: Injury Patterns 37
3ussell #>uare* London bombing*9;;
$iagram used with permission of $irectorate of Public -airs* "etropolitan Police
#ervice* London
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Bombings: Injury Patterns 38
"umbai* India: 4uly 9;;
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Bombings: Injury Patterns 39
Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology
Proposed mechanismsOProposed mechanismsO
0palling0palling
9 Caused by shoc- wave moving throughCaused by shoc- wave moving throughtissues of diKerent densitiestissues of diKerent densities II molecularmolecular
disruptiondisruption
1mplosion1mplosion
9 Caused by entrapped gases in hollowCaused by entrapped gases in holloworgans compressing then e;pandingorgans compressing then e;panding II
visceral disruptionvisceral disruption
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Bombings: Injury Patterns 40
Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology
0hearing0hearing
9 Caused by tissues of diKerent densitiesCaused by tissues of diKerent densities
moving at diKerent speedsmoving at diKerent speeds II visceral tearingvisceral tearing
1rreversible or-1rreversible or-
9 Caused by forces e;ceeding the tensileCaused by forces e;ceeding the tensile
strength of the tissuestrength of the tissue
O0palling* implosion and shearing are thought to be threeO0palling* implosion and shearing are thought to be three
mechanisms that cause blast injuries3 1rreversible wor- ismechanisms that cause blast injuries3 1rreversible wor- is
currently being researched as a more li-ely mechanism ofcurrently being researched as a more li-ely mechanism of
injury3injury3
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Bombings: Injury Patterns 41
Blast Injuries: CategoriesBlast Injuries: Categories
Primary injuryPrimary injury
9 Caused by blast waveCaused by blast wave II over pressureover pressure
0econdary injury0econdary injury9 Caused by Nying debrisCaused by Nying debris I shrapnel woundsI shrapnel wounds
Tertiary injuryTertiary injury
9 Caused by blast windCaused by blast wind II forceful impactforceful impact
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Bombings: Injury Patterns 42
Blast Injuries: PrimaryBlast Injuries: Primary
:lunt trauma from over pressure wave:lunt trauma from over pressure wave
9 UniLue to highorder e;plosivesUniLue to highorder e;plosives
9 2esults from the impact of the over2esults from the impact of the overpressuriFation wave with body surfacespressuriFation wave with body surfaces
9 :lunt force injuries:lunt force injuries
9 Produces barotraumaProduces barotrauma
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Bombings: Injury Patterns 43
$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$*1C!P
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Bombings: Injury Patterns 44
Blast Injuries: PrimaryBlast Injuries: Primary
/ost common injuries>/ost common injuries>9 :last lungpulmonary barotraumas:last lungpulmonary barotraumas
9 Traumatic brain injury (T:1)* concussionTraumatic brain injury (T:1)* concussion9 Tympanic membrane (eardrum) ruptureTympanic membrane (eardrum) rupture
9 /iddle ear damage/iddle ear damage
9 Abdominal hemorrhageAbdominal hemorrhage
9 Abdominal organ perforationAbdominal organ perforation
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Bombings: Injury Patterns 45
Blast Injuries: #econdaryBlast Injuries: #econdary
The most common cause of death in aThe most common cause of death in a
blast event is secondary blast injuries3blast event is secondary blast injuries3
These injuries are caused by NyingThese injuries are caused by Nyingdebris generated by the e;plosion3debris generated by the e;plosion3
Terrorists often add screws* nails* andTerrorists often add screws* nails* and
other sharp objects to bombs toother sharp objects to bombs to
increase injuries3increase injuries3
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Bombings: Injury Patterns 46
$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$* 1C!P
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Bombings: Injury Patterns 47
Blast Injuries: #econdaryBlast Injuries: #econdary
The most common types of secondaryThe most common types of secondary
blast injuries are>blast injuries are>
9 Trauma to the head* nec-* chest*Trauma to the head* nec-* chest*abdomen* and e;tremities in the form ofabdomen* and e;tremities in the form of
penetrating and blunt traumapenetrating and blunt trauma
9 racturesractures
9 Traumatic amputationsTraumatic amputations9 0oft tissue injuries0oft tissue injuries
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Bombings: Injury Patterns 48
Blast Injuries: #econdaryBlast Injuries: #econdary
Penetrating trauma (shrapnel wounds)Penetrating trauma (shrapnel wounds)
9 oreign bodies follow unpredictable pathsoreign bodies follow unpredictable paths
through bodythrough body
9 /ay have only mild e;ternal signs/ay have only mild e;ternal signs
9 Gave a low threshold for imaging studiesGave a low threshold for imaging studies
(plain radiographs* computed tomograms)(plain radiographs* computed tomograms)
9 Consider all wounds contaminatedConsider all wounds contaminated
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Bombings: Injury Patterns 49
#econdaryInjury
=sed with permission of merican 4ournal of 3oentgenology 9;;
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Bombings: Injury Patterns 50
Blast Injuries: TertiaryBlast Injuries: Tertiary
Tertiary injuries result from individuals beingTertiary injuries result from individuals being
thrown by the blast wind3thrown by the blast wind3
The most common types of tertiary blastThe most common types of tertiary blast
injuries are>injuries are>9 Gead injuriesGead injuries
9 0-ull fractures0-ull fractures
9 :one fractures:one fractures
Treatment for most tertiary blast injuriesTreatment for most tertiary blast injuriesfollows established protocols for that speci=cfollows established protocols for that speci=c
injury3injury3
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Bombings: Injury Patterns 51
$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$* 1C!P
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Bombings: Injury Patterns 52
Blast Injuries: HuaternaryBlast Injuries: Huaternary
All e;plosionrelated injuries* illnesses*All e;plosionrelated injuries* illnesses*
or diseases not due to primary*or diseases not due to primary*
secondary* or tertiary mechanisms aresecondary* or tertiary mechanisms areconsidered Luaternary blast injuries3considered Luaternary blast injuries3
This includes e;acerbation orThis includes e;acerbation or
complications of e;isting conditions3complications of e;isting conditions3
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Bombings: Injury Patterns 53
Blast Injuries: HuaternaryBlast Injuries: Huaternary
The most common Luaternary blastThe most common Luaternary blastinjuries include>injuries include>9 :urns:urns
9 Gead injuriesGead injuries9 AsthmaAsthma
9 C7PDC7PD
9 7ther breathing problems7ther breathing problems
9 AnginaAngina
9 GyperglycemiaGyperglycemia
9 GypertensionGypertension
9 Crush injuriesCrush injuries
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Bombings: Injury Patterns 54
Blast Injuries: Blast LungBlast Injuries: Blast Lung
=sed with permission of C/!#T* $ecember 8???G 88
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Bombings: Injury Patterns 55
Blast Injuries: Blast LungBlast Injuries: Blast Lung
3eprinted from merican 4ournal of #urgery* F8?;: ?+?;*
vidan F et al: Blast Lung #urgeryJwith permission from E !(cerpta"edica Inc'
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Bombings: Injury Patterns 56
Blast Injuries: Blast LungBlast Injuries: Blast Lung
Clinical manifestationsClinical manifestations9 TachypneaTachypnea
9 Gypo;iaGypo;ia
9 CyanosisCyanosis9 ApneaApnea
9 heeFingheeFing
9 Decreased breath soundsDecreased breath sounds
9 GemoptysisGemoptysis
9 CoughCough
9 Chest painChest pain
9 DyspneaDyspnea
9 Gemodynamic instabilityGemodynamic instability
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Bombings: Injury Patterns 57
Blast Injuries: Blast LungBlast Injuries: Blast Lung
TreatmentTreatment
9 Gigh Now o;ygen su8cient to preventGigh Now o;ygen su8cient to prevent
hypo;emia via nonrebreather mas-hypo;emia via nonrebreather mas-
9 CPAPCPAP
9 .ndotracheal intubation.ndotracheal intubation
9 Budicious Nuid administration (similar toBudicious Nuid administration (similar to
that of pulmonary contusion)that of pulmonary contusion)
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Bombings: Injury Patterns 58
Blast Injuries: /eadBlast Injuries: /ead
Primary blast waves can causePrimary blast waves can cause
concussions or mild traumatic brainconcussions or mild traumatic brain
injury (/T:1) without a direct blow toinjury (/T:1) without a direct blow to
the headthe head
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Bombings: Injury Patterns 59
Blast Injuries: /eadBlast Injuries: /ead
Consider the pro;imity of the victim toConsider the pro;imity of the victim to
the blast particularly when giventhe blast particularly when given
complaints of>complaints of>
9 ,oss of consciousness,oss of consciousness
9 GeadacheGeadache
9 atigueatigue
9 Poor concentration* lethargy* amnesia* orPoor concentration* lethargy* amnesia* or
other constitutional symptomsother constitutional symptoms
9 0ymptoms of concussion and post traumatic0ymptoms of concussion and post traumatic
stress disorder (PT0D) can be similarstress disorder (PT0D) can be similar
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Bombings: Injury Patterns 60
Blast Injuries: T" 3uptureBlast Injuries: T" 3upture
Tympanic membrane rupture indicatesTympanic membrane rupture indicates
e;posure to an over pressuriFatione;posure to an over pressuriFation
wave3 1t may be found in victims withwave3 1t may be found in victims with
severe pulmonary* intestinal* or othersevere pulmonary* intestinal* or other
injuries* or it may be found in isolation3injuries* or it may be found in isolation3
1ts presence does not indicate that1ts presence does not indicate that
more sinister blast injuries e;ist3more sinister blast injuries e;ist3
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Bombings: Injury Patterns 61
Blast Injuries: T" 3uptureBlast Injuries: T" 3upture
=sed with permission of 6!4"* pril 9;;G @9: 8@@+8@9
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Bombings: Injury Patterns 62
Blast Injuries: !arBlast Injuries: !ar
.ar injuries may include not only T/.ar injuries may include not only T/
rupture* but also ossicular disruption*rupture* but also ossicular disruption*
cochlear damage* and foreign bodies3cochlear damage* and foreign bodies3
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Bombings: Injury Patterns 63
Blast Injuries: !arBlast Injuries: !ar
Presentation> acute hearing lossPresentation> acute hearing loss
(conductive* sensorineural)(conductive* sensorineural)
indings> auditory canal debris*indings> auditory canal debris*tympanic membrane rupture* ossiculartympanic membrane rupture* ossicular
disruption* cochlear damagedisruption* cochlear damage
Treatment> observation #@M ofTreatment> observation #@M of
ruptured tympanic membranes healruptured tympanic membranes healsensorineural hearing loss oftensensorineural hearing loss often
permanentpermanent
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Bombings: Injury Patterns 64
Blast Injuries: bdomenBlast Injuries: bdomen
Abdominal injuries (also called blastAbdominal injuries (also called blast
abdomen) include abdominalabdomen) include abdominal
hemorrhage and abdominal organhemorrhage and abdominal organ
perforationperforation
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Bombings: Injury Patterns 65
Blast Injuries: bdomenBlast Injuries: bdomen
Clinical manifestations include>Clinical manifestations include>9 Abdominal or testicular painAbdominal or testicular pain
9 TenesmusTenesmus
9 2ectal bleeding2ectal bleeding9 0olid organ lacerations0olid organ lacerations
9 2ebound tenderness2ebound tenderness
9 EuardingEuarding
9 Absent bowel soundsAbsent bowel sounds
9 0igns of hypovolemia0igns of hypovolemia
9 5ausea5ausea
9 JomitingJomiting
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Bombings: Injury Patterns 66
Blast Injuries: CombinedBlast Injuries: Combined
InjuriesInjuries
Combined injuries* especially blast andCombined injuries* especially blast and
burn injury or blast and crush injury*burn injury or blast and crush injury*
are common during an e;plosiveare common during an e;plosive
event3event3
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Bombings: Injury Patterns 67
Blast Injuries: CombinedBlast Injuries: Combined
InjuriesInjuries
Avoid tunnel vision during initial assessmentAvoid tunnel vision during initial assessment
Treatment protocols are often contradictoryTreatment protocols are often contradictory
9 :last lung vs3 burn injury* blast lung vs3 crush injury:last lung vs3 burn injury* blast lung vs3 crush injury
Budicious Nuid administration for adeLuateBudicious Nuid administration for adeLuate
tissue perfusion without volume overload maytissue perfusion without volume overload may
be reLuired in the multiple injured patient withbe reLuired in the multiple injured patient with
blast lungblast lung
9 Presence of additional injuries complicatesPresence of additional injuries complicatesadministration* rate* selection of Nuidsadministration* rate* selection of Nuids
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Bombings: Injury Patterns 68
Blast Injury: Combined InjuriesBlast Injury: Combined Injuries
Typical con=ned space (e3g3* a bus) injuriesTypical con=ned space (e3g3* a bus) injuries
Primaryblast lung* intestinal rupture* T/Primaryblast lung* intestinal rupture* T/
rupturerupture
0econdary0econdarypenetrating injury to head*penetrating injury to head*
eye* chest* abdomeneye* chest* abdomen
Tertiarytraumatic amputation* fracturesTertiarytraumatic amputation* fractures
to the face* pelvis* ribs* spineto the face* pelvis* ribs* spine
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Crush InjuryCrush Injury
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Bombings: Injury Patterns 70
Crush Injury: $e0nitionCrush Injury: $e0nition
An injury sustained when a body part isAn injury sustained when a body part is
subjected to a high degree* or prolongedsubjected to a high degree* or prolonged
presence* of force or pressurepresence* of force or pressure
9 Usually applied to both regional (e3g3 bodyUsually applied to both regional (e3g3 body
part) eKects and systemic eKects3part) eKects and systemic eKects3
Acute traumatic ischemia* with or withoutAcute traumatic ischemia* with or without
associated injuries* describes actual insultassociated injuries* describes actual insultto tissuesto tissues
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Bombings: Injury Patterns 71
Crush Injury: Crush #yndromeCrush Injury: Crush #yndrome
Term used to describe the systemsTerm used to describe the systems
manifestations of crush injury aftermanifestations of crush injury after
reperfusion of aKected body part(s)reperfusion of aKected body part(s)
3eprinted with permission of 2rtho5orld'com
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Bombings: Injury Patterns 72
Crush Injury:Crush Injury:
Compartment #yndromeCompartment #yndrome
1s a collection of localiFed signs and1s a collection of localiFed signs and
symptoms that result when thesymptoms that result when the
perfusion pressure falls below theperfusion pressure falls below the
tissue pressure in a closed anatomictissue pressure in a closed anatomic
space for su8cient time thatspace for su8cient time that
compromise of circulation and functioncompromise of circulation and function
of tissues involved occursof tissues involved occurs
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Bombings: Injury Patterns 73
Crush Injury: IncidenceCrush Injury: Incidence
##M of mass casualty situations##M of mass casualty situations9 5atural disasters* especially earthLua-es5atural disasters* especially earthLua-es
and tornadoesand tornadoes
9 0tructural collapse* with or without victim0tructural collapse* with or without victimentrapmententrapment
9 1ndustrial* farm or transportation accidents1ndustrial* farm or transportation accidents
9 :last injury (all types):last injury (all types)
9 CombatCombat9 Prolonged immobiliFation with majorProlonged immobiliFation with major
vascular or microvascular circulationvascular or microvascular circulationcompromisecompromise
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Bombings: Injury Patterns 74
Crush Injury: !(amples ofCrush Injury: !(amples of
eventsevents
Tyre* ,ebanon (?@$)Tyre* ,ebanon (?@$)9 :uilding collapse:uilding collapse
:eirut* ,ebanon (?@'):eirut* ,ebanon (?@')
9 /arine barrac-s bombed/arine barrac-s bombed
7-lahoma City (??#)7-lahoma City (??#)9 /urrah ederal :uilding/urrah ederal :uilding
bombedbombed
Qhobar* 0audi ArabiaQhobar* 0audi Arabia(??&)(??&)9 Qhobar Towers bombedQhobar Towers bombed =sed with permission of P Photo." Chaudhry
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Bombings: Injury Patterns 75
Crush Injury: PathophysiologyCrush Injury: Pathophysiology
Areas most aKectedAreas most aKected
9 ,ower e;tremities,ower e;tremities
9Upper e;tremitiesUpper e;tremities
9 PelvisPelvis
9 Eluteal regionEluteal region
9 Abdominal musclesAbdominal muscles
3eprinted with permission of 2rtho5orld'com
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Crush #yndromeCrush #yndrome
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Bombings: Injury Patterns 77
Crush #yndromeCrush #yndrome
/ay occur in absence of trauma and evolve/ay occur in absence of trauma and evolve
in the absence of early signs or symptomsin the absence of early signs or symptoms
9 Arterial thrombosis or embolismArterial thrombosis or embolism
9 0evere anemia0evere anemia9 To;insTo;ins
9 ,egitimate medications and drugs of abuse,egitimate medications and drugs of abuse
0ystemic eKects due to rhabdomyolysis and0ystemic eKects due to rhabdomyolysis and
reperfusion of hypo;ic and damaged tissuesreperfusion of hypo;ic and damaged tissuesand is the major cause of early mortalityand is the major cause of early mortality
h dC h # d
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Bombings: Injury Patterns 78
Crush #yndrome:Crush #yndrome:
PathophysiologyPathophysiology
2habdomyolysis2habdomyolysis
.Ru; from damaged muscle cells of>.Ru; from damaged muscle cells of>
9 PotassiumPotassium9 PurinesPurines
9 ,actic Acid,actic Acid
9 PhosphatePhosphate
9 /yoglobin/yoglobin9 ThromboplastinThromboplastin
9 CreatineCreatine
C h # dC h # d
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Bombings: Injury Patterns 79
Crush #yndrome :Crush #yndrome :
PathophysiologyPathophysiology
2eperfusion2eperfusion
9 0-eletal muscle damage greatest after0-eletal muscle damage greatest after
reperfusionreperfusion
9 0upero;ide radicals produced during reperfusio0upero;ide radicals produced during reperfusioattac-s free fatty acids* producing cellularattac-s free fatty acids* producing cellular
edema* death* and necrosisedema* death* and necrosis
9 5aQATP pump e;changes intracellular sodium5aQATP pump e;changes intracellular sodium
for calcium with further derangement offor calcium with further derangement ofintracellular metabolismintracellular metabolism
C h # dC h # d
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Bombings: Injury Patterns 80
Crush #yndrome:Crush #yndrome:
PathophysiologyPathophysiology
3esultant e-ects of derangements due to rhabdomyolysis3esultant e-ects of derangements due to rhabdomyolysis andandreperfusionreperfusion
PotassiumPotassium Gyper-alemiaGyper-alemia ArrhythmiasArrhythmias
CalciumCalcium GypocalcemiaGypocalcemia ArrhythmiasArrhythmias PhosphatePhosphate GyperphosphatemiaGyperphosphatemia 2enal damage2enal damage /yoglobin/yoglobin /yoglobinemia/yoglobinemia 2enal damage2enal damage luid shiftsluid shifts GypovolemiaGypovolemia 2enal failure2enal failure 2eperfusion2eperfusion ree radicalsree radicals 2enal damage2enal damage PurinesPurines GyperuricemiaGyperuricemia 2enal damage2enal damage Gypo;emiaGypo;emia ,actic acid,actic acid AcidosisAcidosis ThromboplastinThromboplastin Complement systemComplement system D1CD1C CreatinineCreatinine .levated serum levels.levated serum levels 0odium0odium AFotemiaAFotemia
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C h # d Cli i lC h # d Cli i l
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Bombings: Injury Patterns 82
Crush #yndrome: ClinicalCrush #yndrome: Clinical
PresentationPresentation
AKected part (usually limb)AKected part (usually limb)
9 Tense edema and decreased sensationTense edema and decreased sensation
9 7verlying s-in may be shiny* contused*7verlying s-in may be shiny* contused*
necroticnecrotic
/ay have penetrating wounds (worse/ay have penetrating wounds (worse
diagnosis)diagnosis)
C h # dC h # d
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Bombings: Injury Patterns 83
Crush #yndrome:Crush #yndrome:
Potential ComplicationsPotential Complications
Gyper-alemiaGyper-alemia
GypocalcemiaGypocalcemia
GyperphosphatemiaGyperphosphatemia /etabolic acidosis/etabolic acidosis
GypothermiaGypothermia
Acute 2enal failureAcute 2enal failure
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Bombings: Injury Patterns 84
Crush #yndrome: TreatmentCrush #yndrome: Treatment
Ereatest initial danger is after releaseEreatest initial danger is after releaseof crushed limb from entrapment withof crushed limb from entrapment withrestoration of circulationrestoration of circulation
/ainstay of treatment is aggressive/ainstay of treatment is aggressiveNuid resuscitation and bris- diuresisNuid resuscitation and bris- diuresis
Amount of tissue damage correlatesAmount of tissue damage correlateswith need for dialysiswith need for dialysis9 Cannot determine actual tissue damageCannot determine actual tissue damage
based on area of aKected body partbased on area of aKected body part
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Bombings: Injury Patterns 85
Crush #yndrome: TreatmentCrush #yndrome: Treatment
Delay in treatment associated withDelay in treatment associated with
greater morbidity and mortalitygreater morbidity and mortality
9 #M renal failure at & hours#M renal failure at & hours
9 M renal failure at $ hoursM renal failure at $ hours
9 2habdomyolysis induced renal failure has2habdomyolysis induced renal failure has
%M mortality%M mortality
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Bombings: Injury Patterns 86
Crush #yndrome: TreatmentCrush #yndrome: Treatment
PrehospitalPrehospital
Primary survey and initial stabiliFationPrimary survey and initial stabiliFation
(A:Cs)(A:Cs) luid resuscitation before patient isluid resuscitation before patient is
e;tricated with severe or prolongede;tricated with severe or prolonged
entrapment of limb or pelvis (moreentrapment of limb or pelvis (more
than a hand or foot)than a hand or foot)
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Bombings: Injury Patterns 87
Crush #yndrome: TreatmentCrush #yndrome: Treatment
GospitalGospital luid resuscitationluid resuscitation
:ris- diuresis:ris- diuresis
Diagnose and treat other metabolicDiagnose and treat other metabolic
derangementsderangements9 Gyper-alemiaGyper-alemia
9 GypocalcemiaGypocalcemia
Treat tissue damageTreat tissue damage Pain controlPain control
AgitationAgitation
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Compartment #yndromeCompartment #yndrome
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Bombings: Injury Patterns 89
Compartment #yndromeCompartment #yndrome
1s a collection of localiFed signs and1s a collection of localiFed signs and
symptoms that result when thesymptoms that result when the
perfusion pressure falls below theperfusion pressure falls below the
tissue pressure in a closed anatomictissue pressure in a closed anatomic
space for su8cient time thatspace for su8cient time that
compromise of circulation and functioncompromise of circulation and function
of tissues involved occursof tissues involved occurs
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Bombings: Injury Patterns 90
Compartment #yndromeCompartment #yndrome
Can lead to crush syndrome systemicCan lead to crush syndrome systemic
eKects if left untreated or inadeLuatelyeKects if left untreated or inadeLuately
treated3treated3
Photo used with permission of The Institute for 1ootand nkle 3econstruction at "ercy* Baltimore* "$
http://footandankle.mdmercy.com/conditions/trauma/images/compartment_1.jpg -
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Bombings: Injury Patterns 91
Compartment #yndromeCompartment #yndrome
0uggestive clinical =ndings0uggestive clinical =ndings 0imilar settings to crush injury* but may also0imilar settings to crush injury* but may also
occur with subacute traumaoccur with subacute trauma
:one fractures:one fractures
Gigh velocity penetrating injury to muscles inGigh velocity penetrating injury to muscles in
closed compartment with e;tensive tissueclosed compartment with e;tensive tissue
disruptiondisruption
Can also occur in subacute fashion due toCan also occur in subacute fashion due to
prolonged immobiliFation on hard surfaceprolonged immobiliFation on hard surface
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 92
Compartment #yndrome:Compartment #yndrome:
PathophysiologyPathophysiology
0igni=cance of muscle mass damage0igni=cance of muscle mass damage Typically occurs in major muscle groupsTypically occurs in major muscle groups
enclosed by inelastic* =brous sheathsenclosed by inelastic* =brous sheaths Tissue"muscle damage results in edemaTissue"muscle damage results in edema
in a closed volume spacein a closed volume space9 Progressive cycle of edema* perfusionProgressive cycle of edema* perfusion
compromise* tissue hypo;ia and cellularcompromise* tissue hypo;ia and cellular
derangement* further edema* etc3derangement* further edema* etc39 Untreated* will produce same eKects asUntreated* will produce same eKects as
crush injurycrush injury
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 93
Compartment #yndrome:p y
Clinical PresentationClinical Presentation
The # P6sThe # P6s
9 PainPain
9 PallorPallor
9 ParesthesiaParesthesia
9 ParalysisParalysis
9 PressurePressure
Progression of symptomsProgression of symptoms9 (sometimes the &(sometimes the &ththP)P)
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 94
Compartment #yndrome:Compartment #yndrome:
TreatmentTreatment
PrehospitalPrehospital
Primary survey and initial stabiliFationPrimary survey and initial stabiliFation
(A:C6s)(A:C6s) 0uspect compartment syndrome0uspect compartment syndrome
1mmobiliFe aKected part1mmobiliFe aKected part
Treat other injuriesTreat other injuries
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 95
Compartment #yndrome:Compartment #yndrome:
TreatmentTreatment
GospitalGospital
Primary survey* stabiliFation andPrimary survey* stabiliFation and
resuscitation* secondary surveyresuscitation* secondary survey Diagnosis through e;aminationDiagnosis through e;amination
Treat systemic eKects of compartmentTreat systemic eKects of compartment
syndrome similar to crush injurysyndrome similar to crush injury
treatmenttreatment
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Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 97
Compartment #yndrome:Compartment #yndrome:
Procedural #killsProcedural #kills
/easuring compartment pressures/easuring compartment pressures
Use of QetamineUse of Qetamine
asciotomiesasciotomies
Photo used with permission of Immediate ction #ervices
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 98
Compartment #yndrome:Compartment #yndrome:
Procedural #killsProcedural #kills
asciotomies are a de=nitiveasciotomies are a de=nitive
treatment* but tissue pressure attreatment* but tissue pressure at
which it is reLuired is controversial3which it is reLuired is controversial3
Jarying views include>Jarying views include>9 .arly fasciotomy when pressures S%# mm Gg.arly fasciotomy when pressures S%# mm Gg
or when within $ mm Gg of diastolic pressureor when within $ mm Gg of diastolic pressure
9 Delayed fasciotomy (beyond %@!$ hours)Delayed fasciotomy (beyond %@!$ hours)increases ris- of sepsis and death due toincreases ris- of sepsis and death due to
e;tensive necrotic tissuese;tensive necrotic tissues
Compartment #yndrome:Compartment #yndrome:
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Bombings: Injury Patterns 99
Compartment #yndrome:Compartment #yndrome:
Procedural #killsProcedural #kills
asciotomyasciotomy9 Provide adeLuate analgesia and anesthesiaProvide adeLuate analgesia and anesthesia
9 Preoperative broad spectrum antibioticsPreoperative broad spectrum antibiotics
9 .nsure A,, compartments in e;tremity.nsure A,, compartments in e;tremitychec-ed for pressures (multiplechec-ed for pressures (multiplecompartments may be aKected)compartments may be aKected)
9 Chec- compartment pressures before andChec- compartment pressures before andafter fasciotomyafter fasciotomy
9 .nsure adeLuate hemostasis.nsure adeLuate hemostasis
9 Pac- wound open and use large bul-yPac- wound open and use large bul-ydressingsdressings
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Bombings: Injury Patterns 100
!ntrapped Patient Treatment!ntrapped Patient Treatment
TreatmentTreatment9 luid resuscitation before victim e;tricatedluid resuscitation before victim e;tricated
, 50 bolus* followed by 3# , per hour infusion , 50 bolus* followed by 3# , per hour infusion
9 ,imb stabiliFation,imb stabiliFation9 /inimiFe potential systemic eKects of reperfusion/inimiFe potential systemic eKects of reperfusion
Consider use of tourniLuets prior to releaseConsider use of tourniLuets prior to release
9 Consider al-aliniFation by giving ampule ofConsider al-aliniFation by giving ampule ofsodium bicarbonate (# m.L) immediately priorsodium bicarbonate (# m.L) immediately prior
to e;trication* followed by adding ampule ofto e;trication* followed by adding ampule ofsodium bicarbonate to each liter of 50 infused atsodium bicarbonate to each liter of 50 infused at3# , per hour as above -eep second 1J line3# , per hour as above -eep second 1J lineopen without sodium bicarbonateopen without sodium bicarbonate
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Bombings: Injury Patterns 101
1ield mputation1ield mputation
1ndications>1ndications>
9 Unable to safely e;tricateUnable to safely e;tricate
9 Continued environmental to;ins poseContinued environmental to;ins pose
haFard to victim and rescuershaFard to victim and rescuers
9 Erossly prolonged time until de=nitiveErossly prolonged time until de=nitive
treatment even after e;tricationtreatment even after e;trication
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Bombings: Injury Patterns 102
1ield mputation1ield mputation
:est performed by trauma or orthopedic:est performed by trauma or orthopedic
surgeonsurgeon
ew ./0 systems have protocolsew ./0 systems have protocols
.nsure adeLuate analgesia and.nsure adeLuate analgesia and
anesthesiaanesthesia
9 Qetamine (dissociative anesthetic)Qetamine (dissociative anesthetic)
Decreases or only minimally increases serumDecreases or only minimally increases serumpotassium levelspotassium levels
Patient maintains airway despite adeLuatePatient maintains airway despite adeLuate
anesthesiaanesthesia
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Bombings: Injury Patterns 103
Photo used with permission of Immediate ction#ervices
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"ilitary !(perience"ilitary !(perience
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"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 106
"ilitary !(perience"ilitary !(perience
Death 2ates After oundingDeath 2ates After ounding
9 2evolutionary ar2evolutionary ar %$M%$M
9 1111 ''
9 QoreanQoreanarar $#$#
9 Jietnam arJietnam ar $#$#
9 Persian Eulf arPersian Eulf ar $#$#
9 Elobal ar on Terror (E7T)Elobal ar on Terror (E7T)
"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 107
"ilitary !(perience"ilitary !(perience
/edical Advances from the E7T/edical Advances from the E7T
9 .;panded use of Damage Control 0urgery.;panded use of Damage Control 0urgery
9 hole bloodhole blood
9 TourniLuetsTourniLuets
9 Gemostatic agentsGemostatic agents
9 Gemostatic dressingsGemostatic dressings
"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 108
"ilitary !(perience"ilitary !(perience
Photo used courtesy of Bio Cybernetics International
"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 109
"ilitary !(perience"ilitary !(perience
Damage Control 0urgeryDamage Control 0urgery
9 TechniLue -nown for $ years* but slow toTechniLue -nown for $ years* but slow to
be acceptedbe accepted
9 Central tenet> Avoid the +Deadly Triad4Central tenet> Avoid the +Deadly Triad4 GypothermiaGypothermia
CoagulopathyCoagulopathy
/etabolic acidosis/etabolic acidosis
.ach condition worsens both of the others.ach condition worsens both of the others
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"ilit ! i"ilit ! i
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Bombings: Injury Patterns 111
"ilitary !(perience"ilitary !(perience
Damage Control 0urgeryDamage Control 0urgery
9 2esuscitate in 1CU>2esuscitate in 1CU> 5ormaliFe blood pressure5ormaliFe blood pressure
5ormaliFe body temperature5ormaliFe body temperature 5ormaliFe coagulation factors5ormaliFe coagulation factors
9 2eturn to 72 $@ hours for de=nitive2eturn to 72 $@ hours for de=nitive
surgerysurgery
"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 112
"ilitary !(periencey p
1J Gemostasis1J Gemostasis
9 152S3# on arrival predictive of need for152S3# on arrival predictive of need for
massive transfusion (/T)massive transfusion (/T)
9 resh thawed plasma best resuscitationresh thawed plasma best resuscitationNuid in /TNuid in /T 7ptimum ratio of plasma to crystalloid > to7ptimum ratio of plasma to crystalloid > to
avoid clotting factor dilution S#Mavoid clotting factor dilution S#M
9 ,ess crystalloid (acidotic* inNammatory*,ess crystalloid (acidotic* inNammatory*adverse eKects on coagulation)adverse eKects on coagulation) Ge;tend (a colloid) preferableGe;tend (a colloid) preferable
"ilitary !(perience"ilitary !(perience
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Bombings: Injury Patterns 113
"ilitary !(periencey p
1J Gemostasis1J Gemostasis
9 Use of fresh whole bloodUse of fresh whole blood
9 .arly use of cryoprecipitate.arly use of cryoprecipitate
9 2ecombinant actor J11a (rJlla)2ecombinant actor J11a (rJlla)
"ilitary !(perience"ilitary !(perience
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a y pe e cey p
TourniLuetsTourniLuets
9 ,iberal use encouraged for any signi=cant,iberal use encouraged for any signi=cant
e;tremity hemorrhagee;tremity hemorrhage
9 5o adverse events seen in cases when5o adverse events seen in cases whenapplied inappropriatelyapplied inappropriately
9 Apply early (+=rst resort not last resort4)Apply early (+=rst resort not last resort4)
9 .very soldier carries at least one at all.very soldier carries at least one at all
timestimes
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"ilitary !(perience"ilitary !(perience
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"ilitary !(perience"ilitary !(perience
GemCon (chitosan)GemCon (chitosan)
9 7riginally available as a bandage7riginally available as a bandage
9 5ow available in roll that can be stuKed5ow available in roll that can be stuKed
into woundinto wound
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#pecial Considerations#pecial Considerations
#pecial Considerations#pecial Considerations
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#pecial Considerations#pecial Considerations
PregnancyPregnancy
ChildrenChildren
.lderly.lderly DisabledDisabled
,anguage barriers,anguage barriers
#pecial Considerations:#pecial Considerations:
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pp
PregnancyPregnancy
1njuries to the placenta are possible and must1njuries to the placenta are possible and mustbe detectedbe detected
0econd or third trimester of pregnancy should0econd or third trimester of pregnancy should
be admitted for continuous fetal monitoringbe admitted for continuous fetal monitoring
The placental attachment is at ris- for primaryThe placental attachment is at ris- for primaryblast injuryblast injury
0creening test for fetalmaternal hemorrhage0creening test for fetalmaternal hemorrhagein second or third trimester of pregnancyin second or third trimester of pregnancy
9 Positive test reLuires mandatory pelvic ultrasound*Positive test reLuires mandatory pelvic ultrasound*fetal nonstress test monitoring* andfetal nonstress test monitoring* andobstetrics"gynecology (7:"EW5) consultation3obstetrics"gynecology (7:"EW5) consultation3
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pp
ChildrenChildren
Gistory of event or patient6s complaints may beGistory of event or patient6s complaints may be
di8cult to obtain3di8cult to obtain3
Pulmonary contusion is one of the most commonPulmonary contusion is one of the most common
injuries from blunt thoracic trauma3 The injuryinjuries from blunt thoracic trauma3 The injury
may not be clinically apparent initially and shouldmay not be clinically apparent initially and should
be suspected when abrasions* contusions* or ribbe suspected when abrasions* contusions* or rib
fractures are present3 A chest ;ray is essential infractures are present3 A chest ;ray is essential in
diagnosis especially when blast lung is suspected3diagnosis especially when blast lung is suspected3
0pecialiFed eLuipment0pecialiFed eLuipment 1denti=cation of regional pediatric trauma1denti=cation of regional pediatric trauma
facilitiesfacilities
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p$isabled$isabled
Consideration should be given toConsideration should be given to
patients with underlying medicalpatients with underlying medical
conditionsconditions
Untreated or inadeLuately treatedUntreated or inadeLuately treated
fractures may lead to severe and longfractures may lead to severe and long
lasting disabilitieslasting disabilities
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Photo used courtesy of .wikpoint
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Psychological IssuesPsychological Issues
Psychological IssuesPsychological Issues
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Psychological IssuesPsychological Issues
0eLuelae from an e;plosive event0eLuelae from an e;plosive event
9 AngerAnger
9 rustrationrustration
9 GelplessnessGelplessness
9 Desire to see- revengeDesire to see- revenge
Psychological IssuesPsychological Issues
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Psychological IssuesPsychological Issues
.vents that aKect mental health.vents that aKect mental health
9 ,ittle or no warning,ittle or no warning
9 Un-nown duration of the eventUn-nown duration of the event
9 Potential threat to personal safetyPotential threat to personal safety
9 Un-nown health ris-sUn-nown health ris-s
Psychological IssuesPsychological Issues
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Psychological IssuesPsychological Issues
Tips for 2espondersTips for 2esponders
9 Promotion of safetyPromotion of safety
9 Promote calmPromote calm
9 Promote connectednessPromote connectedness
9 Promote selfe8cacyPromote selfe8cacy
9 Promote hopePromote hope
$iscussion Topics: 3eview$iscussion Topics: 3eview
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$iscussion Topics: 3eview$iscussion Topics: 3eview
:ac-ground:ac-ground
.;plosive .vents.;plosive .vents
:last 1njuries:last 1njuries
9 Primary* 0econdary* Tertiary*
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$iscussion Topics$iscussion Topics
0urge Capacity 1ssues0urge Capacity 1ssues
Gospital after /adrid bombing saw '$Gospital after /adrid bombing saw '$
patients in $3# hourspatients in $3# hours
5eed to surge> CT* 72 suites* staK* and5eed to surge> CT* 72 suites* staK* and
supplies (blood* etc3)supplies (blood* etc3)
Gidden nature of injuries can lead toGidden nature of injuries can lead to
dangerous overtriage and undertriagedangerous overtriage and undertriage