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Blast injury

Blast injury. Presentation by FLTLT Debbie Knight Aeromedical Evacuation Facility. introduction. Explosions are physical, chemical or nuclear reactions that involve the rapid release of considerable amounts of energy. ICRC estimate 2,000 people killed or injured /month.

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Blast injury

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  1. Blast injury Presentation by FLTLT Debbie Knight Aeromedical Evacuation Facility

  2. introduction • Explosions are physical, chemical or nuclear reactions that involve the rapid release of considerable amounts of energy. • ICRC estimate 2,000 people killed or injured /month. • Terrorist devices and military ordnance contain high explosives.

  3. Classification of injury

  4. Explosive devices

  5. Primary Blast Injury • Effects air filled structures. • Pulmonary barotrauma is the most common fatal PBI. • Acute gas embolism. Air bubbles in blood vessels in the brain or spinal cord. • Intestinal barotrauma is more common with underwater than air blast injuries. • The ear is the most susceptible to PBI. Ossicle fracture can occur with high energy explosions.

  6. Secondary Blast Injury • Caused by flying objects striking individuals • This mechanism produces the most casualties. Ie, th glass façade of the Alfred P. Murrah Building in Oklahoma City shattered into thousands of heavy glass chunks that were propelled through the building. • Grenades are designed specifically for this • Civilian terrorist bombers often put screws or other small objects in to increase fragmentation effects.

  7. Tertiary Blast Injury • Caused by objects flying through the air and striking other objects, generally from high-energy explosions. • A person with this kind of injury, usually was close to detonation. In oklahoma City, this accounted for a lot of paediatric cases of fractured skull, and long bone injuries.

  8. Quaternary Blast Injury • Other injuries caused by the explosion • Toxic inhalations, radiation exposure, burns (chemical or thermal) • Crush injuries from collapsed buildings. • Beware going into buildings, as possible secondary toxins, ie halon fire systems (bromine, fluorine, chlorine) • Military white phosphorous, magnesium hydroxide. • Radiation safety officer in hospital should be advised.

  9. pathophysiology • Higher incidence of primary blast injury (PBI) if; • Enclosed space • Victim close to explosion • Individual wearing body armour • Large Explosion • Fuel-air explosives

  10. INDICATIONS FOR HIGH PRESSURE WAVE • Tympanic Membrane rupture (40kpa). Israeli experience of 137 pts with ear drum perforation were discharged with no evidence of internal primary blast injury. • 18 patients who developed pulmonary blast lung, had NO eardrum rupture. • Proximity to blast is very important • Waves reflected by solid surfaces, ie walls • Petechiae in hypopharynx and larynx

  11. Message for Combat Medics • History of where the person was in the blast is very important. It will allow the doctors to determine the possiblity of primary blast injury, and make them go and look for further injury. • Especially true if member has body armour, which has protected them from secondary blast effect, so their injuries may not be as apparent. • Keep an eye on your patients, they may deteriorate suddenly, and require bag and mask. Always give high flow oxygen.

  12. Blast related injury

  13. Pbi of lung • Pressure waves propogate through lungs and cause; • Tears in the alveolar walls • Disruption of alveolar capillary interface • Giant emphysematous spaces filled with blood • Stripping of airway epithelium • Air penetration into pleura, mediastinum, skin and blood vessels.

  14. Symptoms and signs • Symptoms; • Dyspnoea • Chest pain • Haemoptysis • Cough • Worsening hypoxaemia despite other injuries • Signs • Increased RR, Cyanosis, decreased BS, dull PN Subcutaneous crepitus, shock • Clinical picture may take 24-48 hours to develop

  15. Jerusalem experience • A 1996 study from a civilian bus explosion where 47 people died, 18 people survived and 15 people had evidence of primary blast lung injury. • All were admitted to hospital within 1 hour • Blast Lung Injury severity score provided assistance with triage which affected treatment mode and outcome.

  16. Bli severity score

  17. TREATMENT/OUTCOMES

  18. VENTILATION STRATEGIES • POSITIVE PRESSURE VENTILATION • PRESSURE SUPPORT VENTILATION • LUNG PROTECTIVE VENTILATION • PRESSURE CONTROLLED • VOLUME CONTROLLED • ECGE • NO/HFJV

  19. ARTERIAL GAS EMBOLISM • SYMPTOMS • BLINDNESS, WEAKNESS, SENSORY LOSS • CHEST PAIN • HEADACHES, VERTIGO, ATAXIA, LOC • SIGNS • AIR IN RETINAL VESSELS • FOCAL NEURO DEFICITS • LIVEDO RETICULARIS • CONVULSIONS • FACIAL OR TONGUE BLANCHING

  20. GASTROINTESTINAL PBI • SYMPTOMS • ABDOMINAL PAIN • NAUSEA AND VOMITING • HAEMATEMESIS • RECTAL PAIN/TENESMUS • TESTICULAR PAIN • SIGNS • ABDOMINAL TENDERNESS, REBOUND, GUARDING • DECREASED BOWEL SOUNDS • HYPOVOLAEMIA • More common following water blast injury • Effects may be delayed for 2 days

  21. INDICATIONS FOR EX. LAP • CT SCAN FINDINGS • Extraluminal contrast/gas • Haemoperitoneum • Solid organ injury/disruption • Hypodense accumulation of fluid • Bowel wall haematoma • Positive DPL • Overt Peritoneal Signs

  22. Orthopaedic injuries • Traumatic amputation of limbs is unusual in survivors. • If caused by over pressure, amputation is near joints. (Fast jet pilots ejecting) Coupling stress waves fracture bone tissue, particularly upper 1/3 tibia and upper or lower 1/3 femur.

  23. The ear • Most common, cause by positive element of blast wave. • Not a good indicator of other primary blast injury • Ossicular injuries • Inner ear injuries leads to permanent Hearing Loss in 30-55% • 80% TM rupture heals spontaneously

  24. eye injuries • Most eye injuries are secondary to burns, and fragment foreign bodies. PBI of eye causes globe rupture. • 10% all blast injury patients will have eye injuries • Determine if person can see. • Check pupils • Can the patient blink/close the eye? If not the apply a clear protective plastic cover, ie food wrap with a little vaseline • Apply eye pad and eyeshield for perforating injuries. Can make sheilds from a circle of stiff paper. Remember anti-emetic to prevent increased pressure from vomiting, evacuate patient at less than 1000 ft to prevent barotrauma and herniation of eye contents.

  25. Treatment of pbi • KISS (KEEP IT SIMPLE AND SWEET) • AIRWAY, (OXYGEN!!!!!) • BREATHING (WATCH FOR DISTRESS) • CIRCULATION, WITH HAEMORRHAGE CONTROL • CLEAR PLASTIC WRAP FOR BURNS. • MINIMISE MOVEMENT, KEEP ALTITUDE LOW IF POSSIBLE. ANTI EMETIC IS GOOD FOR PREVENTING PRESSURE EFFECTS OF VOMITING.

  26. CONCLUSIONS • Majority of injuries 2° and 3° injuries • Early death occurs through • AGE • Traumatic amputations • Head injuries • Severe primary blast lung injury • Victims close to the blast severely injured • Consider BLI severity score to triage • TM rupture is not a good indication of primary blast injury. • Air evacuation considerations, keep low and smooth. • HISTORY, HISTORY, HISTORY!

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