“Preparing Our Communities”

1. “Preparing Our Communities” Welcome!

2. Faculty Disclosure • For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing education credit authorizing organizations: • In order to assure the highest quality of CME programming, the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to the start of an educational activity. • The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off label usage during this course.

3. Chapter 3:Explosive and Traumatic Events

4. Chapter 3 Objectives • Match each category of blast injury with its appropriate characteristics, body parts affected, and types of injuries that would occur. • Apply the Disaster Paradigm and the concepts of MASS triage to traumatic and explosive events • List scene and safety concerns and how to prepare and respond appropriately to each. • Analyze injuries caused by explosives and develop strategies for managing these injury types.

5. Explosive Events • Scope of problem • 38,362 Explosive Events between 1988 - 1997 • Over 50,000 lbs explosives stolen 1993-1997

6. Newer Devices • Enhanced Blast Weapons • Fuel air explosives • Munitions • Newer technology • Improvised Explosive Devices • Simple pipe bombs • Carried devices • Large-scale vehicle

7. Explosive Events • Explosion- conversion of solid or liquid explosive material into gas causing energy release • Low versus High explosive • Degree of blast injury governed by 3 factors: • Size of charge • Distance • Surrounding environment

8. Blasts Reflected By A Solid Surface • Magnified many times • Anyone between a blast and a wall can have more severe injuries • Body armor may protect from projectiles but could also exacerbate the blast effect

9. D-I-S-A-S-T-E-R Paradigm • D = Detection • I= Incident Command • S= Safety and Security • A = Assess Hazards • S = Support • T = Triage and Treatment • E= Evacuation • R = Recovery

10. D-I-S-A-S-T-E-R ParadigmDetection • Traumatic and explosive events are typically not as predictable as natural disasters • Most common device utilized by terrorists • Simultaneous events

11. D-I-S-A-S-T-E-R ParadigmIncident Command • The Incident Commander should manage traumatic and explosive events like any other disaster incident. • Law enforcement may have lead

12. D-I-S-A-S-T-E-R ParadigmSecurity and Safety • Scene must be secured and perimeter established • Typically a law enforcement role. • Scene security safety hazards must be relayed expeditiously to the Incident Commander

13. D-I-S-A-S-T-E-R ParadigmAssess Hazards • Downed power lines? • Debris? • Fire? • Blood and bodily fluids? • Hazardous materials? • Chemical, radiological, or biological contamination? • Secondary explosive devices? • Structural instability?

14. D-I-S-A-S-T-E-R Paradigm Support • May quickly overwhelm a community’s medical resources • Coordination with trauma and burn centers is essential

15. D-I-S-A-S-T-E-R ParadigmTriage and Treatment • Injuries caused by blast • Primary • Secondary • Tertiary • Quaternary • Quinary • Triage • ABC’s of treatment

16. Primary Blast Injuries • Unique to explosions with high explosives • Causes damage to air filled organs • Causes: • Blast Lung • TM rupture and middle ear damage (#1) • Not a good marker for more serious injury • Abdominal injury • Traumatic brain injury http://www.defence.gov.au/dpe/dhs

17. Primary Blast InjuriesPulmonary Pressure Differentials: • Tear Alveolar Walls • Disrupt Alveolar-Capillary Interface • Discrete Contusions • Multi-Focal Hemorrhage • Hemo-Pneumothorax • Traumatic Emphysema • Subcutaneous Air • Alveolar-Venous Fistulae (air emboli)

18. Primary Blast InjuriesPulmonary Signs: • Difficulty in Completing Sentences in One Breath • Rapid, Shallow Respirations • Poor Chest Wall Expansion • Decreased Breath Sounds • Wheezing and/or Hemoptysis • Cutaneous Emphysema

19. Primary Blast InjuriesPulmonary CXR:Characteristic “Butterfly” Pattern www.bt.cdc.gov/masscasualties/ blastlunginjury.asp

20. Primary Blast Injuries Systemic Air Embolism • Vascular Obstruction… …referable to location of occlusion: • Chest pain (coronary symptoms) • Focal Neurological Deficit • Blindness • Tongue Blanching • Cutis Marmorata www.medscape.com/viewarticle/408472_3

21. Primary Blast Injuries Also: Systemic Air Embolism • Most Common Cause of PBI - Related Sudden Deaths Over the 1st hour • Direct Leak Between Pulmonary Vasculature & Bronchial Tree • Low Venous Pressure and High Airway Pressure Creates Pressure Gradient • Decompensation is Often Immediately after Endotracheal Intubation and Use of Positive Pressure Ventilation (PPV)

22. Treatment Pulmonary Blast Injury / Arterial Gas Embolism • Spontaneous Respiration Preferred if Risk for Systemic Air Embolism • Supplemental O2 Also Improves Bubble Resorption (nitrogen shift) • Hyperbaric O2 Rx May Be Effective for AGE • Airway Pressure < Vascular Pressure • Maximize Preload, Minimize Further Barotrauma and Keep Injured Lung in Dependent Position • Lung Isolation & Unilateral Intubation • Delay Any Non-Emergent Surgery

23. Secondary Blast Injuries • Penetrating trauma caused by acceleration of shrapnel or blast debris • Any body part can be affected • Causes: • Penetrating ballistic fragmentation • Blunt injuries • Eye injuries

24. Secondary Blast Injuries • Entrance wounds may be deceptively small and when time allows a detailed exam is required www.divestmentwatch.com/cities/6skull.jpg

25. Tertiary Blast Injuries • Displacement of body or structural collapse • Body displacement • Any body part could be affected • Fracture and traumatic amputation • Closed and opened brain injury • Structure Collapse • Crush injury • Compartment syndrome

26. Compartment Syndrome • Ecchymosis,Tenderness, Swelling, • Pain with Passive Motion • Hypotension and Shock • Numbness and Flaccid Paralysis • May Have Loss of Distal Pulses

27. Crush Syndrome • Traumatic Rhabdomyolysis • Releases Intracellular Toxins • Sodium, Calcium, Water Shift into Damaged Muscle Cells • Potassium, Phosphate, Lactate, Myoglobin Shift Out of Cells • Potentially Toxic When Circulated through the Blood Stream

28. Peaked T Waves from Hyperkalemia

29. Treatment of Crush Injury / Crush Syndrome Treatment of Hyperkalemia…. • If EKG Evidence of Cardiotoxicity, Treat with IV Glucose and Insulin (1 ampule D50 with 10 units regular insulin) • Inhaled Beta-2 Agonist • Consider Exchange Resin • Calcium Chloride in Critical Collapse • Dialysis (hemo, peritoneal, CAVH) • Remember When Choosing Paralytics

30. Treatment of Crush Syndrome • Early Aggressive Management • Initiate IV Normal Saline ASAP (prior to extrication if possible) • Consider tourniquet for mangled extremity (prior to extrication) • Saline, NOT Lactated Ringer’s • May Need 1.0 - 1.5 Liters per hour • Goal 200 - 300 cc/hr Urine Output • ?? Bicarbonate, ?? Mannitol • Refer for (or perform) Fasciotomy if Compartment Syndrome Present

31. Quaternary Blast Injuries • All explosion related to: • Burns and burn related injuries • Environmental toxins • Exacerbation of underlying illness

32. Quinary Blast Injuries • Purposeful addition of agents • Chemical • Biological • Nuclear

33. D-I-S-A-S-T-E-R ParadigmTriage and Treatment • Difference in the volume of casualties and injury patterns • Accurate triage reduces the acute burden on medical facilities and organizations • Initial treatment focuses on ABC’s (CAB’s for patients with exsanguinating hemorrhage!)

34. Triage • Be aware that patients with TM rupture may not be able to hear you! • FAST exam maybe used for rapid triage in field or ED for patients that may need OR • CT of head, thorax, abdomen can triage patients that need to go directly to OR

35. Treatment ABC’s • A = Airway • Injuries to the airway are first priority unless there is exsanguinating hemorrhage. • Significant airway burns need rapid intubation

36. Treatment ABC’s • B = Breathing • Treat pneumothorax • Consider escharotomy for patients with circumferential thoracic (and extremity) burns

37. Treatment ABC’s (CAB’s) • C = Circulation • External hemorrhage should be controlled with direct pressure when possible • Tourniquet may be placed if bleeding not controlled with conventional means Improvised tourniquet Commercially Available Tourniquet

38. Treatment ABC’s (CAB’s) • C = Circulation • Consider use of advanced hemostatic agents • Delayed primary closure should be utilized • Whole blood transfusion maybe life saving

39. Treatment ABC’s (CAB’s) • C = Circulation • Resuscitate controlled hemorrhage to normal BP • Resuscitate uncontrolled hemorrhage to: • Improved mental status or SBP 90 • Patient needs to get to OR for hemorrhage control

40. Treatment ABC’s Burns • Parkland Formula • Adult: 2-4 mls LR x kg body weight x TBSA. - Give half in the first 8 hours and remainder over the next 16 hours • Children over 10 years: Use the same formula as for adults • Children under 10 years: Start with 3-4 mls LR x kg body weight x TBSA

41. Treatment ABC’s • D = Disability • Obtain baseline neurological exam • Consider AGE in patients with central neurological deficits and primary pulmonary blast injury • Consider psychological impact of the disaster

42. Treatment ABC’s • E = Exposure, Elimination, Environmental Control • Allow for thorough examination • hypothermia may develop • warm intravenous fluids, warm blankets • removal from the outdoor environment as quickly as feasible are important.

43. D-I-S-A-S-T-E-R ParadigmE = Evacuation • Casualties will benefit most from rapid, orderly scene evacuation and hospital management • Managing a balanced flow of patients to regional facilities is paramount to avoid overwhelming any single hospital • Consider utilization of aeromedical transport

44. D-I-S-A-S-T-E-R ParadigmRecovery • The recovery phase begins once most casualties have been removed from the scene • A thorough analysis of the post-incident management is imperative to determine the overall successes and shortfalls of the system. • Psychological Support

45. Summary Highlights • Utilize Good Standard Trauma Care (e.g., BTLS, ATLS) • Unique Aspects in Blasts: Blast Lung, Ears, Abdomen; Crush Syndrome, Tri-Threat of Blunt, Penetrating, Thermal Injuries, Emboli, Compartment Syndromes, Contaminants • High Risk Environment for 2nd Pass: Secondary Devices, Unstable Structures, Contaminant Release, Secondary Fires, etc…

46. Questions?