BLAST INJURIES Fact Sheets for Professionals

National Center for Injury Prevention and Control Division or Injury ResponseU.S. Department of Health and Human Services Centers for Disease Control and Prevention

CS218119-A Blast Injuries In an instant, an explosion or blast can wreck havoc; producing numerous casualties with complex, technically challenging injuries not commonly seen after natural disasters such as floods or hurricanes. To address this issue, Centers for Disease Control and Prevention (CDC), in collaboration with partners from the Terrorism Injuries Information, Dissemination and Exchange (TIIDE) Project, as well as other experts in the field, have developed fact sheets for health care providers that provide detailed information on the treatment of blast injuries. These fact sheets address background, clinical presentation, diagnostic evaluation, management and disposition of blast injury topics and are available in many languages including Arabic, Bengali, Spanish, French, Chinese, Hindi, Marathi, Russian, and Urdu.

Additional terrorist bombing and mass casualty event preparedness and response information for professionals including fact sheets, multimedia tools, and communication messages are available for download and order from CDC’s website at http://emergency.cdc.gov/BlastInjuries.

Post these fact sheets in emergency departments where visible and accessible to staff only and include the fact sheets in your hospital emergency plan binders.

Note: Please use caution with posting these fact sheets in public areas, such as hospital waiting rooms, as this information may cause alarm. • • Lung Injury Primary BlastInjury • Blast Injuries • • • • • • • • Key Concepts • • • • • • • • • •  timeofinitialevaluation,Signs usuallypresentat butmaybedelayedupto48hours High flow O2sufficienttoprevent hypoxemiaviaNRBmask,High flow CPAP, orETtube CXR: “butterfly”pattern withdyspnea,Suspect inanyone cough, hemoptysis, blast orchest pain following Varies petechiae toconfluenthemorrhages fromscattered to theheadortorso withskullfractures,Reported tobemorecommoninpatients >10%BSAburns, injury andpenetrating — Quaternary: All otherinjuriesfromtheblast — Tertiary: Injuriesfromdisplacementofvictimbytheblastwind — Secondary: fromprojectiles(bombfragments, Injury flyingdebris) — Primary: fromover-pressurization surface impactingthebody Injury force(blastwave) tetanustoxoidvaccine(ifnotcurrent) (within 7days)andage-appropriate For thosewithinjuriesresultinginnonintactskinormucousmembraneexposure, Bimmunization hepatitis and firstreceivers offirstresponders contamination radiologicalsecondary Universal precautionseffectivelyprotectagainst ofthevictim;riskexposuretocaregiversissmall contamination Triage proceduresshould neverbedelayedbecauseofthepossibilityradioactive andlifesaving thepotentialforchemicaland/orradiologicalcontamination All bombeventshave exposedtoablast examineandassesspatients Repeatedly arepredominantlyseeninconfinedspaceexplosions blastinjuriesinsurvivors Primary morbidityandmortality with greater Explosions inconfinedspaces(buildings, largevehicles, areassociated mines)and/orstructuralcollapse injuriesandblunttrauma Predominant injuriesinvolvemultiplepenetrating Most severelyinjuredarriveafterthelessinjured, andgodirectlytotheclosest whobypassEMStriage hospitals Expect halfofallinitialcasualtiestoseekmedicalcareoveraone-hourperiod seldomseenoutsidecombat ofinjury Bombs andexplosionscancauseuniquepatterns TM rupture, andairembolization, damage viscusinjury hollow pulmonary Crush injuries, burns, asphyxia, toxicexposures, ofchronicillness exacerbations trauma,Blunt/penetrating fractures, amputations andtraumatic Penetrating trauma, injuries, fragmentation blunttrauma    BLAST INJURIES Essential Facts

U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Essential Facts Essential Facts • • • • • Disposition • • • • • • • Primary BlastInjury • • • • • • • • Other Injury • Ear Injury • Abdominal Injury This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl This factsheet ispartofaseriesmaterials     Patients with ear injury may have tinnitus or deafness; communications andinstructionsmay needtobewritten tinnitusordeafness;communications mayhave Patients withearinjury ofwounds,Close follow-up headinjury, eye, ear, complaints andstress-related Admit 2ndand3rdtrimesterpregnanciesformonitoring injuries Discharge decisionswillalsodependuponassociated No definitiveguidelinesforobservation, admission, ordischarge  formassivehemoptysis, failure Endotracheal intubation impendingairwaycompromiseorrespiratory volumeoverload contusion;ensuretissueperfusionbutavoid similartopulmonary Fluid management Air embolismcanpresentasstroke, MI, acuteabdomen, blindness, deafness, spinalcordinjury, claudication Consider prophylacticchesttubebeforegeneralanesthesiaorairtransport Prompt decompressionforclinical evidenceofpneumothoraxorhemothorax Significant percentage of survivors will have seriouseyeinjuries willhave ofsurvivors Significant percentage Consider possibilityofexposuretoinhaledtoxins(CO, CN, MetHgb)inbothindustrialandterroristexplosions prolonged extrication, severeburns, andsomepoisonings Compartment syndrome, rhabdomyolysis, withstructuralcollapse, andacuterenalfailureareassociated closure wounds,Consider delayedprimary forgrosslycontaminated status andassesstetanusimmunization Concussions arecommonandeasilyoverlooked Traumatic limbisamarkerformulti-systeminjuries ofany amputation external canal, otorrhea) (hearingloss, usuallyevidentonpresentation Signs ofearinjury tinnitus, otalgia, vertigo, bleeding from Tympanic blastinjury membranemostcommonprimary Clinical signscanbeinitiallysubtleuntilacuteabdomenorsepsisisadvanced pain, unexplainedhypovolemia withabdominalpain,Suspect inanyone nausea, vomiting, hematemesis, rectalpain, tenesmus, testicular organ lacerations, andtesticularrupture perforation,Bowel (smallpetechiaetolargehematomas), hemorrhage mesentericshearinjuries, solid Gas-filled structuresmostvulnerable(esp. colon) — ConsidertransferforhyperbaricO2therapy O2;prone,— Highflow semi-leftlateral, position orleftlateral — forsignificantairleaksormassivehemoptysis — Considerselectivebronchialintubation Positive pressuremayriskalveolarruptureorairembolism  (CDC) onblast injuries. For on blastinjuriesandtoorder free copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries (continued)

and Prevention

• Diagnostic Evaluation • • • • • until theonsetofcomplications: unexplained hypovolemia, findingssuggestiveofanacuteabdomen. orany Clinicalfindingsmaybeabsent to anexplosionwithabdominalpain, nausea, vomiting, hematemesis, rectalpain, tenesmus, testicularpain, solid organlacerations, andtesticularrupture. exposed shouldbesuspectedinanyone Blastabdominalinjury perforation,bowel (rangingfromsmallpetechiaetolargehematomas), hemorrhage mesentericshearinjuries, blasteffect.Gas-containing sectionsoftheGItractaremostvulnerabletoprimary This cancauseimmediate Clinical Presentation anatomy. (For pleaserefertoCDC’s furtherinformation “Blast Injuries: Pediatrics” factsheet.) of abdominalinjury. duetotheirunique Childrenaremorepronetoabdominalinjuriesinblastsituations risk oftheblast. asignificantlygreater andthenature depending uponthepatient blastscarry Underwater isunknown. significantly blast injury willvary Incidenceandclinical ofabdominalblastinjury presentation anddeath.Abdominal blastinjuriesareasignificantcauseofinjury Theactualincidenceofabdominal Background      — Work-up abdominaltrauma similartostandardbluntandpenetrating toabdomenandabdominalwall — Quaternary: crushinjury — — Secondary: andbluntabdominal trauma penetrating (colonmostvulnerabletoperforation) — Primary: andperforation abdominalhemorrhage Most commonabdominalblastinjuriesinclude: larger organsrenderchildrenmorevulnerabletoinjuries,— proportionately especiallytoliverandspleen — thinabdominalwallsofferlessprotection — smallerandmorepliablewallsofferlessprotection Children aremorepronetoabdominalblastinjury incompressibilityofwater. withdistancedue totherelative toloseenergy slower fasterandare propagate ofasimilarexplosioninairbecausewaves explosion isaboutthreetimesthat blasts;thelethalradius ofanunderwater Abdominal injuriesareparticularlysevereinunderwater toarterialgasembolism. secondary blastinjury), andtertiary butinclude blastinjuries,blunt trauma(secondary primary including ischemia and involvestandardpenetrating Predominant post-explosionabdominalinjuriesamongsurvivors blastinjuries,primary including abdominalinjury. signs andsymptomsofhypovolemiaorhemorrhage. Victims ofclosed riskformore spacebombingsareat abdominal pain, reboundtenderness, guarding, sounds, absentbowel nauseaandvomiting, fever, and maybeovert, ofabdominalblastinjury Clinical presentation orsubtleandvariable, andmayinclude: Laboratory studies — Laboratory — Serialabdominalexaminations, maybedelayed;serial exams maybedifficultinyoungchildren aspresentation Tertiary: abdominal trauma bluntandpenetrating contusion/laceration, intra-abdominalabscess Radiological studies: free air, unexplainedileus, intra-abdominalhematoma/hemorrhage, solidorgan  BLAST INJURIES Abdominal BlastInjuries U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Abdominal Blast Injuries Abdominal Blast Injuries • Disposition • • • • • • Initial Management • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl This factsheet ispartofaseriesmaterials Appropriate referraltotraumacenterasneeded Appropriate manifestafterdischarge and strictreturninstructionsshouldsignsorsymptomsofabdominalinjury High degreeofsuspicionformissedordelayedabdominalinjuries, including serialexams, close follow-up, for Sonography Trauma (FAST) Radiological studies: plainabdominalfilms, [CT]scan, computedtomography Focused Abdominal monitoring Serial examsandlaboratory Antibiotics andtetanusimmunization duetoriskofhemorrhage) objectsinemergencyAvoid removalofpenetrating intervention room(operative Nothing bymouth ABCs (airway, breathing, asforalltraumapatients circulation) on blastinjuries. For onblast injuriesandtoorderfreecopies moreinformation of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries and Prevention (CDC)

• • • • • • • • • • • Hypotension systemleadstomyoglobinuria,necrotic muscle intothecirculatory whichcausesrenalfailureifuntreated. abnormalities. This conditionmaycauselethalcardiacarrhythmias. Further, thesuddenreleaseof toxins from Sudden releaseofacrushedextremitymayresultinreperfusionsyndrome—acutehypovolemiaandmetabolic Clinical Presentation acute renalfailureandover50%needingfasciotomy. Ofthosewithrenalfailure, 50%needdialysis. 50%ofthosewithcrushsyndromedeveloping incidence ofcrushsyndromeis2-15%withapproximately the that hasdemonstrated causedmajorstructuraldamage Previous experiencewithearthquakesthat abnormalities, including acidosis, hyperkalemia, andhypocalcemia. system.the circulatory Crushsyndromecancauselocaltissueinjury, organdysfunction, andmetabolic (muscle andthereleaseofpotentiallytoxicmuscle breakdown) cellcomponentsandelectrolytesinto withsystemicmanifestations.crush injury rhabdomyolysis These systemiceffectsarecausedbyatraumatic includebody extremities(74%), lower upperextremities(10%), andtrunk(9%). Crushsyndromeislocalized and/orneurologicaldisturbancesintheaffectedareasofbody.swelling Typically affectedareas ofthe causesmuscleexplosion. that is definedascompressionofextremitiesorotherpartsthebody Crushinjury afterabombingor In aterroristattack, andcrushsyndromemayresultfromstructuralcollapse crushinjury Background Secondary Complications Metabolic Abnormalities Renal Failure            Compartment syndromemay occur, whichwillfurtherworsenvascularcompromise this situation arrest; metabolicacidosismay exacerbate cardiacarrhythmias,Imbalance ofpotassiumandcalciummaycauselife-threatening including cardiac Lactic acidisreleasedfromischemicmuscle intosystemiccirculation, causingmetabolic acidosis Potassium isreleasedfromischemic muscle intosystemiccirculation, causinghyperkalemia into muscleCalcium flows cellsthroughleakymembranes, causingsystemichypocalcemia Release ofelectrolytesfromischemicmuscles causesmetabolicabnormalities Myoglobinuria mayresultinrenaltubularnecrosisifuntreated Rhabdomyolysis releasesmyoglobin, potassium, phosphorous, intothecirculation andcreatinine Hypotension mayalsocontributetorenalfailure within aclosed space;compartmentsyndromeoftenrequiresfasciotomy anatomical suchascompartmentsyndrome, complications Third spacingmayleadtosecondary whichisswelling sequester (thirdspace)>12Loffluidinthecrushedareaovera48-hourperiod Massive thirdspacingoccurs,patients may requiringconsiderablefluidreplacementinthefirst24hours; BLAST INJURIES Crush InjuryandSyndrome

U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Crush Injury and Crush Syndrome Crush Injury and Crush Syndrome patients arelikelyto regainnormalkidneyfunction. patients unlesssepsisispresent,Patients withacuterenalfailuremayrequireupto60daysofdialysistreatment; Disposition • • • • • • • • • • • • • Prehospital setting: Initial Management Secondary Complications Metabolic Abnormalities Renal Failure Hypotension Hospital setting: This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials              failure canoccur ofrenal >12hoursmayincreasetheincidenceofrenalfailure; delayed manifestations Delays inhydration allcrushcasualties,Observe eventhosewholookwell and pulselessness icetoinjuredareasandmonitorforthe5P’s:Apply pain, pallor, parasthesias, painwithpassivemovement, Treat openwoundswithantibiotics, tetanustoxoid, anddebridement ofnecrotictissue consider emergency fasciotomyforcompartmentsyndrome Monitor casualtiesforcompartmentsyndrome;monitorcompartmentalpressureifequipmentisavailable; Cardiac Arrhythmias: Monitorforcardiacarrhythmiasandarrest, accordingly andtreat 25-50gwithsorbitol 20%100mLPOorPR insulin 5-10UandD5O1-2ampulesIVbolus;kayexalate push;regular 1 meq/kgIVslow 10cc orcalciumchloride10%5ccIVover2minutes;sodiumbicarbonate Hyperkalemia/Hypocalcemia: (adult doses): Consideradministeringthefollowing 10% calciumgluconate prevent myoglobinanduricaciddepositioninkidneys Acidosis: untilurinepHreaches6.5to ofurineiscritical;administerIVsodiumbicarbonate Alkalinization Triage tohemodialysisasneeded 300 cc/hr hydration,at least Prevent renalfailurewithappropriate usingIVfluidsandmannitoltomaintaindiuresisof to1.5L/hour (orcontinue)IVhydration—up Initiate canbeinitiated (IV)hydration intravenous If thisprocedureisnotpossible, considershort-termuseofatourniquetontheaffectedlimbuntil cases ofprolongedcrush[>4hours];however, crushsyndromecanoccurinscenariosof<1hour) part. fluidsbeforereleasingthecrushedbody Administer intravenous (Thisstepisespeciallyimportantin (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

• • • • • • • • • Tympanic Membrane(TM) • • Ear External Clinical Presentation referral, pooroutcomeandmorbiditycanbeminimized. often missed. However, withsimplescreeningprotocols, limited management, otolaryngologic andappropriate injuries, oflife-threatening is andtreatment diagnosis otologicinjury As highestpriorityisdirectedtoward result insymptomsoftinnitus, earache, hearingloss, orvertigo. afterablast.the middleandinnerearrepresentsmostcommontypeofinjury totheearmay Blastinjury blastinjury.The earisthemostsusceptibleorgantoprimary andsensitivestructuresof tothedelicate Injury symptoms, blastinjury. tobeamarkerforoccultprimary doesnotappear Despite earlierreportstothecontrary, tympanicmembraneperforation, isolated withoutadditionalsignsand oftheblastandsusceptibilitytissues.power istypicallytheear.The firstorgantosustaindamage succession, tendstooccurinanatomical totheorgansofbody dependingonthe blastinjury Primary Background Inner Ear Middle Ear •          mayoccur;consideredtobeaseriousinjury Degloving ofthecartilage blastinjury) totheexternaleariscausedmostoftenbyflyingdebris(secondary Injury hearing withinhours, forothers resolutionmaytakedaystoweeks hearingthreshold change;mostregain willexperience atemporary The typicalblast-injuredpatient andvestibularcomponentsoftheinnerearmay alsooccur totheauditory Damage potentiallyfatal making theinjury palsy,nerve suchasbrainabscessandmeningitis, systemcomplications aswellcentralnervous Sequelae ofdiseasecancauseconductiveandsensorineural hearingloss, vestibulardisturbances, cranial importantstructuresofthemiddleear, canerodeanddestroy that temporalbone, and skull base mayoccurandarepotentiallydestructive lesions within themiddleearandmastoidcavity Cholesteatoma Disruption oftheossicularchainmayoccur, especially inlargerblasts maybesmooth and linear, ofthelaceration The shape punchedout, withtheedgesinvertedoreverted orragged orbilateral,Perforations maybeunilateral smallorcomplete, andsingleordouble blasts inpowerful tympanic membraneperforation maybeseen,A spectrumofinjury inminorcasestototal rangingfromintra-tympanichemorrhage canal,Blast overpressureenterstheexternalauditory stretchinganddisplacingthe TM medially encounteredbyimpulsiveandcontinuoussoundwaves pressure oscillations The pressureasitfunctionstotransmitminute ofatmospheric TM isexquisitelysensitivetovariations BLAST INJURIES Ear BlastInjuries U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Ear Blast Injuries Ear Blast Injuries • • • • Disposition • • • • • • • • • • Initial Management Treatment ofMiddleandInnerEarInjuries Treatment ofTympanic MembraneRupture Treatment EarInjuries ofExternal This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials               and do not resolve; follow-up is indicated biannuallyforaminimumoftwoyears isindicated and donotresolve;follow-up Any formation, arelarger runstheriskofcholesteatoma that TM perforation especiallythoseperforations Tympanoplasty afterclose ifspontaneousresolutionisnotobserved observation isindicated resolve mostfrequentlyinthefirstthreemonthsafterinjury For withevertedflap, irregularperforations realignmentmayimprovechancesofhealing;perforations anexcellent prognosiswithspontaneousresolutioninthemajorityofcases typicallyhave TM perforations progressduringrecovery follow to audiometricevaluation withinterval shouldbefollowed patients notedbythepatient; and notalways becausehearingdeficitsarecommon hasbeenadvocated inallblast-injuredpatients Baseline audiometry Treatment is available formiddleandinnerearinjuriestypicallycanbedeferreduntil anotolaryngologist ear canallacerations andclearAntibiotic eardropstoirrigate theearofdebrisorbloodclots for areindicated or TM perforations The earshouldbekeptclean anddry, shouldbereferredtoaspecialist andthepatient these canbecarefullysuctionedandcleaned byanotolaryngologist Treatment of istypically expectant;ifcerumenorbloodclotsTM perforations obscureviewoftheeardrum, or aplasticsurgeon) degloved, itshouldbeburiedinthepostauricularpouch(mayrequireexpertiseofanotolaryngologist mustnotbeleftexposed;woundsshouldclosedCartilage ofthepinnais primarily;ifthecartilage wounds, andclosure removal, toforeignbody asothersofttissueinjurieswithattention Manage cleaning of andirrigation blastinjury. tobeamarkerforoccultprimary appear injury, tympanicmembraneperforation, butisolated withoutadditionalsignsandsymptoms, doesnot Tympanic blast shouldraiseclinical foradditionalprimary membraneinjury suspicionandevaluation should include ofthe otoscopicevaluation canal TM andexternalauditory beenaddressed, measuresandsevereinjurieshave exam After basiclifesaving afocusedsecondary oftheblastpatient and management beaddressedfirstintheassessment measuresshouldalways Standard traumaprotocolsandlifesaving (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

• • • • • • • Diagnostic Evaluation • • • proximity totheexplosion. implantedwithinthebomb(e.g.,materials nails, screws), flyingglass, madeairborneby orfromlocalmaterials traumafromthebombcasingfragments, totheextremitiesismarkedbypenetrating blastinjury Secondary andblastwind. oftheblastwave combination andmayresultfromthe thanjointdisarticulations shaftrather primarilyoccurthroughthebony amputations Traumatic isoftenconsideredamarkerforlethalinjury. blastinjury fromprimary amputation Blast-induced Clinical Presentation The mostextremeoftheseinjuries, amputation, thetraumatic isreportedtooccurin1%–3%ofblastvictims. ofbombings. insurvivors thehighestincidenceofbodilyinjury The softtissueandmusculoskeletalsystemshave Background please refertoCDC’s andCrushSyndrome:“Crush Injury Clinicians NeedtoKnow”What factsheet) andthepotentialforcompartmentsyndrome. mayproducecrushinjury Building collapse (For furtherinformation surroundingstructures.blunt impactforceswhenpropelledagainst Tertiary toextremitiesmoreclosely blastinjury resemblesciviliantrauma. andquaternary Victims sufferfrom           Lower extremity injury scores do not accurately predicttheneedforamputation scoresdonotaccurately extremityinjury Lower overtime willregainthisprotectivesensation patients 50%of intheblast-injured extremityisnotpredictiveforamputation; The initialabsenceofplantar sensation injuries characterize bony ofinjuredextremitiesshouldbeliberallyutilizedtoidentifydeepforeignbodiesand Radiological examination ideally, photographed Each openwoundshouldbewelldocumented—notingsize, exposedbone, andtypeofcontamination—and, notbeenpublished arteriogramhave mandatory protocols incorporating oftheblast-injuredextremity,Although diligenceiswarrantedinassessingthevascular status institutional detecting vascularinjuriesfromblastthanroutinecivilian trauma isless reliablefor fromavascularperspective;physicalexamination Extremities shouldbethoroughlyevaluated musculoskeletal,Document asystematic neurological, andvascularexam foreachextremity debridement, anddevitalizedtissuecanproducehighly morbidinfectiouscomplications asdeepcontamination Even withsmallentrancewounds, threshold forperformingathorough surgeonsshouldmaintainalow Irregular projectilesresultinextensivetissuedamage from thebomberorvictimsinproximitytoexplosion (e.g., ofbiologicmaterial implantation Wound mayoccurfromthetraumatic bonefragments) contamination BLAST INJURIES Blast Extremity Injuries U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Blast Extremity Injuries Blast Extremity Injuries • • • • • • • • • • Surgical Management • • • • • Initial Management This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials                overall health potentiallyfunctionallimbswithout jeopardizingthepatient’smust beconsidered;theoverallgoalistopreserve procedure, Before andduringeachoperative thelimb limbviabilityandfeasibilityofcontinuedeffortstosave expectantly treated involvingsofttissueonly,fragments withsmallwounds andnoactiveinfectionorgrosscontamination, maybe ofsmall, onthemanagement Literature small imbedded foreignbodiesislimited;itmaybethecasethat is attained 24–72hours, debridementisplannedevery extent,Repeat dependingontheinjury untilastablesofttissuebed management Cultures aregenerallynotusefulduringthisacuteinjury ofavacuum wounddressing antibiotic beadpouchorapplication ofan Following stabilization, isgenerallyaddressedwithcreation debridementandbony softtissueinjury be used isimportant;wherevesselsmaynotbeligated, of injury autologousveingraftsforcriticalreconstructions should vascularinjuries,When treating zones prostheticgraftsorrepairs/reconstructionwithincontaminated avoiding fixation intramedullary or conversiontodefinitiveplate withsecondary isoftenprovidedbyexternal fixation stabilization Bony thewound tothoroughlyirrigate Following maybeemployed debridement, lavage pulsatile low-pressure tissueiscriticalbecausethereatendencynecrotic andcontaminated thesofttissueinjury tounderestimate debridementof willextendwellbeyondinitialskinwoundsandfracturesites;aggressive The zoneofinjury fashion wounds shouldbeenlargedwithextensivelongitudinalincisionsanddebridedinsystematic lifeandlimb; roomtopreserve shouldbedoneintheoperating stabilization Initial debridementandbony Extremity fracturesshouldbesplintedtoprovidemechanicalstabilityandrelievepain Tetanus withinfiveyearscanbedocumented prophylaxisshouldbeadministeredunlessimmunization soaked sponges;oncedressed, exploration re-exposureshouldwaituntiloperative withsterilesalineanddressediodophore(Betadine)- woundsshouldbeirrigated Obviously contaminated cephalosporin and/oraminoglycocide, extendedspectrumpenicillin) (firstgeneration andshouldreceiveearlyantibiotictreatment All openfracturesareconsideredcontaminated thorough debridement smallentrancewounds, Even whenblastvictimshave thresholdforperforming surgeonsshouldmaintainalow (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

• • Diagnostic Evaluation • • • Clinical Presentation bodies (IOFB), ororbitalfractures. corneal abrasionsandforeignbodiestoextensiveeyelidlacerations, open globeinjuries, intraocularforeign tissues oftheglobe, lids, orbit, orocularadnexa. Frequently, andmayrangefromminor injuriesarebilateral occurring fromterroristbombsmaybeextensive, tothe traumainjury andmayinvolvebluntorpenetrating fromthe bomb andmayalsopropelsoilorganicmatter. metallicfragments accelerate Ocularinjuries FBeyeinjuries. fromexplosionsinbuildingscancreate other materials Explosionsinopenspacestendto andforeignbodies(FBs)affectingthe eye.Glass isamajorsourceoflacerations Concrete, metal, wood, and cornea orsclera andentertheeye. unprotected headsandeyes. sharpparticles, accelerated Rapidly largeorsmall, orrupturethe canlacerate disruption., blastinjury Secondary causedbyflyingdebrisorfragments, toexposedand isaparticularthreat totheeyehasbeenreportedinliterature. blastinjury Lesserforcecanresultininternalocular primary from ablastoverpressurewave. Givenenoughforce, however, rupturecanoccur. Onlyonecaseofpure The eye, withitsprotectiveorbit, tarsalplates, andtoughsclera, ruptureresulting isresistanttotraumatic isafrequentcauseofmorbidityinterroristblastvictims,Ocular injury occurringinupto28%ofsurvivors. Background • • • • part oftheeye Intraocular foreignbodiesmay belargeandobvious, inany orsmallanddifficulttodetect; maybelocated anteriorchamber the globe;orabnormallydeepshallow orpigmentedtissueoutside theglobe;clear, pupil;brown misshapen hemorrhage; gel-liketissueoutside subtle—signsofarupturedglobeincludeRuptured globesorIOFBsmaybevery 360-degreeconjunctival Assume alleyeinjuriesharboraruptureoftheglobe detatchment, choroidal rupture, injuries andopticnerve eyeinjuriesincludeSerious non-penetrating hyphema, cataract, traumatic vitreoushemorrhage, retinal Eyelid lacerations, oftenextensive, eyeinjuries accountfor20%–60%ofblast-related eyeinjuries(upto20%–50%ofthosewith injuries) common seriousblast-related Open globeinjuries, includinginjuriestothecorneaorsclera, andperforating penetrating arethemost eyeinjuriesincludeMinor blast-related cornealabrasions, conjunctivitis, andsuperficialforeignbodies bleeding, orbruising orperiorbitalswelling symptoms; thesemayinclude orpain, eyeirritation sensation, foreignbody decreasedoralteredvision, maybepresentwithnormalvisionandminimal significanteyedamage that It iscriticaltoappreciate loss ofvision Blast eyeinjuriesmaypresentwithawiderangeofsymptoms, fromminimaldiscomforttoseverepainor BLAST INJURIES Eye BlastInjuries

U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Eye Blast Injuries Eye Blast Injuries • Disposition • • • • Initial Management • • Diagnostic Evaluation • • • • • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials operating room (OR) capabilities should be themaingoal room(OR)capabilities operating and protectionoftheeye, ofthepatient After initialstabilization transporttofacilitieswithophthalmic rapid thresholdforreferral;consultanophthalmologistasearlypossible and alow withahighlevelofsuspicionforocculteyeinjuries ofblastvictimsshouldbeapproached The examination wounds organic material-contaminated suggestions include ceftazadime/vancomycin;considerIVclindamycin thecombination fordirtysoil/ (IV)broad-spectrumantibioticsifarupturedglobeis suspected;current Administer intravenous Administer anti-emeticstoreducenauseaandvomiting Administer tetanusifwarranted requires specialextractiontechniques that maybeinalocation Do notremoveimpaledforeignbodies;thedistalaspectofbody tothesurroundingbonesprotectglobe orStyrofoamcupbetaped paper totheeye—useaconvexplasticormetalshield, orbandage apatch Do notapply orthebottomofaclean mayberuptured pressureonaneyethat Assume alleyeinjuriesharborarupturedglobe;donotputany ofthelids hematoma or Do notforcethelidsopentoexamineeye;deferexaminingeyeifthereismassiveswelling may behelpfulinidentifyingnon-metallic(wood, plastic, organic)foreignbodies untilitisprovennometallicFBsarepresent;MRI (MRI)iscontraindicated resonanceimaging Magnetic (CT)oftheorbitsmaybehelpfulinidentifyingforeignbodies Thin-cut computedtomography Obtain visualacuityofeacheyeifpossible;testforlightperception(LP), handmotion(HM), and count fingers(CF) (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries (continued)

• Management • Diagnostic Evaluation • • Clinical Presentation injuriesfromexplosions. totreat abouthow information the presentation, evaluation, management, andoutcomesofBLIs. formore Pleaseseethereferencelistbelow canresult.and othertypesofinjuriesthat Basicclinical isprovidedheretoinformpractitioners of information injuries.explosion-related Emergency careprovidersareurgedtolearnmoreaboutthephysicsofexplosions with explosions, patients experiencetreating have yetfewcivilianhealthcareprovidersintheUnitedStates to increasedthepotentialforcasualtiesrelated inworldwideterroristactivityhave Current patterns tothechest. which mayoccurwithoutobviousexternalinjury perfusion mismatch. difficultyandhypoxia, BLIisaclinical andischaracterizedbyrespiratory diagnosis impact uponthelungresultsintearing, hemorrhage, contusion, andedemawithresultantventilation- thesceneandamonginitialsurvivors.morbidity andmortalityforblastvictimsbothat The blastwave’s uponthebody. fromhighexplosivedetonations consequence oftheblastwave BLIisa majorcauseof (BLI)presentsuniquetriage,Blast lunginjury diagnostic, challengesandisadirect andmanagement Background • • • • • • Clinical interventions interventions Clinical  ensuringtissueperfusionwithout volumeoverload.and administration In general, contusion, BLIissimilartocaringfor pulmonary managing whichrequiresjudiciousfluiduse optionsmaybelimitedinadisasterormass casualtysituation. ortherapeutic diagnostic Initial triage, trauma resuscitation, treatment, some standardprotocols;however andtransfer shouldfollow or extrication, suspected chemicalorbiologicevent, etc). of theexplosion(e.g. confinedspace, fire, prolonged entrapment protocols andfurtherdirectedbaseduponthenature resuscitation testingcanbeconductedper anddiagnostic Most laboratory maybeused.technology Arterial bloodgases, computerizedtomography, anddoppler A characteristic “butterfly” mayberevealeduponx-ray. pattern whoisexposedtoablast. foranyone isnecessary Chest radiography Other injuriesmaybepresent. pneumothoraces. mayinclude pathology bronchopleuralfistula,Associated airemboli, and hemothoracesor instability.hemodynamic Signs mayinclude tachypnea, hypoxia, cyanosis, apnea, wheezing, sounds, decreasedbreath and Symptoms mayinclude dyspnea, hemoptysis, cough, andchestpain. BLAST INJURIES Blast LungInjury U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention Photo courtesyofChest, 1999

Blast Lung Injury Blast Lung Injury • Disposition andOutcome • • Management • • • • • • year follow-up”, by Hirshberg, Boaz, MD, etal. Dec1999, Vol 116(6), p1683-88. Photo Source: ReprintedbypermissionfromChest. X-rayFigure Iin fromBlastLungInjury:“Recovery One • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials In general, and withnormalchestradiographs patients ABGs, wouldsuggest nocomplaintsthat whohave including thepatient’s currentsocialsituation. injuries,Discharge decisionswillalsodependuponassociated totheevent, andother issuesrelated care unit. inthehospital. complaintsorfindingssuspiciousforBLIshouldbeobserved Patients withany andshouldbeadmittedtoanintensive withBLImayrequirecomplexmanagement Patients diagnosed anexplosion. with possible BLIfollowing forpatients department evaluation There arenodefinitiveguidelinesforobservation, admission, emergency ordischargefollowing hyperbaric chamber. in prone, semi-leftlateral, positions. orleftlateral forairembolishouldbetransferredtoa Patients treated oxygenshouldbeadministeredifairembolismissuspected,High flow shouldbeplaced andthepatient risk ofalveolarruptureandairembolism. patients,in thedecisiontointubate andpositiveendpressuremayincreasethe asmechanicalventilation failureisimminentoroccurs, however, shouldbeintubated; If ventilatory patients cautionshould beused Clinical evidenceoforsuspicionforahemothoraxpneumothoraxwarrantspromptdecompression. from selectivebronchusintubation. tosecuretheairway.intervention Patients withmassivehemoptysisorsignificantairleaksmaybenefit Impending airwaycompromise, edema, secondary injury, ormassivehemoptysisrequiresimmediate endotracheal intubation). mayinclude masks,prevent hypoxemia(delivery non-rebreather continuouspositiveairwaypressure, or oxygensufficientto withsuspectedorconfirmedBLIshouldreceivesupplementalhighflow All patients physical examinations andchestradiographs,physical examinations andmosthadnormallungfunctiontests. oneyearpostinjury, conductedonsurvivors study complaints, hadpulmonary nopatients allhadnormal withBLIiscurrentlylimited. ontheshortandlong-termoutcomesofpatients Data However, inone BLI, canbeconsideredfordischargeafter4-6hoursofobservation. (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information (continued) of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

• Prehospital ManagementConsiderations • • Clinical Presentation highestrisk.at BLIpresentsuniquetriage, diagnostic, challenges. andmanagement obvious externalchestinjury. Persons inenclosed-space explosionsorinclose proximitytotheexplosionare injury—or, BLI. difficultyandhypoxia. Itischaracterizedbyrespiratory BLIcanoccur, althoughrarely, without withtheseinjuries.patients isblastlung uponthebody Onedirectconsequenceofhigh-explosivedetonations explosions, experiencetreating have yetfewcivilianemergency providersintheUnitedStates medicalservice to increasedthepotentialforcasualtiesrelated inworldwideterroristactivityhave Current patterns Background • • • • • • • • — — — Symptomsmayinclude dyspnea, hemoptysis, cough, andchestpain.

Hemothoracesorpneumothoracesmayoccur. surface area (BSA) are more likely to have BLI.surface area(BSA)aremorelikelytohave Victims withskullfractures, injuriespenetra observation is warranted for any patient suspectedofBLI whoistransportedbyair. patient iswarranted forany observation clinicallydecompression shouldbeperformed forpatients presenting withatensionpneumothorax. Close hypoxemia. Note thepatient’s thetimeofinjury. andthesurroundingenvironmentat location ormasscasualties.injured patients 24to48hoursafteranexplosion.BLI canappear system,embolic eventsinvolvingthecentralnervous retinalarteries, arteries. orcoronary instability.hemodynamic Clinical evidenceorsuspicion ofahemothoraxorpneumothoraxwarrantsclose obser oxygentoprevent Patients withsuspectedorconfirmedBLIshouldreceivesupplementalhigh-flow blastinjur Explosions inconfinedspacesresultahigherincidenceofprimary Initial triage, traumaresuscitation, standardprotocolsformultiple shouldfollow and transportofpatients Other injuriesareoftenpresent. theinitialevalua Clinical evidenceofBLIistypicallypresentat orvasculartearing, Due topulmonary Signs mayinclude tachypnea,  A compromised airway requires immediate intervention.A compromisedairwayrequiresimmediate   placed inaprone, semi-leftlateral, position. orleftlateral oxygenshould beadministeredifairembolismissuspected,High-flow should be andthepatient alveolar rupture, pneumothorax, andairembolismin BLIpatients. andpositivepressuremayincreasetherisk of mechanicalventilation providers mustrealizethat failureisimminentoroccurs, however, shouldbeintubated; If ventilatory patients prehospital BLAST INJURIES Prehospital Care Providers Blast LungInjury:AnOverviewfor hypoxia, cyanosis, apnea, wheezing, sounds, decreasedbreath and U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention air may enter the arterial circulation (airemboli)andresultin airmayenterthearterialcirculation ting torsoorhead, orburnscoveringmorethan10%body

tion; however, evidenceof that reportsshow y, including lunginjury.

vation. Chest

Blast Lung Injury: Prehospital Care Providers Blast Lung Injury: Prehospital Care Providers **High flow oxygen, transport.**High flow andrapid appropriate, as foradditionalinjury airwaymanagement evaluate *There isahigherincidenceofBLIinenclosed spaces. Blast LungInjuryManagementProtocol • Prehospital ManagementConsiderations • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials

community responseplansformasscasualtyevents. status.result involumeoverloadandworsenpulmonary Patients with BLI should be transported rapidly tothenearest,Patients withBLIshouldbetransportedrapidly facility, appropriate inaccordancewith Fluids shouldbeadministeredjudiciously, asoverzealousfluidadministra (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information No Transport tothe rapidly mass casualtyevents. facility inaccordance nearest, appropriate response plansfor with community Appropriate Treatment of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries Respiratory Distress Respiratory suggestive ofBLIor Signs orsymptoms Compromised ** Transport explosive event monitor I.V. Vital signs, ** oxygen, Ventilation Blast or No and

suspicion ofBLIwhoistransported clinically presentingwithatension observation. Chestdecompression pneumothorax. Closeobservation should be preformed for patients should bepreformedforpatients is warranted for any patient with patient is warrantedforany Yes Suspicion forahemothoraxor peumothorax warrantsclose Initial triage, traumaresuscitation, standard protocolsformultiple *inanopenorclosed space? and transport should follow and transportshouldfollow intubated; however,intubated; cautionshouldbeusedasmechanicalventilation and positivepressuremayincreasetheriskofalveolarrupture or masscasualties. injured patients injured patients If ventilatory failure isimminentoroccurs, shouldbe If ventilatory patients by air. (continued) management management protocol Airway

air embolism. penetrating torsoorheadinjuries. penetrating BSA burns, skullfractures, and trauma. for>10% patient Evaluate chest trauma, andbluntchest (source ofairembolism), penetrating and hemorrhage, A-V fistulas pneumothorax, contusion pulmonary Blast lung, hemothorax, Clinical concerns chest pain Dyspnea, hemoptysis, cough, and Symptoms ofBLI hemoptysis sounds,decreased breath or wheezing, dullnesstopercussion, hypoxia andcyanosis, cough, Apnea, tachypneaorhypopnea, Signs ofBLI much fluidmayresult in volumeoverload administrating too administrating pulmonary status. pulmonary and worseningof be administered Fluids should judiciously, if required, as tion in the patient withBLImay tion inthepatient

• • • • • • • • • personnel asneeded: Provide psychologicalfirst aid(PFA) topatients,familymembers,andemergency response Initial Management • • • • Clinical Presentation care.patient Cliniciansshouldtakeallreportsofphysical, emotional, cognitive, reactionsseriously. andbehavioral Most fearanddistressreactionsarenormal, expected, usingprinciplesofgoodpsychological andcanbemanaged symptoms resulting from continuedexposure todeathanddevastation. Emergency responders andotherhealthcare providers mayalsoexperiencepsychological aboutlovedones;andthewitnessingofhorrificfrighteningscenes.of knowledge factors, fromorlack offamilymembersandfriends; separation ordeath including ofselfand/orinjury injury oflongtermpsychologicalsymptoms.rates The leveloffearanddistressafterabombingdependsonseveral confusion. disasters, Incomparisontonatural withhigher intentionalmasscasualtyeventsareassociated Intentional masscasualtyeventssuchasbombingsaredesignedtocausedeath, destruction, fear, and Background              be happening next be happening Provide familymemberswith accurate, timely, will andwhat status aboutpatient andcredibleinformation services follow-up Link withappropriate/needed tocope regardingsignsofdistressandhow andeducation Provide information Provide practicalassistance totalkabouttheeventasthismayintensifysymptoms patient Avoid encouraging regardingcurrentneedsandconcerns information Gather Stabilize, asnecessary Provide/ensure safetyandsecurity Establish contactandengagement being distant, judgmental, orover-controlling. Abuse ofsubstancesand/oralcoholisalsoacommonsymptom. reactions,hypervigilance/startle withdrawal, isolation/social distrust, irritability, feelingrejectedorabandoned, reactions:Behavioral sleepproblems, easily, crying excessiveactivity level, increasedconflictswithothers, indecisiveness, worry, span, shortenedattention loss, memory unwantedmemories, orself-blame. things,trouble concentrating/remembering difficultymakingdecisions, questioning spiritualbeliefs, disorientation, Cognitive reactions: confusion/disorganization, recurringdreamsornightmares, withthedisaster, preoccupation guilt/self-doubt, unpredictablemoodswings, emotionalnumbness, affect. flat or inappropriately Emotional reactions: depression/sadness, irritability/anger/resentment, anxiety/fear, despair/hopelessness, headache, worseningchronicconditions, complaints, somatic orracing heartbeat. Physical reactions: fatigue/exhaustion, gastrointestinaldistress, tightening inthroat/chest/stomach, BLAST INJURIES Bombings andMentalHealth

U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Bombings and Mental Health Bombings and Mental Health • • • Disposition • • • • • • • • • • • • • • • • • • • Initial Management(continued) Address emergency responseasneeded: personnelconcerns Refer toabehavioralhealthspecialistwhenthefollowingsignsoccur: This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials                       specialist forongoingcare illness, including psychosis, severeanxiety, anddepression, shouldbereferredtoamental health exhibitcontinuingsignsofdistress,Individuals andfamiliesthat andthoseexhibitingsignsofmental than thosewhodonot Individuals whobelongtostrongsocialnetworks, such asfamiliesandfaithcommunities, tendtodobetter however, toallpatients, shouldbemade available families, referral services and emergency responsepersonnel of amentalhealthspecialist; Most fearanddistressreactionsarenormalwillresolve withouttheintervention ofstressandfearsinyourfamilyresultingfromwork/role Be aware Seek helpfromamentalhealthspecialistifnecessary Provide PFA asneeded systemtoidentifystress Use abuddy Enforce breaks Identify physical, emotional, cognitive, signsinselfand coworkers, andbehavioral andpracticeself-care ofpersonalstressvulnerabilitiesinemergencyBe aware responders Domestic violence: child, spouse, elder, oranimalabuse useofalcoholordrugs Problematic Suicidal orhomicidalthoughtsplans Inability tocareforoneself: orbathe, doesnoteat fromothers, isolated tasksofdailyliving orunabletomanage withideasorthoughts preoccupation Psychosis: hearing voices, are not there, seeing things that out of touch with reality, appearing or excessive reason, fornoapparent crying orwithdrawal Severe depression: hopelessnessanddespair, unrelentingfeelingsofworthlessnessorguilt, frequent environment asunreal, ortimedistortion Dissociation: emotionaldisconnection, senseofseeingselffromanotherperspective, seeingthe intrusive thoughts High anxietyandhyper-arousal: highlyagitated, unabletosleep, frequentnightmares, flashbacks, or Disorientation: date, inabilitytoknow location, orrecentevents andchaplains ofhospitalsocialservices Optimize services increases distress whereseparation andotherpatients ofpediatric Minimize separation fromdistressingsignsandsounds away Provide familymembersaquietlocation (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

• Diagnostic Evaluation • • Clinical Presentation thecareofanolderblastvictim.be takenintoaccountwhenmanaging and anemiaofchronicdisease. Eachoftheseconditions, usedforthem, alongwiththemedications needto mellitus, dementia, cerebrovasculardisease, chronicrenalfailure, arthritis, refluxdisease, gastro-esophageal co-morbidities include: disease, artery coronary hypertension, chronicobstructivelungdisease, diabetes pre-hospital care, medical/surgicalinterventions, services. andrehabilitation Somepotentiallysignificant Additionally, outcomesareaffectedbyco-morbidconditions, physiologicreserve, multipleconcurrentinjuries, • • older adults, areespeciallysubjectto: includingolderpatients asthefactthat suchconsiderations ofblastinjuriesamong carecanprovideinsightintothetreatment learned fromday-to-daytraumaandgeriatrics andcareofthevictimsbombingsarenotfocusedspecificallyonolderadults.of injury However, lessons inolderpatients. onthepatterns ofblastinjury Nearlyalldata regardingtreatment Limited researchisavailable Background • • • •

organs, strainforces; applied inadditiontothedecreasedabilityoforganswithstandrapidly An increasedriskoffractures(e.g., hip, exacerbate anindividual’sexacerbate injuries. andstressor,mask orbluntthenormalphysiologicresponsetoinjury insome cases(e.g., warfarin), may inolderadults(e.g.,Commonly prescribedmedications beta-blockers, calciumchannelblockers)can supplements, etc.), shouldbeobtainedandassessed forpossibleadverseeffectsandinteractions. histor A completemedication oftheoldertraumapatient. andtreatment forinitialevaluation appropriate andresuscita The useofstandardevaluation Traumatic and braininjury; can be extremely painful and may be lethal if not managed aggressively.can beextremelypainfuland maybelethalifnotmanaged forflailchestalongwithotherserious chestinjuries.evaluated Fractured ribsand/orchestwallcontusion issuspected. (CT)scanningshouldbeconsideredifheadinjury early useofcomputedtomography intracranial bleedingfromaclosed beforesymptomsofincreasedintracranialpressureoccur; headinjury olderadultscanbedifficulttoassessandmayrequiretheearlyuse ofinvasivemonitoring. many of volumestatus andpreexistingdiseases;intravascular duetomedications be seenintheolderpatients Flail chest(particularlyanterior) maynotbeobviousintheolderpatient, changes inbrainsizewitha Because ofnatural (e.g., Physiologic responsestohypovolemiaseeninyoungerpatients Physiologic derangementsinolderadultscanbeoccult. Post-traumatic complications. BLAST INJURIES Treatment ofOlderAdults

y, including (herbal useofprescriptionandnon-prescriptionmedications U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention ribs, skull)asaresultofdecreasedelasticitytissuesand tion protocols(e.g., Advanced Trauma LifeSupport)is ging, cansustainasignificantamountof olderpatients They need to be aggressively pursued.They needtobeaggressively tachycardia, hypotension)maynot and patients shouldbethoroughly andpatients

Treatment of Older Adults Treatment of Older Adults • • Disposition • Initial Management • Diagnostic Evaluation • • • • • • • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials

All surgical patients older than age 60years areconsidereda olderthanage All surgicalpatients thrombosis andshouldreceiveprophylaxis. when creatinine clearancewhen creatinine islessthan60ml/min. level.merely byserumcreatinine undergo renalexcretionmayneeddosingadjustment that Medications medical care. tothespecificsof thesedirectivesrelate should assistfamilymembersinunderstandinghow post-operatively.be encouraged ofolderadults, shouldbeconsultedearlyinthehospitalization pharmacology andearlymobilityshould and neck, intrathoracic, intraperitoneal, ororthopedicsurgery. areundergoingemergent, ifsuchpatients riskofcardiaccomplications or intermediate vascular, head co-morbidities. andtomanage maximize physiologicreserve need forreliefandfunctionalimprovementwiththepotentialadverseevents. withalteredconsciousnessorcognitivechange. ascontributingfactorsinpatients evaluated until itisprovenotherwise. retention. Duringinitialevaluation, areversibleetiology withdeliriumshouldbeassumedtohave patients neurological conditions, dehydration, severepain, immobility, sleepdeprivation, fecalimpaction, orurinary electrolyte imbalance, endorganfailure, hypoglycemiaorhyperglycemia, hypoxia, arrhythmias, infections (e.g., pneumonia, urosepsis), othermedicalconditions, ormany including: acutebloodloss, Measures to prevent skin breakdown should be evaluated onanongoingbasis. shouldbeevaluated Measures topreventskinbreakdown clearanceRenal functionshouldbedeterminedbycreatinine (reducedwithincreasinga delirium. Unrecognized dementiaisariskfactorforpost-operative Family membersshouldbequeriedregardingexistingadvanceddirectives, andhealthprofessionals Social services, medicine, rehabilitation physicaltherapy, therapy, occupational nutrition, and contraindications, In theabsenceofany surgicalproceduresshouldbe delayedforabriefperiodto Non-emergent orothernon-life-threatening Pain, whichcanbemanifestedasdeliriuminolderadults, bybalancingthe shouldbeoptimallymanaged Decreased hearingandvisualimpairmentarecommoninolderadults. These conditionsneedtobe Delirium isnotuncommon, (inc anditmaybeduetomedications (CDC) onblast injuries. For on blastinjuriesandtoorder free copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries (continued) perioperative beta-blocker use is appropriate for patients at high at forpatients beta-blockeruseisappropriate perioperative t high risk of postoperative deepvenous t highriskofpostoperative luding prescriptionandnonprescription), ge) andnot

 •  • Clinical Presentation infantsandchildren.treating below. differencesfollow The highlightsofthesetreatment blast victims, allclinicians adultsand shouldunderstandthereareimportantdifferences betweentreating children.upon totreat Although thegeneralprinciplesofemergencyexplosive- whentreating medicineapply After abombblastorexplosion, experiencecouldbecalled healthcarepersonnelwithlittleornopediatric Background •

Abdominal Injuries Brain andOtherNeurologicalInjuries — — — A traumatic brain injury (TBI) can occur without the patient losing consciousness. (TBI)canoccurwithoutthepatient braininjury Consequently,A traumatic children — aremorepronetoinjury. proportionally largerorgansthat — Childrenhave offerthemlessprotection. thinabdominal wallsthat — Childrenhave — : asfollows patterns can affectinjury differencesfromadultswithregardtotheabdomen. significantanatomical Children exhibitmany These — — airwaysandas a resultaremorepronetobronchospasmandobstruction. narrower — Childrenhave — patterns.an explosiveblast. uniquetochildrenaffecttheirinjury For features Severalanatomical example: Chest injuries, usuallycausedbyblunt-forceimpact, inchildrensubjectedto areacommoncauseofdeath Chest Injuries — Persistent vomiting — the following: of toahospitaliftheyexhibitany whenfirst examinedshouldbetriaged alertandawake who appear

The spleen and liver are the organs most vulnerable to injury from blunt- or penetrating-force trauma. fromblunt-orpenetrating-force The spleenandliveraretheorgansmostvulnerableto injury suchasirritabilityorexcessivesleepiness Abnormal behavior protection thanthoseinadults. Children aremorepronetoabdominalinjuriesbecause theirsmallerandmorepliableribsofferless pneumothorax inthehypotensive, hypoxicchild. andcardiovascularcompromise.the mediastinumcausingrespiratory considertension Always moremobilemediastinalstructures.Children have Accordingly, atensionpneumothoraxcanshift thoracic injuriescanoccurwithoutsignificantexternalevidenceofinjury. occursmorecommonly.extubation ismoredifficult, ashortertracheaandsoendotrachealintubation Children have andunintentional Evidence ofacerebrospinalfluidleak(CSF) Loss ofconsciousness Seizures  muchmorecompliantchestwalls;ribfracturesareless commonandsevere Children have  BLAST INJURIES Pediatrics U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention

Pediatrics Pediatrics • Other Considerations • • Initial Management • • • • Clinical Presentation (continued) • • • •

This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials Orthopedic Injuries — — For onpsychologicalfirstaidforchildrenandfamilies, furtherinformation pleasereferto CDC’s factsheet eventsuchas abomb experiencedatraumatic Mental healthissuesarecommoninchildrenwhohave children inthepresenceofparentswheneverpossibletominimizedisruptionandreduce Decontaminate evenminimalsignsofshockwillnotoccuruntil25% of aremarkablecardiovascularreserve; Children have withtheirinitial areessentialbecause youngchildrenoftenarenotabletocooperate examinations Repeat inchildrenwithheadinjur spineinjury Consider possiblecervical “Blast Injuries: BombingsandMentalHealth.” blast. Ifparentsareaccessible, providethemwithmental healthreferralsources. anxiety.the possibilityofseparation blood volumeislost. is20–30cc/kg ofnormalsalineorRinger’s Recommendedinitialfluidresuscitation lactate. examiner. • • — — Several factorsuniquetochildrenaffecttheircriticalcare. These include: Critical Care — — Forearm fracture—involvingradiusandulnausuallyoccursafterfalls. — thesideoppositeofforceimpact. — Greenstickfracture—fractureofonecortexat — bonewithoutevidenceofcorticaldisruption. — Plasticdeformity—bowed Common orthopedicinjuriesinchildreninclude: include: aclosedabdomen orchestagainst glottis. Treatment issupportive. asphyxia Symptomsoftraumatic Traumatic asphyxiaoccursalmostexclusively inchildren. Itresultsfromsuddencompressionofthe causedbythefulcrumeffectinC1–C3area. spineinjury susceptible tocervical Young neckmusculature. largeheadswithimmature relatively childrenhave This makesthemmore convection, andevaporation. Temperature lossbyradiation, isimportantbecausechildrenaremoresusceptibletoheat regulation Torus (buckle)fracture—bendingofthecortex. careful neurovascular exam is necessary to detect potential damage tothebrachialartery. todetectpotentialdamage careful neurovascularexamisnecessary isconsideredanorthopedicemergency. fracture—involvingdistalhumerusandelbow Supracondylar A fractures. of pediatric plate). 18% Physeal fracture—involvingthephysis(growth Physealfracturesrepresentapproximately abnormality). withoutradiographic 8yearsalsoaresusceptibletoSCIWORA(spinalcordinjury Children underage  

Respiratory failure Respiratory Petechiae inupperbody Disorientation Hyperemicsclera Seizures (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries y.

• • Initial Management 3. Category 2. Category 1. Category forexposuretobloodorbodilyfluids: risk categories intooneofthreemajor Individuals presentingfromthesceneofabombingcansubsequentlybecategorized Clinical Presentation virus (HCV), andhumanimmunodeficiency virus(HIV). Bvirus(HBV), fluidsincreasestheriskofexposuretohepatitis exposure tobloodandotherbody C hepatitis As notedintheU.S. exposureofhealthcareworkers, guidelinesforoccupational PublicHealthService spectrum ofblastinjury. of anexplosiveevent, contributetothe biologicalforeignbodiessuchasbonecanbecomeprojectilesthat and foreignbodiessuchasbone, fragments, weapon contaminated orotherdebris. For victimsnearthescene transport efforts, including firstresponders, fluids viabody at riskofexposuretobloodbornepathogens are Victims presentingfromthesceneofanexplosiveevent, and inrecovery aswellthoseparticipating Background See Table 1forsummary. • • — —

for Category 2). for Category (4–6months)anti-HCVand baseline (within7–14days)andfollow-up ALT 1;generallynoaction (Category orlikelyHCV-infectedif exposureistoaknown sourceormultiplesources. Iftestingisperformed, obtain There isnoprophylaxisrecommendedforHCV. superficial skin exposure (Category 3). superficial skinexposure(Category HIV-infected 1and2). source(Categories than7daysafterexposure.and notlater The vaccineshouldbeadministered tothosewho: assoonpossible, doseandschedule)shouldbeinitiated preferablywithin24hours (age-appropriate 1and2).nonintact skinormucousmembraneexposure(Categories series Bvaccination The hepatitis No PEPortestingisrecommendedforthoseindividuals presentingfromthescenewithpossible Generally, noPEPiswarranted forHIV—consideractionONLY orhighlylikely ifexposureistoaknown HBV postexposureprophylaxis(PEP)isrecommendedforindividualspresentingfromthescenewith Have no previous history of contraindication to immunization against HBV. against toimmunization ofcontraindication noprevioushistory Have HBV; against and ofimmunization Lack areliablehistory BLAST INJURIES Bloodborne Pathogens Bloodborne Post Exposure Prophylaxis for

Superficial intactskinexposureswithoutmucousmembraneinvolvement Mucous membraneexposures Penetrating injuriesornonintactskinexposures U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention Consider testing (immediately or during follow-up referral) orduringfollow-up Considertesting(immediately

Post Exposure Prophylaxis for Bloodborne Pathogens Post Exposure Prophylaxis for Bloodborne Pathogens • • • • • Special ConsiderationsregardingHIVPEPRecommendations exceedslocalresources. vaccinedemandthat ahepatitis create inresponsetoamasscasualtyeventcould these recommendations following it shouldberecognizedthat education, testing, and, medicalfollow-up ifPEPisinitiated, ofadverseevents. management Inaddition, andprecautions, regardingcontraindications existing guidelinesandrecommendations counselingand andpregnantwomen. patients pediatric aboutconsulting Healthcareprofessionalsshouldbeknowledgeable aboutHBV, fromhealthcarespecialistsknowledgeable Consultation HCV, andHIVisideal, inparticularfor Special ConsiderationsregardingPEPRecommendations 3. Category 2.Category 1. Category Risk Category pathogen Table 1.Recommendedpostexposure managementbyriskcategoryandspecific • • • • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials Test laws state/local inaccordancewithapplicable Collectspecimensforbaselinetesting: HIV, CBC, LFTs, creatinine, pregnancy test Ifindicated, donotdelayPEPforHIVtestresults ifitisindicated, HIVPEPshouldberarelyindicated; startassoonpossibleafterexposure HIVspecialistshouldreassesswithin72hours Dischargewithwritteninformation, a5–7daysupplyofmedication, appointment andafollow-up Continuefor4weeks

HIV/AIDS Rx information service http://aidsinfo.nih.gov service HIV/AIDS Rxinformation state, orfederalpublichealthauthorities PEPline 24-hours/day: 888-448-4911(preferred)orhttp://www.ucsf.edu/hivcntr/Hotlines/PEPline.html Or Consult experts: localinfectiousdisease, hospitalepidemiolog

(CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries NO ACTION INTERVENE HBV INTERVENE

NO ACTION CONSIDER NO ACTION TESTING HCV GENERALLY

y, healthconsultant;local, oroccupational NO ACTION GENERALLY NO ACTION NO ACTION HIV GENERALLY

• • Numerous challengesandpotentialconcernsmustbeaddressedbyEMSproviders. Challenges forEMSProviders traumacenters,appropriate toothermedicalfacilities. anddirection oflessinjuredpatients withpotentiallysignificantinjuriesto andtransportofpatients byidentification event medicalmanagement Even thoughitfacesthesechallenges, theprehospitalmedicalcaresystemwillplayapivotalroleinblast and limitedevidencebasefortheprofession. response timedisparities, inconsistentqualityofcare, lackofdisasterreadiness, dividedprofessionalidentity, Institute ofMedicine, keyissues: EMSsystemsarechallengedbythefollowing insufficientcoordination, andclinical isoftenmarkedlydifferentinoperational among jurisdictions.that approaches According tothe thelocallevel.at Nationwide, thisresults inanincrediblydiverseprehospitalemergency medicalcaresystem In theUnitedStates, themajorityofemergency (EMS)systemsareorganizedandcoordinated medicalservice • • • issues: following prehospitalemergencycasualty eventcausedbyanexplosionrequiresthat medicalcaresystemsaddressthe activities, mortalityandmorbidityrates. anditmaydirectlyaffectpatient The complexityandscopeofamass quality ofprehospitalemergency medicalresponsewillaffectthequalityofallsubsequentclinical care theemergencyplay acriticalroleinmanaging medicalresponsetothiskindofmasscasualtyevent. The Because aterroristbombingcancauselargenumberofseriouslyinjuredpersons, prehospitalcaresystems Background • • • • • — —

A nationally standardized triage methodology doesnotcurrentlyexist. methodology standardizedtriage A nationally closest hospital(s). thebombing scene.dangers at environmental hazards(e.g., toxins, fires)andstructuralinstability. Due toinfrequentoccurrence andthediversityofblastevents, rigorousstud isanessentialcomponentofmedicalmana Effective prehospitaltriage fromtheexplosionsiteto moveontheirown injuriesmayrapidly Patients withmildtomoderate ofsur Exhaustive prehospitalevaluations Blast sitesaredangerous;EMSpersonnelmustbesafetyconsciousandalertforhazardssuchas: tria Expedient patient withacutecaremedicalresourcesandemergenc Effective communication injuries. withsignificant blast related patients Identification withaterroristbombing, Recognition ofspecifichazardsassociated is difficult. fire, environmentalexposure, orstructuralcollapse. deviceexplosions;and secondary BLAST INJURIES Prehospital Care ge to match available resources with patient needs. resourceswithpatient available ge tomatch U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention vivors areimpracticalduetolimitedresourcesandpotential such as secondary devices, suchassecondary gement foranexplosiveevent. y management resources.y management y of triage methodologies y oftriage

Prehospital Care Prehospital Care • • • systemincludes:effective prehospitaltriage at thelocallevel. efforttostandardizeprocessesanddefinitions mass casualtyeventsshouldmakeevery An methodology, prehospitaltriage In theabsenceofadefinednational at agencies withresponsibilityfortriage Improving Prehospital Care AfterBlastEvents • Challenges forEMSProviders (continued) • • • shouldfocuson: medical systemadministrators theresourcesrequiredtocareforthem. have bombing victimsaretransportedtofacilitiesthat Prehospital its emergencythemostseverelyinjured arecriticallyimportanttoensuringthat responsemethodology byprehospitalmedicalcaresystems.preparation intothelocaltraumasystemandunderstanding Integration oftheemergencyEffective management medicalresponsetoamasscasualtybombingrequiressubstantial • • This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials

guidelines that facilitates moving these patients tothehighestleveltraumacenter(s)inlocalsystem. movingthesepatients facilitates guidelines that training prehospital medical providers to recognize external signs of significant blast injury anddesigningtriage training prehospitalmedicalproviderstorecognizeexternalsignsofsignificantblastinjury the complex injury patterns producedbysuchanevent. patterns the complexinjury methodology.triage response processesanddefinitions. response; and those criticallyinjured. among themmaycauseconfusionduringachaoticsituation. methodologies, ofwhichpossesssimilarprocessesanddefinitions;however, many subtledifferences ensuring that prehospital medical care providers have a basic understanding of blast pathophysiology and abasicunderstandingofblastpathophysiology prehospitalmedicalcareprovidershave ensuring that interagencybystandardizingcommandstructure,facilitating collaboration linesofcommunication, and understanding ofemergencyfunctional exerciseswhereprehospitalmedicalprovidersdemonstrate possiblyusedduring anemergency toolsandrecordkeepinginstrumentsforapparatus deployable amountsofmedicaleducation; easily understoodprotocolsforproviderswithvarying andprocesses; common terminology maydepletelimitedresources,Overtriage of careandincreasingmortalityrates thusdegradingpatient andlocallycrea adoptedavarietyofcommerciallyavailable Prehospital medicalrespondershave (CDC) onblast injuries. For on blastinjuriesandtoorderfree copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

ted

• • • • • • • • Decontaminating theInjured • • • • • • Triage andStaff Protection areprovidedbelow.treatment shouldnotposeahealthrisktocareproviders. patients radioactivity levelsofcontaminated Guidelinesforprotectionand injuries. forlife-threatening assoonpossibleafterbeingtreated shouldbedecontaminated patients Contaminated The clothing. occurswhenradioactiveparticles Internalcontamination areinhaled, ingested, orlodgedinanopenwound. occursexternallywhenlooseparticlesContamination aredepositedonsurfaces, ofradioactivematerial skin, or illnessiftheirdoseishighenough,People cansufferradiation exposedtoradiation buttheydonotbecomeradioactive. isusedinaterroristbombing,radioactive material victimsmustbeassessedforbothexposureandcontamination. conductedwithspecializedradiologicalequipmentistheonlywaytoconfirmpresenceofradiation. A survey If exposuresaredelayed.effects ofallbutthemostsevereradiation The clinical ofexposedcasualtieswillmostlyresembleconventionalinjuries. presentation This isbecausetheclinical thanphysicalharmbyinducingpanicandterrorinthetargetpopulation. primarily usedtoproducepsychologicalrather areamaybekilledorinjuredinitiallyfromtheeffectsofblastandnotradioactivity.in theimmediate RDDsare explosives. overanareaaslargemultiplecityblocks. theycandispersesuchmaterial Their forceissopowerful People Radiological DispersalDevices(RDDs)or “dirty bombs” combinedwithconventional consistofradioactivematerial Background • • •

contaminated area and washing inward; do not irritate orabrade. areaandwashing inward; donotirritate contaminated Wash first. woundswithsalineorwarmwater Gently andwater,cleanse intactskin withsoap startingoutsidethe              background orthelevelremains unchanged. contamination. casualties. toreplacecontaminated Stockasufficientquantityofhospital-supplied gowns clothing. Survey and note radiation level again; repeat washing until survey indicates radiation level is no more than twice the levelisno morethantwicethe radiation indicates washinguntilsurvey repeat levelagain; andnoteradiation Survey Flush eyes, nose, andears, occurred. andrinsemouth iffacialcontamination levels. andrecord contamination survey thepatient Repeat clothingDouble-bag usingradioactivehazardouswasteguidelinesandthenlabelthebag. clothingthefeettocontain Remove patient fromthefacetoward bycarefullycuttingandrollingitaway andlevelofan Use astandardizedformtorecordlocation Handle easily-removableradioactiveobjectswithforcepsand storetheminleadcontainers. Note exceptionallylargeamountsofsurfaceorimbeddedradioactive material. meterusingaconsistenttechniqueandtrainedpersonnel. witharadiation thepatient Survey handsandclothingfrequentintervals. meterat Survey witharadiation N95masks, Ensure surgicalmasksareadequate; Follow standardguidelinesforprotectionfrommicrobiologicalcontamination. meter,Using aradiation area. thebodiesofpersonswhentheyexitacontaminated survey outergarmentswhenlea Remove contaminated areaandac Establish bothacontaminated areainaloca Establish anadhoctriage BLAST INJURIES and RadiationInjury Radiological Dispersal Devices Radiological DispersalDevices U.S. Department ofHealthandHuman Services tion basedonthehospital’s numberof disasterplanandtheanticipated Centers forDiseaseControl and Prevention lean area and separate thembyabufferzone.lean areaandseparate ving the contaminated area.ving thecontaminated ifavailable, arerecommended. y contamination found. y contamination

Radiological Dispersal Devices and Radiation Injury Radiological Dispersal Devices and Radiation Injury • • • Psychosocial Issues • • oringestion. inhalation decontamination. Itgenerallydoesnotcauseearlysymptoms. mayindicate Noseormouthcontamination readingsarenotedfollowing Internal Contaminationshouldbeconsideredifpersistentlyhighsurvey • • totheskin. injury isacuteradiation Cutaneous RadiationInjury • ordelayed,Symptoms canbeimmediate mildorsevere, dose. basedonradiation body. exposure. levelsofradiation low A dirtybombwilllikelygenerate deliveredtolarge portionsofthe arerapidly that Acute RadiationSyndrome(ARS)iscausedbyhighdosesofradiation Radiation-related • • • • • Diagnosis andTreatment • • Decontaminating theInjured (continued) • • • • • This fact sheet is part of a series of materials developed bytheCentersforDiseaseControlandPrevention This factsheetispartofaseries ofmaterials

Treat localizedinjuriessymptomatically, focusingonpainandinfectioncontrol. theselesionsfromthermal burns. The delayinoccurrencedifferentiates Transient itching, tingling, erythema, oredemamaybeseenwithinhours ordays, byalatent andisusuallyfollowed Treat andfocusonpreventinginfection;useantibiotics. symptomatically Vomiting due to radiation exposure is usually recurrent rather thanepisodic.Vomiting exposure isusuallyrecurrentrather duetoradiation Assessment mayinclude analyzingurine, period; lesionsmaynotbeseenforweekstomonthspostexposure.           decontamination, willsimplyseekreassurance. andmany Prussian Blue, DTPA, orBicarbonate. systemeffectsaresignsofacuteillness. cardiovascular/central nervous ofradiation. anddoseestimation diagnosis Include mentalhealthprofessionalsontheresponse team. Psychogenic illnesssymptoms, suchasnauseaorvomiting, In urbanareas, hundredstothousandsmayseekcare. Gastric lavage, antacids, assistinclearing andcathartics ingestedcontaminants. ofradionuclide-specificagentssuchas expertsmayrecommendearlyadministration Radiation decorporation ofillness, Depending onthestage bysymptomsofbonemarro Early onsetofvomitingfollowed Nausea orvomitingmayoccurminutestodaysafterexposure. recovery.Perform within48hoursordelaythemuntilafterhematopoietic surgicalinterventions Consider cytokines, e.g., factors. growth Neupogen®andhematopoietic instability Monitor forfluidandelectrolytebalanceevidenceofhemodynamic Perform sequentialCBCswithdifferentialtoassessdeclines inlymphocyte levels. patients. For andnon-ambulatory masscasualties, areasforambulatory shower considerestablishing separate dressing. Cover woundswithwaterproof (CDC) onblastinjuries. For onblastinjuries andtoorderfreecopies moreinformation For emergencies, aboutradiation more information visit: of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries I llness/Injury a patient maybeasymptomatic. apatient

blood, counts. andfecalsamplesorwholebody Many mayseekradiologicalscreening, Many willneed many maymanifest. w suppression, gastrointestinaldestruction, and The rapid onset of vomiting is a major factor in onsetofvomitingisamajorfactorin The rapid www.bt.cdc.gov/radiation.

.

• • and pneumothorax. alveolarhemorrhage todiffusepulmonary secondary opacification barotrauma ischaracterizedbypulmonary andentericbarotrauma. focusesonpulmonary blastinjury Pulmonary ofprimary Radiological diagnosis reflection ofsurfacesasseenin closed-space explosions(e.g., insideabuilding, bus, train). affecting air-filled suchastheear, organsandcavities lung, and abdomen. bythe ismagnified Thisblastwave producedbyhigh-orderexplosives, iscausedbytheoverpressureblastwave BlastInjury primarily Primary Initial Evaluation oftheexplosiveinjuredpatient. essential elementintheoptimizingmanagement andisan andtriage resourceshasthepotentialtoimpactin-hospitaldiagnosis ofradiology utilization ofresources.multiplicity ofinjurieswhichrequireahigherallocation With thiscaveat, theappropriate and mechanismsarethenumberofpatients andotherinjury injury difference betweenexplosion-related overwhelmed. resourcescanberapidly mass casualtyeventsinwhichhumanandmaterial Onesignificant experiencewith fewprovidersormedicalfacilitieshave bythefactthat of thisscenarioisexacerbated thepotentialtoinflictnumerouscasualtieswithmultipleinjuries.Explosive eventshave Thecomplexity Background • mayrequiretimelyintervention. that Forinjury example, canbeusedasfollows: radiologicalimaging byidentifyinglife-threatening helpstoprioritizetreatment blastinjury ofsecondary Radiological diagnosis regionofthebody, ofany penetration regions. inmultiplebody penetrations fragment andtypicallyhave trauma, primarilycausespenetrating blast injury butmayalsocauseblunttrauma. Patients cansustain issecondarilypropelled bytheexplosion.It canalsoresultfromdebrisexternaltothebombthat Secondary of thebombinadditiontoobjectsaddeddeviceincreaselethality(e.g., screws, nails, nutsandbolts). Blast Injury Secondary • • •

whodonotneedsurgicaltherapy. injured byfragments The CTscancanbeused toidentifypatients injuries, The thoracoabdominalCTscancanbeusedtoidentify unapparent withfra Conventional x-raycanbeusedtoidentifypatients Portable patterns. biplanarx-raycanbe used todefinebasicpenetration hemodynamically stable patients with blast fragment penetrations. withblastfragment stable patients hemodynamically penetration.) cavity sensitive forbody injury,intracavitary whothenwillrequire more advancemethodsofimaging. (Conventionalx-rayisnot In theabsenceofperitonitisorclinical signs, symptomswhich oftenpresentwithsignificantpulmonary blastinjury Patients withsubstantialpulmonary radiography. freeairthandoesconventional sensitivityforthedetectionofintraperitoneal (CT) hasamuchgreater freeair. manifestingasintraperitoneal injuries istoidentifyentericinjury Computerizedtomography may include dyspnea, tachypnea, andcyanosis. test. isaconfirmatory A chestradiograph BLAST INJURIES Radiological Diagnosis is characterized by trauma due to impact from bomb fragments, to include the casing U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention the role of radiological studies in assessing primary blast theroleofradiologicalstudiesinassessingprimary gment woundssuspiciousforcausing including among

Radiological Diagnosis Radiological Diagnosis • medical providers. challengesforemergencyThe severityanddiversityofinjuriescausedbyexplosionsprovidetreatment Summary andDisposition • • detection ofotherinjuries. For example: primarilyfocusesonidentifyingfractures, blastinjury oftertiary butalsoincludesRadiological evaluation the sharp object). primarily involveblunttrauma, butmayalsobeclassified trauma(e.g., aspenetrating impalementon Tertiary bytheforceofblastwind. resultsfromthevictimbeingthrown blastinjury These injuries Initial Evaluation(continued) • • •

This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl This factsheet ispartofaseriesmaterials If radiography resourcespermit,If radiography phasetoincrease shouldbeusedliberallyintheacutediagnostic imaging anexplosion,Due tothepotentialforsurgeandnearbyhospitalsfollowing effectiveuseofradiolog   the accuracy andenhancetreatment. ofdiagnosis interventions.of life-and-limbsaving need withthegreatest ofpatients andinidentification triage resources isvitallyimportantduringpatient pathology.for determiningtraumatic blastinjury, algorithmforthesecondary Similar tothediagnostic theCTscanisbothsensitiveandspecific to beblood. withblunt-forcetraumainjuries. fluidinpatients intraperitoneal Inexplosiveevents, thisfluidispresumed Focused abdominalsonogramfortrauma(FAST) thepresenceof diagnose canbeusedtorapidly Pelvic isusedtoexclude radiography ofpelvisfractures. ortodeterminethemorphology contusion, consistentwithacutethoracicaorticinjury. aswellstigmata thethoraxforsignsofpneumothorax,Plain filmsareusefulinevaluating hemothorax, orpulmonary

on blastinjuries. For onblast injuriesandtoorderfreecopies moreinformation of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries

and Prevention (CDC)

y • • • Airway/Inhalation Injuries • • Immediate Steps Initial HospitalManagement • • • Initial Prehospital Management • otherblastinjuries. • Clinical Presentation may bechallengingduetoconflictingfluidrequirements. injury. blastinjury, withprimary thermalinjuriesassociated Effectivelymanaging particularlyblastlunginjury, neck, andhead). Confinedspaceexplosionscanenhancethermaleffectsandincreasetheriskofinhalation parts(e.g., expandingfireballfromtheexplosionmaycauseflashburnsoverexposedbody rapidly hands, blastinjuries. areclassifiedThermal injuriesfromexplosionsofconventionalweapons asquaternary The Background

Rapidly cooling the isolated burn (cool water irrigation, burn(coolwater coolingtheisolated noice)willreducethezoneofstasisassociated Rapidly mucosal swelling and progressive edema that oblitera andprogressiveedemathat mucosal swelling resources). overwhelmthelaboratory witha: injury Suspect aninhalation matter, smoke, gases, superheated andtoxicby-products. canresultfromtheexplosion’s injury Inhalation ofparticulate oxygenandcreation extinctionofavailable this areaarepotentiallyreversible. Donotuseiceandbecognizantofthepotentialforhypothermia. to helpreducetheareacontainedinzoneofstasis. thermalinjurieswithcoolwater Irrigate Injuriesin oxygen. firesinthepresenceofhighflow secondary Remove restrictiveandsmolderingclothing tostopburning, allo woundcontamination. simpledressingstolimitsecondary Apply hypothermiaandfreezingtissue. avoid with initialthermalinjury; Stop theburningprocess;removerestrictiveandsmolderingclothing. explosionsinconfined spaces. common(18%)amongthosewhosurvive isrelatively injury Inhalation surfacearea(TBSA), burnscover<20%ofthetotalbody Most bomb-related If airway injury exists,If airwayinjury early. intubate ifapatient’s canbefatal injury Inhalation airwayisblockeddueto — — Singednasalvibrissaeorcarbonaceoussputum; — Closedspaceexplosion; Elevated CO or CN levels (obtain only if victim numbers are low— indiscriminantorderingwill COorCNlevels (obtainonlyifvictimnumbersarelow— Elevated BLAST INJURIES Thermal Injuries U.S. Department ofHealthandHuman Services Centers forDiseaseControl and Prevention tes normalairwaystructures. w forathoroughexamination, andprevent but occur in combination with butoccurincombination

Thermal Injuries Thermal Injuries • • • • Disposition • • Other Considerations • • Pain Management • • • • Fluid Resuscitation • Initial HospitalManagement • • • •

 This fact sheet is part of a series of materials developedbythe CentersforDiseaseControl andPrevention This factsheet ispartofaseriesmaterials unknown. Recognize whenresourcesmaybelimited(e.g., aRhodeIslandnightclub fireexhaustedathree-month Give narcoticsforpain. theburn. totheblastinjuredlungmustbebalancedwithneedprovide IVfluidstomanage hydration Take alsosufferedablastlunginjury. burnvictimswhohave carewhentreating The riskofaggressive byadequa isdemonstrated Effective fluidresuscitation duringthenext16hours. post-injury, hypovolemiaoccur. leakandrelative whencapillary volumeandtomaintaintissueperfusioninthefirst48hours The goalistoreplacethelossofintravascular riskofbarotrauma. increasetheriskofalveolarruptureandairembolism. Pa any associated burn. associated any shouldbeadmittedtothehospital, blastlunginjury withprimary regardlessoftheextent Patients diagnosed and lunginvolvement, ofthevictim. andtheage fromburnsisdependent on:Death of thepercentage TBSA affected, presenceorabsenceof significantairway Burns covering>30%of withincreaseddea TBSA areassociated isanindependentpredictorof prolongedICUcareandmortality. injury Inhalation require anescharotomy. Full-thickness burnsofthoraxandextremitiesmaycausetheconstrictionunderlyingstructures didnotreceiveaboosterinthelastfive years,Administer tetanustoxoidifpatient orifda aLevelItraumaandburncenter). phaseat narcotic supplyduringtheacuteresuscitation — — 4cc/kg/%TBSAinthefirst24hours Ringers(LR): Give Lactated withalmost100%mortality.associated is morethanfourhourspost-injury isinitiated that forsignificantthermalinjury Fluid resuscitation increasesmorbidityandmortality. fluidresuscitation Inadequate cover>15%of isrequiredforvictimswithburnsthat Fluid resuscitation TBSA. tothelung, blastinjury andpositivepressuremay withprimary mechanicalventilation Among patients aggressive pulmonary toiletisneeded. pulmonary aggressive At admission, thefiberopticairwaytodetermineifsubsequentinter considerevaluating Give halfinthefirsteighthoursstartingfromtimeofburninsultitself, andtheremaininghalf (CDC) onblast injuries. For on blastinjuriesandtoorder free copies more information of theblastfact sheets,visithttp://emergency.cdc.gov/BlastInjuries (continued) te urineoutput. tients with inhalational injury may be at ahigher maybeat injury tients withinhalational th rates. te ofboosteris

vention or

Free Blast Injury Products Available!

BOMBINGS: INJURY PATTERNS AND CARE INTERACTIVE Scenario-based Training 2.0

This course focuses on the effects of explosive events and provides the latest clinical information regarding blast-related injuries from terrorism. It was developed to compliment all hazards disaster response training programs and also serve as an independent training source for emergency responders and hospital staff.

The interactive scenario-based training includes: • Sixty minutes of instruction • Practice scenarios and assessment situations with feedback used to provide context and realism • Visuals of several types including photos of actual blast events with patients, photos taken specifically for the training, charts, and diagrams • Final exam

The interactive scenario-based training, as well as curriculum guides and PowerPoint presentations for one and three hour courses (CE and CECBEMS accredited), and the quick reference pocket guide are available free of charge at: http://emergency.cdc.gov/BlastInjuries

Available Online Soon Bombings Injury Patterns and Care: System Preparedness Course 1.0 This course is designed to assist system administrators including public safety, healthcare, public health, emergency management) and leadership in their preparation and response to terrorist bombings. The principles outlined in this course, while focused on bombings, can be translated to any crisis or disaster. Specifically, this course: • Discusses challenges to effective preparedness • Proposes solutions to systems preparedness • Reviews current resources available for preparedness and response Developed under the Terrorism Injuries: Information, Dissemination, & Exchange (TIIDE) partnership agreement in with American Trauma Society, this course focuses on the core competencies in effective leadership and crisis management, challenge recognition, systems approach to preparedness, and best practices for saving lives in the event of terrorist bombings. Helping all people live to their full potential

For more information on blast injuries and to order free copies of the blast fact sheets, visit http://www.emergency.cdc.gov/blastinjuries

Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Injury Response

CS218119-A