UNIVERSAL BLAST Bombings: Blast Event PRIMARY INJURIES SECONDARY INJURIES Unique to high-order explosives; results from the impact of the over-pressurization Results from flying debris and bomb fragments causing shrapnel wounds. Injury Patterns and wave with body surfaces by the blast wave. Common injuries include: SCENE SAFETY HEAD INJURIES • Trauma to the head, neck, chest, abdomen, and extremities in the form of • May or may not include history of loss of consciousness penetrating and blunt trauma. • Check in at staging area for safety briefing. Care Pocket Guide • Headache, seizures, dizziness, memory problems • Fractures • Soft tissue injuries • Personnel safety • Gait/balance problems, nausea/vomiting, difficulty concentrating. • PPE – Protective clothing, hard hats, eye protection, respiratory protection. • Visual disturbances, tinnitus, slurred speech. • Protection of uninvolved public and volunteers. TERTIARY INJURIES • Disoriented, irritability, confusion. • Protection of injured. Results from individuals being thrown by the blast wind. • Extremity weakness or numbness. • Be aware of secondary explosive devices. Common injuries include: TYMPANIC MEMBRANE – EAR INJURIES • Be aware of multi-agent devices, e.g. chemical release, dirty bomb, etc. • Head injuries • Skull fractures • Bone fractures • Evaluate and resuscitate per standing protocols. • Impaired hearing may complicate triage process. TRIAGE CONSIDERATIONS • Secondary evaluation and examination to identify all blast-related injuries QUATERNARY INJURIES • Unique patterns, multiple and occult injuries. including perforated tympanic membranes. All explosion-related injuries, illnesses, or diseases not due to primary, secondary, • Death is often a result of combined blast, ballistic, and thermal effect injuries. • Serious blast injuries can occur in the absence or presence of tympanic or tertiary mechanisms. membrane rupture. • Walking wounded and non-critical patients are time intensive. Common injuries include: • Stable patients without signs and symptoms of significant blast injury, may be • Hidden/internal injuries • Burns • Head injuries • Exacerbation of pre-existing medical conditions discharged after 4 to 6 hours of observation despite the presence of TM rupture. • Overtriage can increase critical mortality – resulting from poor patient • Patients should have urgent consultation and follow up care with ENT specialist. CRUSH INJURIES – Go to Crush Injury Section distribution from scene and self-referrals to hospitals. • Spontaneous healing occurs in 50-80% of all patients with perforations. • Up to 75% of victims self-refer to hospital. • Do patients require decontamination? ABDOMINAL INJURIES COMBINED INJURIES • Treatment follows established protocols. • Avoid tunnel vision on one injury. Initial triage, trauma resuscitation, and transport should follow standard • Perforations can be delayed and develop 24 to 48 hours post blast. • Monitor fluid replacement amounts when treating blast lung with another injury protocols for multiple injured patients or mass casualties. Manifestations of peritonitis can occur hours or days after a blast. to avoid fluid overload which can exacerbate blast lung injury. • There is the possibility of missed injury, especially in semiconscious • Airway management and oxygenation/ ventilation are critical and performed or unconscious patients. with standard techniques. FACTORS THAT CONTRIBUTE TO Treatment follows established protocols, but it is important to remember BURN/BLAST INJURY BLAST INJURY SEVERITY that these injuries may be easily missed. ENVIRONMENT PREHOSPITAL BLAST LUNG – Go to Blast Lung Injury Section • Was The Bombing In An Open Or Closed Space? The effects of the blast • Burn injury will require significant amounts of fluid resuscitation while avoiding wave are more intense in a confined space such as a building, bus or train. fluid overload to prevent further pulmonary injury. • Fluid resuscitation targeted to vital signs, to avoid hypotension; judicious fluid AGENT OTHER FACTORS SECONDARY, TERTIARY, AND QUATERNARY INJURIES ARE COMMON IN BLAST EVENTS, AND LARGE MAJORITY ARE NOT CRITICAL. administration to maintain perfusion without volume overload. • Low-order Explosive • Device type – large (vehicle) or small (suitcase) • Transfer to a facility with specific expertise in both trauma and burn management, IT IS UNLIKELY TO EXPERIENCE PATIENTS WITH INJURIES ISOLATED TO • High-order Explosive • Delivery method or at least the trauma management. ONE CATEGORY. A MORE LIKELY SCENARIO WOULD BE TO EXPERIENCE ™ • Distance from device PATIENTS WITH A COMBINATION OF ALL THE INJURIES LISTED BELOW. HOSPITAL • Protective barriers TREATMENT FOR MOST OF THESE BLAST INJURIES FOLLOWS • Fluid resuscitation guided by urine output. Consider monitoring central venous This project was supported by Cooperative Agreement Number U38/CCU624161-01-3107 ESTABLISHED PROTOCOLS FOR THAT SPECIFIC INJURY. pressure, and systemic vascular resistance when indicated. from the U.S. Centers for Disease Control and Prevention (CDC). 10/07 Additional resources can be found at: www.acep.org/blastinjury or www.bt.cdc.gov/masscasualties/ CRUSH INJURY BLAST LUNG INJURY

Blast Event Blast Event MANAGEMENT FIELD AMPUTATION OXYGENATION INDICATED? Field Amputation • High flow O sufficient to prevent hypoxemia via non-rebreather mask, CPAP, or INITIAL TRIAGE, TRAUMA RESUSCITATION, AND TRANSPORT 2 ENTRAPPED PATIENT TREATMENT INDICATIONS • Best performed by an endotracheal intubation. SHOULD FOLLOW STANDARD PROTOCOLS FOR MULTIPLE • Fluid resuscitation before extrication • Consider alkalinization • Inability to safely extricate the patient. appropriately trained • Hemothorax or Pneumothorax u 1 L NS bolus, 1-1.5 L/hr infusion u 1 ampule Sodium Bicarbonate (50 mEq) physician, such as a trauma INJURED PATIENTS OR MASS CASUALTIES • Continued environmental toxins that CLOSE OBSERVATION • Limb Stabilization prior to extrication, followed by 1 ampule of or orthopedic surgeon. Was the Bombing in an Open or Closed Space? Sodium Bicarbonate with each liter of NS pose a hazard to victims or rescuers. There is a higher incidence of blast lung injury in enclosed spaces • Chest decompression for clinical presentation of tension pneumothorax. • Minimize potential systemic effects infused at 1-1.5 L/hr. Maintain a second IV • When the extrication time would be • Ensure adequate analgesia of reperfusion (tourniquets) w/o Sodium Bicarbonate. long enough that it would endanger the and anesthesia. • Fluid administration patient’s life without field amputation. • Provide enough fluid to ensure tissue perfusion but avoiding volume overload. AIR EMBOLISM* Vital signs, oxygen, EKG, IV — Additional treatment and transport NO SIGNS OR SYMPTOMS SUGGESTIVE • Position in prone, semi-left lateral, or left lateral positions; transport to a facility CRUSH INJURY TREATMENT – PREHOSPITAL OF BLI OR RESPIRATORY DISTRESS with a hyperbaric chamber. CRUSH SYNDROME SIGNS – Apnea, tachypnea or hypopnea, hypoxia and cyanosis, cough, *Close observation for any patient suspected of BLI for the development of tension IS CRUSH SYNDROME OR COMPARTMENT • Primary survey and initial stabilization (ABCs) wheezing, dullness to percussion, decreased breath sounds, or hemoptysis pneumothorax transported by air. SYNDROME SUSPECTED? • Fluid resuscitation before patient is extricated with severe or SYMPTOMS – Dyspnea, hemoptysis, cough, and chest pain prolonged entrapment of limb or pelvis (more than a hand or foot). Areas commonly affected: • Lower/ Upper extremities • Pelvis CLINICAL CONCERNS – Blast lung, hemothorax, pneumothorax, pulmonary • Gluteal region • Abdominal muscles COMPARTMENT SYNDROME contusion and hemorrhage, A-V fistulas (source of air embolism), penetrating HOSPITAL DIAGNOSTIC EVALUATION • Primary survey and initial stabilization (ABCs) chest trauma, and blunt chest trauma. Evaluate patient for >10% BSA burns, • Chest radiography • Suspect compartment syndrome due to mechanisms of injury, examination, skull fractures, and penetrating torso or head injuries SIGNS AND PRESENTATION SIGNS OF COMPARTMENT and patient complaints. • Arterial blood gases, computed tomography, and doppler ultrasound can be used to OF CRUSH SYNDROME SYNDROME • Treat other injuries help diagnose BLI and air emboli. The general condition of a patient Pain, Pallor, Paresthesia, Paralysis, • Immobilize affected part; do not use constricting bandages or MAST trousers. • Most lab and diagnostic testing conducted per resuscitation protocols – based upon with crush injury is dictated by: Pulselessness Progression of symptoms nature of explosion (e.g. confined space, fire, etc.). (1) other injuries, (2) delay in extrication, (the 6th P) COMPROMISED and (3) environmental conditions. NO YES Clinical concerns: CRUSH INJURY TREATMENT – HOSPITAL VENTILATION Common presentations are: • Bone fractures with extravasation of blood • Hypothermia or hyperthermia or edema within a closed compartment. CRUSH SYNDROME HOSPITAL DISPOSITION AND OUTCOME dehydration/shock • High velocity penetrating injury to muscles • Fluid resuscitation • Brisk diuresis (2 ml/kg/hr) • No definitive guidelines for observation, admission, or discharge following emergency • Mental status varies from alert to comatose in closed compartment with extensive • Diagnose and treat other • Pain control department evaluation for patients with possible BLI following an explosion. tissue disruption. Vital Signs, Oxygen, Monitor IV Clinical concerns: metabolic derangements: • Anxiolysis • Patients diagnosed with BLI may require complex management and should be • The systemic effects are due to • Can also occur in sub acute fashion due to u Hyperkalemia admitted to an intensive care unit. Patients with any complaints or findings rhabdomyolysis and reperfusion of prolonged immobilization on hard surface. u Hypocalcemia suspicious for BLI should be observed in the hospital. Airway Management hypoxic and damaged tissues. • Compartment syndrome typically occurs in COMPARTMENT SYNDROME • Discharge decisions will also depend on associated injuries; other issues related major muscle groups enclosed by inelastic, Protocol • Reperfusion of body part results in • Primary survey, stabilization and to the event, including the patient’s current social situation. the systemic effects of crush injury. fibrous sheaths. • If injury is open: If ventilatory failure occurs or resuscitation, secondary survey. u • In general, patients with normal chest radiographs, blood gasses, and pulse • Patients may appear well until extricated, • Principal areas for compartment syndrome Antibiotics, tetanus, jet irrigation. is imminent, patients should be • Diagnosis through examination u oximetry who have no complaints suggesting a BLI, can be considered for and then precipitously decompensate. are upper extremities, including thenar and Debridement of nonviable tissues. Appropriate intubated; caution should be used hypothenar eminences of hand, and lower and confirmation with compartment u discharge after 4-6 hours of observation. • Skeletal muscle damage is greatest Early amputation for severely as positive pressure and mechanical extremities, including the foot. pressure measurements. Treatment after reperfusion. injured limbs may be required to ventilation may increase the risk of • Data on the short and long-term outcomes of patients with BLI is currently limited. • Untreated compartment syndrome will • Treat systemic effects of compartment reduce sepsis. further pulmonary injury • Cardiovascular instability due to massive and Transport However, in one study conducted on survivors one year post injury, no patients had produce the same effects as a crush injury. fluid shift, electrolyte abnormalities, and syndrome similar to crush injury. • Fasciotomy pulmonary complaints, all had normal physical examinations and chest radiographs, direct myocardial toxicity. and most had normal pulmonary function tests. Additional resources can be found at: www.acep.org/blastinjury or www.bt.cdc.gov/masscasualties/ Additional resources can be found at: www.acep.org/blastinjury or www.bt.cdc.gov/masscasualties/