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Symptoms Acute (0-2 Hours) Sub-Acute (2-48 Hours) Chronic (>48 Hours)
Constitutional
• Dyspnea • Progressively
Worsening Dyspnea
• Malaise
• Fever
• Apathy
• Amnesia
Localized Persistent Hearing Loss
• Pleuritic Chest Pain • New or Progressive
Chest Pain
• Non-productive cough
• Productive Cough
• Cardiac Chest Pain
• Bilious Emesis
• Abdominal Pain
• New or Progressive
Abdominal Pain
• Hematochezia
• Hematemesis
• Nausea
• Ear Pain
• Urge to Defecate
• Hearing Loss
• Tinnitus
• Vertigo
• Balance Problems
• Eye Pain
• Visual Changes
• Focal Numbness
• Paresthesias
Focused Questions
Quantity –
• Are you short of breath? (Pulmonary contusion inhibits oxygen diffusion and
requires more effort to inhale. Pneumothorax and hemothorax decrease the
volume of air that can be inspired. Shock will cause the sensation of dyspnea due
to poor tissue perfusion.)
• Do you have chest pain? (Chest pain indicates the possibility of penetrating or
blunt trauma, pneumothorax, or myocardial ischemia or infarction due to coronary
AGE.)
• Do you have abdominal or testicular pain, nausea, urge to defecate, or blood in
your stools? (Penetrating and blunt abdominal trauma cause pain, but PBI of air-
containing structures in the GI tract may cause any of the listed symptoms.)
• Do you have eye pain or problems with your vision? (Evaluate for penetrating or
blunt eye trauma as described in the chapter on Ophthalmology.)
• Do you have ear pain or problems with your hearing? (Ruptures of TMs occur
commonly but are not life-threatening, unless the casualty cannot hear life-saving
commands or communications.)
Quality –
• How bad is the [symptom above]? (The severity of any single symptom or
combination of symptoms must be evaluated relative to the casualty’s ability to
carry out his duties and either facilitate or hamper mission accomplishment.)
Duration –
• Did the [symptom above] occur at the time of the blast or develop later? (Any
positive finding indicates injury, but new symptoms appearing over time usually
represents deterioration.)
Alleviating or Aggravating Factors –
• How much exertion is required to cause any shortness of breath? (Dyspnea at rest
indicates shock due to external or internal hemorrhage, pneumothorax, or serious
pulmonary contusion. The more exertion required to elicit dyspnea, the less lung
injury is likely.)
Signs Acute (0-2 Hours) Sub-Acute (2-48 Hours)
Inspection
• Penetrating trauma
• Traumatic amputation
• Seizure activity
• Respiratory difficulty
• Hemoptysis
• Pharyngeal petechiae
• Tongue blanching
• Abrasions
Auscultation
• Asymmetric Breath Sounds • Newly Asymmetric Breath Sounds
• Rales
• Wheezes
Palpation
• Subcutaneous Emphysema • New or progressive abdominal
tenderness
• Abdominal Tenderness
• Abdominal rigidity or rebound
tenderness
• Spinal deformity or Tenderness
Percussion
• Asymmetrical Chest Percussion
Other
• Altered Mental Status • Fever
General:
• Identify sites of life-threatening external hemorrhage first. (#1 cause of
preventable death on battlefield.)
• Categorize dyspnea by its severity at rest or by the degree of exertion that causes
it. (Do not purposefully exert the casualty just to see how much exertion elicits
dyspnea.)
• Altered mental status may be transient or not. (May be due to head trauma,
shock, or cerebral AGE.)
Vital Signs:
• Tachycardia indicates stress from external or internal hemorrhage, hypoxia,
exertion, dehydration, or anxiety.
• Bradycardia is inappropriate but may be transient following a blast-induced
vasovagal reaction stimulated by suddenly increased intra-pulmonary pressures.
• Irregular heart rhythm may indicate cardiac irritability from shock or coronary
AGE. Rapid, shallow respirations are common after blast exposure, regardless of
the degree of lung injury, but can also indicate other thoracic damage, shock,
exertion, or anxiety.
• Hypotension may result from hemorrhage, other causes of shock, or a vasovagal
reaction.
Inspection:
• Identify external abrasions, contusions, penetrating wounds (Figure 1 & Figure 2),
and traumatic amputations (Figure 8 & Figure 9)
• Watch for inadequate chest-wall movement.
• Look for central and peripheral cyanosis (indicating hypoxia) and well-
demarcated mottling or blanching of the tongue or areas of skin (indicating
AGE).
• Otorrhea or bleeding from the ears indicates TM rupture or basilar skull fracture.
Auscultation:
• Listen for asymmetrical breath sounds, poor air movement, and wheezing.
Auscultation of bowel sounds is not necessary in the field.
Palpation:
• Subcutaneous emphysema indicates an open external wound or rupture of an air-
containing internal structure.
• Abdominal tenderness may indicate internal hemorrhage or GI tract rupture.
• Palpation of the spine or extremities may be appropriate to decide if the casualty
can move under his own power or needs to be transported in an immobilized
position.
Percussion:
• When the environment is quiet enough, percussion may facilitate detection of air
or fluid in the chest.
Clinical Tests:
• A detailed neurological examination may identify subtle deficits.
• The possibility of AGE should be evaluated as described in the chapter on Diving
Medicine.
Pulse Oximeter:
• A SPO2 < 95% on room air indicates some degree of lung injury, inadequate
respirations, shock, or exposure to a chemical agent such as cyanide.
• See the Assessment section of this chapter on using pulse oximetry to categorize
the severity of blast lung injury.
Using Advanced Tools
Stool Guaiac:
• If casualties with primary bowel injury have bleeding, it is usually gross
hematochezia, but guaiac-positive stool indicates possible occult penetrating,
blunt, or blast trauma.
Ophthalmoscope:
• Magnification allows close inspection of the possibility of penetrating anterior-
eye trauma.
• Visualizing hemorrhage or a foreign body on funduscopic examination or the
absence of a red reflex indicates posterior-eye trauma.
• If air is noted in retinal vessels, it proves AGE.
Otoscope:
• Look for ruptured TM.
• Significant debris in the external canal should be left alone.
Cardiac Monitor:
• Evaluate dysrhythmias occurring secondary to hypoxia, shock, or coronary AGE.
Hemoglobin & Hematocrit:
• May be a useful baseline before travel to altitude or to assess slow hemorrhage
during evacuation.
Prediction of Respiratory Problems
Insignificant pulmonary injury may be defined as no dyspnea with exertion after 1 hour
of rest. Significant pulmonary blast injuries may be classified as mild, moderate, or
severe based on pulse oximetry. This may help predict the likelihood of complications,
requirement for positive-pressure ventilation (PPV), and need for higher-than-normal
positive end-expiratory pressure (PEEP).
Mild Moderate Severe
• SPO2 > 75% on room air • SPO2 > 90% on 100% oxygen • SPO2 < 90% on 100% oxygen
• Unlikely to need PPV • Likely to need conventional PPV • Likely to need unconventional PPV
• Normal PEEP if PPV initiated • PEEP of 5-10 cmH2O usually needed • PEEP > 10 cmH2O usually needed
Peak Inspiratory Pressures > 35 cmH2O: Double-check that the definitive airway is in
place. Evaluate for tension pneumothorax, and correct if present. Increase I:E ratio by
proportionally increasing inspiratory time and decreasing inspiratory flow (e.g., 4 mL/sec
per kg of body weight for 2 sec). Consider selective intubation and independent lung
ventilation with half the tidal volume.
Treatment of Vasovagal Syncope:
• Primary: Place the casualty’s head at the level of his heart and elevate his lower
extremities.
• Alternate: Wait until casualty awakens. Unlike syncope from fright, this may
take up to 2 hours in a blast-injured casualty.
Treatment of GI Bleeding: Same as outlined in the chapter on Gastrointestinal Problems.