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Bombings:

Injury Patterns and


Care

This project was funded by the Centers for


Disease Control and Prevention (CDC) under
Cooperative Agreement U17/CCU524163-01,
Linkages of Acute Care and EMS to State and
Local Injury Prevention Programs for Terrorism
Preparedness and Response.

The Bombings: Injury Patterns and Care curriculum was


developed through the Linkages of Acute Care and EMS
to State and Local Injury Prevention Programs project
that was funded by the Centers for Disease Control and
Prevention (CDC). The American College of Emergency
Physicians (ACEP) served as the lead grantee for the
project along with the following six other organizations:

American Medical Association (AMA)


American Trauma Society (ATS)
National Association of EMS Physicians (NAEMSP)
National Association of EMTs (NAEMT)
National Association of State EMS Officials (NASEMSO)
National Native American EMS Association (NNAEMSA)

Bombings: Injury Patterns

A task force was established with representative experts from


emergency medicine including physicians, surgeons, nursing,
and EMS. Core competencies and knowledge objectives were
developed using a consensus approach. A writing group then
developed teaching objectives and course content based on the
core competencies.
The Bombings: Injury Patterns and Care curriculum is designed
to be the minimum content that should be included in any allhazards disaster response training program. This content is
designed to update the student with the latest clinical
information regarding blast related injuries from terrorism.

Bombings: Injury Patterns

American College of Emergency Physicians (ACEP) Grant Staf

Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic


Injuries from
Terrorism Task Force (CO-TIFT)
Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle
Investigator
Marshall Gardner, EMT-P, EMS and Disaster Preparedness Manager
Diana S. Jester, EMS and Disaster Response Coordinator
Cynthia Singh, MS, Grants and Development Manager
Kathryn Mensah, MS, Grants Administrator
Mary Whiteside, PhD, Curriculum Development Consultant

Centers for Disease Control and Prevention (CDC) Staf

Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National


Center for Injury Prevention and Control
Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response,
National Center
for Injury Prevention and Control
Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response,
National
Center for Injury Prevention and Control
Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National
Center
for Injury Prevention and Control
Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of
Injury
Response, National Center for Injury Prevention and Control

12/06

Bombings: Injury Patterns

Discussion Topics

Background
Explosive Events
Blast Injuries
Primary, Secondary, Tertiary, Quaternary

Crush Injuries and Compartment Syndrome


Military Experience
Special Considerations
Psychological Issues

Bombings: Injury Patterns

Background

Bombings: Injury Patterns

Background

Terrorism can be defined as containing


four key elements:

Premeditated
Political
Aimed at civilians
Carried out by sub-national groups

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Background

Explosive use increasing in terrorist


events
Result in mass casualty incidents
Recent examples

Mumbai (2006)
Tel Aviv (2006)
London subway (2005)
Madrid subway (2004)
Tel Aviv (2001)

Bombings: Injury Patterns

Background: Historical
Perspective

1968-1999
7000 international terrorist bombings

1969-1980
187 bombings in Northern Ireland

1980-2001
324 criminal bombing events in the US

2001-2003
500 International terrorist bombings

2005
399 International terrorist bombings
Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research
Centre

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Background: Blast Devices

Photo used with permission of MAJ Benjamin Gonzalez, MD

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Background: Blast Devices

Improvised explosive devices (IEDs)

Car and truck bombs (Oklahoma City, World Trade Center I)


Letter and parcel bombs (Idaho Unabomber)
Pipe bombs (Atlanta Olympics)
Backpack and satchel bombs (Israel, London)

Incendiary bombs
Airplane bombs (World Trade Center II, Pentagon)

Rocket propelled grenades (RPGs)


Surface to air missiles (SAMs)
Enhanced blast devices

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Background: Blast Devices


IEDs
Improvised/homemade explosive devices
Made from explosives, commercial blasting
supplies, or fertilizer and household
ingredients
Designed to cause injury and death
Often packed with metal objects such as nails
or ball bearings; could contain toxic chemicals
or radiological materials (dirty bomb)
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Background: Blast Agents


High-order explosive: HE Low-order explosive:
Nitroglycerin (NTG)
LE
Petroleum products
Dynamite
Plastic
(Molotov cocktail)
Gunpowder
Ammonium nitrate/
fuel oil (ANFO)
(black powder)
Trinitrotoluene (TNT)
Can become HE, if
Triacetone triperoxide
contained (e.g.,
(TAPT)
pipe bomb)
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Explosive Events

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Explosive Events

Incident command
Entire area = crime scene evidence
preservation
Multi-jurisdictional response

Scene safety
Dirty bombs, secondary devices, building
collapse, high dust environment (possibly
contaminated), bomb fragments

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Explosive Events:
Criminal Investigation

Principles of criminal investigation and


evidence preservation

Indicators for crime scene


Evidence and chain of custody
Avoid disturbing or compromising evidence
Detection of possible suspects/perpetrators
Quick identification and note taking
Documentation of statements by victims
and witnesses

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Scene Safety

Scene Safety: Common Hazards

Secondary devices
Shrapnel
Building collapse
Air-borne contaminants
Contaminated patients
Contaminated scene/environment
Perpetrators
Terrorist patients

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Scene Safety: Common Hazards

Victims with no soft tissue injuries


Vehicles coming or leaving scene (out of
place)
People acting oddly
Packages or containers at scene (out of
place)
Vehicles not damaged or out of place
Structural damage
Weather
Possible places for secondary devices

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Scene Safety:
Appropriate PPE for blasts

Coveralls
Heavy coat
Heavy gloves
Steel-toed boots
Hard hat
Eye protection
Dust particle mask
Breathing apparatus for toxic fumes

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Scene Safety: Common


Principles

Contain the incident


Deny entry to all but responders
Set up zones

Hot
Warm
Cold

Contain the people


Do not let anyone leave
scene until checked
Decontaminate if necessary

Photo used with permission of Connie Doyle, MD,


FACEP

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Scene Safety: Common


Principles

Cause no further injury or destruction


Protect yourself
Activate command and
hazard response (ICS)
Limit access
Contain the incident

Photo used with permission of Kathryn Brinsfield, MD, FACEP

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Scene Safety: Common


Principles

Worker safety
Protection of uninvolved public and
volunteers
Protection of injured
Treatment of injured
Surveillance of patients and workers
for long-term effects

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Triage

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Triage

Unique patterns, multiple and occult


injuries
Death often result of combined blast,
ballistic, and thermal effect injuries
(multidimensional injury)
Walking wounded
Hidden/internal injuries
Many non-critical patients who require
time intensive workups

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Triage

Nature of injuries may lead to


overtriage
Up to 75% of victims self-refer to
hospital; arrive by private
transportation
Field triage
Dynamic process

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Triage

Factors that determine when needs


exceed resources
Large number of patients make rapid
triage impossible
Large number of patients cause delay in
transport to hospitals
Large number of patients exceed
responder treatment capabilities
Surge at local hospitals

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Blast Injuries

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Blast Injuries: Unique Aspects

Inflict multi-system injuries on large


groups of people
Cause many simultaneous lifethreatening injuries
Hidden pattern of injury

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Blast Injuries: Blast Physics

Rapid chemical conversion of a solid or


liquid into highly pressurized gases
Gases expand rapidly and compress
the surrounding air
Pressure wave and blast wind are
generated and spread in all directions
Is affected by the medium through
which it travels, i.e., air vs. water

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Blast Injuries: Blast Physics


Importance of Injury Types vs.
Distance

Emergency War Surgery, 3rd Edition

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Diagram used with permission of John-Phillipe Dionne. PhD

Background: Physics of Blasts

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Click to view
animation.

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Blast Injury: Severity

Nature of device agent, amount


Method of delivery incendiary,
explosive
Nature of environment open, closed
Distance from device
Intervening protective barrier
Other environmental hazards

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Murrah
Building

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Photo Courtesy of the City Of Oklahoma City

35

Murrah Federal Building, Oklahoma City (1993) distribution of


injuries

JAMA, August 1996, 276 (5): 382-387 1996 American Medical


Association

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Russell Square, London bombing,


2005

Bombings: Injury Patterns

Diagram used with permission of Directorate of Public Afairs, Metropolitan Police


Service, London

37

Mumbai, India: July 2006

Reuters/Prashanth Vishwanathan

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Blast Injuries: Pathophysiology


Proposed mechanisms*
Spalling
Caused by shock wave moving through
tissues of different densities molecular
disruption

Implosion
Caused by entrapped gases in hollow
organs compressing then expanding
visceral disruption

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Blast Injuries: Pathophysiology

Shearing
Caused by tissues of different densities
moving at different speeds visceral tearing

Irreversible Work
Caused by forces exceeding the tensile
strength of the tissue

*Spalling, implosion and shearing are thought to be three


mechanisms that cause blast injuries. Irreversible work is
currently being researched as a more likely mechanism of
injury.
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Blast Injuries: Categories

Primary injury
Caused by blast wave over pressure

Secondary injury
Caused by flying debris shrapnel wounds

Tertiary injury
Caused by blast wind forceful impact

Quaternary injury
Caused by other vectors heat, radiation

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Blast Injuries: Primary

Blunt trauma from over pressure wave


Unique to high-order explosives
Results from the impact of the overpressurization wave with body surfaces
Blunt force injuries
Produces barotrauma

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Diagram used with permission of LTC John McManus, Jr., MD,


FACEP

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Blast Injuries: Primary

Most common injuries:

Blast lungpulmonary barotraumas


Traumatic brain injury (TBI), concussion
Tympanic membrane (eardrum) rupture
Middle ear damage
Abdominal hemorrhage
Abdominal organ perforation

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Blast Injuries: Secondary

The most common cause of death in a


blast event is secondary blast injuries.
These injuries are caused by flying
debris generated by the explosion.
Terrorists often add screws, nails, and
other sharp objects to bombs to
increase injuries.

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Diagram used with permission of LTC John McManus, Jr., MD, FACEP

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Blast Injuries: Secondary

The most common types of secondary


blast injuries are:
Trauma to the head, neck, chest,
abdomen, and extremities in the form of
penetrating and blunt trauma
Fractures
Traumatic amputations
Soft tissue injuries

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Blast Injuries: Secondary

Penetrating trauma (shrapnel wounds)


Foreign bodies follow unpredictable paths
through body
May have only mild external signs
Have a low threshold for imaging studies
(plain radiographs, computed tomograms)
Consider all wounds contaminated

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Secondary
Injury

Used with permission of American Journal of Roentgenology 2006;


187:609-616

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Blast Injuries: Tertiary

Tertiary injuries result from individuals being


thrown by the blast wind.
The most common types of tertiary blast
injuries are:

Head injuries
Skull fractures
Bone fractures

Treatment for most tertiary blast injuries


follows established protocols for that specific
injury.

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Diagram used with permission of LTC John McManus, Jr., MD, FACEP

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Blast Injuries: Quaternary

All explosion-related injuries, illnesses,


or diseases not due to primary,
secondary, or tertiary mechanisms are
considered quaternary blast injuries.
This includes exacerbation or
complications of existing conditions.

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Blast Injuries: Quaternary

The most common quaternary blast


injuries include:

Burns
Head injuries
Asthma
COPD
Other breathing problems
Angina
Hyperglycemia
Hypertension
Crush injuries

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Blast Injuries: Blast Lung

Used with permission of CHEST, December 1999; 116(6): 1683-1688

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Blast Injuries: Blast Lung

Reprinted from American Journal of Surgery, V190: 945-950,


Avidan V et al: Blast Lung Surgerywith permission from Excerpta
Medica Inc.

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Blast Injuries: Blast Lung

Clinical manifestations

Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability

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Blast Injuries: Blast Lung

Treatment
High flow oxygen sufficient to prevent
hypoxemia via non-rebreather mask
CPAP
Endotracheal intubation
Judicious fluid administration (similar to
that of pulmonary contusion)

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Blast Injuries: Head

Primary blast waves can cause


concussions or mild traumatic brain
injury (MTBI) without a direct blow to
the head

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Blast Injuries: Head

Consider the proximity of the victim to


the blast particularly when given
complaints of:

Loss of consciousness
Headache
Fatigue
Poor concentration, lethargy, amnesia, or
other constitutional symptoms
Symptoms of concussion and post traumatic
stress disorder (PTSD) can be similar
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Blast Injuries: TM Rupture

Tympanic membrane rupture indicates


exposure to an over pressurization
wave. It may be found in victims with
severe pulmonary, intestinal, or other
injuries, or it may be found in isolation.
Its presence does not indicate that
more sinister blast injuries exist.

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Blast Injuries: TM Rupture

Used with permission of NEJM, April 2005; 352: 1335-1342

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Blast Injuries: Ear

Ear injuries may include not only TM


rupture, but also ossicular disruption,
cochlear damage, and foreign bodies.

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Blast Injuries: Ear

Presentation: acute hearing loss


(conductive, sensorineural)
Findings: auditory canal debris,
tympanic membrane rupture, ossicular
disruption, cochlear damage
Treatment: observation; 50-80% of
ruptured tympanic membranes heal;
sensorineural hearing loss often
permanent

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Blast Injuries: Abdomen

Abdominal injuries (also called blast


abdomen) include abdominal
hemorrhage and abdominal organ
perforation

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Blast Injuries: Abdomen

Clinical manifestations include:

Abdominal or testicular pain


Tenesmus
Rectal bleeding
Solid organ lacerations
Rebound tenderness
Guarding
Absent bowel sounds
Signs of hypovolemia
Nausea
Vomiting

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Blast Injuries: Combined


Injuries

Combined injuries, especially blast and


burn injury or blast and crush injury,
are common during an explosive
event.

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Blast Injuries: Combined


Injuries

Avoid tunnel vision during initial assessment


Treatment protocols are often contradictory
Blast lung vs. burn injury, blast lung vs. crush injury

Judicious fluid administration for adequate


tissue perfusion without volume overload may
be required in the multiple injured patient with
blast lung
Presence of additional injuries complicates
administration, rate, selection of fluids

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Blast Injury: Combined Injuries


Typical confined space (e.g., a bus) injuries
Primaryblast lung, intestinal rupture, TM
rupture
Secondarypenetrating injury to head,
eye, chest, abdomen
Tertiarytraumatic amputation, fractures
to the face, pelvis, ribs, spine
Quaternary crush injuries, superficial and
partial to full thickness burns
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Crush Injury

Crush Injury: Definition

An injury sustained when a body part is


subjected to a high degree, or prolonged
presence, of force or pressure
Usually applied to both regional (e.g. body
part) effects and systemic effects.

Acute traumatic ischemia, with or without


associated injuries, describes actual insult
to tissues

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Crush Injury: Crush Syndrome

Term used to describe the systems


manifestations of crush injury after
reperfusion of affected body part(s)

Reprinted with permission of OrthoWorld.com

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Crush Injury:
Compartment Syndrome

Is a collection of localized signs and


symptoms that result when the
perfusion pressure falls below the
tissue pressure in a closed anatomic
space for sufficient time that
compromise of circulation and function
of tissues involved occurs

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Crush Injury: Incidence

5-15% of mass casualty situations


Natural disasters, especially earthquakes
and tornadoes
Structural collapse, with or without victim
entrapment
Industrial, farm or transportation accidents
Blast injury (all types)
Combat
Prolonged immobilization with major
vascular or microvascular circulation
compromise

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Crush Injury: Examples of


events

Tyre, Lebanon (1982)


Building collapse

Beirut, Lebanon (1983)


Marine barracks bombed

Oklahoma City (1995)


Murrah Federal Building
bombed

Khobar, Saudi Arabia


(1996)
Khobar Towers bombed

Bombings: Injury Patterns

Used with permission of AP Photo/KM Chaudhry

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Crush Injury: Pathophysiology

Areas most affected

Lower extremities
Upper extremities
Pelvis
Gluteal region
Abdominal muscles

Reprinted with permission of OrthoWorld.com

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Crush Syndrome

Crush Syndrome

May occur in absence of trauma and evolve


in the absence of early signs or symptoms

Arterial thrombosis or embolism


Severe anemia
Toxins
Legitimate medications and drugs of abuse

Systemic effects due to rhabdomyolysis and


reperfusion of hypoxic and damaged tissues
and is the major cause of early mortality

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Crush Syndrome:
Pathophysiology
Rhabdomyolysis
Efflux from damaged muscle cells of:

Potassium
Purines
Lactic Acid
Phosphate
Myoglobin
Thromboplastin
Creatine

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Crush Syndrome :
Pathophysiology

Reperfusion

Skeletal muscle damage greatest after


reperfusion
Superoxide radicals produced during reperfusion
attacks free fatty acids, producing cellular
edema, death, and necrosis
Na-K-ATP pump exchanges intracellular sodium
for calcium with further derangement of
intracellular metabolism

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Crush Syndrome:
Pathophysiology

Resultant efects of derangements due to rhabdomyolysis and


reperfusion

Potassium

Calcium

Phosphate

Myoglobin

Fluid shifts

Reperfusion
Purines

Hypoxemia

Thromboplastin
Creatinine

Sodium

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Hyperkalemia

Arrhythmias
Hypocalcemia

Arrhythmias
Hyperphosphatemia

Renal damage
Myoglobinemia
Renal damage
Hypovolemia

Renal failure
Free radicals

Renal damage
Hyperuricemia

Renal damage
Lactic acid

Acidosis

Complement system

DIC
Elevated serum levels
Azotemia

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Crush Syndrome: Clinical


Presentation

General condition of a patient with


crush injury dictated by other injuries,
delay in extrication, environmental
conditions
Common presentations

Hypothermia or hyperthermia
Dehydration/shock
Mental status varies from alert to
comatose

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Crush Syndrome: Clinical


Presentation

Affected part (usually limb)


Tense edema and decreased sensation
Overlying skin may be shiny, contused,
necrotic

May have penetrating wounds (worse


diagnosis)

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Crush Syndrome:
Potential Complications

Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Hypothermia
Acute Renal failure

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Crush Syndrome: Treatment

Greatest initial danger is after release


of crushed limb from entrapment with
restoration of circulation
Mainstay of treatment is aggressive
fluid resuscitation and brisk diuresis
Amount of tissue damage correlates
with need for dialysis
Cannot determine actual tissue damage
based on area of affected body part

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Crush Syndrome: Treatment

Delay in treatment associated with


greater morbidity and mortality

50% renal failure at 6 hours


100% renal failure at 12 hours
Rhabdomyolysis induced renal failure has
40% mortality

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Crush Syndrome: Treatment


Prehospital
Primary survey and initial stabilization
(ABCs)
Fluid resuscitation before patient is
extricated with severe or prolonged
entrapment of limb or pelvis (more
than a hand or foot)

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Crush Syndrome: Treatment


Hospital

Fluid resuscitation
Brisk diuresis
Diagnose and treat other metabolic
derangements
Hyperkalemia
Hypocalcemia

Treat tissue damage


Pain control
Agitation

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Compartment Syndrome

Compartment Syndrome

Is a collection of localized signs and


symptoms that result when the
perfusion pressure falls below the
tissue pressure in a closed anatomic
space for sufficient time that
compromise of circulation and function
of tissues involved occurs

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Compartment Syndrome

Can lead to crush syndrome systemic


effects if left untreated or inadequately
treated.

Photo used with permission of The Institute for Foot


and Ankle Reconstruction at Mercy, Baltimore, MD

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Compartment Syndrome
Suggestive clinical findings

Similar settings to crush injury, but may also


occur with subacute trauma
Bone fractures
High velocity penetrating injury to muscles in
closed compartment with extensive tissue
disruption
Can also occur in subacute fashion due to
prolonged immobilization on hard surface

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Compartment Syndrome:
Pathophysiology

Significance of muscle mass damage


Typically occurs in major muscle groups
enclosed by inelastic, fibrous sheaths
Tissue/muscle damage results in edema
in a closed volume space
Progressive cycle of edema, perfusion
compromise, tissue hypoxia and cellular
derangement, further edema, etc.
Untreated, will produce same effects as
crush injury

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Compartment Syndrome:
Clinical Presentation

The 5 Ps

Pain
Pallor
Paresthesia
Paralysis
Pressure

Progression of symptoms
(sometimes the 6th P)

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Compartment Syndrome:
Treatment
Prehospital
Primary survey and initial stabilization
(ABCs)
Suspect compartment syndrome
Immobilize affected part
Treat other injuries

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Compartment Syndrome:
Treatment
Hospital
Primary survey, stabilization and
resuscitation, secondary survey
Diagnosis through examination
Treat systemic effects of compartment
syndrome similar to crush injury
treatment

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Compartment Syndrome:
Extremity Injuries

Management of extremity injuries

Indication for field amputation


Appropriate use of tourniquet application
Appropriate use of hemostatic dressings
Appropriate anesthesia/analgesic

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Compartment Syndrome:
Procedural Skills

Measuring compartment pressures


Use of Ketamine
Fasciotomies

Photo used with permission of Immediate Action Services

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Compartment Syndrome:
Procedural Skills

Fasciotomies are a definitive


treatment, but tissue pressure at
which it is required is controversial.
Varying views include:
Early fasciotomy when pressures >45 mm Hg
or when within 20 mm Hg of diastolic pressure
Delayed fasciotomy (beyond 48-72 hours)
increases risk of sepsis and death due to
extensive necrotic tissues

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Compartment Syndrome:
Procedural Skills

Fasciotomy

Provide adequate analgesia and anesthesia


Pre-operative broad spectrum antibiotics
Ensure ALL compartments in extremity
checked for pressures (multiple
compartments may be affected)
Check compartment pressures before and
after fasciotomy
Ensure adequate hemostasis
Pack wound open and use large bulky
dressings
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Entrapped Patient Treatment

Treatment
Fluid resuscitation before victim extricated

1 L NS bolus, followed by 1-1.5 L per hour infusion

Limb stabilization
Minimize potential systemic effects of reperfusion

Consider use of tourniquets prior to release

Consider alkalinization by giving 1 ampule of


sodium bicarbonate (50 mEq) immediately prior
to extrication, followed by adding 1 ampule of
sodium bicarbonate to each liter of NS infused at
1-1.5 L per hour as above; keep second IV line
open without sodium bicarbonate
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Field Amputation

Indications:
Unable to safely extricate
Continued environmental toxins pose
hazard to victim and rescuers
Grossly prolonged time until definitive
treatment even after extrication

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Field Amputation

Best performed by trauma or orthopedic


surgeon
Few EMS systems have protocols
Ensure adequate analgesia and
anesthesia
Ketamine (dissociative anesthetic)

Decreases or only minimally increases serum


potassium levels
Patient maintains airway despite adequate
anesthesia

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Photo used with permission of Immediate Action


Services

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Military Experience

Military Experience

U.S. Military has significant experience


in dealing with blast and explosive
injuries
Military has been quick to seek and
adopt new strategies in treating
hemorrhage, the leading cause of
preventable death
Mortality rates dramatically lower for
the current conflict

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Military Experience

Death Rates After Wounding

Revolutionary War
WWII
Korean War
Vietnam War
Persian Gulf War
Global War on Terror (GWOT)

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42%
30
~25
~25
~25
<10

106

Military Experience

Medical Advances from the GWOT

Expanded use of Damage Control Surgery


Whole blood
Tourniquets
Hemostatic agents
Hemostatic dressings

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Military Experience

Photo used courtesy of Bio Cybernetics International

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Military Experience

Damage Control Surgery


Technique known for 20 years, but slow to
be accepted
Central tenet: Avoid the Deadly Triad

Hypothermia
Coagulopathy
Metabolic acidosis

Each condition worsens both of the others


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Military Experience

Damage Control Surgery

Stop the bleeding


Remove major contaminants
Wounds left open to avoid abdominal
compartment syndrome

Pack em and wrap em

Transfer to ICU

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Military Experience

Damage Control Surgery


Resuscitate in ICU:

Normalize blood pressure


Normalize body temperature
Normalize coagulation factors

Return to OR 12-18 hours for definitive


surgery

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Military Experience

IV Hemostasis
INR>1.5 on arrival predictive of need for
massive transfusion (MT)
Fresh thawed plasma best resuscitation
fluid in MT

Optimum ratio of plasma to crystalloid 1:1 to


avoid clotting factor dilution >50%

Less crystalloid (acidotic, inflammatory,


adverse effects on coagulation)

Hextend (a colloid) preferable

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Military Experience

IV Hemostasis

Use of fresh whole blood


Early use of cryoprecipitate
Recombinant Factor VIIa (rFVlla)

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Military Experience

Tourniquets
Liberal use encouraged for any significant
extremity hemorrhage
No adverse events seen in cases when
applied inappropriately
Apply early (first resort not last resort)
Every soldier carries at least one at all
times

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Military Experience

Hemostatic Dressings
Key to avoiding coagulopathy from MT is
to control bleeding in the first place
Primarily used for non-extremity
hemorrhage
Dressings applied with pressure x 5
minutes; patient wrapped and transported

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Military Experience

HemCon (chitosan)
Originally available as a bandage
Now available in roll that can be stuffed
into wound

QuikClot

Very exothermic (up to 147 deg F)


Difficult to debride
New Advanced Clotting Sponge (ACS)

Gauze sack easily removed from wound

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Special Considerations

Special Considerations

Pregnancy
Children
Elderly
Disabled
Language barriers

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Special Considerations:
Pregnancy

Injuries to the placenta are possible and must


be detected
Second or third trimester of pregnancy should
be admitted for continuous fetal monitoring
The placental attachment is at risk for primary
blast injury
Screening test for fetal-maternal hemorrhage
in second or third trimester of pregnancy
Positive test requires mandatory pelvic ultrasound,
fetal non-stress test monitoring, and
obstetrics/gynecology (OB/GYN) consultation.

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Special Considerations:
Children

History of event or patients complaints may be


difficult to obtain.
Pulmonary contusion is one of the most common
injuries from blunt thoracic trauma. The injury
may not be clinically apparent initially and should
be suspected when abrasions, contusions, or rib
fractures are present. A chest x-ray is essential in
diagnosis especially when blast lungis suspected.
Specialized equipment
Identification of regional pediatric trauma
facilities

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Special Considerations: Elderly

May be at a higher risk of mortality and the inhospital stay may be longer and more
complicated
Orthopedic injuries may be more prevalent
Blunt chest trauma should be of special
consideration
Decontamination methods may need
modification due to limited mobility
Technical decontamination of medical equipment
such as wheelchairs, walkers and other walking
aides may be needed

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Special Considerations:
Disabled

Consideration should be given to


patients with underlying medical
conditions
Untreated or inadequately treated
fractures may lead to severe and long
lasting disabilities

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Special Considerations:
Language Barriers

Diverse population speaking multiple


languages may be an unforeseen obstacle
Interaction with the deaf, hard of hearing, latedeafened and the deaf-blind
History of the event maybe difficult to obtain
as well as the individual history for the patient.
Translation
On scene resources
Pool of medical interpreters including sign language
Telephone translation services

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Photo used courtesy of Kwikpoint

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Psychological Issues

Psychological Issues

Sequelae from an explosive event

Anger
Frustration
Helplessness
Desire to seek revenge

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Psychological Issues

Events that affect mental health

Little or no warning
Unknown duration of the event
Potential threat to personal safety
Unknown health risks

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Psychological Issues

Tips for Responders

Promotion of safety
Promote calm
Promote connectedness
Promote self-efficacy
Promote hope

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Discussion Topics: Review

Background
Explosive Events
Blast Injuries
Primary, Secondary, Tertiary, Quaternary

Crush Injuries and Compartment Syndrome


Military Experience
Special Considerations
Psychological Issues

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Discussion Topics
Surge Capacity Issues
Hospital after Madrid bombing saw 312
patients in 2.5 hours
Need to surge: CT, OR suites, staff, and
supplies (blood, etc.)
Hidden nature of injuries can lead to
dangerous overtriage and undertriage

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