**Bombings: Injury Patterns and Care**

**Blast Injuries Seminar**

**Curriculum Guide**

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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 EMT's (NAEMT)

National Association of State EMS Officials (NASEMSO)

National Native American EMS Association (NNAEMSA)

A task force was established with representative experts from emergency
medicine including physicians, surgeons, nurses, 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 all-hazards disaster
response training program. This content is designed to update the
student with the latest clinical information regarding blast related
injuries from terrorism.

[American College of Emergency Physicians (ACEP) Grant
Staff]{.underline}

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

Taskforce (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 Development Manager

Kathryn Mensah, MS, Grants Administrator

Mary Whiteside, PhD, Curriculum Development Consultant

[Centers for Disease Control and Prevention (CDC) Staff]{.underline}

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

This curriculum was supported by Cooperative Agreement Number
U38/CCU624161-01-3107 from the U.S. Centers for Disease Control and
Prevention (CDC).

Release date: 12/06

**Table of Contents**

[[[Content Design]{.smallcaps} 3]{.mark}](#content-design)

[[[Content Topics]{.smallcaps} 3]{.mark}](#content-topics)

[[[Target Audience]{.smallcaps} 3]{.mark}](#target-audience)

[[[Goals]{.smallcaps} 3]{.mark}](#goals)

[[[Time Requirements]{.smallcaps} 3]{.mark}](#time-requirements)

[[[Learning Objectives]{.smallcaps} 3]{.mark}](#learning-objectives)

[[[Background Information: Explosives and Terrorist
Bombings]{.smallcaps}
3]{.mark}](#background-information-explosives-and-terrorist-bombings)

[[[Blast Injuries]{.smallcaps} 3]{.mark}](#blast-injuries-1)

[[[Crush Injuries]{.smallcaps} 3]{.mark}](#crush-injuries-1)

[[[Compartment Syndrome]{.smallcaps} 3]{.mark}](#compartment-syndrome-1)

[[[Military Experience in Blast Injury Care]{.smallcaps}
3]{.mark}](#military-experience-in-blast-injury-care)

[[[Special Considerations]{.smallcaps}
3]{.mark}](#special-considerations-1)

[[[Psychological Issues]{.smallcaps} 3]{.mark}](#psychological-issues-1)

[[[Patient Cases]{.smallcaps} 3]{.mark}](#patient-cases)

[[Appendix A: Curriculum on Traumatic Injuries from Terrorism Task Force
(CO-TIFT)
3]{.mark}](#appendix-a-curriculum-on-traumatic-injuries-from-terrorism-task-force-co-tift)

[[Appendix B: Curriculum Writing Group
3]{.mark}](#appendix-b-curriculum-writing-group)

> []{.mark}

+-----------------+----------------------------------------------------+
| # [Content Desi | This content covers eight main topic areas         |
| gn]{.smallcaps} | designed to educate emergency medical personnel in |
|                 | the assessment and initial management of patients  |
|                 | who are injured during an explosive event. The     |
|                 | content builds on existing knowledge developed in  |
|                 | HAZMAT and WMD training courses and is designed to |
|                 | be integrated into courses and other training      |
|                 | experiences using an all-hazards approach. The     |
|                 | emphasis for each topic is the unique              |
|                 | characteristics of an explosive event, such as a   |
|                 | terrorist bombing, that results in mass            |
|                 | casualties.                                        |
|                 |                                                    |
|                 | #                                                  |
|                 |                                                    |
|                 | The content for each topic is accompanied by       |
|                 | slides. A few teaching tips are provided in the    |
|                 | Curriculum Guide.                                  |
+-----------------+----------------------------------------------------+
| #               | #                                                  |
+-----------------+----------------------------------------------------+
| # [Content Topi | #                                                  |
| cs]{.smallcaps} | Background (Explosives and Terrorist Bombings)  {# |
|                 | background-explosives-and-terrorist-bombings .Nom} |
|                 |                                                    |
|                 | # Scene Safety {#scene-safety .Nom}                |
|                 |                                                    |
|                 | -   Triage                                         |
|                 |                                                    |
|                 | -   Blast Injuries                                 |
|                 |                                                    |
|                 | -   Crush Injuries and Compartment Syndrome        |
|                 |                                                    |
|                 | -   Military Experience                            |
|                 |                                                    |
|                 | -   Special Considerations                         |
|                 |                                                    |
|                 | -   Psychological Issues                           |
+-----------------+----------------------------------------------------+
| #               | #                                                  |
+-----------------+----------------------------------------------------+
| #               | -   Emergency physicians                           |
|  [Target Audien |                                                    |
| ce]{.smallcaps} | -   Emergency nurses                               |
|                 |                                                    |
|                 | -   Emergency medical service personnel            |
|                 |                                                    |
|                 | -   Other healthcare personnel who would be        |
|                 |     involved in a mass casualty event              |
+-----------------+----------------------------------------------------+
| ##              |                                                    |
+-----------------+----------------------------------------------------+
| # [Goa          | In general, the goal of this content is to cover   |
| ls]{.smallcaps} | the unique knowledge and skills required to        |
|                 | effectively respond to a mass casualty explosive   |
|                 | or bombing event. The content can be integrated    |
|                 | into existing materials or taught as a stand-alone |
|                 | course. The content includes: (1) the uniqueness   |
|                 | of blast injury, including blast physics, (2) the  |
|                 | most common types of blast injuries, and (3) the   |
|                 | appropriate treatment (prehospital and initial     |
|                 | hospital) for injures that result from blasts.     |
+-----------------+----------------------------------------------------+
| ##              |                                                    |
+-----------------+----------------------------------------------------+
| Teaching Tips   | These topics can be most successfully taught using |
|                 | real-life scenarios, cases, and examples to        |
|                 | facilitate an interactive instructional            |
|                 | strategy---one that focuses on active learning.    |
|                 | Active learning requires that learners are         |
|                 | involved in the learning process.                  |
|                 |                                                    |
|                 | To provide an active learning environment,         |
|                 | learners must interact or become involved with     |
|                 | realistic situations and knowledge. By             |
|                 | incorporating techniques that encourage            |
|                 | participants to discuss, question, and clarify,    |
|                 | instructors can increase retention and encourage   |
|                 | the use of problem solving skills.                 |
+-----------------+----------------------------------------------------+
| #               | #                                                  |
+-----------------+----------------------------------------------------+
| # [             | The basic content can be completed in              |
| Time Requiremen | approximately three hours. However, the topics are |
| ts]{.smallcaps} | designed for flexibility and can be adapted to     |
|                 | presentations that vary in length by increasing or |
|                 | decreasing the amount of detail and the level of   |
|                 | learner interaction.                               |
|                 |                                                    |
|                 | For a 3-hour session, the following times are      |
|                 | suggested:                                         |
|                 |                                                    |
|                 | -   Background 10 minutes                          |
|                 |                                                    |
|                 | -   Explosive Events 10 minutes                    |
|                 |                                                    |
|                 | -   Blast Injuries 40 minutes                      |
|                 |                                                    |
|                 | -   Crush Injuries 30 minutes                      |
|                 |                                                    |
|                 | -   Military Experiences 10 minutes                |
|                 |                                                    |
|                 | -   Special Considerations 10 minutes              |
|                 |                                                    |
|                 | -   Psychological Issues 10 minutes                |
|                 |                                                    |
|                 | -   Patient Cases 60 minutes                       |
+-----------------+----------------------------------------------------+
| #               | #                                                  |
+-----------------+----------------------------------------------------+
| # [Le           | The following learning objectives cover all of the |
| arning Objectiv | content. They are intended as a blueprint for what |
| es]{.smallcaps} | learners should know after the content has been    |
|                 | taught. (There are no learning objectives for the  |
|                 | background content.)                               |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ##              | 1.  Describe common hazards that could be          |
|  *Scene Safety* |     encountered in an explosive event.             |
|                 |                                                    |
|                 | 2.  Recognize the personal protective equipment    |
|                 |     (PPE) appropriate for use during explosive     |
|                 |     events.                                        |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *Triage*     | 3.  List the factors common to explosive events    |
|                 |     that may complicate effective triage.          |
|                 |                                                    |
|                 | 4.  Explain the possible effect of overtriage at   |
|                 |     explosive events.                              |
|                 |                                                    |
|                 | 5.  Explain the issues related to patient          |
|                 |     self-referral in explosive events.             |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *            | 6.  Describe the unique aspects of blast injury,   |
| Blast Injuries* |     including blast physics and the pattern of     |
|                 |     injuries.                                      |
|                 |                                                    |
|                 | 7.  List the factors affecting severity (morbidity |
|                 |     and mortality) of injuries in an explosive     |
|                 |     event.                                         |
|                 |                                                    |
|                 | 8.  Explain the pathophysiology of blast injuries. |
|                 |                                                    |
|                 | 9.  Define the four categories of blast injuries.  |
|                 |                                                    |
|                 | 10. List the most common types of injuries in each |
|                 |     category---primary, secondary, tertiary, and   |
|                 |     quaternary (miscellaneous).                    |
+-----------------+----------------------------------------------------+
| ##              |                                                    |
+-----------------+----------------------------------------------------+
| ## *Primary Bla | 11. Describe the pathophysiology of blast lung.    |
| st Lung Injury* |                                                    |
|                 | 12. Describe the clinical manifestations of blast  |
|                 |     lung injury.                                   |
|                 |                                                    |
|                 | 13. Explain the appropriate treatment (prehospital |
|                 |     and initial hospital) for blast lung injury.   |
|                 |                                                    |
|                 | 14. Explain why tympanic membrane rupture may or   |
|                 |     may not be an indicator for blast lung injury. |
+-----------------+----------------------------------------------------+
| ## *Addi        | 15. Describe the presentation and clinical         |
| tional Primary  |     manifestations of other primary blast          |
| Blast Injuries* |     injuries, including ear, abdominal, and head   |
|                 |     injuries.                                      |
| #               |                                                    |
|                 | 16. Explain the appropriate treatment (prehospital |
|                 |     and initial hospital) for other primary blast  |
|                 |     injuries, including ear, abdominal, and head   |
|                 |     injuries.                                      |
|                 |                                                    |
|                 | 17. Explain the treatment priorities (prehospital  |
|                 |     and initial hospital) for combined injuries,   |
|                 |     including blast lung injury and burn injury;   |
|                 |     blast lung injury and crush injury.            |
+-----------------+----------------------------------------------------+
| #               | ##                                                 |
+-----------------+----------------------------------------------------+
| ## *            | 18. Define crush injury, crush syndrome, and       |
| Crush Injuries* |     compartment syndrome.                          |
|                 |                                                    |
|                 | 19. Explain the pathophysiology of crush injury.   |
|                 |                                                    |
|                 | 20. Describe the clinical presentations common     |
|                 |     with crush injury.                             |
|                 |                                                    |
|                 | 21. List the potential complications for crush     |
|                 |     injury.                                        |
|                 |                                                    |
|                 | 22. Explain the treatment (prehospital and initial |
|                 |     hospital) for crush injury.                    |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *Compar      | 23. Explain the pathophysiology of compartment     |
| tment Syndrome* |     syndrome.                                      |
|                 |                                                    |
|                 | 24. Describe the clinical presentation common with |
|                 |     compartment syndrome.                          |
|                 |                                                    |
|                 | 25. Explain the treatment (prehospital and initial |
|                 |     hospital) for compartment syndrome.            |
|                 |                                                    |
|                 | 26. Describe the procedural skills needed for      |
|                 |     management of compartment syndrome, including  |
|                 |     measuring compartment pressures, use of        |
|                 |     ketamine, and fasciotomies.                    |
|                 |                                                    |
|                 | 27. Describe the unique treatment of an entrapped  |
|                 |     patient.                                       |
|                 |                                                    |
|                 | 28. Describe the indications (potential need) for  |
|                 |     field amputation.                              |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *Milita      | 29. Discuss current military experiences in blast  |
| ry Experiences* |     injury care, such as hemorrhage control and    |
|                 |     use of tourniquets.                            |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *Special     | 30. Describe the considerations that should be     |
| Considerations* |     addressed for special needs patients such as   |
|                 |     children, women who are pregnant, the elderly, |
|                 |     the disabled, and those with language          |
|                 |     barriers.                                      |
+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| ## *Psycho      | 31. Describe factors that affect mental health     |
| logical Issues* |     during an explosive event.                     |
+-----------------+----------------------------------------------------+

+-----------------+---+----------------------------------------------------+
| #               |   |                                                    |
+-----------------+---+----------------------------------------------------+
| # [Background   |   | This topic provides a brief history of recent      |
| Information: Ex |   | explosions and bombings used by terrorists. The    |
| plosives and Te |   | types of explosives used, the characteristics of   |
| rrorist Bombing |   | explosives, and explosive classification are also  |
| s]{.smallcaps}  |   | included. There are no specific learning           |
|                 |   | objectives related to this topic, since it is      |
|                 |   | designed to provide background and context to the  |
|                 |   | subsequent topics.                                 |
|                 |   |                                                    |
|                 |   | Explosive devices are a rather inexpensive and     |
|                 |   | easy method for terrorists to trigger major        |
|                 |   | disruptions to our everyday lives. Terrorists have |
|                 |   | used everything from a small backpack to large     |
|                 |   | trucks and even commercial jet airliners to        |
|                 |   | deliver the explosive agent. Injuries can vary     |
|                 |   | from various forms of trauma and burns to          |
|                 |   | amputations or even immediate death.               |
|                 |   |                                                    |
|                 |   | Even though an all-hazards approach is used, the   |
|                 |   | content covered in this curriculum is focused on   |
|                 |   | terrorist events that result in mass casualties.   |
|                 |   | Most disaster training experiences cover the       |
|                 |   | definition and types of terrorism. This            |
|                 |   | information is included here as a review, if it is |
|                 |   | needed.                                            |
+-----------------+---+----------------------------------------------------+
| #               |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ## Key Elemen   |   | Terrorism can be defined as containing four key    |
| ts of Terrorism |   | elements.                                          |
|                 |   |                                                    |
|                 |   | 1.  It is premeditated---planned in advance,       |
|                 |   |     rather than an impulsive act of rage.          |
|                 |   |                                                    |
|                 |   | 2.  It is political---not criminal but designed to |
|                 |   |     change the existing political order.           |
|                 |   |                                                    |
|                 |   | 3.  It is aimed at civilians---not at military     |
|                 |   |     targets or combat ready troops.                |
|                 |   |                                                    |
|                 |   | 4.  It is carried out by sub-national groups---not |
|                 |   |     by the army of a country.                      |
+-----------------+---+----------------------------------------------------+
| #               |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ## Typ          |   | > Nationalist terrorism---seeks to form a separate |
| es of Terrorism |   | > state for their own national group. These        |
|                 |   | > terrorists use violence to capture national      |
|                 |   | > attention and to alienate those not supporting   |
|                 |   | > their movement. Examples include the Irish       |
|                 |   | > Republican Army (IRA), Palestine Liberation      |
|                 |   | > Organization (PLO), and Kurdistan Workers' Party |
|                 |   | > (KWP).                                           |
|                 |   |                                                    |
|                 |   | Religious terrorism---uses violence to further     |
|                 |   | their purpose targeting broad categories of        |
|                 |   | enemies. Religious terrorists come from major      |
|                 |   | faiths as well as small cults. The more extreme    |
|                 |   | sects use an almost limitless amount of violence   |
|                 |   | against anyone who is not part of their religious  |
|                 |   | group, and they are considered some of the most    |
|                 |   | dangerous terrorists. Nearly half of the 56 known  |
|                 |   | international terrorist groups are religiously     |
|                 |   | motivated. Examples include Osama bin Laden's      |
|                 |   | al-Qaeda network and the Aum Shinrikyo doomsday    |
|                 |   | cult in Japan.                                     |
|                 |   |                                                    |
|                 |   | State-sponsored terrorism---use of terrorist       |
|                 |   | groups or surrogate warriors by radical states as  |
|                 |   | a foreign policy tool. With enhanced state funded  |
|                 |   | resources at their disposal, they are often able   |
|                 |   | to carry out larger and more deadly attacks        |
|                 |   | including commercial airliner bombings. One        |
|                 |   | example is the Iranian government sponsorship of   |
|                 |   | young militants to seize the American embassy in   |
|                 |   | Tehran in 1979.                                    |
|                 |   |                                                    |
|                 |   | Suicide terrorism---used throughout history but it |
|                 |   | has become much more common in the last 20 years.  |
|                 |   | Both religious and secular terrorist groups use    |
|                 |   | this form of terrorism. Some feel suicide          |
|                 |   | terrorists are crazy, but many experts say such    |
|                 |   | terrorists are just deeply committed to their      |
|                 |   | cause and see themselves as martyrs who can        |
|                 |   | inspire imitation.                                 |
|                 |   |                                                    |
|                 |   | These types of terrorism are not mutually          |
|                 |   | exclusive. For example, terrorism that is achieved |
|                 |   | through suicide bombings is often both religiously |
|                 |   | and nationalistically motivated.                   |
+-----------------+---+----------------------------------------------------+
| #####           |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ## Rec          |   | *Mumbai bombing, India* July 11, 2006 -- Seven     |
| ent Terrorist E |   | bombs were placed on commuter trains during rush   |
| xplosive Events |   | hour. 209 were killed and over 700 were injured.   |
|                 |   |                                                    |
|                 |   | *Tel Aviv, Israel*, January 19, 2006---A suicide   |
|                 |   | bomber in a small fast food restaurant killed      |
|                 |   | himself and wounded 20 others. Most customers were |
|                 |   | outside the restaurant, but the bomber went inside |
|                 |   | and detonated the bomb.                            |
|                 |   |                                                    |
|                 |   | *Iraq hotel bombing, Baghdad*, October 24,         |
|                 |   | 2005---Three car bombs were detonated at the       |
|                 |   | Palestine and Sheraton hotels. Six people were     |
|                 |   | killed and 15 others were wounded.                 |
|                 |   |                                                    |
|                 |   | *London Subway Bombing*, July 11, 2005---Three     |
|                 |   | bombs on the underground trains and one bomb on a  |
|                 |   | bus killed 56 (including the 4 terrorists) and     |
|                 |   | injured over 700; 350 required hospital treatment; |
|                 |   | 22 were admitted in serious or critical condition. |
|                 |   |                                                    |
|                 |   | *Madrid Train Bombing*, March 11, 2004---Ten bombs |
|                 |   | exploded in 4 commuter trains, killing 177         |
|                 |   | instantly and injuring more than 2000. Fourteen    |
|                 |   | people died later. Total casualties were 191       |
|                 |   | people.                                            |
|                 |   |                                                    |
|                 |   | *World Trade Center*, September 11, 2001---Total   |
|                 |   | dead and missing 2,992; 2749 in New York, 184 at   |
|                 |   | the Pentagon, 40 in Pennsylvania, and 19           |
|                 |   | hijackers.                                         |
+-----------------+---+----------------------------------------------------+
|                 |   | *Tel Aviv Disco*, June 1, 2001---A suicide bomber  |
|                 |   | killed 20 and injured 120. The terrorist mingled   |
|                 |   | with a large group of teenagers, who were standing |
|                 |   | in line to enter a disco. While still in line, he  |
|                 |   | detonated the explosives strapped to his body. The |
|                 |   | explosive charge contained a large number of metal |
|                 |   | objects, including balls and screws, designed to   |
|                 |   | increase the extent of injuries.                   |
|                 |   |                                                    |
|                 |   | *Centennial Olympic Park, Atlanta, GA***,** July   |
|                 |   | 27, 1996---A shrapnel-laden pipe bomb hidden in a  |
|                 |   | backpack exploded during the Summer Olympics. Two  |
|                 |   | people were killed and 111 were injured.           |
|                 |   |                                                    |
|                 |   | *Murrah Federal Building, Oklahoma City*, OK,      |
|                 |   | April 19, 1995---A rented truck containing about   |
|                 |   | 5,000 pounds (2,300 kg) of explosive material      |
|                 |   | exploded killing 168 people, including one person  |
|                 |   | who died in the rescue effort. Over 800 people     |
|                 |   | were wounded. The bomb was composed of ammonium    |
|                 |   | nitrate (an agricultural fertilizer) and           |
|                 |   | nitromethane (a highly volatile motor-racing fuel) |
|                 |   | in a mixture also known as ANFO (ammonium          |
|                 |   | nitrate/fuel oil) or Kinepak.                      |
|                 |   |                                                    |
|                 |   | *World Trade Center*, February 26, 1993---A car    |
|                 |   | bomb exploded in a basement garage, killing 6 and  |
|                 |   | injuring 1040 others. The complex 1300 lb (600 kg) |
|                 |   | bomb was made of urea pellets, nitroglycerin,      |
|                 |   | sulfuric acid, aluminum azide, magnesium azide,    |
|                 |   | and bottled hydrogen. Sodium cyanide had been      |
|                 |   | added to the mix so that the vapors could go       |
|                 |   | through the ventilation shafts and elevators of    |
|                 |   | the towers.                                        |
|                 |   |                                                    |
|                 |   | *Pan Am 103, Lockerbie, Scotland***,** December    |
|                 |   | 21, 1988---A terrorist bomb exploded in flight     |
|                 |   | killing 259 passengers and 11 people who were on   |
|                 |   | the ground. Twelve to 16 oz (340 to 450 g) of      |
|                 |   | plastic explosive was detonated in the plane's     |
|                 |   | forward cargo hold, triggering a sequence of       |
|                 |   | events that led to rapid destruction of the        |
|                 |   | aircraft.                                          |
|                 |   |                                                    |
|                 |   | *Unabomber* **(**Theodore John Kaczynski, PhD) --  |
|                 |   | The Unabomber was convicted of murder for sending  |
|                 |   | mail bombs to various people over almost 18 years  |
|                 |   | from the late 1970's through the early 1990's. His |
|                 |   | bombs killed three and wounded 29. He justified    |
|                 |   | his crimes as a fight against the evils of         |
|                 |   | technological progress.                            |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ## Type         |   | Car and truck bombs are very powerful weapons in   |
| s of Explosives |   | the terrorist's arsenal, especially for suicide    |
|                 |   | attacks. Terrorists also employ letter and parcel  |
|                 |   | bombs, explosive and incendiary bombs, and a few   |
|                 |   | groups are known to possess either                 |
|                 |   | rocket-propelled grenades (RPGs) or surface-to-air |
|                 |   | shoulder-fired missiles that can bring down        |
|                 |   | civilian or military aircraft.                     |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ***Improvised   | I |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ###### Fuel     | A |                                                    |
| -air explosives | l |                                                    |
|                 | s |                                                    |
|                 | o |                                                    |
|                 | c |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 | l |                                                    |
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|                 | d |                                                    |
|                 | h |                                                    |
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|                 | h |                                                    |
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|                 | m |                                                    |
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|                 | s |                                                    |
|                 | ( |                                                    |
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|                 | ) |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
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|                 | n |                                                    |
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|                 | s |                                                    |
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|                 | T |                                                    |
|                 | h |                                                    |
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|                 | m |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
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|                 | e |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | g |                                                    |
|                 | y |                                                    |
|                 | f |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 | a |                                                    |
|                 | g |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | z |                                                    |
|                 | e |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
|                 | d |                                                    |
|                 | o |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
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|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #####           | T |                                                    |
| # "Dirty" bombs | h |                                                    |
|                 | e |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | m |                                                    |
|                 | * |                                                    |
|                 | * |                                                    |
|                 | d |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ###### I        | A |                                                    |
| ncendiary bombs | l |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ###### Mil      | M |                                                    |
| itary munitions | i |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| *               | E |                                                    |
| *Classification | x |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **[Background   | T |                                                    |
| Information:    | h |                                                    |
| Criminal        | e |                                                    |
| Investigation   | e |                                                    |
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| Preservation    | t |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **[Scene        |   |                                                    |
| Safety          |   |                                                    |
| ]{.smallcaps}** |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #####           |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ##              | 1 |                                                    |
| ### *Objective* | . |                                                    |
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ######          | - |                                                    |
|  Common Hazards |   |                                                    |
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|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
|                 | d |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | s |                                                    |
|                 | c |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | e |                                                    |
|                 | / |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | v |                                                    |
|                 | i |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
|                 | m |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 | p |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| Teaching Tip    | U |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 | e |                                                    |
|                 | x |                                                    |
|                 | a |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
|                 | f |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 | v |                                                    |
|                 | i |                                                    |
|                 | o |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 | a |                                                    |
|                 | c |                                                    |
|                 | h |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 | h |                                                    |
|                 | a |                                                    |
|                 | z |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | d |                                                    |
|                 | s |                                                    |
|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ##              | 2 |                                                    |
| ### *Objective* | . |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
|                 | R |                                                    |
|                 | e |                                                    |
|                 | c |                                                    |
|                 | o |                                                    |
|                 | g |                                                    |
|                 | n |                                                    |
|                 | i |                                                    |
|                 | z |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | p |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | s |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 | c |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | q |                                                    |
|                 | u |                                                    |
|                 | i |                                                    |
|                 | p |                                                    |
|                 | m |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | ( |                                                    |
|                 | P |                                                    |
|                 | P |                                                    |
|                 | E |                                                    |
|                 | ) |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | p |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | d |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | g |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **PPE for       | - |                                                    |
| Explosive       |   |                                                    |
| Events**        |   |                                                    |
|                 |   |                                                    |
|                 | C |                                                    |
|                 | o |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 | l |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 | a |                                                    |
|                 | v |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | o |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 | a |                                                    |
|                 | v |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | g |                                                    |
|                 | l |                                                    |
|                 | o |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
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|                 | e |                                                    |
|                 | l |                                                    |
|                 | - |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 | e |                                                    |
|                 | d |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | b |                                                    |
|                 | o |                                                    |
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|                 | s |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
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|                 |   |                                                    |
|                 | h |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | d |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
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|                 | e |                                                    |
|                 | y |                                                    |
|                 | e |                                                    |
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|                 |   |                                                    |
|                 |   |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
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|                 | e |                                                    |
|                 | c |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | d |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | p |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | c |                                                    |
|                 | l |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | m |                                                    |
|                 | a |                                                    |
|                 | s |                                                    |
|                 | k |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
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|                 |   |                                                    |
|                 | b |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | g |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | p |                                                    |
|                 | p |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 | x |                                                    |
|                 | i |                                                    |
|                 | c |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | u |                                                    |
|                 | m |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **[Triage       |   |                                                    |
| ]{.smallcaps}** |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ##              | 3 |                                                    |
| ### *Objective* | . |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
|                 | L |                                                    |
|                 | i |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | a |                                                    |
|                 | c |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
|                 | m |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | m |                                                    |
|                 | a |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | i |                                                    |
|                 | c |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | e |                                                    |
|                 | f |                                                    |
|                 | f |                                                    |
|                 | e |                                                    |
|                 | c |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 | g |                                                    |
|                 | e |                                                    |
|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
| **Factors       | - |                                                    |
| Complicating    |   |                                                    |
| Effective       |   |                                                    |
| Triage**        |   |                                                    |
|                 | S |                                                    |
|                 | e |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | n |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | j |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | e |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | a |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 | d |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | b |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | b |                                                    |
|                 | l |                                                    |
|                 | a |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | w |                                                    |
|                 | a |                                                    |
|                 | v |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | m |                                                    |
|                 | a |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 | n |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
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|                 | b |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | i |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 | l |                                                    |
|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | p |                                                    |
|                 | p |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 |   |                                                    |
|                 | d |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | g |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | r |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 | g |                                                    |
|                 | e |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | I |                                                    |
|                 | n |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | m |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
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| ##              | 4 |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ***Objective*** | 5 |                                                    |
|                 | . |                                                    |
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ###### Patien   | U |                                                    |
| t Self-referral | p |                                                    |
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| Teaching Tip    | T |                                                    |
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+-----------------+---+----------------------------------------------------+
| #####           |   |                                                    |
+-----------------+---+----------------------------------------------------+
| # [Blast Injuri |   |                                                    |
| es]{.smallcaps} |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #######         |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ####            | 6 |                                                    |
| ### *Objective* | . |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #######         | B |                                                    |
| # Blast Physics | l |                                                    |
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+-----------------+---+----------------------------------------------------+
| ###### Patt     | T |                                                    |
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|                 |   |                                                    |
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+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ####            | 8 |                                                    |
| ### *Objective* | . |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **              | T |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ####            | 9 |                                                    |
| ### *Objective* | . |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Categories of | P |                                                    |
| Blast           | r |                                                    |
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+-----------------+---+----------------------------------------------------+
| ####            | 1 |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Common        | T |                                                    |
| Secondary       | h |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Common        | T |                                                    |
| Tertiary        | e |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Common        | A |                                                    |
| Quaternary      | l |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Primary Blast | B |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| Teaching Tip    | I |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ####            | 1 |                                                    |
| ### *Objective* | 1 |                                                    |
|                 | . |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Blast Lung:   | T |                                                    |
| Pa              | h |                                                    |
| thophysiology** | e |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
| []{.mark}       |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 1 |                                                    |
| ##### Objective | 2 |                                                    |
|                 | . |                                                    |
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|                 |   |                                                    |
|                 |   |                                                    |
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|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Blast Lung:   | - |                                                    |
| Clinical        |   |                                                    |
| M               |   |                                                    |
| anifestations** |   |                                                    |
|                 | T |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ####            | 1 |                                                    |
| ### *Objective* | 3 |                                                    |
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+-----------------+---+----------------------------------------------------+
| ###             |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ### Blast       | P |                                                    |
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+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+
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|                 | 4 |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ###             | 1 |                                                    |
| ##### Objective | 4 |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
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+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 1 |                                                    |
| ##### Objective | 5 |                                                    |
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|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Ear           | E |                                                    |
| Injuries**      | a |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Abdominal     | A |                                                    |
| Injuries**      | b |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Head          | P |                                                    |
| Injuries**      | r |                                                    |
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|                 | m |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| Teaching Tip    | C |                                                    |
|                 | o |                                                    |
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|                 | t |                                                    |
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|                 | h |                                                    |
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|                 | p |                                                    |
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|                 | t |                                                    |
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|                 | d |                                                    |
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|                 | m |                                                    |
|                 | o |                                                    |
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|                 | t |                                                    |
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|                 | a |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
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|                 | a |                                                    |
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|                 | m |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 1 |                                                    |
| ##### Objective | 6 |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
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|                 | p |                                                    |
|                 | p |                                                    |
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|                 | m |                                                    |
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|                 | t |                                                    |
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|                 | t |                                                    |
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|                 |   |                                                    |
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|                 | d |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Treatment**   | T |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
| ##              | F |                                                    |
| ###### Treatmen | o |                                                    |
| t: Ear Injuries | r |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Treatment:    | T |                                                    |
| Abdominal       | r |                                                    |
| Injuries**      | e |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Treatment:    | F |                                                    |
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 1 |                                                    |
| ##### Objective | 7 |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ##### Co        | C |                                                    |
| mbined Injuries | o |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
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|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Crush         | C |                                                    |
| Syndrome**      | r |                                                    |
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|                 | c |                                                    |
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|                 | s |                                                    |
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|                 | a |                                                    |
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|                 | c |                                                    |
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|                 | t |                                                    |
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|                 | o |                                                    |
|                 | n |                                                    |
|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 | [ |                                                    |
|                 | ] |                                                    |
|                 | { |                                                    |
|                 | . |                                                    |
|                 | m |                                                    |
|                 | a |                                                    |
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|                 | k |                                                    |
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|                 |   |                                                    |
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|                 | { |                                                    |
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|                 | m |                                                    |
|                 | a |                                                    |
|                 | r |                                                    |
|                 | k |                                                    |
|                 | } |                                                    |
+-----------------+---+----------------------------------------------------+
| **Compartment   | C |                                                    |
| Syndrome**      | o |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | a |                                                    |
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|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | s |                                                    |
|                 | y |                                                    |
|                 | n |                                                    |
|                 | d |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
|                 | e |                                                    |
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|                 | s |                                                    |
|                 | a |                                                    |
|                 | c |                                                    |
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|                 | l |                                                    |
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|                 | i |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
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|                 | f |                                                    |
|                 | l |                                                    |
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|                 | c |                                                    |
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|                 | l |                                                    |
|                 | i |                                                    |
|                 | z |                                                    |
|                 | e |                                                    |
|                 | d |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | g |                                                    |
|                 | n |                                                    |
|                 | s |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
|                 | d |                                                    |
|                 | s |                                                    |
|                 | y |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | t |                                                    |
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|                 | m |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
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|                 | a |                                                    |
|                 | t |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
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|                 | t |                                                    |
|                 | w |                                                    |
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|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
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|                 | s |                                                    |
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|                 | p |                                                    |
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|                 | e |                                                    |
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|                 | s |                                                    |
|                 | u |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Incidence of  | F |                                                    |
| Crush Injury**  | i |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 1 |                                                    |
| ##### Objective | 9 |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
|                 | E |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | a |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
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|                 | e |                                                    |
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|                 | p |                                                    |
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|                 | i |                                                    |
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|                 | o |                                                    |
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|                 | y |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | o |                                                    |
|                 | f |                                                    |
|                 |   |                                                    |
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|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | r |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | h |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | j |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | y |                                                    |
|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Crush Injury: | T |                                                    |
| Pa              | h |                                                    |
| thophysiology** | e |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
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|                 | a |                                                    |
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|                 | m |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
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|                 | m |                                                    |
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|                 | l |                                                    |
|                 | y |                                                    |
|                 | a |                                                    |
|                 | f |                                                    |
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+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 2 |                                                    |
| ##### Objective | 0 |                                                    |
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+-----------------+---+----------------------------------------------------+
| ######          |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Crush Injury: | T |                                                    |
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+-----------------+---+----------------------------------------------------+
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|                 | l |                                                    |
|                 | l |                                                    |
|                 | ( |                                                    |
|                 | w |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 | s |                                                    |
|                 | e |                                                    |
|                 | p |                                                    |
|                 | r |                                                    |
|                 | o |                                                    |
|                 | g |                                                    |
|                 | n |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | i |                                                    |
|                 | s |                                                    |
|                 | ) |                                                    |
|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 2 |                                                    |
| ##### Objective | 1 |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
|                 | L |                                                    |
|                 | i |                                                    |
|                 | s |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | p |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
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|                 | n |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | o |                                                    |
|                 | m |                                                    |
|                 | p |                                                    |
|                 | l |                                                    |
|                 | i |                                                    |
|                 | c |                                                    |
|                 | a |                                                    |
|                 | t |                                                    |
|                 | i |                                                    |
|                 | o |                                                    |
|                 | n |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | r |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | h |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | j |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | y |                                                    |
|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Crush Injury: | - |                                                    |
| Potential       |   |                                                    |
| Complications** |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | y |                                                    |
|                 | p |                                                    |
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|                 | r |                                                    |
|                 | k |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 | e |                                                    |
|                 | m |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | y |                                                    |
|                 | p |                                                    |
|                 | o |                                                    |
|                 | c |                                                    |
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|                 | l |                                                    |
|                 | c |                                                    |
|                 | e |                                                    |
|                 | m |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | y |                                                    |
|                 | p |                                                    |
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|                 | r |                                                    |
|                 | p |                                                    |
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|                 | p |                                                    |
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|                 | a |                                                    |
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|                 | m |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
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|                 | c |                                                    |
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|                 | d |                                                    |
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|                 | i |                                                    |
|                 | s |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | y |                                                    |
|                 | p |                                                    |
|                 | o |                                                    |
|                 | t |                                                    |
|                 | h |                                                    |
|                 | e |                                                    |
|                 | r |                                                    |
|                 | m |                                                    |
|                 | i |                                                    |
|                 | a |                                                    |
|                 |   |                                                    |
|                 | - |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | c |                                                    |
|                 | u |                                                    |
|                 | t |                                                    |
|                 | e |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | a |                                                    |
|                 | i |                                                    |
|                 | l |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | e |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| #               | 2 |                                                    |
| ##### Objective | 2 |                                                    |
|                 | . |                                                    |
|                 |   |                                                    |
|                 | * |                                                    |
|                 | E |                                                    |
|                 | x |                                                    |
|                 | p |                                                    |
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|                 | m |                                                    |
|                 | e |                                                    |
|                 | n |                                                    |
|                 | t |                                                    |
|                 |   |                                                    |
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|                 | p |                                                    |
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|                 | p |                                                    |
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|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | a |                                                    |
|                 | n |                                                    |
|                 | d |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | i |                                                    |
|                 | n |                                                    |
|                 | i |                                                    |
|                 | t |                                                    |
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|                 | a |                                                    |
|                 | l |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | h |                                                    |
|                 | o |                                                    |
|                 | s |                                                    |
|                 | p |                                                    |
|                 | i |                                                    |
|                 | t |                                                    |
|                 | a |                                                    |
|                 | l |                                                    |
|                 | ) |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | f |                                                    |
|                 | o |                                                    |
|                 | r |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 | c |                                                    |
|                 | r |                                                    |
|                 | u |                                                    |
|                 | s |                                                    |
|                 | h |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
|                 |   |                                                    |
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|                 | n |                                                    |
|                 | j |                                                    |
|                 | u |                                                    |
|                 | r |                                                    |
|                 | y |                                                    |
|                 | . |                                                    |
|                 | * |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| **Crush Injury: | T |                                                    |
| Treatment**     | h |                                                    |
|                 | e |                                                    |
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|                 | r |                                                    |
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|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ***Prehospital  | - |                                                    |
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|                 | . |                                                    |
+-----------------+---+----------------------------------------------------+
|                 |   |                                                    |
+-----------------+---+----------------------------------------------------+
| ######## Hos    | - |                                                    |
| pital Treatment |   |                                                    |
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+-----------------+---+----------------------------------------------------+
|                 | [ |                                                    |
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+-----------------+---+----------------------------------------------------+
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+-----------------+---+----------------------------------------------------+

+-----------------+----------------------------------------------------+
| #               |                                                    |
+-----------------+----------------------------------------------------+
| # [Com          |                                                    |
| partment Syndro |                                                    |
| me]{.smallcaps} |                                                    |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| #               | 23. *Explain the pathophysiology of compartment    |
| ##### Objective |     syndrome.*                                     |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| **Compartment   | The anatomical areas and other injuries usually    |
| Syndrome:       | involved in compartment syndrome include:          |
| Pa              |                                                    |
| thophysiology** | -   bone fractures with extravasation of blood or  |
|                 |     edema within a closed compartment              |
|                 |                                                    |
|                 | -   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       |
+-----------------+----------------------------------------------------+
|                 | Compartment syndrome typically occurs in major     |
|                 | muscle groups enclosed by inelastic, fibrous       |
|                 | sheaths.                                           |
|                 |                                                    |
|                 | Principal areas for compartment syndrome are upper |
|                 | extremities, including thenar and hypothenar       |
|                 | eminences of hand, and lower extremities,          |
|                 | including the foot.                                |
|                 |                                                    |
|                 | -   tissue/muscle trauma results in edema in a     |
|                 |     closed volume space                            |
|                 |                                                    |
|                 | -   progressive cycle of edema, perfusion          |
|                 |     compromise, tissue hypoxia and cellular        |
|                 |     derangement, further edema, etc.               |
|                 |                                                    |
|                 | Untreated compartment syndrome will produce the    |
|                 | same effects as a crush injury.                    |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| #               | 24. *Describe the clinical presentation common     |
| ##### Objective |     with compartment syndrome.*                    |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| **Compartment   | The clinical presentation of compartment syndrome  |
| Syndrome:       | includes the "5 P's".                              |
| Clinical        |                                                    |
| Presentation**  | -   Pain to muscle group affected, especially with |
|                 |     passive stretch                                |
|                 |                                                    |
|                 | -   Pallor due to decreased circulation            |
|                 |                                                    |
|                 | -   Paresthesia initially due to metabolically     |
|                 |     induced neuropraxia                            |
|                 |                                                    |
|                 | -   Paralysis initially due to metabolically       |
|                 |     induced neuropraxia                            |
|                 |                                                    |
|                 | -   Pressure---tense muscle compartment (compare   |
|                 |     to other side)                                 |
|                 |                                                    |
|                 | > \> 30 mm Hg for 6 hours resulting in tissue      |
|                 | > necrosis                                         |
|                 |                                                    |
|                 | -   Progression of symptoms is sometimes added as  |
|                 |     the "6^th^ P". Compartment syndrome progresses |
|                 |     over several hours, so a negative initial      |
|                 |     evaluation does not guarantee that compartment |
|                 |     syndrome will not develop later.               |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| #               | 25. *Explain the treatment (prehospital and        |
| ##### Objective |     initial hospital) for compartment syndrome.*   |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| **Prehospital   | -   Primary survey and initial stabilization (A,   |
| Treatment**     |     B, Cs)                                         |
|                 |                                                    |
|                 | -   Suspect compartment syndrome due to mechanisms |
|                 |     of injury, examination, and patient complaints |
|                 |                                                    |
|                 | -   Treat other injuries                           |
|                 |                                                    |
|                 | -   Immobilize affected part; do not use           |
|                 |     constricting bandages or MAST trousers         |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| **Hospital      | -   Primary survey, stabilization and              |
| Treatment**     |     resuscitation, secondary survey                |
|                 |                                                    |
|                 | -   Diagnosis through examination and confirmation |
|                 |     with tissue pressure measurements              |
|                 |                                                    |
|                 | -   Treat systemic effects of compartment syndrome |
|                 |     similar to crush injury                        |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        | If injury is open:                                 |
|                 |                                                    |
|                 | -   antibiotics, tetanus, thorough cleansing       |
|                 |                                                    |
|                 | -   debridement of nonviable tissues               |
|                 |                                                    |
|                 | -   early amputation for severely injured limbs    |
|                 |     may be required to reduce sepsis               |
+-----------------+----------------------------------------------------+
| Teaching Tip    | Continue to use a scenario and patient cases to    |
|                 | explain crush injury and compartment syndrome.     |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+
| ####            | Fasciotomy is definitive treatment, but tissue     |
| #### Fasciotomy | 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                     |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 26. *Describe the procedural skills needed for     |
| ##### Objective |     management of compartment syndrome, including  |
|                 |     measuring compartment pressures, use of        |
|                 |     ketamine, and fasciotomies.*                   |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ######## Proc   | Measurement of compartment pressures is the        |
| edural Skills:  | standard for the diagnosis of compartment          |
| Measuring Compa | syndrome.                                          |
| rtment Pressure |                                                    |
|                 | Methodology                                        |
|                 |                                                    |
|                 | Various methods, as well as equipment, are         |
|                 | available for this purpose. A transducer connected |
|                 | to a catheter usually is introduced into the       |
|                 | compartment to be measured. This method is the     |
|                 | most accurate method for measuring compartment     |
|                 | pressure and diagnosing compartment syndrome.      |
|                 | Measurement of the compartment pressure then can   |
|                 | be performed at rest, as well as during and after  |
|                 | exercise.                                          |
|                 |                                                    |
|                 | With acute syndrome, the exact threshold is        |
|                 | controversial, but typical ranges are from 30-45   |
|                 | mm Hg at rest. Some sources state that it is       |
|                 | better to associate this pressure to diastolic     |
|                 | pressure (i.e., within 10-30 mm Hg of diastolic    |
|                 | pressure).                                         |
|                 |                                                    |
|                 | With chronic compartment syndrome, resting         |
|                 | intracompartmental pressure above 15 mm Hg or      |
|                 | exertional pressure greater than 30 mm Hg          |
|                 | generally is considered elevated. Prolonged        |
|                 | elevated pressures of more than 20 mm Hg for 5     |
|                 | minutes or more after completion of exercise is    |
|                 | also considered abnormal. (Abraham T Rasul, Jr,    |
|                 | MD, *Compartment Syndrome*, eMedicine)             |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ######## Proc   | Ketamine is a parenteral anesthetic drug with      |
| edural Skills:  | several properties that yields it particularly     |
| Use of Ketamine | useful in disaster situations. Because of its      |
|                 | unique properties, it has been used in battlefield |
|                 | situations as well as in disaster scenarios where  |
|                 | anesthesia had to be provided in the field (e.g.,  |
|                 | in field amputation secondary to building          |
|                 | collapse). It is also an anesthetic choice to be   |
|                 | considered in the emergency department.            |
|                 |                                                    |
|                 | Within a wide therapeutic range, it provides       |
|                 | excellent analgesia and amnesia while supporting   |
|                 | respiratory reflexes and spontaneous ventilation.  |
|                 | This is a noteworthy quality given the potential   |
|                 | of inadequate numbers of ventilators available in  |
|                 | a disaster situation. Because of sympathomimetic   |
|                 | properties, cardiac function is not depressed nor  |
|                 | is there the peripheral vasodilation seen with     |
|                 | most anesthetic drugs, making it an ideal choice   |
|                 | in the hypotensive patient. It also is a superb    |
|                 | bronchodilator.                                    |
|                 |                                                    |
|                 | Ketamine is a dissociative anesthetic and produces |
|                 | an unusual sedative state. The onset of anesthesia |
|                 | occurs in 30-60 seconds given IV, but is           |
|                 | considerably longer given IM (20 to 30 minutes or  |
|                 | longer). The patient appears catatonic with eyes   |
|                 | open, sometimes with nystagmus present. Although   |
|                 | brainstem function is maintained, higher cognitive |
|                 | awareness is disconnected from somatic sensory     |
|                 | input. Normal or slightly enhanced muscle tone is  |
|                 | maintained, and varying degrees of skeletal        |
|                 | movement despite analgesia and amnesia is to be    |
|                 | expected.                                          |
|                 |                                                    |
|                 | In contrast with most anesthetics, upper airway    |
|                 | reflexes remain intact even at induction doses.    |
|                 | Sonorous respirations are observed frequently and  |
|                 | may be managed by repositioning the patient\'s     |
|                 | head and airway. Stimulation of the vocal cords by |
|                 | instrumentation or secretions may produce mild     |
|                 | laryngospasm rarely. Brief apnea may occur when    |
|                 | ketamine is administered via rapid intravenous     |
|                 | push. Laryngospasm is rare and usually responds to |
|                 | brief gentle positive pressure ventilation with a  |
|                 | bag-valve-mask device. Mild upper airway           |
|                 | obstruction secondary to the tongue is more        |
|                 | common, and this usually responds to repositioning |
|                 | of the patient\'s head or a jaw thrust. Although   |
|                 | ventilatory drive is maintained, supplemental      |
|                 | oxygen should be administered.                     |
|                 |                                                    |
|                 | In addition to the catatonic state and             |
|                 | intermittent motor activity, other side effects    |
|                 | include increased salivation, which may be blunted |
|                 | with pre-treatment with an antisialagogue.         |
|                 | Intracranial pressure is also increased, and so it |
|                 | is not the ideal drug for a head-injured patient.  |
|                 | In adult patients, there is also a frequent        |
|                 | emergence phenomenon during recovery characterized |
|                 | by hallucinations and terrifying dreams. This      |
|                 | reaction can be ameliorated with benzodiazepines,  |
|                 | although this may prolong recovery times due to    |
|                 | sedation. A quiet and calm environment during      |
|                 | recovery will decrease the incidence of the        |
|                 | emergence reaction. This is not seen in patients   |
|                 | less than 10 years of age.                         |
|                 |                                                    |
|                 | Dosing                                             |
|                 |                                                    |
|                 | -   usual induction dose is 1-2 mg/kg IV or 4-8    |
|                 |     mg/kg IM (additional drug may be necessary)    |
|                 |                                                    |
|                 | -   IV dosing is preferred, more reliable, and     |
|                 |     more readily titratable                        |
|                 |                                                    |
|                 | -   analgesia can be attained with lower doses     |
|                 |                                                    |
|                 | -   effects last approximately one hour            |
|                 |                                                    |
|                 | -   may be maintained with additional boluses of   |
|                 |     .5-1mg/kg IV or 2mg/kg IM                      |
|                 |                                                    |
|                 | -   may instead use an infusion of 200mg ketamine  |
|                 |     in NS 50cc at .5cc/kg/hr; stop infusion 15     |
|                 |     minutes prior to end of procedure              |
|                 |                                                    |
|                 | -   consider glycopyrrolate .01 to .02 mg/kg (not  |
|                 |     to exceed .2 mg) or atropine .01 mg/kg (not to |
|                 |     exceed .5 mg) as premedication to decrease     |
|                 |     secretions                                     |
|                 |                                                    |
|                 | -   supplemental oxygen, cardiac monitoring, and   |
|                 |     pulse oximetry should be provided              |
|                 |                                                    |
|                 | -   small doses (as little as 10mg IV) can provide |
|                 |     limited analgesia, and have been successfully  |
|                 |     used especially as an adjunct to narcotic      |
|                 |     administration                                 |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        | Methodology                                        |
| Procedural Skil |                                                    |
| ls: Faciotomies | -   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  |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 27. *Describe the treatment of an entrapped        |
| ##### Objective |     patient.*                                      |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| #######         | -   fluid resuscitation before victim extricated   |
| # Entrapped Pat |                                                    |
| ient: Treatment | -   1 L NS bolus, followed by 1-1.5 L per hour     |
|                 |     infusion                                       |
|                 |                                                    |
|                 | -   limb stabilization                             |
|                 |                                                    |
|                 | -   minimize potential systemic effects of         |
|                 |     reperfusion                                    |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   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.          |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 28. *Describe the indications (potential need) for |
| ##### Objective |     field amputation.*                             |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        | The context may dictate the need for field         |
|  Indications: F | amputation. Indications would include the          |
| ield Amputation | inability to safely extricate the patient,         |
|                 | continued environmental toxins that pose a hazard  |
|                 | to victims or rescuers, and a grossly prolonged    |
|                 | time until definitive treatment is available even  |
|                 | after extrication.                                 |
|                 |                                                    |
|                 | Field amputations are best performed by trauma or  |
|                 | orthopedic surgeons. Few EMS systems have          |
|                 | amputation protocols. If a field amputation is     |
|                 | performed, ensure adequate analgesia and           |
|                 | anesthesia. Ketamine, a dissociative anesthestic   |
|                 | that does not cause cardiorespiratory depression,  |
|                 | decreases or only minimally increases serum        |
|                 | potassium levels.                                  |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 29. *Describe the military experience in blast     |
| ##### Objective |     injury care, such as hemorrhage control issues |
|                 |     and issues related to the use of tourniquets.* |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| # [Military     | The U.S. Military has gained extensive experience  |
|  Experience in  | in dealing with blast injuries in Iraq and         |
| Blast Injury Ca | Afghanistan. They have actively sought and quickly |
| re]{.smallcaps} | adapted different strategies for treatment,        |
|                 | particularly in the area of hemorrhage, which is   |
|                 | the leading cause of preventable death. As a       |
|                 | result, there has been a tremendous drop in        |
|                 | mortality from previous wars.                      |
|                 |                                                    |
|                 | Damage Control Surgery (DCS) is routinely applied  |
|                 | for victims with significant hemorrhage to avoid   |
|                 | the "Deadly Triad" of hypothermia, coagulopathy,   |
|                 | and metabolic acidosis. The patient is transported |
|                 | directly to the operating room upon arrival, and   |
|                 | resuscitation ensues concurrently with surgery.    |
|                 | The goals of DCS are to quickly stop the bleeding, |
|                 | remove major contaminants, and leave the wound     |
|                 | open (to avoid abdominal compartment syndrome).    |
|                 | The patient is transferred to the ICU for          |
|                 | continued resuscitation and normalization of blood |
|                 | pressure, body temperature, and coagulation        |
|                 | factors. The patient returns for more definitive   |
|                 | surgery 12-18 hours later.                         |
|                 |                                                    |
|                 | Resuscitative techniques for major hemorrhage      |
|                 | differ from current civilian medical practice. The |
|                 | initial resuscitation fluid of choice in massive   |
|                 | transfusion (MT) is fresh thawed plasma (thawed    |
|                 | fresh frozen plasma lasts 5 days at 4 deg C.);     |
|                 | optimum ratio of plasma to crystalloid is 1:1 to   |
|                 | avoid clotting factor dilution \>50%. Crystalloid  |
|                 | (which is acidotic, inflammatory, and has adverse  |
|                 | effects on coagulation) is minimized, and colloid  |
|                 | (Hextend) is preferred. Fresh whole blood is used  |
|                 | routinely for MT. Cryoprecipitate and recombinant  |
|                 | Factor VIIa is often used, early in the            |
|                 | transfusion.                                       |
|                 |                                                    |
|                 | Tourniquets are carried by every soldier, each of  |
|                 | whom has received instruction in its proper        |
|                 | application. Liberal use is encouraged for any     |
|                 | significant extremity hemorrhage. Early            |
|                 | application of the tourniquet is advocated for the |
|                 | avoidance of blood loss ("first resort not last    |
|                 | resort"). Adverse effects in cases when            |
|                 | tourniquets were applied inappropriately have not  |
|                 | been seen.                                         |
|                 |                                                    |
|                 | New hemostatic dressings are used for              |
|                 | non-extremity hemorrhage. The dressings are        |
|                 | applied with pressure x 5 minutes, and then the    |
|                 | patient is wrapped and transported. Personnel      |
|                 | using these agents have been extremely impressed.  |
|                 | HemCon bandage has been the predominant dressing   |
|                 | used; a new formulation in the form of a roll that |
|                 | can be stuffed in wounds is now available.         |
|                 | QuikClot has not been used as much due to its      |
|                 | exothermic nature and the difficulty of debriding  |
|                 | the powder from a wound; a new Advanced Clotting   |
|                 | Sponge (ACS) form is now available, which can      |
|                 | easily be removed from the wound. Another          |
|                 | hemorrhage control agent, Celox, is currently      |
|                 | undergoing testing but is not currently being used |
|                 | by the military.                                   |
+-----------------+----------------------------------------------------+
|                 |                                                    |
+-----------------+----------------------------------------------------+

+-----------------+----------------------------------------------------+
| # [Speci        |                                                    |
| al Consideratio |                                                    |
| ns]{.smallcaps} |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 30. *Describe the considerations that should be    |
| ##### Objective |     addressed for special needs patients such as   |
|                 |     children, women who are pregnant, the elderly, |
|                 |     the disabled, and those with language          |
|                 |     barriers.*                                     |
+-----------------+----------------------------------------------------+
| ########        | #                                                  |
+-----------------+----------------------------------------------------+
| ########        | (The content related to this objective could be    |
|                 | integrated into the appropriate sections, but      |
|                 | general content related to these special needs     |
|                 | populations could be taught in a separate          |
|                 | section.)                                          |
|                 |                                                    |
|                 | Consideration should be given to the following     |
|                 | groups:                                            |
|                 |                                                    |
|                 | -   pregnant women                                 |
|                 |                                                    |
|                 | -   children                                       |
|                 |                                                    |
|                 | -   elderly people                                 |
|                 |                                                    |
|                 | -   disabled people                                |
|                 |                                                    |
|                 | -   people with language barriers                  |
+-----------------+----------------------------------------------------+
| #               | Blast injuries involving pregnant patients will    |
| ##### Pregnancy | warrant special consideration. Direct injury to    |
|                 | the fetus is uncommon but injuries to the placenta |
|                 | are possible and must be detected. Patients in the |
|                 | second or third trimester of pregnancy should be   |
|                 | admitted to the labor and delivery area for        |
|                 | continuous fetal monitoring and further testing    |
|                 | and evaluation. The placental attachment is at     |
|                 | risk for primary blast injury because of the       |
|                 | effect of spalling. In addition, tissues of        |
|                 | different densities are accelerated by the blast   |
|                 | wave at different rates, causing shearing injuries |
|                 | and placental abruption.                           |
+-----------------+----------------------------------------------------+
| ######          | A screening test for fetal-maternal hemorrhage     |
|                 | should be performed on all women in the second or  |
|                 | third trimester of pregnancy. A positive test      |
|                 | requires mandatory pelvic ultrasound, fetal        |
|                 | non-stress test monitoring, and                    |
|                 | obstetrics/gynecology (OB/GYN) consultation.       |
+-----------------+----------------------------------------------------+
| ***Children***  | A history of the event or patient's complaints may |
|                 | be difficult to obtain.  An event history from     |
| ***Elderly***   | bystanders and other victims could be the only     |
|                 | source of information.                             |
| ***Disabled***  |                                                    |
|                 | Pulmonary contusion is one of the most common      |
| ***Language     | injuries from blunt thoracic trauma in pediatric   |
| Barriers***     | patients.  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 lung is suspected.           |
|                 |                                                    |
|                 | Consideration should be given to specialized       |
|                 | equipment for the prehospital environment, or      |
|                 | non-pediatric hospitals.  Identification of        |
|                 | regional pediatric trauma facilities and           |
|                 | pre-notification may be beneficial when transfers  |
|                 | are indicated.                                     |
|                 |                                                    |
|                 | The elderly may be at a higher risk of mortality   |
|                 | and the in-hospital stay may be longer and more    |
|                 | complicated.  As with most traumatic injuries in   |
|                 | this category of patient, underlying medical       |
|                 | conditions may be exacerbated by the effects of a  |
|                 | blast injury, or some injuries may be masked by    |
|                 | pre-existing conditions.                           |
|                 |                                                    |
|                 | Orthopedic injuries may be more prevalent as a     |
|                 | result of tertiary blast injuries due to a         |
|                 | decrease in bone density and reduced body mass.    |
|                 |                                                    |
|                 | Blunt chest trauma should be of special            |
|                 | consideration due to the risk for pulmonary        |
|                 | deterioration in the several days post-injury, and |
|                 | patients should be monitored carefully regardless  |
|                 | of their initial presentation.                     |
|                 |                                                    |
|                 | Decontamination methods may need modification to   |
|                 | accommodate patients with limited mobility.        |
|                 | Technical decontamination of medical equipment     |
|                 | such as wheelchairs, walkers and other walking     |
|                 | aides may be needed.                               |
|                 |                                                    |
|                 | Extra consideration should be give to patients     |
|                 | with underlying medical conditions.  These         |
|                 | conditions may not affect the acute treatment      |
|                 | process, but should be considered for long term    |
|                 | affects.  In addition, untreated or inadequately   |
|                 | treated fractures and infected wounds may lead to  |
|                 | severe and long lasting disabilities in this group |
|                 | of patients.                                       |
|                 |                                                    |
|                 | Since most bombing events occur in public places   |
|                 | or large venues, a diverse population speaking     |
|                 | multiple languages may be an unforeseen obstacle.  |
|                 | Other communication barriers to consider would be  |
|                 | interaction with the deaf, hard of hearing,        |
|                 | late-deafened and the deaf-blind. A history of the |
|                 | event maybe difficult to obtain as well as the     |
|                 | individual history for the patient.                |
|                 |                                                    |
|                 | Reliance on friends, family members of the         |
|                 | patient, or bystanders, for translation may be     |
|                 | necessary in the prehospital environment.  These   |
|                 | individuals, if not injured, should accompany the  |
|                 | patient to the hospital to ensure communication    |
|                 | can continue.  Maintaining a pool of certified     |
|                 | medical interpreters to include sign language, or  |
|                 | access to telephone translation services should be |
|                 | considered for large metropolitan hospitals.       |
+-----------------+----------------------------------------------------+
| # [Psy          |                                                    |
| chological Issu |                                                    |
| es]{.smallcaps} |                                                    |
|                 |                                                    |
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ###             | 31. *Describe the factors that affect mental       |
| ##### Objective |     health during an explosive event.*             |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ######## Fact   | This section is designed to provide a brief        |
| ors That Affect | background on the recognition, evaluation, and     |
|  Mental Health  | treatment of both victims and responders with      |
|                 | psychological concerns from terrorist events       |
|                 | involving explosions and bombs.                    |
+-----------------+----------------------------------------------------+
| ########        | Acts of terrorism tend to erode the sense of       |
|                 | security and safety that we normally enjoy.        |
|                 | Terrorism challenges the stability we enjoy in a   |
|                 | predictable, orderly, and controlled world.        |
|                 | Feelings of anger, frustration, helplessness,      |
|                 | fear, guilt, distress, and a desire to seek        |
|                 | revenge are all common responses.                  |
+-----------------+----------------------------------------------------+
| ########        | In a terrorist event, there is:                    |
|                 |                                                    |
|                 | -   Little or no warning---Most events occur       |
|                 |     without warning, which makes it difficult for  |
|                 |     individuals to prepare psychologically. This   |
|                 |     lack of warning causes a perceived loss of     |
|                 |     control, a sense of helplessness, and a        |
|                 |     feeling of vulnerability.                      |
|                 |                                                    |
|                 | -   Unknown duration of the event---Depending on   |
|                 |     the terrorist act, there may be an uncertain   |
|                 |     end point that could intensify the             |
|                 |     psychological effects.                         |
|                 |                                                    |
|                 | -   Potential threat to personal safety---Due to   |
|                 |     the nature of terrorist events, people may     |
|                 |     feel personally targeted or threatened. In     |
|                 |     addition, the fear of further attacks may make |
|                 |     them question the safety of other buildings    |
|                 |     and locations. They may feel no place is safe  |
|                 |     to seek shelter. Responders may also have to   |
|                 |     deal with the threat of secondary devices      |
|                 |     placed just to kill or injure those who        |
|                 |     respond to the scene.                          |
|                 |                                                    |
|                 | -   Unknown health risks---Health risks from       |
|                 |     unknown agents also contribute to the          |
|                 |     psychological effects of terrorism. Long term  |
|                 |     health risks would be a major fear.            |
+-----------------+----------------------------------------------------+
| ########        | Humans have a strong natural ability to recover    |
|                 | from traumatic events. For most, the feelings of   |
|                 | fear and anxiety will gradually decrease over      |
|                 | time, but some will need professional help to      |
|                 | totally recover.                                   |
|                 |                                                    |
|                 | Tips for both responders and planners include:     |
|                 |                                                    |
|                 | -   Promotion of safety: help people meet the      |
|                 |     basic needs for shelter and food, provide a    |
|                 |     'recovery environment' to include limited      |
|                 |     exposure to news and other media related to    |
|                 |     the event, encourage those who are relocated   |
|                 |     to return only when their areas are deemed     |
|                 |     safe.                                          |
|                 |                                                    |
|                 | -   Promote calm: offer accurate information about |
|                 |     the event and the efforts underway to help the |
|                 |     situation.                                     |
|                 |                                                    |
|                 | -   Promote connectedness: help to reunite         |
|                 |     families and friends, establish a sense of     |
|                 |     normalcy for children by reinforcing           |
|                 |     parent-child bond, reuniting children with     |
|                 |     playmates, and reestablishing if possible,     |
|                 |     school and other safe environments.            |
|                 |                                                    |
|                 | -   Promote self-efficacy: give practical          |
|                 |     suggestions and referrals that move people to  |
|                 |     help themselves.                               |
|                 |                                                    |
|                 | -   Promote hope: direct people to services that   |
|                 |     are available, remind people (if you know)     |
|                 |     that more assistance will be arriving.         |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ####            | http://www.bt.cdc.gov/masscasualties               |
| #### Resources  |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+
| ########        |                                                    |
+-----------------+----------------------------------------------------+

#  [Patient Cases]{.smallcaps}

These patient cases are provided to assist in facilitating discussion
for the individual objectives previously identified. The following
patient cases are based on an explosion at a subway station and follow
the assessment and treatment of four patients in the prehospital and
hospital settings. The four patient cases include blast lung, combined
injuries, blast brain and crush injuries.

Background

Two IEDs hidden in backpacks have exploded in separate cars of a
southbound subway train that was stopped at the station. A few minutes
later, a car bomb exploded in front of the main entrance of the station.

The two IEDs in the subway cars were contained in small backpacks or
briefcases. Both contained shrapnel, which increased the injuries. Those
immediately surrounding the blast were killed instantly. The glass
windows were blown out but there was little structural damage to the
cars except in the immediate area of the bombs. The severity of injuries
decreased with further distance from the blast. The car bomb at the
front of the station was a much larger explosion and caused major
structural damage to the building. Walls collapsed and many people were
trapped. The structural damage, debris and the number of injured has
caused a major delay in the rescue effort.

The subway blast site is a scene of devastation and confusion. The area
has been declared clear of further explosive hazards, but the scene is
littered with glass and metal debris that pose an injury risk to
patients and rescuers. The site has been secured and is now considered
safe. Teams have completed initial triage.

The two subway cars had about 100 people riding in each when the IEDs
detonated. 200 more people were in the lobby and nearby outside areas
when the car bomb exploded. Approximately 400 total injured at the
scene, located throughout the entire blast area. The initial triage
numbers are: 68 Immediate, 117 Delayed, 97 Minor and 35 Deceased. A
large number of Minor injured and untriaged people have left the scene
and are presumed to be going directly to a hospital.

Triage for an explosive event poses different challenges from triage for
other emergencies. A blast wave can cause severe internal injuries that
are not immediately apparent, which is a very dangerous situation for
patients. Patients also may have combined blast, ballistic, and burn
injuries, including soft tissue injuries that can be difficult to
detect. Accurate and efficient triage is extremely important and
overtriage can delay recognition and treatment for patients with hidden
or delayed injuries.

As many as 75 % of the victims at a blast event will go to hospitals on
their own or will be taken to hospitals by people at the scene. These
patients may not be badly injured, or they might have hidden injuries
they are not aware of. They may arrive at the hospital before the most
severely injured people who arrive by ambulance. This causes problems
associated with inadequate surge capacity. Self-referred patients create
a difficult situation at the hospital, because these people have not
been assessed, triaged, or decontaminated. Hospitals must be prepared to
decontaminate and triage large numbers of patients who arrive on their
own.

**[Patient #1:]{.underline}**

Your patient is a young male who was seated in one of the subway cars
where the first IED exploded. He was moved to the lobby and was sitting
against the wall when the second bomb exploded. He is conscious but does
not respond appropriately to your questions. He keeps shouting, "What?
What are you saying?"

He has been initially triaged as Delayed. As you visually survey the
patient, you note he is now experiencing some difficulty in breathing
and cyanosis is present on his face and hands. He has obvious signs of
trauma on his face, chest, and extremities, including lacerations and
bruising.

**[Prehospital Treatment]{.underline}**

What do you do first?

a\. Do a rapid primary survey and perform any necessary interventions to
ensure an adequate airway is maintained.

b\. Identify hemorrhage and treat appropriately

c\. Start high flow oxygen and two large bore IVs wide open to see if
his condition improves before completing your assessment.

d\. Immediately place him flat on backboard and place C-Collar and head
immobilization devices

### Correct answer is: a

In this situation, the first priority is to secure the airway prior to
transport. Large bore IVs are indicated, but administering too much
fluid could cause serious damage to this patient. The cervical spine
should be immobilized prior to transport. Control of hemorrhage is
important, but the airway takes precedence.

##### Patient Assessment

Heart: Good heart sounds, regular rhythm, bradycardia. Heart rate 56.

Head: Neuro exam shows patient is slightly confused but follows
commands.

Moves all extremities. GCS = 14.

Mouth: The patient has hemoptysis

Lungs: You note tachypnea, wheezing, and decreased breath sounds.
Respiratory rate 32.

Ear: His hearing is impaired.

BP: Blood pressure is 80 systolic.

Abdomen: Abdomen is not tender, soft and not distended.

The patient tells you he cannot hear anything. Why is hearing loss an
important observation in victims of an explosion?

a\. Ear injuries need to be identified and may need to be treated by a
specialist when the patient is stable.

b\. Hearing loss caused by tympanic membrane rupture may or may not
indicate other primary blast injuries.

c\. Other types of barotrauma cannot be present in the absence of ear
barotraumas.

d\. Tympanic membrane rupture is the most common type of barotrauma
after an explosion occurs.

### Correct answers are: a, b, d

Lack of hearing could suggest tympanic membrane rupture, which may or
may not indicate other primary blast injuries caused by a blast pressure
wave. Tympanic membrane rupture is the most common type of barotrauma
after explosions due to the lower pressure needed to injure the TM
versus the lung or intestines. In the absence of tympanic membrane
rupture, other significant barotrauma is unlikely, but not impossible.
Patients with TM rupture should be observed for shortness of breath or
abdominal pain for 4 to 6 hours to ensure no delayed barotrauma has
occurred. If no TM rupture is present and the patient has no complaints
or evidence of injuries on exam, the patient can be discharged. Damage
to the deeper structures of the ear such as the ossicles or round window
can occur and would be managed by a specialist when more serious
injuries have been stabilized.

Your assessment has led you to suspect that this patient may be
suffering from blast lung. What will your initial treatment include?

a\. High flow oxygen with judicious fluid administration

b\. High flow oxygen and wide open IV lines

c\. Minimal oxygen flow with restricted fluid administration

d\. Minimal oxygen flow with wide open IV lines

**Correct answer is: a**

For blast lung injury, you need to use high flow oxygen with judicious
fluid administration to ensure tissue perfusion without volume overload.
All patients with suspected or confirmed blast lung should receive
supplemental high flow oxygen sufficient to prevent hypoxemia. However,
in blast lung, wide open IV lines can cause fluid to accumulate in the
lungs secondary to structural damage resulting in worsening pulmonary
function.

**What's Next?**

This patient is being transported to County Memorial Emergency
Department.

##### Hospital Treatment 

When the patient arrives in the ED, he is receiving high flow oxygen via
a non-rebreather mask and IV fluid at a maintenance rate. He is in
respiratory distress with hemoptysis with declining oxygen saturations.

What treatment do you initiate?

a\. Non-invasive Continuous Positive Airway Pressure (CPAP) treatment

b\. Immediate surgical cricothyrotomy

c\. Endotracheal intubation

d\. Immediate needle thoracostomy

**Correct answer is: c**

Early endotracheal intubation should be done to secure the airway. CPAP
treatment will not prevent airway compromise. Surgical cricothyrotomy
would only be done emergently if unable to intubate the patient in a
patient with a severely compromised airway. A needle thoracostomy is not
indicated unless tension pneumothorax is suspected.

If the patient is intubated and is placed on a ventilator. What type of
settings would you select?

a\. High frequency ventilation

b\. High tidal volume, rapid respiratory rate

c\. Tidal volumes resulting in low peak inspiratory pressures

d\. Permissive hypercapnia

e\. Achieving a normal CO2 even if it requires high tidal volumes

**Correct answers are: a, c, d**

Pulse oximetry indicating decreased oxygen saturation can signal early
blast lung injury even before other symptoms are present. High
inspiratory pressures and volumes increase the risk of air embolism and
pneumothorax. Hypercapnea with respiratory acidosis may result from
relatively low pressures and volumes, but is acceptable to minimize
additional pulmonary trauma from the ventilator itself (so-called
permissive hypercapnea).

Since you suspect blast lung, you order a chest X-ray. What could you
expect to see?

a\. Bihilar "butterfly" pattern

b\. Pneumothorax or hemothorax

c\. Widened mediastinium

d\. Subcutaneous emphysema

e\. Pneumomediastinum

**Correct answers are: a, b, d, e**

All of these can be caused by pressure effects on the lungs except
widened mediastinium. Widened mediastinium can occur with blunt trauma
to the chest but not with blast lung.

The patient has improved, but the Chest X-ray shows a bilateral
butterfly pattern diffusely. What do you recommend as the next step?

a\. Admission to the ICU

b\. Transfer to a hyperbaric chamber

c\. Observe for evidence of intestinal injury

d\. Observe for evidence of air embolism

**Correct answers are: a, c, d**

Patients diagnosed with blast lung may require complex management and
should be admitted to an intensive care unit. Those with findings
suspicious for early blast lung should be observed in the hospital.
Patients should be watched closely for evidence of intestinal
barotraumas or air emboli (to the heart, brain, spinal cord, etc)
Patients with air emboli should be transferred to a hyperbaric chamber.

What's Next?

This patient has improved.

Discuss further actions for this patient.

#### **Case Summary**

So what really happened to this patient in the blast?

He was a young male riding in one of the subway cars when an IED
exploded. He had been moved to the lobby by rescue teams and was sitting
against the wall when the car bomb exploded.

From his delayed-onset symptoms and the chest x-ray showing a bihiliar
"butterfly" pattern, you determined that he received a blast lung injury
from one of the explosions, probably the first one.

He is able to maintain 96-97% oxygen saturation levels with supplemental
oxygen.

This patient recovered from his injuries and was discharged from the
hospital after eight days. Subsequent chest X-rays show resolution of
the blast lung and no pneumothorax, hemothorax or pneumomediastinum. At
discharge he exhibited no shortness of breath and maintained 99-100%
oxygen saturation on room air.

*The most important things to learn from this case are that:*

-   Rapid recognition of respiratory compromise at triage is essential.

-   Hearing loss could be an indicator of blast lung, although this is
    not always so.

-   Oxygen therapy, airway management, judicious IV fluids, chest X-ray
    and close observation for progressing complications are key
    components of care for this type of injury.

-   Bradycardia can be present.

[Patient #2]{.underline}

This patient is a 40-year-old female who is five months pregnant with
first degree and superficial partial thickness second-degree flash burns
to her face, hands, and legs. BSA burn involvement is approximately 22
percent. She has soft tissue lacerations on her face and upper torso
caused by glass and metal. She says she was blown down by the blast.

##### Prehospital Treatment

Which would be your initial priorities for treatment?

a\. Place her on her left side and check for fetal heart tones.

b\. Establish large-bore IV.

c\. Immobilize for possible spinal injuries.

d\. Stabilize the airway and start supplemental oxygen.

**Correct Answers are: b, c, d**

Management of the mother is of primary concern and is the best way to
ensure fetal survival. Securing the airway, stabilizing the cervical
spine and providing supplemental oxygen are all high priorities with
this patient. Large bore IV's should be started in trauma patients in
case serious underlying injuries with hemorrhage occur. For women in the
second or third trimester, lying on their left side can increase
circulation, but fetal heart tone assessment is not part of initial
management.

Early on in the management of this patient, which of the following do
you consider?

a\. Providing immediate pain control and sedation

b\. Maintaining perfusion of the tissue

c\. Administering tetanus toxoid to prevent infection

d\. Avoiding overhydration of the lungs

**Correct Answers are: a, b, d**

IV access and fluid administration will allow for adequate fluid
resuscitation and tissue perfusion, access for administration of
antibiotics and pain medications. The possibility of over hydration
should always be considered and the patient closely monitored for this.
Over hydration for cases of blast lung is contraindicated. Tetanus
toxoid, while important, is not an initial assessment priority.

Based on the mechanism of injury for this patient, she should be
observed for signs and symptoms of all of the following conditions,
except:

a\. Abruptio placenta

b\. Placenta previa

c\. Concussion

d\. Blast lung

**Correct answer is: b**

Placenta previa is a condition in which the placenta is formed low in
the uterus and close to or covering the cervical opening. This condition
is physiological and cannot be created through a trauma event.

During transport this patient becomes unresponsive and hypotensive, but
is breathing adequately. Interventions you might perform include all the
following except:

a\. Insertion of a nasopharyngeal airway and high flow oxygen by
non-rebreather mask

b\. Administration of narcotic analgesia to overcome the pain of the
injuries and burns

c\. While maintaining cervical immobilization, elevating the spineboard
so the patient is tilted on her left

side to help shift the uterus off the vena cava, thus improving blood
flow

d\. Insertion of a second large bore IV and immediate administration of
normal saline 20 ml/kg bolus

**Correct answer is: b**

Trauma or burn patients who become unresponsive require the
establishment and protection of the airway. A nasopharyngeal airway is a
reasonable initial intervention for a patient with good respiratory
effort; however endotracheal intubation may be necessary. Elevation of
the pregnant patient's left side in the second or third trimester is
important for maintaining cardiac output. An IV bolus of normal saline
is indicated for trauma-induced hypotension. Narcotic analgesia is
contraindicated in the hypotensive and unresponsive patient.

**What's Next?**

The patient's airway is being maintained with a nasopharyngeal airway
and high flow oxygen. The patient has been tilted to her left side with
C-spine precautions in place and a second IV has been established. The
patient is now enroute to the Emergency Department.

##### Hospital Treatment

As this patient arrives in the emergency department, what initial
actions do you take to identify potential life threatening injuries?

[]{.mark}

a\. Checking the distal extremities for foreign bodies

b\. Checking for equal lung sounds and ordering and reading a chest
X-ray

c\. Checking for intra-abdominal injury

d\. Checking for airway patency

**Correct answers are: b, c, d**

The primary assessment and initial management of this patient should
include securing a patent airway, assessing breathing and lung sounds,
and assessing for bleeding sources. Checking extremities for foreign
bodies would occur during the secondary survey.

Which of the following *secondary* treatment priorities would you select
for this patient?

a\. Checking for tympanic membrane injury

b\. Treating burns and wounds

c\. Evaluating for corneal abrasions

d\. Placing a chest tube or performing a needle thoracostomy for simple
pneumothorax

**Correct answers are: a, b, c**

Treatment for plethora is a primary treatment priority, not secondary.
All other interventions are appropriate as secondary treatment
priorities. Although this patient meets criteria for transfer to a burn
unit, only critical burn patients are being transferred during this
event.

What other consultations would be useful in the emergency department for
this patient?

a\. Plastic surgery consult for possible scarring of the face

b\. OB and/or L&D consultation for fetal monitoring

c\. Call regional burn center for guidance on management for potential
complications

d\. Critical care consultation for blast lung injury

**Correct answers are: b, c, d**

An OB or L&D consultation for fetal assessment and monitoring would be
appropriate for this patient with a 22-week gestational age. A critical
care consultation is indicated if you suspect blast lung injury. A
plastic surgeon consultation would not be initiated in the emergency
department in the initial phase of care during a mass casualty incident
(MCI).

What specific considerations do you have related to a pregnant patient
presenting after a blast injury?

a\. Primary injuries to the fetus are common.

b\. Placental abruption can occur.

c\. Fetal monitoring should be initiated.

d\. Rhogam injection for Rh negative mother

**Correct answers are: b, c, d**

Because the fetus is surrounded by amniotic fluid, direct injury to the
fetus is relatively uncommon. Injuries to the placenta are more common
due to the effect of pressure waves on tissues of different densities
(i.e. the placenta and uterus). Different tissue densities accelerate at
different rates and this can lead to shearing forces and abruption.
After life-threatening conditions have been stabilized, patients in the
second or third trimester of pregnancy who have been exposed to blast
injury should be admitted to the labor and delivery area for continuous
fetal monitoring. There is a risk of mixing maternal and fetal blood,
which indicates the need for a pelvic ultrasound and helps to guide Rh
immune globulin therapy in an Rh negative mother.

**What's Next?**

This patient has improved.

Discuss further actions for this patient.

**Patient Summary**

This 40-year-old female reported she was blown down by the bomb blast.
She is five months pregnant and had first degree and superficial
second-degree flash burns to her face, hands, and legs with BSA burn
involvement approximately 22 percent. Flying glass and metal caused soft
tissue lacerations on her face and upper torso.

##### *Key points for pregnant patients injured in an explosive event are:*

[]{.mark}

-   Pregnant patients demonstrate anatomical and physiological
    differences when compared to non-pregnant trauma patients, which can
    modify assessment findings and subsequent interventions.

-   The priorities of care in the pregnant patient are the same as those
    for the non-pregnant patient. Optimizing maternal airway, breathing
    and circulation will optimize the fetal outcome.

-   Blast patients with multiple injuries present unique challenges for
    maintaining airway while addressing inadequate tissue perfusion.

-   Hospitals should be prepared to treat and admit patient with degrees
    of injury or types of conditions they are not accustomed to, because
    the system may be overwhelmed.

[]{.mark}

After consultation with the burn unit, this patient was not transferred
due to the large volume of critical burn patients. She was discharged
four weeks later with instructions to follow up with her obstetrician.

**[Patient #3]{.underline}**

This patient is a 50-year-old male who was seated in one of the subway
cars when the blast occurred. He was thrown about 20 feet against the
side of the car. He was initially triaged as Minor with only minor cuts
on the head, face, and upper body from flying glass. It has now been
more than an hour since the blast.

Extrication, the large number of critical patients, and a lack of
personnel and transport vehicles have delayed this patient from
receiving ALS care and transportation. Information on the triage tag
states that the patient originally appeared as conscious and alert;
oriented to person, place, time, and events; complained of a severe
headache; with stable vitals.

**Prehospital Treatment**

Head: Initial assessment reveals he is no longer oriented to person,
time, and place. He seems to be having difficulty processing your
questions. His verbal responses are confused; he responds with some
inappropriate words. GCS = 11

Eyes: There is some delay in pupillary response; his eyes open in
response to your voice.

Lungs: Respiration is 24 per minute.

Arm: He has localized motor response to pain. 

With this assessment information, what is the next step in treating this
patient?

a\. Administer bolus IV of saline over 5 minutes

b\. Mark for transport as Immediate to nearest ED

c\. Continue to monitor in casualty collection area

d\. Sedate the patient with midazolam (1 to 2 mg IV push)

**Correct answer is: b**

As his level of orientation is changing, he needs evaluation in the
hospital for a potential blast brain injury. Sedating him or providing a
fluid bolus would not be appropriate treatments for a brain injury. Mark
for transport as Immediate to the nearest ED.

Given the results of your assessment, what will your treatment include?

a\. High-flow oxygen with a non-rebreather mask

b\. Hyperventilate the patient with a BVM

c\. Stabilize the patient's c-spine with a long backboard and collar

d\. IV access with D5W at fluid maintenance rate

e\. IV access with NaCl at fluid maintenance rate

**Correct answers are: a, c, e**

Supplemental high flow oxygen may decrease secondary brain injury and
should be used whenever possible in this setting. Do not hyperventilate
because it can cause cerebral ischemia and should be reserved for
clinical circumstances where herniation is strongly suspected. Using D5W
leads to more tissue swelling since it leaves the vascular space
rapidly. An intravenous access site is preferred, but should only be
accomplished after higher priorities are addressed at the mass casualty
scene.

As the patient is going through a re-triage, you note that his pulse is
about 130 beats per minute. This finding along with bleeding from
multiple small wounds in the abdomen might indicate:

a\. The patient has a ruptured abdominal aortic aneurism.

b\. The patient has a potential for significant abdominal injuries due
to shrapnel.

c\. The increased pulse rate is an indicator of increased intracranial
pressure.

d\. The increased pulse rate is not a cause for concern.

**Correct answer is: b**

Even though you suspect the patient may have a significant head injury,
any time there is a major change in the pulse rate, whether an increase
or decrease, there is cause for concern. Increasing intracranial
pressure would be suspected if there were a decrease of the patient's
pulse, along with hypertension and either widening pulse pressures, or
varying respirations (Cushing's Triad). However, the elevation in pulse
rate in this scenario should be a clue that other significant injuries
may be present that were not previously identified.

**Hospital Treatment**

When the patient arrives at the hospital, you learn there are currently
no ED beds available and most exam rooms have two or three patients in
each. The ED is overcrowded with a large number of walking wounded who
arrived on their own. The staff has been trying to triage and
decontaminate patients before they are allowed inside the ED. The EMS
crew notifies you that there are three more Immediate patients who will
arrive in the next 15 minutes.

What are the immediate priorities you must address to manage the current
patient load in the ED?

a.  Continue to triage and retriage all patients.

b.  Keep walking wounded at casualty collection area outside ED.

c.  Begin evaluation of this Immediate patient.

d.  Move this patient to a holding area.

**Correct answers are: a, b, c**

[]{.mark}

Triage is a process, not a location. In an evolving mass casualty
situation, patients' conditions and triage prioritization may change
rapidly. Lower priority patients should not take up necessary emergency
department resources, when higher priority patients need interventions.
Patients triaged as Immediate take precedence for resources over lower
priority patients.

Re-examination indicates the patient is now unconscious and
hemodynamically stable. What are the immediate priorities you must
address to manage this patient?

a\. Intubation for airway protection

b\. Mechanical ventilation to achieve normal CO~2~

c\. Suturing of small, dirty arm laceration

d\. CT scan to evaluate for intracranial injury

e\. Bilateral burr hole placement for cerebral decompression

**Correct answers are: a, b, d**

Endotracheal intubation is indicated for all treatable patients with
suspected traumatic brain injury who are unresponsive or have a Glasgow
Coma Score of less than or equal to 8. Airway protection, supplemental
oxygenation, and evaluation of end-tidal or arterial CO~2~ concentration
should be achieved expeditiously, and prior to neuroimaging, initially
with cranial CT scanning. Suturing of lacerations which are not actively
bleeding, especially those that will require debridement and aggressive
irrigation should be accomplished as a secondary or tertiary task. Burr
holes may be performed for brain herniation when rapid decompressive
craniotomy is unavailable.

Now that this patient is stabilized, you turn your attention to the
small lacerations on the chest and extremities. You note that there are
multiple lacerations from 1cm to 2.5 cm across the abdomen. Correct
initial workup of these lacerations include:

a\. Exploration and debridement of each wound

b\. Immediate irrigation and suturing of each wound

c\. CT scan of chest/abdomen to look for shrapnel

d\. Probing of wounds with a cotton swab to determine depth

**Correct answer is: c**

Many IEDs are packed with nails, bolts and other objects designed to
become projectiles when the bomb explodes. All patients with lacerations
of indeterminate depth should be worked up as if each laceration was a
penetrating injury. Irrigation, debridement and suturing may all be
delayed.

**What's Next?**

This patient is improving and awaiting CT Scan results.

Discuss further actions for this patient.

**Patient Summary**

This 50-year-old male was in one of the subway cars when the blast
occurred. He was thrown about 20 feet against the side of the car. He
was initially triaged as Minor but an hour later had difficulty
answering questions and was disoriented. At the ED, he was intubated and
placed on mechanical ventilation. A CT scan was ordered to evaluate for
intracranial injury. A CT scan of the abdomen revealed multiple small
nail-like objects throughout the abdominal cavity. No significant loss
of blood is noted.

*Key points for patients who have brain and other injuries caused from
an explosive event include:*

-   Triage is dynamic.

-   Securing the airway is a priority.

-   Do not aggressively hyperventilate.

-   Do not be distracted by injuries that are not life-threatening

-   Many innocuous seeming small lacerations may indicate shrapnel

This patient will have long-term brain injury and needs to be referred
to a brain injury rehabilitation facility.

**[Patient #4]{.underline}**

This patient is a 26-year-old female who was found in the far corner of
the subway station four hours after the explosion with both legs trapped
by part of a collapsed concrete wall. You note massive tissue damage and
possible fractures to her legs.

##### Prehospital Treatment

Which of the following is true regarding compartment syndrome?

a\. May occur in the absence of fracture.

b\. Cannot occur in the presence of an open fracture.

c\. Can lead to ischemia and limb loss if not treated promptly.

d\. Loss of distal pulses is an early indicator.

e\. Requires measurement of compartment measures to confirm the
diagnosis.

**Correct answers are: a, c, e**

Though less common, compartment syndrome can occur in the absence of a
fracture.

An open fracture does not guarantee decompression of the involved
compartment.

Compartment syndrome must be treated aggressively; if left untreated,
loss of life or limb can result. While the 5 P's (pain, pallor,
pulselessness, parasthesias, paralysis) are commonly cited as indicators
of compartment syndrome, loss of pulses is generally a late sign.
Compartment syndrome is suspected clinically, but can only be confirmed
by measuring pressures in the affected compartments.

Due to the length of time the patient was trapped you suspect crush
syndrome. Why should you begin aggressive treatment before extrication
of the patient?

a\. Dysrhythmias may occur immediately after freeing the limbs.

b\. Toxins will be released into the bloodstream as soon as the
extremities are freed.

c\. Edema may prevent placement of IV lines after extrication.

d\. Kidney function could be impaired after extrication.

e\. With isolated crush syndrome, core temperature will drop
significantly after extrication.

**Correct answers are: a, b, c, and d**

Muscle breakdown and cell lysis releases potassium and creatinine
kinase/myoglobin into the bloodstream, which in high concentrations may
produce toxic effects on heart rhythm and renal function. Significant
soft tissue edema is likely with crushing injuries. Early placement or
placement in a non-injured area of adequate vascular access will
facilitate fluid resuscitation. Hypothermia may occur during or after
resuscitation due to other associated trauma and the administration of
IV fluids, but not with isolated crush syndrome.

What will your initial treatment priorities include?

a\. High flow oxygen

b\. Coordinate time of extrication

c\. Apply ice directly to the injury sites

d\. IV NaCl with 1 to 2 liter bolus just prior to release

e\. Administer 2 mEq/kg of sodium bicarbonate just prior to extrication

**Correct answers are: a, b, d, e**

Supportive care with supplemental oxygen and fluid resuscitation are
standard treatments for crush and compartment syndromes. Some experts
recommend sodium bicarbonate prior to extrication, although data
supporting this intervention is limited. Ice may worsen ischemia and
damage to the injured areas and is therefore not routinely recommended.

What treatment would you consider providing during transport?

a\. Splinting

b\. Analgesia

c\. Elevation of limb 6-12 inches above the heart

d\. Cardiac monitoring

e\. Snug elastic bandage

**Correct answers are: a, b, c, d**

Cardiac monitoring is critical because of the potential for
life-threatening arrhythmias from hyperkalemia. Analgesia, splinting and
gentle limb elevation are all indicated treatments, while a tight
elastic bandage may restrict circulation and should not be applied.

**What's Next?**

This patient is being transported to County Memorial Emergency
Department. In the field, she received high flow oxygen by
non-rebreather mask, a 2 liter bolus of isotonic saline, and 2
milliequivalents per kilogram of sodium bicarbonate prior to
extrication. She presents to the E.D. in moderate to severe pain.

##### Hospital Treatment

This patient arrives in the ED in moderate to severe pain.

Immediate interventions in the E.D. for this patient with a crushed
extremity would include which of the following?

a.  Verification of patent airway, and adequate breathing and
    circulation

b.  EKG to assess for hyperkalemia

c.  Drawing chemistries to check potassium levels and for other
    metabolic abnormalities

d.  Sending a creatinine kinase or myoglobin level to assess for
    rhabdomyolysis

e.  Debriding any dead tissue on the crushed limbs

**Correct answers are: a, b, c, d**

[]{.mark}

Supportive care and monitoring for expected effects of muscle and
cellular injury and lysis are critical actions for initial
hospital-based care. Monitoring for increased levels of creatinine
kinase and myoglobin are appropriate laboratory assessments for these
patients. Aggressive debridement may inadvertently remove tissue which
may be ischemic, and should be left for subsequent surgical discretion.
It is inappropriate on initial presentation to the E.D.

What fluid management strategies would you choose for this patient?

a\. Fluids to ensure a minimum urine output of 1 to 2 ml/kg per hour

b\. D5W as the resuscitation fluid to prevent hypoglycemia

c\. Avoidance of initial fluids containing potassium because of the risk
of hyperkalemia

d\. Alkalinization of the urine as needed with fluids containing sodium
bicarbonate

e\. Fluid restriction to avoid exacerbation of edema in the crushed
extremities

**Correct answers are: a, c, d**

[]{.mark}

Aggressive isotonic fluid resuscitation is indicated in patients with
crush injury and compartment syndrome to maintain perfusion to tissues
and prevent development of shock and acidemia. Muscle breakdown will
release intracellular potassium risking complications from hyperkalemia.
Alkalinization may be effective in enhancing urinary capture and
excretion of myoglobin.

What next steps will you consider for this patient?

a\. Fasciotomy of the lower extremity compartments may be indicated to
treat the progression of compartment syndrome

b\. Amputation of both lower extremities should be performed immediately
to prevent sepsis

c\. Systolic blood pressure should be kept at approximately 80 mm Hg (no
higher) to prevent exacerbation of lower extremity hemorrhage

d\. Hypothermia should be initiated to help prevent lower extremity
ischemia

e\. The patient should be completely undressed and undergo a full
evaluation for other signs of trauma

**Correct answers are: a, e**

It is important to completely undress and assess trauma patients from
head to toe without being distracted by a single area of obvious injury.
Fasciotomy can sometimes prevent compartment syndrome, but amputation
may be necessary after further assessment and monitoring. There is no
role for controlled hypotension in the absence of uncontrolled internal
hemorrhage. Hypothermia would not mitigate lower extremity ischemia.

**What's Next?**

This patient has improved.

Discuss further actions for this patient.

**Patient Summary**

This 26-year-old female was found in the far corner of the subway
station. She was trapped by a collapsed concrete wall for more than four
hours with both legs were pinned under debris. She received basic
resuscitative measures in the field along with aggressive fluid
resuscitation prior to extrication. She was treated for pain and
monitored for hyperkalemia and acidosis.

This patient eventually underwent bilateral amputations and is currently
in rehabilitation.

*Key points when caring for a patient with crush injury and compartment
syndrome include:*

-   Suspect crush injury and compartment syndrome in an entrapped
    patient who must be extricated.

-   Know the early signs for complications of crush injury and
    compartment syndrome (such as hyperkalemia, rhabdomyolysis,
    hypotension, acidosis, sepsis)

-   IV fluid resuscitation and possibly sodium bicarbonate should be
    administered prior to extrication of an entrapped patient to prevent
    shock.

-   Patients with crush injury should be monitored for the development
    of hyperkalemia and rhabdomyolysis.

-   Monitoring of fluid status through urinary output or other reliable
    means is important.

**TEST**

**Question #1**

Which of the following are *common* hazards that could be encountered in
an explosive event? Select all that apply.

a.  Building collapse

b.  Electrical hazards

c.  Secondary devices

d.  Noise

e.  Civil unrest

**Correct answers are: A, C, D**

Even though noise and electrical hazards may be encountered, they are
not common hazards in an explosive event. Civil unrest most likely will
be uncommon. However, fear and frustration can be expected among
victims.

**Question #2**

Which of these factors may complicate effective triage during an
explosive event? Select all that apply.

a.  Explosive devices packed with sharp devices such as nails.

b.  Victims must be transported from the scene immediately.

> c\. Most casualties will suffer temporary blindness.

d.  Some severe injuries may not be detectable right away.

e.  Most patients will be able to walk but not able to talk.

**Correct answers are: A, D**

The factors that complicate triage include terrorists' use of explosive
devices that contain of shrapnel and sharp objects, severe internal
injuries that are not immediately detectable. Also, severe soft tissue
injuries may not be initially apparent. Another complicating factor may
be overtriage that reduces care for hidden or delayed injuries.

**Question #3**

The majority of patients at the scene of an open-space explosion

a.  Are dead

b.  Have sustained life-threatening critical injuries requiring
    immediate intervention

c.  Have minor injuries, including lacerations, fractures, and abrasions

d.  Will wait for EMS to process them through a field triage protocol

**Correct answer is: C**

Most patients at the scene of a bombing have relatively minor injuries,
and will self-triage and refer to the closest facility.

**Question #4**

The damage and injuries that result from a high explosive detonation
depend on which of the following? Select all that apply.

a.  Type of explosive used

b.  Amount of explosive used

c.  Location of the explosion

d.  Victim's proximity to the blast

**Correct answers are: A,B,C,D**

Several factors affect the level and types of injuries that patient
suffer. The amount and composition of the materials as well as the type
of device used to make the bomb affect the size and destructiveness of
the blast. The environment of the blast, whether the bomb is detonated
in a closed or open area, and any intervening protective barrier also
have effects on the resulting injuries. The location of the victim when
the blast occurred is also a factor in the severity of injuries.

**Question #5**

Which basic blast mechanism is most likely to affect a patient's gas
filled organs and structures?

a.  Primary blast mechanism

b.  Secondary blast mechanism

c.  Tertiary blast mechanism

d.  Quaternary blast mechanism

**Correct answer is: A**

Primary blast mechanism refers to the intense over-pressurization
impulse created by a high-order detonation. The blast wave (which can
affect gas filled organs and structures) causes damage at the
tissue-fluid/gas interface. Damage is characterized by anatomical and
physiological changes from the direct or reflective over-pressurization
force impacting the body's surface.

**Question #6**

The shock wave from a blast causes injuries through a combination of
different mechanisms including:

a.  Compression, scalding and claudication

## Spalling, shearing, implosion and irreversible work

b.  Implosion, compression, scalding and claudication

c.  Shearing, implosion and claudication

**Correct answer is: B**

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. An explosive detonated within an
enclosed space places patients inside at greater risk of injury than who
are outside. Head injuries account for approximately 50-70 % of all
deaths but most head injuries are non-lethal. Blast lung (pulmonary
barotrauma) is a major cause of morbidity and mortality that often
causes immediate death, but may present as late as 48 hours after
explosion.

**Question #7**

Which of the following defines primary blast injury?

a.  Unique to high explosive detonations

b.  Results from penetrating or blunt trauma

c.  Typically involves the ear, lungs, and abdomen

d.  Often occurs in isolation without evidence of additional injury

**Correct answers are: A, C**

By definition, primary blast injury is not the result of penetrating or
blunt trauma and it rarely occurs without evidence of secondary,
tertiary, or quaternary injury.

**Question #8**

Secondary blast injuries include:

a.  Toxic exposure

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a.  Burns

b.  Fractures

c.  Penetrating trauma

d.  Blunt trauma

**Correct answers are: D, E**

Secondary blast injuries result from flying debris and bomb fragments.
The most common types of injuries are penetrating and blunt trauma.

**Question #9**

Quaternary blast injuries include which of the following? Select all
that apply.

a.  Burns

b.  Complications of chronic disease as a result of the event

c.  Chemical exposures as a result of the explosion

d.  Blunt trauma

e.  Traumatic amputation

**Correct answers are: A, B, C**

Quaternary blast injury includes all explosion-related injuries,
illnesses, or diseases not due to primary, secondary, or tertiary
mechanisms and exacerbation or complications of existing conditions.
Blunt trauma is a secondary injury and traumatic amputation is caused by
tertiary mechanisms.

**Question #10**

Which category of blast or explosive injury is a result of trauma caused
by being thrown against a fixed object?

a.  Primary

b.  Secondary

c.  Tertiary

d.  Quaternary

**Correct answer is: C**

Primary blast injury (PBI) occurs as a direct effect of changes in
atmospheric pressure caused by a blast wave. Secondary blast injuries
occur when objects accelerated by the energy of the explosion strike a
victim, causing either blunt or penetrating ballistic trauma. Tertiary
blast injuries result from a victim\'s body being displaced by expanding
gasses and high winds; trauma then occurs from tumbling and impacting
objects. Quaternary injuries include everything else: inhalations of
dust, smoke, carbon monoxide, and other chemicals; burns from hot gasses
or secondary fires; and crushing injuries from structural collapses.

**Question #11**

Common primary blast injuries include:

a.  Blast lung, concussion and tympanic membrane rupture

b.  Penetrating chest trauma, fractures and traumatic amputations

c.  Hyperglycemia, crush syndrome and COPD

d.  Blast lung, penetrating abdominal injury and crush syndrome

**Correct answer is: A**

Primary blast injury is caused by the direct effect of blast
overpressure on tissue. Since air is easily compressed, primary blast
injury almost always affects air-filled structures such as the lung,
ear, and gastrointestinal (GI) tract

**Question #12**

Which of the following are *true* about blast lung injury (BLI)? Select
all that apply.

a.  Bradycardia may be present.

b.  Oxygen therapy, airway management, and judicious use of IV fluids
    are important.

c.  Immediate needle thoracostomy should be performed.

d.  Tetanus should be administered as a priority.

**Correct answers are: A, B**

In general, managing BLI is similar to caring for pulmonary contusion,
which requires judicious fluid use and administration ensuring tissue
perfusion without volume overload. All patients with suspected or
confirmed BLI should receive supplemental high flow oxygen sufficient to
prevent hypoxemia (delivery may include non-rebreather masks, or
endotracheal intubation). Bradycardia can be present in a patient with
blast lung injury.

**Question #13**

When treating patients with combined injuries, such as burns and blast
lung or crush and blast lung, which of the following are true? Select
all that apply.

a.  Airway management and oxygenation are critical.

b.  Avoid tunnel vision that results in focusing on one injury and not
    others.

c.  Remember fluid replacement issues when treating blast lung combined
    with other injuries.

d.  Blast lung should be treated as the priority.

**Correct answers are: A, B, C**

When treating patients with combined injuries, it is important to
consider all of the injuries and not focus on one particular injury.

**Question #14**

Which of the following are NOT TRUE regarding blast injuries?

a.  Tympanic membrane rupture can be used as a screening triage tool to
    indicate the presence of severe underlying injury and need for a
    minimum of 24-hours of observation.

b.  Patients may present with combined injuries, especially blast and
    burn or blast and crush.

c.  Treatment of blast lung is similar to treatment for pulmonary
    contusion.

d.  Blast lung, globe rupture, abdominal organ perforation, and
    traumatic brain injury are all examples of primary blast injuries.

e.  Secondary blast injuries caused by flying debris generated by the
    explosion are the most common cause of death in a blast event.

**Correct answer is: A**

Tympanic membrane rupture in and of itself does not indicate the need
for prolonged observation. Stable patients without hemoptysis or
tachypnea and in whom the primary evaluation reveals no evidence of
other clinically significant injuries may be discharged if vital signs
are stable after four to six hours of observation despite the presence
of tympanic membrane rupture.

**Question #15**

What is the appropriate intervention for a patient who presents with
tachypnea, wheezing, hemoptysis, cough, and chest pain following a blast
event?

a.  High flow oxygen and judicious intravenous fluid replacement

b.  Low flow oxygen by nasal cannula to prevent barotraumas

c.  Arterial blood gases and blood chemistry laboratory tests

d.  Fluid boluses to increase urinary output for excretion of myoglobin

**Correct answer is: A**

Use high flow oxygen with judicious fluid administration to ensure
tissue perfusion without volume overload. Patients with suspected or
confirmed blast lung should receive supplemental high flow oxygen
sufficient to prevent hypoxemia. In blast lung, wide open IV lines can
cause fluid to accumulate in the lungs secondary to structural damage
resulting in worsening pulmonary function.

# Appendix A: Curriculum on Traumatic Injuries from Terrorism Task Force (CO-TIFT) 

Task Force Members

[American Academy of Pediatrics (AAP)]{.underline}

Thomas Bojko, MD, MS

Kathleen Brown, MD, FACEP

Arthur Cooper, MD, MS, FACS, FAAP, FCCM

[American College of Emergency Physicians (ACEP)]{.underline}

Kathryn Brinsfield, MD, MPH, FACEP, Chair

Jonathan Burstein, MD, FACEP

Edward Eitzen, MD, FACEP

Edward Jasper, MD, FACEP

Kristi Koenig, MD, FACEP

Jerry Mothershead, MD, FACEP

Thomas Terndrup, MD, FACEP

Ramon Johnson, MD, FACEP (Board Liaison)

[American College of Surgeons -- Committee on Trauma
(ACS-COT)]{.underline} -

John Armstrong, MD, FACS

Jeffrey Hammond, MD, FACS

[American Medical Association (AMA)]{.underline}

James James, MD, DrPH, MHA

Jim Lyznicki, MS, MPH

Ruth Anne Steinbrecher, MPH

Raymond Swienton, MD, FACEP

Richard Schwartz, MD, FACEP

[American Nurses Association (ANA)]{.underline}

Marilyn Pattillo, PhD, RN, NP

[American Trauma Society (ATS)]{.underline}

John Sacra, MD, FACEP

[Emergency Nurses Association (ENA)]{.underline}

Kristine Powell, RN, BSN, CEN

[National Association of EMS Physicians (NAEMSP)]{.underline}

Mark Gebhart, MD, EMT-P;

Eric Ossmann, MD, FACEP

[National Association of EMT (NAEMT)]{.underline}

Bubba Bell, NREMT-P

[National Association of State EMS Officials (NASEMSO)]{.underline}

Brian Bishop

[National Native American EMS Association (NNAEMSA)]{.underline}

Larry Richmond, NREMT-P

Linda Squirrel, EMT-1, LPN

[Society of Critical Care Medicine (SCCM)]{.underline}

Daniel Talmor, MD, MPH

[The University of Texas Southwestern Medical Center at Dallas
(UTSW)]{.underline}

Paul Pepe, MD, MPH, FACEP, FCCM

**Peer Review Work Group**:

[American College of Emergency Physicians (ACEP)]{.underline}

Thomas Blackwell, MD, FACEP

Stephen Cantrill, MD, FACEP

CPT Robert Darling, MD, FACEP (USN)

Robert A. DeLorenzo, MD, FACEP (USA)

David Hogan, DO, FACEP

John G. McManus, Jr., MD, FACEP (USA)

Carl Schultz, MD, FACEP

Frank Walter, MD, FACEP

Lt. Col. John Wightman, EMT-T/P, MD, FACEP (USAF)

[American Academy of Pediatrics (AAP)]{.underline}

Susan Fuchs, MD, FACEP

Mark Joffe, MD

Patricia O'Malley, MD

[American Medical Association (AMA)]{.underline}

Jill A. Antoine, MD

[American Nurses Association (ANA)]{.underline}

Cheryl Peterson, MSN, RN

[National Association of EMT (NAEMT)]{.underline}

Les Powell, NREMT-P

[National Association of EMS Physicians (NAEMSP)]{.underline}

Robert O'Connor, MD, MPH, FACEP

[Society of Critical Care Medicine (SCCM)]{.underline}

Kyle Gunnerson, MD

# Appendix B: Curriculum Writing Group

[American College of Emergency Physicians (ACEP)]{.underline}

Kathryn H. Brinsfield, MD, MPH, FACEP

Jonathan Burstein, MD, FACEP

Lt. Col Robert A. De Lorenzo, MD, FACEP

Col (Ret) Edward Eitzen, MD, MPH, FACEP

Marshall Gardner, EMT-P

Edward H. Jasper, MD, FACEP

Diana S. Jester

Kristi Koenig MD, FACEP

Lt Col John G. McManus Jr, MD, FACEP

CMDR (Ret) Jerry Mothershead, MD, FACEP

Rick Murray, EMT-P

Thomas Terndrup, MD, FACEP

Mary Whiteside, PhD

[American College of Surgeons (ACS)]{.underline}

Arthur Cooper, MD, MS, FACS, FAAP, FCCM

Jeffrey S. Hammond, MD, FACS

[Emergency Nurses Association (ENA)]{.underline}

Kris Powell RN, BSN, CEN

[National Association of EMT's (NAEMT)]{.underline}

Vincent Parker, MS, NREMT-P

Doug York, NREMT-P, PS

[The University of Texas Southwestern Medical Center at
Dallas]{.underline}

Paul E. Pepe, MD, MPH, FACEP, FCCM

Raymond E. Swienton, MD, FACEP

[Centers for Disease Control and Prevention]{.underline}

Richard C. Hunt, MD, FACEP

Ernest E. Sullivent, III, MD

Scott M. Sasser, MD, FACEP, Director, International Programs; Associate
Director, Center for Injury Control, Department of Emergency Medicine,
Emory University School of Medicine

Ivan Mustafa, REMT-P, MSN, ARNP-C, Pilot Course Presenter

John Todaro, RN, EMT-P, Pilot Course Presenter

Scott Weingart, MD, Pilot Course Presenter