# Presentation: 554202

## Bombings: Injury Patterns and Care

## This project was funded by the Centers for Disease Control and Prevention (CDC) under Cooperative Agreement U17/CCU524163-01, “Linkages of Acute Care and EMS to State and Local Injury Prevention Programs for Terrorism Preparedness and Response.”

## 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)

- 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)

**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:**

- Bombings: Injury Patterns and Care

## 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. 

**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. **

- Bombings: Injury Patterns and Care

## American College of Emergency Physicians (ACEP) Grant Staff
Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic Injuries from 	Terrorism Task Force (CO-TIFT) 
Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle Investigator
Marshall Gardner, EMT-P, EMS and Disaster Preparedness Manager
Diana S. Jester, EMS and Disaster Response Coordinator
Cynthia Singh, MS, Grants Development Manager
Kathryn Mensah, MS, Grants Administrator
Mary Whiteside, PhD, Curriculum Development Consultant

Centers for Disease Control and Prevention (CDC) Staff
Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National Center for 	Injury Prevention and Control
Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, National Center 	for Injury Prevention and Control
Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, National 	Center for Injury Prevention and Control
Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National Center 	for Injury Prevention and Control
Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Injury 	Response, National Center for Injury Prevention and Control

12/06

**Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic Injuries from ****	****Terrorism Task Force (CO-TIFT) **
**Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle Investigator**
**Marshall Gardner, EMT-P, EMS and Disaster Preparedness Manager**
**Diana S. Jester, EMS and Disaster Response Coordinator**
**Cynthia Singh, MS, Grants Development Manager**
**Kathryn Mensah, MS, Grants Administrator**
**Mary Whiteside, PhD, Curriculum Development Consultant**
_**Centers for Disease Control and Prevention (CDC) Staff**_
**Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National Center for ****	****Injury Prevention and Control**
**Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, National Center ****	****for Injury Prevention and Control**
**Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, National ****	****Center for Injury Prevention and Control**
**Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National Center ****	****for Injury Prevention and Control**
**Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Injury ****	****Response, National Center for Injury Prevention and Control**
**12/06**

- Bombings: Injury Patterns and Care

## Discussion Topics

- Background
- Explosive Events
- Blast Injuries
- Primary, Secondary, Tertiary, Quaternary
- Crush Injuries and Compartment Syndrome
- Military Experience
- Special Considerations
- Psychological Issues

- Bombings: Injury Patterns and Care

## Background

- Bombings: Injury Patterns and Care

## Background

- Terrorism can be defined as containing four key elements:
- Premeditated
- Political
- Aimed at civilians
- Carried out by sub-national groups

- Bombings: Injury Patterns and Care

## Background

- Explosive use increasing in terrorist events
- Result in mass casualty incidents
- Recent examples
- Mumbai (2006)
- Tel Aviv (2006)
- London subway (2005)
- Madrid subway (2004)
- Tel Aviv (2001)

- Bombings: Injury Patterns and Care

## Background: Historical Perspective

- 1968-1999
- 7000 international terrorist bombings
- 1969-1980
- 187 bombings in Northern Ireland
- 1980-2001
- 324 criminal bombing events in the US
- 2001-2003
- 500 International terrorist bombings
- 2005
- 399 International terrorist bombings

- Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre

- Bombings: Injury Patterns and Care

## Background: Blast Devices

**Background: Blast Devices**

**Photo used with permission of MAJ Benjamin Gonzalez, MD**

- Bombings: Injury Patterns and Care

## Background: Blast Devices

- Improvised explosive devices (IEDs)
- Car and truck bombs (Oklahoma City, World Trade Center I)
- Letter and parcel bombs (Idaho “Unabomber”)
- Pipe bombs (Atlanta Olympics)
- Backpack and satchel bombs (Israel, London)
- Incendiary bombs
- Airplane bombs (World Trade Center II, Pentagon)
- Rocket propelled grenades (RPGs)
- Surface to air missiles (SAMs)
- Enhanced blast devices

- Bombings: Injury Patterns and Care

## Background: Blast Devices

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

- Bombings: Injury Patterns and Care

## Background: Blast Agents

- High-order explosive: HE
- Nitroglycerin (NTG)
- Dynamite
- Plastic
- Ammonium nitrate/                fuel oil (ANFO)
- Trinitrotoluene (TNT)
- Triacetone triperoxide        (TAPT)

- Low-order explosive: LE
- Petroleum products
- 	(“Molotov cocktail”)
- Gunpowder
- (“black” powder)
- Can become HE, if contained (e.g., pipe bomb)

- Bombings: Injury Patterns and Care

## Explosive Events

- Bombings: Injury Patterns and Care

## Explosive Events

- Incident command
- Entire area = crime scene → evidence preservation
- Multi-jurisdictional response
- Scene safety
- Dirty bombs, secondary devices, building collapse, high dust environment (possibly contaminated), bomb fragments

- Bombings: Injury Patterns and Care

## Explosive Events: Criminal Investigation

- Principles of criminal investigation and evidence preservation
- Indicators for crime scene
- Evidence and chain of custody
- Avoid disturbing or compromising evidence
- Detection of possible suspects/perpetrators
- Quick identification and note taking
- Documentation of statements by victims and witnesses

- Bombings: Injury Patterns and Care

## Scene Safety

## Scene Safety: Common Hazards

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

- Bombings: Injury Patterns and Care

## Scene Safety: Common Hazards

- Victims with no soft tissue injuries
- Vehicles coming or leaving scene (out of place)
- People acting oddly
- Packages or containers at scene (out of place)
- Vehicles not damaged or out of place
- Structural damage
- Weather
- Possible places for secondary devices

- Bombings: Injury Patterns and Care

## Scene Safety:Appropriate PPE for blasts

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

- Bombings: Injury Patterns and Care

## Scene Safety: Common Principles

- Contain the incident
- Deny entry to all but responders
- Set up zones
- Hot
- Warm
- Cold
- Contain the people
- Do not let anyone leave                                         scene until checked
- Decontaminate if necessary

**Photo used with permission of Connie Doyle, MD, FACEP**

- Bombings: Injury Patterns and Care

## Scene Safety: Common Principles

- Cause no further injury or destruction
- Protect yourself
- Activate command and                     hazard response (ICS)
- Limit access
- Contain the incident

**Photo used with permission of Kathryn Brinsfield, MD, FACEP****	**

- Bombings: Injury Patterns and Care

## Scene Safety: Common Principles

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

- Bombings: Injury Patterns and Care

## Triage

- Bombings: Injury Patterns and Care

## Triage

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

- Bombings: Injury Patterns and Care

## Triage

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

- Bombings: Injury Patterns and Care

## Triage

- Factors that determine when needs exceed resources
- Large number of patients make rapid triage impossible
- Large number of patients cause delay in transport to hospitals
- Large number of patients exceed responder treatment capabilities
- Surge at local hospitals

- Bombings: Injury Patterns and Care

## Blast Injuries

- Bombings: Injury Patterns and Care

## Blast Injuries: Unique Aspects

- Inflict multi-system injuries on large groups of people
- Cause many simultaneous life-threatening injuries
- Hidden pattern of injury

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Physics 

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Physics

**Emergency War Surgery, 3rd Edition**

- Importance of Injury Types vs. Distance

**Diagram used with permission of John-Phillipe Dionne. PhD**

- Bombings: Injury Patterns and Care

## Background: Physics of Blasts

- Click to view animation.

- Bombings: Injury Patterns and Care

## Blast Injury: Severity

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

- Bombings: Injury Patterns and Care

## Murrah Building

**Photo Courtesy of the City Of Oklahoma City**

- Bombings: Injury Patterns and Care

## Murrah Federal Building, Oklahoma City (1993) – distribution of injuries

**Murrah Federal Building, Oklahoma City (1993) – distribution of injuries**

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

- Bombings: Injury Patterns and Care

## Russell Square, London bombing, 2005

**Russell Square, London bombing, 2005**

**Diagram used with permission of  Directorate of Public Affairs, Metropolitan Police Service, London**

- Bombings: Injury Patterns and Care

## Mumbai, India:  July 2006	

**Reuters/Prashanth Vishwanathan**

- Bombings: Injury Patterns and Care

## Blast Injuries: Pathophysiology

- Proposed mechanisms*
- Spalling
- Caused by shock wave moving through tissues of different densities → molecular disruption
- Implosion
- Caused by entrapped gases in hollow organs compressing then expanding → visceral disruption

- Bombings: Injury Patterns and Care

## Blast Injuries: Pathophysiology

- Shearing
- Caused by tissues of different densities moving at different speeds → visceral tearing
- Irreversible Work
- Caused by forces exceeding the tensile strength of the tissue
- *Spalling, implosion and shearing are thought to be three
- mechanisms that cause blast injuries. Irreversible work is
- currently being researched as a more likely mechanism of injury.

- Bombings: Injury Patterns and Care

## Blast Injuries: Categories

- Primary injury
- Caused by blast wave → over pressure
- Secondary injury
- Caused by flying debris → shrapnel wounds
- Tertiary injury
- Caused by blast wind → forceful impact
- Quaternary injury
- Caused by other vectors → heat, radiation

- Bombings: Injury Patterns and Care

## Blast Injuries: Primary

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

- Bombings: Injury Patterns and Care

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

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Primary

- Most common injuries:** **
- Blast lung—pulmonary barotraumas
- Traumatic brain injury (TBI), concussion
- Tympanic membrane (eardrum) rupture
- Middle ear damage
- Abdominal hemorrhage
- Abdominal organ perforation

- Bombings: Injury Patterns and Care

## Blast Injuries: Secondary

- The most common cause of death in a blast event is secondary blast injuries. These injuries are caused by flying debris generated by the explosion. Terrorists often add screws, nails, and other sharp objects to bombs to increase injuries.

- Bombings: Injury Patterns and Care

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

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Secondary

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Secondary

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

- Bombings: Injury Patterns and Care

## Secondary Injury

**Secondary Injury**

**Used with permission of American Journal of Roentgenology 2006; 187:609-616**

- Bombings: Injury Patterns and Care

## Blast Injuries: Tertiary

- Tertiary injuries result from individuals being thrown by the blast wind.
- The most common types of tertiary blast injuries are:
- Head injuries
- Skull fractures
- Bone fractures
- Treatment for most tertiary blast injuries follows established protocols for that specific injury.

- Bombings: Injury Patterns and Care

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

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Quaternary

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Quaternary

- The most common quaternary blast injuries include:
- Burns
- Head injuries
- Asthma
- COPD
- Other breathing problems
- Angina
- Hyperglycemia
- Hypertension
- Crush injuries

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Lung

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Lung

**Blast Injuries: Blast Lung**

**Reprinted from American Journal of Surgery, V190: 945-950,**
** ****Avidan V et al: Blast Lung Surgery...with permission from © Excerpta Medica Inc.**

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Lung

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Blast Lung 

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Head

- Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head

- Bombings: Injury Patterns and Care

## Blast Injuries: Head

- Consider the proximity of the victim to the blast particularly when given complaints of:
- Loss of consciousness
- Headache
- Fatigue
- Poor concentration, lethargy, amnesia, or other constitutional symptoms
- Symptoms of concussion and post traumatic stress disorder (PTSD) can be similar

- Bombings: Injury Patterns and Care

## Blast Injuries: TM Rupture

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

- Bombings: Injury Patterns and Care

## Blast Injuries: TM Rupture

**Blast Injuries: TM Rupture**

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Ear

- Ear injuries may include not only TM rupture, but also ossicular disruption, cochlear damage, and foreign bodies.

- Bombings: Injury Patterns and Care

## Blast Injuries: Ear

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

- Bombings: Injury Patterns and Care

## Blast Injuries: Abdomen

- Abdominal injuries (also called blast abdomen) include abdominal hemorrhage and abdominal organ perforation

- Bombings: Injury Patterns and Care

## Blast Injuries: Abdomen

- Clinical manifestations include:
- Abdominal or testicular pain
- Tenesmus
- Rectal bleeding
- Solid organ lacerations
- Rebound tenderness
- Guarding
- Absent bowel sounds
- Signs of hypovolemia
- Nausea
- Vomiting

- Bombings: Injury Patterns and Care

## Blast Injuries:  Combined Injuries

- Combined injuries, especially blast and burn injury or blast and crush injury, are common during an explosive event.

- Bombings: Injury Patterns and Care

## Blast Injuries: Combined Injuries

- Avoid tunnel vision during initial assessment
- Treatment protocols are often contradictory
- Blast lung vs. burn injury, blast lung vs. crush injury
- Judicious fluid administration for adequate tissue perfusion without volume overload may be required in the multiple injured patient with blast lung
- Presence of additional injuries complicates administration, rate, selection of fluids

- Bombings: Injury Patterns and Care

## Blast Injury: Combined Injuries

- Typical confined space (e.g., a bus) injuries
- Primary—blast lung, intestinal rupture, TM rupture
- Secondary—penetrating injury to head, eye, chest, abdomen
- Tertiary—traumatic amputation, fractures to the face, pelvis, ribs, spine
- Quaternary— crush injuries, superficial and partial to full thickness burns

- Bombings: Injury Patterns and Care

## Crush Injury

## Crush Injury: Definition

- An injury sustained when a body part is subjected to a high degree, or prolonged presence, of force or pressure
- Usually applied to both regional (e.g. body part) effects and systemic effects.
- Acute traumatic ischemia, with or without associated injuries, describes actual insult to tissues

- Bombings: Injury Patterns and Care

## Crush Injury: Crush Syndrome

- Term used to describe the systems manifestations of crush injury after reperfusion of affected body part(s)

**Reprinted with permission of OrthoWorld.com**

- Bombings: Injury Patterns and Care

## Crush Injury:Compartment Syndrome

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

- Bombings: Injury Patterns and Care

## Crush Injury: Incidence

- 5-15% of mass casualty situations
- Natural disasters, especially earthquakes and tornadoes
- Structural collapse, with or without victim entrapment
- Industrial, farm or transportation accidents
- Blast injury (all types)
- Combat
- Prolonged immobilization with major vascular or microvascular circulation compromise

- Bombings: Injury Patterns and Care

## Crush Injury: Examples of events

- Tyre, Lebanon  (1982)
- Building collapse
- Beirut, Lebanon (1983)
- Marine barracks bombed
- Oklahoma City (1995)
- Murrah Federal Building bombed
- Khobar, Saudi Arabia (1996)
- Khobar Towers bombed

**Used with permission of AP Photo/KM Chaudhry**

- Bombings: Injury Patterns and Care

## Crush Injury: Pathophysiology

- Areas most affected
- Lower extremities
- Upper extremities
- Pelvis
- Gluteal region
- Abdominal muscles

**Reprinted with permission of OrthoWorld.com**

- Bombings: Injury Patterns and Care

## Crush Syndrome

## Crush Syndrome

- May occur in absence of trauma and evolve in the absence of early signs or symptoms
- Arterial thrombosis or embolism
- Severe anemia
- Toxins
- Legitimate medications and drugs of abuse
- Systemic effects due to rhabdomyolysis and reperfusion of hypoxic and damaged tissues and is the major cause of early mortality

- Bombings: Injury Patterns and Care

## Crush Syndrome: Pathophysiology

- Rhabdomyolysis
- Efflux from damaged muscle cells of:
- Potassium
- Purines
- Lactic Acid
- Phosphate
- Myoglobin
- Thromboplastin
- Creatine

- Bombings: Injury Patterns and Care

## Crush Syndrome : Pathophysiology

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

- Bombings: Injury Patterns and Care

## Crush Syndrome: Pathophysiology

**Resultant effects of derangements due to rhabdomyolysis *****and***** reperfusion**
- Potassium		Hyperkalemia		Arrhythmias
- Calcium		Hypocalcemia		Arrhythmias
- Phosphate		Hyperphosphatemia		Renal damage
- Myoglobin		Myoglobinemia		Renal damage
- Fluid shifts		Hypovolemia		Renal failure
- Reperfusion		Free radicals		Renal damage
- Purines		Hyperuricemia		Renal damage
- Hypoxemia		Lactic acid		Acidosis
- Thromboplastin		Complement system		DIC
- Creatinine		Elevated serum levels
- Sodium		Azotemia

- Bombings: Injury Patterns and Care

## Crush Syndrome: Clinical Presentation

- General condition of a patient with crush injury dictated by other injuries, delay in extrication, environmental conditions
- Common presentations
- Hypothermia or hyperthermia
- Dehydration/shock
- Mental status varies from alert to comatose

- Bombings: Injury Patterns and Care

## Crush Syndrome: Clinical Presentation

- Affected part (usually limb)
- Tense edema and decreased sensation
- Overlying skin may be shiny, contused, necrotic
- May have penetrating wounds (worse diagnosis)

- Bombings: Injury Patterns and Care

## Crush Syndrome: Potential Complications

- Hyperkalemia
- Hypocalcemia
- Hyperphosphatemia
- Metabolic acidosis
- Hypothermia
- Acute Renal failure

- Bombings: Injury Patterns and Care

## Crush Syndrome: Treatment

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

- Bombings: Injury Patterns and Care

## Crush Syndrome: Treatment

- Delay in treatment associated with greater morbidity and mortality
- 50% renal failure at 6 hours
- 100% renal failure at 12 hours
- Rhabdomyolysis induced renal failure has 40% mortality

- Bombings: Injury Patterns and Care

## Crush Syndrome: Treatment

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

- Bombings: Injury Patterns and Care

## Crush Syndrome: Treatment

- Hospital
- Fluid resuscitation
- Brisk diuresis
- Diagnose and treat other metabolic derangements
- Hyperkalemia
- Hypocalcemia
- Treat tissue damage
- Pain control
- Agitation

- Bombings: Injury Patterns and Care

## Compartment Syndrome

## Compartment Syndrome

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

- Bombings: Injury Patterns and Care

## Compartment Syndrome

- Can lead to crush syndrome systemic effects if left untreated or inadequately treated.

**Photo used with permission of The Institute for Foot **
**and Ankle Reconstruction at Mercy, Baltimore, MD**

- Bombings: Injury Patterns and Care

## Compartment Syndrome

- Suggestive clinical findings
- Similar settings to crush injury, but may also occur with subacute trauma
- Bone fractures
- High velocity penetrating injury to muscles in closed compartment with extensive tissue disruption
- Can also occur in subacute fashion due to prolonged immobilization on hard surface

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Pathophysiology

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

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Clinical Presentation

- The 5 P’s
- Pain
- Pallor
- Paresthesia
- Paralysis
- Pressure
- Progression of symptoms
-  (sometimes the 6th P)

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Treatment

- Prehospital
- Primary survey and initial stabilization (ABC’s)
- Suspect compartment syndrome
- Immobilize affected part
- Treat other injuries

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Treatment

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

- Bombings: Injury Patterns and Care

## Compartment Syndrome:Extremity Injuries

- Management of extremity injuries
- Indication for field amputation
- Appropriate use of tourniquet application
- Appropriate use of hemostatic dressings
- Appropriate anesthesia/analgesic

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Procedural Skills

- Measuring compartment pressures
- Use of Ketamine
- Fasciotomies

**Photo used with permission of Immediate Action Services**

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Procedural Skills

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

- Bombings: Injury Patterns and Care

## Compartment Syndrome: Procedural Skills

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

- Bombings: Injury Patterns and Care

## Entrapped Patient Treatment

- Treatment
- Fluid resuscitation before victim extricated
- 1 L NS bolus, followed by 1-1.5 L per hour infusion
- Limb stabilization
- Minimize potential systemic effects of reperfusion
- Consider use of tourniquets prior to release
- Consider alkalinization by giving 1 ampule of sodium bicarbonate (50 mEq) immediately prior to extrication, followed by adding 1 ampule of sodium bicarbonate to each liter of NS infused at 1-1.5 L per hour as above; keep second IV line open without sodium bicarbonate

- Bombings: Injury Patterns and Care

## Field Amputation

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

- Bombings: Injury Patterns and Care

## Field Amputation

- Best performed by trauma or orthopedic surgeon
- Few EMS systems have protocols
- Ensure adequate analgesia and anesthesia
- Ketamine (dissociative anesthetic)
- Decreases or only minimally increases serum potassium levels
- Patient maintains airway despite adequate anesthesia

- Bombings: Injury Patterns and Care

## Photo used with permission of Immediate Action Services

**Photo used with permission of Immediate Action Services**

- Bombings: Injury Patterns and Care

## Military Experience

## Military Experience

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

- Bombings: Injury Patterns and Care

## Military Experience 

- Death Rates After Wounding
- Revolutionary War			  	  42%
- WWII						  30
- Korean	War					~25
- Vietnam War					~25
- Persian Gulf War				~25
- Global War on Terror (GWOT)		<10

- Bombings: Injury Patterns and Care

## Military Experience 

- Medical Advances from the GWOT
- Expanded use of Damage Control Surgery
- Whole blood
- Tourniquets
- Hemostatic agents
- Hemostatic dressings

- Bombings: Injury Patterns and Care

## Military Experience 

**Photo used courtesy of Bio Cybernetics International**

- Bombings: Injury Patterns and Care

## Military Experience 

- Damage Control Surgery
- Technique known for 20 years, but slow to be accepted
- Central tenet: Avoid the “Deadly Triad”
- Hypothermia
- Coagulopathy
- Metabolic acidosis
- Each condition worsens both of the others

- Bombings: Injury Patterns and Care

## Military Experience

- Damage Control Surgery
- Stop the bleeding
- Remove major contaminants
- Wounds left open to avoid abdominal compartment syndrome
- “Pack ‘em and wrap ‘em”
- Transfer to ICU

- Bombings: Injury Patterns and Care

## Military Experience

- Damage Control Surgery
- Resuscitate in ICU:
- Normalize blood pressure
- Normalize body temperature
- Normalize coagulation factors
- Return to OR 12-18 hours for definitive surgery

- Bombings: Injury Patterns and Care

## Military Experience

- IV Hemostasis
- INR>1.5 on arrival predictive of need for massive transfusion (MT)
- Fresh thawed plasma best resuscitation fluid in MT
- Optimum ratio of plasma to crystalloid 1:1 to avoid clotting factor dilution >50%
- Less crystalloid (acidotic, inflammatory, adverse effects on coagulation)
- Hextend (a colloid) preferable

- Bombings: Injury Patterns and Care

## Military Experience

- IV Hemostasis
- Use of fresh whole blood
- Early use of cryoprecipitate
- Recombinant Factor VIIa (rFVlla)

- Bombings: Injury Patterns and Care

## Military Experience

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

- Bombings: Injury Patterns and Care

## Military Experience

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

- Bombings: Injury Patterns and Care

## Military Experience

- HemCon (chitosan)
- Originally available as a bandage
- Now available in roll that can be stuffed into wound
- QuikClot
- Very exothermic (up to 147 deg F)
- Difficult to debride
- New Advanced Clotting Sponge (ACS)
- Gauze sack – easily removed from wound

- Bombings: Injury Patterns and Care

## Special Considerations

## Special Considerations

- Pregnancy
- Children
- Elderly
- Disabled
- Language barriers

- Bombings: Injury Patterns and Care

## Special Considerations: Pregnancy

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

- Bombings: Injury Patterns and Care

## Special Considerations: Children

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

- Bombings: Injury Patterns and Care

## Special Considerations: Elderly

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

- Bombings: Injury Patterns and Care

## Special Considerations: Disabled

- Consideration should be given to patients with underlying medical conditions
- Untreated or inadequately treated fractures may lead to severe and long lasting disabilities

- Bombings: Injury Patterns and Care

## Special Considerations:Language Barriers

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

- Bombings: Injury Patterns and Care

## Photo used courtesy of Kwikpoint

**Photo used courtesy of Kwikpoint**

- Bombings: Injury Patterns and Care

## Used courtesy of the American Red Cross

**Used courtesy of the American Red Cross**

## Psychological Issues

## Psychological Issues

- Sequelae from an explosive event
- Anger
- Frustration
- Helplessness
- Desire to seek revenge

- Bombings: Injury Patterns and Care

## Psychological Issues

- Events that affect mental health
- Little or no warning
- Unknown duration of the event
- Potential threat to personal safety
- Unknown health risks

- Bombings: Injury Patterns and Care

## Psychological Issues

- Tips for Responders
- Promotion of safety
- Promote calm
- Promote connectedness
- Promote self-efficacy
- Promote hope

- Bombings: Injury Patterns and Care

## Discussion Topics: Review

- Background
- Explosive Events
- Blast Injuries
- Primary, Secondary, Tertiary, Quaternary
- Crush Injuries and Compartment Syndrome
- Military Experience
- Special Considerations
- Psychological Issues

- Bombings: Injury Patterns and Care

## Discussion Topics

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

- Bombings: Injury Patterns and Care