Department of Emergency Medicine

Division of Clinical Research and Leadership

Immediate Bystander Aid in Response to Blast and Ballistic Trauma Events

Dr S.J. Hatfill MD Adjunct Assistant Professor Department of Emergency Medicine George Washington University Medical Center

Medical Environment of the Military Battlefield

Rapidly developing scenarios. Confusion Severe trauma casualties. Multiple area mass casualties. Limited medical personnel. Limited on-site medical supplies. Disorganized or overtaxed medical support infrastructure.

Some Natural and Social Disasters have a Medical Environment Similar to the Battlefield

Breslan School North Hollywood Shootout

Virginia Tech Interstate Multiple Car Crash

Oklahoma City

London Bombings

Bystanders May Be the First Responders After a Mass Casualty Event Involving Blast and Ballistic Trauma

However, some type of training is necessary

This Course
The material you will be taught today is derived from the U.S. Special Operations Command Doctrine of Tactical Combat Casualty Care. TCCC is taught to all SEALS, Army RANGERS and Special Forces, as well as all Army Medics and Navy and Corpsmen. It is designed to control the preventable causes of death resulting from blast and ballistic injury until higher level care can be provided.

Course Content
You will be introduced to the major causes of death in blast and ballistic trauma and learn how to: - control catastrophic hemorrhage - manage an airway - manage an open chest wound - i.d. casualties requiring immediate advanced care

Course Content

You will be able to accomplish these tasks using only minimal improvised equipment.

You will also learn how to create a prepackaged Emergency Trauma Medical Kit using commercially available medical materials.

Mechanism of Blast and Ballistic Injury

Explosive Blast
Rapid conversion of an explosive solid or liquid into highly pressurized gases which expand / compress the surrounding air. Thermal pulse, pressure wave, blast wind, and shrapnel are generated and spread in all directions.

Blast Injuries
Related to the distance from the epicenter of the blast (reversed in water)
1.0
Inury Type Distance from epicenter

Thermal

Pressure Shock Wave

Ballistic

Blast Injury

THERMAL PULSE

Burn damage, 1o to full thickness skin and soft tissue.

BALLISTIC Shrapnel Fragments and Debris - 5,900 ft/sec to 1,900 ft/sec. OVERPRESSURE Partial or complete traumatic amputation. Debris, bone fragments, and other tissues are driven up between proximal tissue planes with muscles stripped from the bone.

Primary Effects of Blast Injury

Combined thermal, overpressure blast, and ballistic injury.
Blasts may cause multiple lifethreatening injuries. Hidden patterns of injury may be present.

Tympanic Membrane ( Eardrum) Rupture Primary Blast Injuries: TM Rupture

Tympanic membrane rupture indicates an exposure to an overpressurization wave.

It may be found as an isolated injury or in association with other severe blast injuries.
However, its presence does not indicate that more sinister blast injuries exist.

Blast Injury to Lung

Over-pressure injury spreads down the trachea and bronchi causing alveolar rupture with hemorrhage into the alveoli. Bleeding can be significant (1000ml) in severe cases.
LEAF effect - blast wave disrupts alveolar tissue but leaves overall bronchiole structure.

Blast Injury to Lung

Systemic Air Embolism
Most common cause of blast - related sudden death in the 1st hour Direct leak of air from alveoli and bronchial tree into the pulmonary vasculature

Blast Injury to Lung

Possible Systemic Air Embolism Signs

Chest pain Signs of a Stroke Unilateral Blindness Tongue blanching Cutus Marmorata

Overpressure Blast Injury to Gut

Abdomen / GIT Bowel wall contusions Blood may appear in stool. Can cause perforation from 24 - hours up to 1-2 weeks later.

Blunt Force Traumatic Brain Injury Coup-Countercoup Mechanism

Sudden force applied to side of head

Overpressure Blast Injury to Brain

Traumatic Brain Injury (TBI )

Damage to select surface areas of the brain caused by blast pressure wave Nerve fibers stretched and broken. Unconsciousness. Length of Coma indicates severity of damage

Severe TBI Is Associated With Prolonged Coma

Damage to select areas of the brain. Damage to the wiring that connects these different surface areas.

Traumatic Brain Injury (TBI)

Consider the proximity of the casualty to the blast - particularly when given complaints of:
Loss of consciousness. Headache. Fatigue. Later persisting poor concentration, lethargy, amnesia, or other constitutional symptoms.

The symptoms of concussion and mild TBI can be similar.

Secondary Blast Injuries

Injury from flying debris

Responsible for the majority of casualties Small skin wound but devastating underlying trauma Essential to perform a careful primary survey of any blast casualty.

Secondary Blast Injury The Eye :

Up to 10% blast injuries will have significant eye injury with initially only minimal discomfort Pain Photophobia Burning/irritation Foreign body sensation Altered vision Periorbital swelling

Mechanisms of Ballistic Injury

Permanent Cavity

Temporary Cavity

Deceleration Yaw
SOFT TISSUE Sonic Shock Wave

Permanent Cavity - localized tissue death along bullet tract Temporary Cavity - elastic tissue displacement and rebound Exit wounds are not always greater than entrance wounds

Tissue Ballistics

36% Fragmentation

Tissue Destruction

Ballistic Injury To Solid Organs

Effect of temporary cavitation in a solid organ as a result of a penetrating high-velocity projectile (7.62.x39 mm).

Ballistic Injury to Air-Filled Organs

Crushed Tissue and Contusion

Contusion (severe bruising) can be seen in both blast and ballistic injury.

A minor degree may occur with trauma or high velocity nonpenetrating plate strikes.
Micro-hemorrhage into the lung alveoli in addition to the penetrating injury.

The Revolution in Battlefield Medicine

Beginning Of The Revolution In Modern Combat Medicine

Operation Just Cause, Panama
01h00 December 20, 1989

Navy SEAL Task Force PAPA tasked to destroy Noriegas personal jet aircraft located at Punta Paitilla Airfield.
3 SEAL Assault platoons encircled the Learjet hanger the night of the invasion.

Sudden Contact
Combat involved 48 SEALS and a small number of gunmen inside the hanger. 3 initial casualties turned into 14. 6 SEALS Killed, 8 Wounded. The incident prompted a full review of Navy Special Operations Medicine and Tactics.

Major Military Research Undertaken Into Combat Death

Special Operations and Army medical community conduct a complete review of numerous previous conflicts and battlefield deaths. Thousands of cases of combat death were examined in detail.

Hallmark Historical Study Of Blast and Ballistic Death In Ground Combat

Bellamy, RF. Causes of Death in Conventional Land Warfare

KIA: 31% Head Trauma With Brain Injury

Expectant Head Casualties (Unconscious With Visible Brain Tissue)

KIA: 25% Surgically Uncorrectable Torso Trauma

Direct Gunshot Wound to Heart

10% KIA Delayed Management of Potentially Correctable Torso Trauma

Causes of death in potentially correctable torso trauma:

- Failure to control preventable causes of death at the site of injury - Improperly managed: - Hypothermia - Shock - Delayed TACEVAC.

Delayed Care and Shock

Normal

2500ml Loss Unconscious

Death Probable

The Golden Hour In Severe Shock

Shock becomes irreversible.
Progressive organ failure leads to eventual death.

100

Percent Survival

50

30

60

90

Minutes

Shock Kidney Shock Lung Shock Liver

DOW: 12% Wound Infections and Irreversible Shock

Lactic Acid Buildup in the Blood

Prolonged Shock

Hypothermia

Bleeding Abnormalities

Multiple Organ Dysfunction and Failure Days Later

KIA: 5% Tension Pneumothorax

KIA: 1% Airway Obstruction and Suffocation

Simple Unconscious Airway Obstruction Complicated Airway Trauma

7 % KIA Multisystem Mutilating Blast Trauma

KIA: 9% Bleeding to Death from Extremity Wounds

Irrespective of the Conflict Studied Ground Combat Shows a Trimodal Distribution of Death
First peak of deaths occurs with minutes from tears of aorta, heart, brain, major extremity hemorrhage.
Im m e d ia te : CNS injury or he a rt a nd g re a t ve sse l injury
Pe rc e nt o f tra um a d e a ths

50 40 30 20 10 0 0 1 2 3 4 1-2 We e ks 5-6 Ea rly: Ma jor He m orrha g e

L a te : Infe c tion a nd
Multiorg a n fa ilure

Second peak occurs from 1-4 hours from pneumothorax, shock, or internal bleeding.

Hours a fte r injury

Third peak days or weeks later from sepsis, and multiple organ failure from prolonged shock.

Where can the greatest medical impact be made to improve survival from blast and ballistic trauma ?

Preventable Death In Blast and Ballistic Injury

Bleed-out from extremity wounds 60% Airway issues 1%

Tension pneumothorax 33%

15% of Blast and Ballistic Deaths are Preventable

Airway obstruction 6%

Before We Learn to Manage the Preventable Causes of Death---It is Necessary to Understand Some Basic Trauma Anatomy

Musculoskeletal System
Muscle tissue will always be involved in blast and ballistic injury.

These wounds may appear to be horrible when in fact, they are a minor surgical nature and not immediately life threatening.

Soft Tissue Injury

Avulsion
Deep Laceration Jagged Edge Laceration

Soft Tissue Surgical Management

Irrigation and Cleaning

Surgical Debridement

Wound Packing

The Severity of Soft Tissue Injury Is Based On Hemorrhage NOT the Appearance Of The Wound

Head and Airway Anatomy

Neck Anatomy
Penetrating shrapnel injury with laceration of the right common carotid artery

The Thoracic Cavity

Respiratory System

Cardiovascular System

Superior Vena Cava

Aorta

Inferior Vena Cava

Midline Vascular Structures

Tissue Circulation
Total Blood Volume- 5 L Muscle Layers

Valve

Arterioles Veinules

Gas and Fluid exchange with tissues

Human Pelvis Anatomy

Major Pelvic Fracture Break in the Pelvic Ring in more than 1 place

Unstable Pelvic Fractures Can Lead to Fatal Internal Hemorrhage

Massive Retroperitoneal Hemorrhage

Anatomy of the Abdomen

Anatomical Distribution of Penetrating Wounds ( % ) in Blast and Ballistic Injury

Basic Arm Anatomy

Note: The major artery in the upper arm is located in the axilla.

Basic Leg Anatomy

The major artery in the thigh is just below the skin.

Take a 5-Minute Break

Bystander Management of the Preventable Causes of Death From Blast and Ballistic Trauma

The S. C. A. B Survey

The SCAB Acronym

Situation Catastrophic Bleeding / Communicate

Get off the X

Airway Breathing

Situation Assess the Situation You Are In

Fallujah, Iraq
Soldier wounded in Femoral artery. 2d soldier and a medic rush from cover to assist casualty. 2d soldier is shot.

Assess the Situation

Boston Bombing

Catastrophic Hemorrhage Must be Controlled First

Bleeding from extremity wounds is the number one cause of preventable death in blast and ballistic trauma.

90 seconds to 3 minutes to die from a Femoral Artery and Vein disruption

Immediate Pressure Point Technique

Apply manual direct pressure to bleeding site or at a pressure point.
This is a stop-gap measure while getting a tourniquet applied. Apply Direct Pressure to yourself if you are injured

Immediate Pressure Point Technique

The Tourniquet
Tourniquet for catastrophic extremity hemorrhage.

Manufactured tourniquets are designed for a single use.

Apply over clothing as high as possible

Emergency Use of Tourniquet

Direct the casualty to control hemorrhage by direct pressure if able. Use a tourniquet as a definitive treatment for limb hemorrhage. - Apply tourniquet high on limb, over clothing. - Tighten, and reassess the situation. - Periodically reassess for tourniquet effectiveness Tourniquet application causes significant pain, and is not an indication of incorrect application, or that the tourniquet should be discontinued.

Tissue Damage After Tourniquet Application

111 minutes Possible Limb Loss
Widespread Muscle and Nerve Damage Severe Effects Upon Tourniquet Removal (Cardiac, Renal)

Increasing Pain

Nerve and Muscle Compression Injury

4
Hours

Damage to the arm or leg is rare if the tourniquet is left on less than a110 minutes. Pneumatic tourniquets are often left in place for 2 hours during elective surgical procedures.

Prolonged 5-6 Hour Tourniquet Use

Muscle cell death releases myoglobin and potassium into the circulation when tourniquet is removed. Causes sudden heartbeat irregularities and Kidney damage. Further increased tissue damage when the extremity is re-perfused with blood.

Even if Not Bleeding All Amputations or Partial Amputations Need a Tourniquet

Active hemorrhage can occur at any time

Do not apply over a Joint

The Field Expedient Tourniquet

Cravat & Windlass Other Materials: - 3 x 3 clothing - 4 pencils or pens - Debris from explosion - Purse strap Waist belts do not work

Improvised Tourniquet Use

Maintain DIRECT PRESSURE while applying the tourniquet. If limb is fully exposed ; apply 2-3 inches above injury and tightened effectively Constantly reassess to ensure effectiveness

Blast Debris Used as an Improvised Tourniquet

Boston Bombing

The Medical Emergency Tourniquet

Lightweight Does not need to be fully cinched tight before operating windlass Aluminum Non-breakable windlass Simple operation Can be applied and secured in seconds

Answer This

Does This Wound Need a Tourniquet ?

Where Is the Correct Placement For a Tourniquet In This Casualty ?

Example of Ineffective Tourniquet Application

Casualty wounded by RPG and sustained a leg wound with major femoral bleeding Bled to death despite the placement of 3 field-expedient tourniquets The soldier lacked an adequate tourniquet and was unable to improvise an effective one.

Cargo-Strap Tourniquet Ranger Ratchet

CAT (Combat Application Tourniquet)

Simple operation
Must be fully cinched tight before operating windlass. The friction adaptor buckle should be inserted. Occasional length problem with some thick thighs

Tourniquets
Get tourniquets on BEFORE onset of shock.
Mortality is very high if casualties are already in shock before tourniquet application If bleeding not controlled with first tourniquet use a second one just proximal to first

Get off the X

One-Person Drag

Cradle Drop Drag

Two- Person Drag

SEAL Team Two-Person Lift and Carry

Summary
Assess the safety of the scene-beware of secondary explosive devices. Stop life-threatening limb hemorrhage with tourniquet. For life threatening bleeding not anatomically amendable to a tourniquet, continue to use direct pressure if possible.

Situation - Control Hemorrhage - Airway - Breathing

Hands-on Practice
Tourniquet Demonstration
Partner-up for Scenario
- Move to Casualty - Apply Direct Manual Pressure to Pressure Points - Apply Tourniquet High on Limp Over Clothing

The Situation is Now Safe or You are Behind Cover

Continue Hemorrhage Control

If tourniquet application is ineffective or unfeasible because of the anatomical location of the wound, proceed to the use of Wound Packing and a Pressure Bandage. Reassess all previous tourniquet applications.

Wound Packing and Pressure Bandage for Hemorrhage Control

Junctional Hemorrhage is the most difficult to manage. If a tourniquet cannot be applied, the techniques of wound packing and pressure bandage can be used for hemorrhage control.

Wound Packing
Placement of any

foreign material directly into an open wound, directly activates the clotting mechanism Fully expose the wound and pack tightly from wall to wall and apex to apex

GAUZE ROLL 6-ply sterile crinkle cotton folded fluff bandage

Combat Gauze folded fluff bandage impregnated with Hemostatic Agent

Packing

Elastic Pressure Bandage

The Pressure Bandage

Packing, together with an overlying Pressure Bandage can control life threatening bleeding on most of the arm and from the knee down
Pressure Bandage applied over the gauze packing applies high direct pressure over damaged tissue arteries

Collateral circulation to the distal extremity still remains.

Minimize Pain / Trauma During Pressure Bandage Application

Limb-Groin Technique
Avoids repetitive lifting of injured limb Allows operator to use both hands to apply the dressing By leaning back slightly, effective traction is placed on a fracture
From the personal archive of Dr. S. Hatfill MD

Pressure Dressings Problems From the Front Line

- Wound not fully exposed
- Gauze not properly packed - Bandage not tight - Bandage not secured with an added half hitch - Bandage allowed to spindle.

Use of Hemostatic Agents

Certain types of life-threatening hemorrhage cannot be controlled with tourniquets or bandages because of anatomical constraints (high groin, neck, deep armpit). Hemostatic agents may assist in these cases.

Hemostatic Agents
Hemostatic agents incorporate proteins or chemicals designed to initiate and accelerate the fibrin clotting process. Some agents act to chemically seal damaged arteries and veins involved in uncontrolled hemorrhage. Must be used with sustained direct pressure. Takes 3-4 minutes of continued direct pressure to work.

4-Generations of Hemostatic Agents Have Been Developed

Primary Agent : Combat Gauze

CoTCCC 1st line agent of choice Does not generate heat Effectively combines clotting agent with packing gauze

The recommended time for direct pressure has been changed from 2 minutes to 3 minutes.

Life Threatening Hemorrhage Should Now Be Controlled

Reassess situational awareness, consolidate cover
Continue MARCH-E assessment of the casualty This involves assessing the airway next.

Copyright 2009 ATS Inc., LLC

Bleeding Control Is Often Achieved By a Combination Of Methods

Direct Manual Pressure
Tourniquet Gauze Packing

Pressure Bandage
Haemostatic Agents

Hands-on Practice
Pressure Bandage Demonstration
Partner-up for Scenario
- Move to Casualty - Apply Direct Manual Pressure to Pressure Points - Apply Packing and Pressure Dressing

Situation - Control Hemorrhage - Airway Breathing

The Mass Casualty Collection Point

In a CCP, all the casualties are grouped close together in a secure location.
Then the airway and breathing are assessed.

The Upper Airway

Airway

Manage the Airway

If casualty is talking They Have a Good Airway ! Perform positioning on an unconscious casualty. Recognize potential complicated airway problems and be ready to alert EMS personnel when they arrive.

Is There Airway Obstruction ?

Should diagnose this "from across the room" by observing :

Abnormal respiratory effort. Cyanosis. Intercostal / suprasternal / subcostal retractions. Snoring / gurgling / hoarseness / stridor. Agitation or decreasing consciousness.

Specific Causes of Airway Obstruction

Decreased mental status: Shock, Head Facial Fractures
Injury

Posture with casualty slumped forward

Blood , Vomit, Foreign Body (teeth).

Unconscious with tongue blocking airway Increased pressure on the airway structures
- Neck hematomas from trauma - Airway wall edema from burns/smoke inhalation

Stop-Gap Management Of Airway Obstruction

1. Airway opening maneuvers. Positioning, Chin-lift, Jaw-thrust

2. Military uses an artificial airway for ALL Unconscious casualties - Nasopharyngeal airway 4. Place all unconscious casualties in recovery position when feasible.

Casualty Positioning

A casualty with bleeding into the mouth or nose may be better able to maintain an airway by sitting up and leaning forward.

Do not force them to lay down !

Massive Maxillofacial Trauma

Severe airway damage, casualty awake and alert
Medic attempted to force him into supine position respiratory distress ensued Eventually transported sitting up and leaning forward Survived with good maxillofacial repair results

Casualty did not require advanced airway procedures in the field

Stop-Gap Airway Opening Maneuvers in an Unconscious Casualty

Chin lift

The Nasopharyngeal Airway

(Prevents the tongue from blocking the upper airway)

Place a NPA in all unconscious casualties

From the personal archive of Dr. S. Hatfill MD

Placement of the Nasopharyngeal Airway

Lubricate Insert along floor of nasal cavity If resistance is met, use back and forth motion Do not force, use other nostril If patient gags, withdraw slightly

90 degrees

Copyright 2009 ATS Inc., LLC

Contraindication To Nasopharyngeal Airway

Relatively contraindicated in children (may cause bleeding from enlarged adenoids). Anatomical deformity complicating nasal passage of the NPA tube.

The Recovery Position

All unconscious casualties are placed in the recovery position (injured side of chest down)

Burns Can Cause Airway Obstruction Requiring Advanced Airway Management

Severe facial and inhalation burns may cause rapid development of severe upper airway edema.
NPA may not provide an adequate airway in these cases.

Advanced EMT Airway Management Endotracheal Intubation

- Medical Personnel - Provides a temporary and secure airway. - Vomit cannot be aspirated. - Requires practice and skill.

Advanced EMT Airway Management The Emergency Cricoidotomy

Anatomical location, purpose, and level of procedure difficulty are different
Surgical Cricoidotomy
Fast, Simple, Safe, Medic/corpsman Level

Surgical Tracheotomy
Long Term Airway, Physician Level

Surgical Cricoidotomy
- Field emergency airway - Airway not secure
- Vomit can be aspirated
Small tube inserted into the cricothyroid membrane to keep the airway open

Mismanagement of Airway Trauma

Gunshot wound to the lower jaw that also damaged the tongue and upper airway structures Attempted field intubation was unsuccessful
Died of airway obstruction. Airway could have been achieved with a Surgical Cricoidotomy.

Nasopharyngeal Demonstration

Escape For a 1-Hour Lunch Break

Situation - Control Hemorrhage - Airway Breathing

Respiration

1. Assess the breathing of your casualty. 2. Seal any open chest wounds 3. Alert EMS personnel if your casualty has chest trauma and is developing progressive respiratory distress.

Check Respiration
What do we want to know about the Respiration ? Is casualty actually breathing? Is there respiratory difficulty (increased work of breathing)?

Is there blunt or penetrating torso trauma?

Is the Casualty Actually Breathing ?

CPR is ineffective in Trauma

Time consuming Casualty stays dead CPR has not been shown to be effective in casualties with Trauma

Cardiopulmonary Resuscitation in Trauma

Study of 138 Trauma patients with pre-hospital cardiac arrest with CPR resuscitation attempted.
No Survivors
Trauma patients in cardiopulmonary arrest should not be transported emergently to a trauma center even in a civilian setting, due to a lack of significant chance for survival. Rosemurgy et al. J. Trauma 1993

Exceptions To The No CPR Rule

Only in the case of non-traumatic disorders should CPR be considered prior to Ambulance evacuation.

Hypothermia Near-drowning Electrocution

Use the Current American Heart Association Protocol of 2 Breaths /100 Compressions.

Is There Respiratory Difficulty ?

Impaired mentation
dizziness anxiety, combativeness confusion unconsciousness

Nasal flaring Coughing Chest Tightness Excessive use of accessory muscles Cyanosis

Respiratory noise
wheezing rattling Stridor

Is There Blunt or Penetrating Trauma ?

Ask if there is chest pain. If unconscious, expose / examine the neck, axilla, front of chest
- Look at facial/lip skin color - Look at chest for breathing

Inspect the back only after pelvis has been checked.

Injuries you are looking for:

Penetrating Injuries Open pneumothorax Tension pneumothorax
Blunt Trauma Bruising Broken ribs Flail chest

Penetrating Injury Of The Chest Wall

The Open Pneumothorax
Loss of negative pressure between lung and the chest wall.

The elastic tissue of lung causes it to collapse towards the midline. An empty space is left inside the chest cavity on the injured side
Empty Space

Open Pneumothorax Sucking Chest Wound

You may or may not hear air rushing in and out of the chest cavity (Sucking Chest Wound.

Open entrance wound > 5-cent coin allows air to move in and out of the pleural space.

If chest wall opening is 2/3 or more of the diameter of the trachea, air will preferentially go into the chest cavity.

Anatomical Signs Of Open Pneumothorax

Penetrating wound in chest larger than a nickel coin. Air may be moving in and out through the hole as the chest wall moves. Slight marginal wound bleeding with bubbles may be present.

Clinical Signs Of Open Pneumothorax)

Difficulty Breathing Rapid Respiratory Rate Possible Coughing Blood Cyanosis may be present

Rapid Heartbeat

Bruising or Fractured Ribs

It is Imperative to Convert the Open Chest Wound Into a Closed Wound

Inferior Vena Cava becomes repeatedly pinched as the chest wall moves and out. The return of venous blood to the heart is compromised. Poor air entry into good lung.

All open or sucking chest wounds should be treated by applying an occlusive material to cover the defect.

Military Use Valve Chest Seals

Valve Chest Seals are a selfadhesive occlusive dressing with a one-way Valve. Clean area around the wound using the pull-off gauze. Remove paper backing from the adhesive side of the Chest Seal. Apply carefully to the chest with the Chest Seal hole lined up over the wound.
Asherman Chest Seal

Expedient Chest Seal

The occlusive material used in a chest seal may be any nonporous material such as plastic wrap or foil.
The critical action is to seal the chest wound.

Apply a Valve or Occlusive Chest Seal To Any Penetrating Wound Between the Navel and Shoulder

Reinforce The Chest Seal If Possible

The Chest Seal edges should be covered with tape when possible.
Place a conscious casualty in the sitting position

(if possible).
Place unconscious casualty in recovery position (injured side down} Monitor for possible development of further difficulty such as a Tension Pneumothorax.

The Tension Pneumothorax

Small entrance wound allows air in the pleural space. Lung collapses, air continues to leak from damaged lung.

Air is progressively trapped under increasing pressure.

Increasing pressure presses on heart and trachea, and kinks major blood vessels.

Signs and symptoms develop over 10 60 minutes

Tension Pneumothorax A True Medical Emergency

Chest trauma PLUS
Increasing difficulty breathing Chest pain. Air hunger. Increasing restlessness, agitation. Increasing heart rate Progression into shock

Signs of a Tension Pneumothorax

Progressive difficulty breathing, air hunger and anxiety Increasing cyanosis Stridor on Inspiration Distended neck veins Skin cold and clammy

Tracheal Displacement to normal side (late)

air bubbles under the skin

Casualty becomes progressively worse

EMT Management Of Tension Pneumothorax

Done by EMT Medical Personnel The Stop-Gap treatment for tension pneumothorax is to decompress the injured side of the chest cavity with a needle (needle thoracostomy).
This is done if a casualty has:
1. 2. Torso trauma Increasing respiratory distress

Needle Chest Decompression (Needle Thoracostomy)

2 to 3 finger widths below the middle of the collar bone

Mistakes Made
The midpoint of the mid-clavicular line is difficult to determine. Decompressions are being done too medially. Use entry point at or lateral to the nipple line

The Danger Box

What if the casualty does not have a tension pneumothorax when a needle decompression is done?

If there is already a collapsed lung, blood, and air in the chest cavity.
The needle wont make it worse if there is no tension pneumothorax.

Broken Ribs Can Cause a Tension Pneumothorax.

Broken Ribs puncture lung causing a closed Tension Pneumothorax.

Hemothorax develops due to bleeding from the damaged lung tissue.

Tension pneumothorax develops from air leaking from the collapsed lung into the closed chest cavity.

No visible penetrating injury

Tension pneumothorax is the second leading cause of preventable death in blast and ballistic trauma.

In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax.

Alert EMS personnel about your casualtys condition. EMS are trained to decompress on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the mid-clavicular line. Frequently reassess

The Definitive Surgical Treatment for 80% of Penetrating Chest Wounds

Surgical Chest Tube with Underwater Drain

Blunt Trauma Injuries

Bruising Indicates Blunt Trauma Has Occurred
Possible Broken Ribs
Possible Underlying Lung Contusion Possible Development of Tension Pneumothorax Severe Blunt Force Trauma May Have An Associated Head Injury

The Flail Chest Injury

Flail chest caused by extreme blunt trauma. Mechanisms can be car accidents, falls, blasts etc Defined as a break of two or more ribs in two or more places. The injured chest wall falls inward on inspiration.

Emergency Treatment Of Flail Chest

Current concepts for medical treatment of a flail chest is conservative. Position casualty in lateral prone position (recovery position) to improve lung function. Injured side goes down. Monitor for Tension Pneumothorax

Lung Ventilation / Perfusion Improved In Lateral Prone Position

Immediate Care of the Wounded , C.C. Cloonan , 2007, Brookside Associates, Ltd.

Finish The Front Survey For Injuries

Quickly check abdomen for bruising or penetrating injury.
Check the pelvis before lifting or rolling the casualty to examine the back.

Physical Exam : Assess Pelvic Stability

Gently manipulate the pelvis by squeeze and rock.

Grasp iliac wings and assess AP stability

Check for lateral stability

If pelvis is intact it is safe to move the patient to

examine the back

Indications Of a Pelvic Fracture

Local pain / tenderness on pressure
Perineal bruising associated with a high-energy injury, strongly suggest a possible pelvic fracture. Look for perineal swelling and bruising above inguinal ligament. Take extreme care when moving the casualty.

If Pelvis is Intact Finish The Survey By Examining the Back

Lift or roll casualty to examine the back. Apply an occlusive cover to any penetrating injury between the top of the hips and shoulder.

Respiration Summary

Penetrating chest wounds should be closed immediately with an occlusive material, either a vented chest seal or some type of plastic occlusive dressing.

Monitor the casualty for the development of a tension pneumothorax.

Respiration Summary

EMS personnel need to perform needle decompression for any casualty with chest trauma with a progressive respiratory distress.

Needle Decompression Done by EMS Personnel

Chest exam
Exam for holes Exam for Tension Demo JVD Talk through needle drill Danger Box

2 ICS-MCL

If the 2 ICS-MCL cannot be used, keep to the outside of the nipple line

Constructing an Individual Medical Kit for S.C.A.B. Management

Commercial Tourniquet 3 x Ace Wraps 3 x Curlex packing 1 x Chest Seal 1 x NP Airway 1 x Hemostatic Gauze

5-minute Break

The Preventable Causes of Death in Blast and Ballistic Trauma Have now Been Addressed

Perform Another Survey to Assess For Other Injuries

Head to Toe Treat as You Go

Reassess the Casualty

Is Casualty in Shock ?
Identify Possible Head and Eye Injury Prevent Hypothermia Splinting

Determine if Casualty is in Shock

Reassess all previous hemorrhage control

Check to see if the casualty is in shock:
- Assess level of consciousness.

- Look for a pulse in the wrist. If both arms are injured, assess the femoral pulse in the leg.

What Is Hypovolemic Shock ?

Caused by any significant reduction in cardiovascular system blood volume. Commonly due to hemorrhage. Can be due to other significant fluid loss: Severe burns. Protracted vomiting, diarrhea, sweating. Fluid shifts i.e. smoke inhalation.

Hypovolemic (Hemorrhage) Shock

Blood volume has decreased to the point where blood flow through the capillaries is sluggish or has stopped.

Cells switch from aerobic to anaerobic metabolism, energy production decreases. Lactic Acid and other waste products build-up.
Cells / tissues in internal organs begin to die.

Hypovolemic (Hemorrhage) Shock

Class II Shock Class III Class IV

1500ml Loss Alert / Anxious Death Unlikely Radial Pulse Weak Pulse 100 Respiration 30

2000ml Loss Confused / Lethargic Possible Death Radial Pulse Weak Pulse 120 Respiration 35

2500ml Loss Unconscious Death Probable Femoral Pulse Weak Pulse 140 Respiration >35

Casualties May Also Have Hidden Blood Loss

Hemothorax 1 Liter Pelvic Fracture 1 Liter Long Bone Fracture 500ml
2500ml

Well conditioned athlete has greater fluid and cardiac reserves, so a greater blood loss needed to progress through stages. Casualty may suddenly crash.

The Golden Hour

Percent Survival

100

50

As the time between an injured patient developing serious shock (loss of radial pulse) and the onset of resuscitation increases, the percentage of surviving patients decreases.
0 30 60 90

Minutes

The survival rate after 1 hour of severe, untreated shock is very low. Death of Wounds 4-10 days later

Assess For Shock AVPU Consciousness Level

A Alert V Verbal
Open your eyes

P Pain Responsive

U - Unresponsive
Decreasing consciousness is the best quick indication of shock in a non-head injured patient.

Location of the Pulse Helps To Determine Shock

Carotid
Radial Femoral Pedal

(60mmHg)
(80mmHg) (70mmHg) (90mmHg)

The Radial Pulse Is Lost In Significant Shock

Check for a Radial Pulse in a non-injured arm. Note if the pulse is normal or fast.

An altered level of consciousness combined with a lost radial pulse, indicates significant shock is present
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Reassess Any Prior Tourniquet Application

Expose wound and determine if tourniquet is needed. If so, apply another tourniquet 2-3 inches above wound and this time, apply directly to the skin. Remove 1st Tourniquet and ensure pulse is absent. If a distal pulse is still present, tighten the tourniquet to eliminate the pulse. Note the time of tourniquet application for later recording.

Diagnosis Of Shock
Clinical indicators of Significant Shock;
Decreased consciousness Wrist pulse weak or absent. Heart rate > 120 bpm. Continued bleeding from non-compressible wound. Color- pallor/pale.

Elevating the Legs is NOT a Stop-Gap Treatment For Shock

Elevation of the legs was a procedure adopted during WW I as an anti-shock technique. Continues to be popular despite repeated evidence that it has no effect in shock. (J. Trauma 1982; 22:190-193). The best management of hemorrhagic shock is to stop blood loss and replace lost circulatory fluid by using IV Fluids.

EMS Will Administer IV to Casualties in Shock

NOT All Casualties Get an IV

Aggressive fluid resuscitation to normal BP level in severe trauma is dangerous.

Aggressive Fluid Resuscitation in Uncontrolled Hemorrhage Is Bad

Large Prospective Trial Bickell et al NEJM 1993

598 patients penetrating torso trauma /shock

Aggressive fluid resuscitation -survival rate 62%. No aggressive fluid replacement- survival rate 70%.

If bleeding is not controlled (internal) fluids may hurt rather than help because raising the blood pressure to normal may increase the bleeding.

No Aggressive Fluid Resuscitation in Uncontrolled Hemorrhage

Large Prospective Trial Bickell et al NEJM 1993

598 patients-penetrating torso trauma and hypotension. Aggressive fluid resuscitation - survival rate of 62%. No aggressive fluid replacement - survival rate of 70%.
IV dilution of clotting factors. Raising the blood pressure may increase bleeding. Permissive hypotension is allowed in all but severe head injury,

Head to Toe, Treat As You Go.

Hypothermia Head Bandaging and Splinting Burns and eye injury

Hypothermia and Shock

Hypothermia
Hypothermia occurs in Shock, even in hot environments. Hypothermia decreases blood clotting and is a major factor in trauma death.

Severe casualties do not produce enough body heat to stay warm.

Prevention of Hypothermia
Minimize Exposure
Keep clothing on Expose only to treat wounds Replace wet clothing with dry Replace body armor

Wrap Casualty
- Space Blanket, Dry blanket - Poncho liner, sleeping bag, - Body bag, or even a trash bag liner.
Hypothermia Prevention Kits are available.

Small Individual Hypothermia Prevention Kit

Space Blanket
Chemical Warmers - Tape to femoral pressure points - Tape to axillary pressure points

Quickly Assess For Serious Head Injury

Monitor AVPU and note any change
Examine for depressed fractures and small wounds Check Pupils if possible Bleeding into brain may be evident by development of unequal pupils Alert EMS Personnel

Splinting Of Skeletal Fractures

Open Fracture Overlying skin is broken. Closed Fracture Overlying skin intact.

Clues to a Closed Fracture

Trauma AND;
Marked swelling Audible / perceived snap Length or shape of limb Loss of pulse or sensation

Crepitus
PAIN

Basic Fracture Management

Expose Wound

Pack and Pressure Dressing For Bleeding

Immobilize by Splinting

Fracture Splinting
Splinting Objectives: Prevent further injury

Protect arteries and nerves - Check pulse

before and after splinting

Make casualty more comfortable

Splinting Materials
Commercial Other body part Field expedient
SAM Splint

Improvised

Splinting Principals

Try to splint before moving casualty. Give Pain Meds if not contra-indicated.

Give Combat Pill Pack

Splint in position of function. Pad bony prominences.

The Splinting Rule of Twos

Two Pulses (check before and after splinting). Two Ties (immobilize) One above the injury One below the injury Two Joints One tie above the joint One tie below the joint

It is Essential To Check For a Pulse After Splinting

Major blood vessel pinched-off with progressive limb tissue death. Neurological damage with partial limb paralysis can also occur.

Things to Avoid in Splinting

Minimize manipulation of extremity before splinting to avoid damaging blood vessels or nerves. Do not wrap the splint too tight and cut off the circulation to tissues below the splint.

Special Splinting Problem The Shattered Limb

Use traction when moving limb Long splint underneath extremity to stabilize the tissue. Slightly-tight elastic bandage wrapped circumferentially.

Special Splinting Problem Emergency Pelvic Stabilization

Tie both feet and legs together. Use cargo belt or elastic bandage below Pelvic Crest to stabilize the pelvis.

EMS Transport of Suspected Pelvic Fracture

Tie feet and legs together.

Use of hard stretcher IV started for suspected posterior fractures

Special Splinting Problem Impaled Objects

Do not remove impaled objects EMS will remove object only if: It prevents opening an airway, stopping life threatening hemorrhage, or prevents casualty evacuation.

Splint Object in place

Special Bandaging Problem Acute Red Eye

Any pain in the eye associated with exposure to shrapnel must be considered to be an open globe until an ophthalmologist says otherwise, especially in the setting of shrapnel injury to the face.

Iris Prolapsed

Special Care Must Be Used in Bandaging the Open Globe

Aqueous Humor (low viscosity) fluid in the anterior chamber of the eye. Vitreous Humor (high viscosity) fluid in the posterior chamber. Care must be taken not to exert pressure on the eye in an open globe injury, to avoid further fluid loss from these chambers.

Eye Bandaging Obvious Open Globe

Field Expedient

Penetrating Eye Trauma

Shield obvious or suspected eye wounds. Avoids preventable and permanent loss of vision Sunglasses / eyeglasses can be used for this purpose

Shield after injury

No shield after injury

Penetrating Eye Trauma

If a penetrating eye injury is noted or suspected: Cover eye with rigid shield (NOT a pressure patch-do not allow shied to touch eyeball .)

URGENT medical evacuation

Special Bandaging Problem Burn

Fluid Requirements In Second and Third Degree Burns

Tremendous fluid requirements are associated with 30 burns.
Shock can occur in 30 burns that cover over 10% body surface area (BSA).
Early IV fluids.

Basic Early Burn Management

Stop the Burning Process.
Wrap affected area in loose Curlex.

Early Airway Management following facial and inhalation burns.

Alert EMS for burns greater than 10% BSA Prevent hypothermia.

Waiting for EMS

Waiting for EMS

Establish a CCP.
Reassess all Field Treatments

Monitor Vital Signs, look for deterioration

Identify most serious cases to EMS

Positioning The Casualty While Awaiting EMS

Conscious casualties should be encouraged to sit upright - if not in shock. This may help the breathing. Makes it easier to watch the casualty for additional difficulty. Unconscious or casualties in shock are placed in the recovery position. Unconscious thorax injuries, place casualty with injured side down.

Record the Time of Tourniquet Application

Writing T on the casualtys forehead does not work well. Ink marker on tape applied to the casualtys chest. Package for hypothermia and transport Identify most serious casualties to EMS

10 Triage Rules of Thumb

IMMEDIATE TACEVAC Shock. Penetrating wounds to the chest with respiratory distress unrelieved by needle decompression. Face / neck trauma with airway problems. Head trauma with consciousness. Globe damage to eye. 3d degree burns > than the surface area of one arm. DELAYED TACEVAC Obvious brain damage + unconsciousness (Expectant). Extremity bleeding controlled with Tourniquet. . Soft tissue injuries dont kill unless associated with shock.
Copyright 2009 ATS Inc., LLC

5-minute Break and Prepare for Individual Practice of S.C.A.B. Techniques

The Mass Casualty Scenario

Mass Casualties

A mass casualty situation is when there is one more

casualty than you can manage.

There are 4 critical rules for managing a battlefield mass casualty situation.
Failure to adhere to any one of these principles will result in excess casualty morbidity and mortality.

Copyright 2009 ATS Inc., LLC

Military Concept For Managing Multiple Casualties

Win the Fight or Control the Situation
Take a few seconds to assess the situation and the area over which the mass casualties are spread.
Select a potential Casualty Collection Point with good cover. Send recovery personnel to perform TCCC only to the extent of Control Catastrophic Hemorrhage. Move all casualties into a secure CCP - All unconscious casualties are put in recovery position
Copyright 2009 ATS Inc., LLC

Rule 1: Establish a Casualty Collection Point

Perimeter Security is established with Close Security around casualties being treated. All the casualties in the CCP are grouped close together for monitoring, medical C&C, and triage of medical supplies.

Copyright 2009 ATS Inc., LLC

Rule 2. Set up the CCP Correctly !! Catastrophic Hemorrhage Control is the Priority
Arrange the casualties in a line with all heads facing the same way, or in a star with all heads pointing inwards with a Corpsman or medic, in the center. Corpsman/Medic works at the casualtys head. Nonmedical personnel work from the foot-end and can be directed by the Corpsman/Medic. Keep enough space between casualties to sit down to start an IV.
Copyright 2009 ATS Inc., LLC

Rule 3. Someone Must Take Charge of the CCP (This Should Not Be the Medic or Corpsman).
The individual in charge of the CCP cannot also be involved in providing medical treatment.
The individual in charge of the CCP will :

- Manage the triage of medical supplies. - Keep track of the triage priorities of the casualties. - Make the initial TACEVAC request. - Control the security of the site.
Copyright 2009 ATS Inc., Le

Rule 4.
Corpsman or Medic Will Use Operators As Medical Assistants
Once all life-threatening hemorrhage is controlled, all casualties are assessed for an adequate Airway.

Corpsman / Medic will assist with complicated hemorrhage control and assist with complicated airway cases. At the same time, Corpsman / Medic will use Operators as Medical Assistants to perform the TCCC protocols for MARCH-E on all casualties.

Analysis of the Boston Marathon Bombing

Significant Event Planning by Boston EMS Special Operations Unit

Large medical tent for race injuries. Dispatcher dedicated solely for marathon communications Medical response geared towards dehydration, exhaustion, and other race related injuries, not massive trauma.
50 additional EMS personnel strategically placed at medical tents, water stations, on bicycle, 4-wheeled ATVs, and ambulances throughout the race route. 4 physicians on site for the event.

Boston Marathon

Finish Line

Medical tent

April 15, 2013 20:50.00 PM

Explosions 12 seconds apart No tertiary devices Casualties 3 Dead 264 Wounded

Use of Field Expedient Devices

Are there First Aid Kits in any of the surrounding shops and stores? What in the blast debris would be useful for constructing an improvised tourniquet ?

Explosive Device

12-Seconds Later Second Explosion

Explosions 12 seconds apart No tertiary devices Casualties 3 Dead 264 Wounded

Can this patient hear ?

Explosive Device

Blast Analysis
2 Devices
6L Pressure Cookers filled with gunpowder from fireworks

Black bags (duffel or back packs) Shrapnel Metallic BBs and Nails, contained with adhesive

RC car remote Hobby fuse Yechnique detailed in AQ Inspire article

Medical tent already treating dozens for race injuries.

Shortly following blast medical tent became trauma center Staff began triage. Tent did have small number of tourniquets available By 1600L most patients moved to hospitals

Medical Tent Equipped to Handle Marathon Runners

Casualties Begin to Flow Into Medical Tent

Boston Globe

Rapid Medical Tent Reorganization

Transport to Area Medical Hospitals

Incident Time Line

3 Dead, 264 Wounded 16 Amputees 3 of which were multiple amputations 10 children among wounded
Most injuries to lower extremities

General Notes
Physicians and EMS personnel were already on-site for the Boston Marathon. Treatment tent was able to be rapidly reconfigured for trauma. A few tourniquets were available in medical tent but not brought to incident site. Airway problems in casualties were minimal. Bystanders had to try and provide initial life saving measures

General Notes
Police were first on the scene but had no training in controlling hemorrhage and no lightweight tourniquet or pressure bandage.
No secure CCP established and the scene remained essentially unsafe throughout the response, due to the potential risk of secondary explosive devices.

General Notes
Civilian man-made mass casualty blast and ballistic events are becoming more frequent and such incidents can be expected to continue. Bystanders may be the initial first responders. The ability to control catastrophic hemorrhage and provide an airway should be a basic skill of every police officer on the street. It is not.

The National TECC Committee

The concept, workshops, EMS doctrine, and equipment for Tactical Emergency Casualty Care have been promoted for the three years. A National TECC Committee exists.

The doctrine is being adapted too slowly or not at all by many EMS departments and even fewer Police Departments.

Resources
Boston Globe http://www.cnn.com/2013/04/15/us/boston-marathon-thingswe-know/index.html http://us.cnn.com/2013/04/15/us/boston-bombingsinjuries/?iref=obinsite http://www.boston.com/lifestyle/health/blogs/white-coatnotes/2013/04/15/marathon-medical-tent-transformed-intotrauma-unit/gUAgQIMwTYqwzRkcIDs5PJ/blog.html http://canton.patch.com/articles/boston-marathon-explosionsmedical-tent-nurse-describes-monday-scene-to-canton-patch http://espn.go.com/video/clip?id=9175656 http://healthybostonblog.wordpress.com/2013/

Questions and Discussion