BLAST:
Explosions
are physical, chemical, or nuclear reactions involving a large, rapid release of energy
BLAST PHYSIOLOGY:
Blast
injury Based on mechanism of tissue injury & physical tissue damage defined and broken into 4 categories Primary Secondary Tertiary quaternary
BLAST PHYSIOLOGY:
space density, pressure & temperature of gas increases a shock wave, or blast wave, develops moving at supersonic speeds (3000 to 8000 m/sec) loses its pressure and velocity as distance increases
called blast wind Leaves behind a negative pressure area which reverses the movement of gas
damage can occur from both In nuclear blast- precursor shock wave is observed.
amount of impact and injury horizontal fashion - less direct surface contact for impact underwater detonations: force of blast wave greatest at the deepest depths & begins to dissipate as blast wave approaches the surface
Perforation of eardrums (overpressure 15-50 psi) pneumothoraces (over[ressure 50-100 psi) At psi 65 fatality rate approaches 99%
Other injuries:
Intestinal /hollow viscus injury Brain injuries
Factors potentiating outcome to blast injuries magnitude of the explosion potential building collapse open air versus enclosed space (6 fold in pulmonary injuries in confines spaces) Enhanced wounding measures Ball bearings, nails, incendiary
blast injury
SECONDARY INJURIES:
Injury from flying debris Classic shrapnel injuries Of various velocities Primary bomb fragments Secondary fragments or missiles Inert from inanimate objects Biological allogenic bone fragments etc may be HIV, HBSAg infected Potential for pathogen transmission Cases seen in israel n iraq
SECONDARY INJURIES:
Environmental
debris such as glass, splinters, soil, and various structural particles may be major cause. Interface of debris with skin characteristic skin pattern called spalling More common than primary injury: Reason - Victim doesnt have to be near blast site No 1 military killer in 20th century
Spine
Orthopedic
Head Solid & hollow organ
Burns :
Thermal
Radiation Chemical
occur
walking smart bomb. High grade explosive material used Ability to precisely time the explosion Ability to detonate in close proximity to victims Large load of heavy shrapnel as well as explosive material body parts acting as missile fragments and projectiles may carry with them HIV, hepatitis, and other serious and yet to be identified threats Suicide Bomb victims suffer with the worst of both ie Explosion and Penetrating shrapnel
However, amniotic fluid, potentially amplifies 3-fold the blast wave, as in underwater detonations
concern of potential maternal-fetal injury
Chemical injuries:
Spontaneous abortions (about 4 fold in bhopal
Radiation injuries depend on: gestational age at time of the exposure period between the 2-8 weeks - extremely sensitive At significant risk is the central nervous system fetal dose of absorption. low birth weight
best chance for fetal survival is that of the stability of the mother suffering traumatic injury
Second most susceptible organ (1st TM) Direct consequence of blast wave on the body Overpressure needed - about 40 psi (40 psi being produced by 20Kg TNT exploding 6 meters away) Most common CRITICAL Injury in victims close to bomb Can be life threatening May not have obvious external injury to chest
Other pulmonary injuries include: Pneumothorax Hemothorax Pneumomediastinum Subcutaneous emphysema Air emboli
edema Micro -hemorrhages in alveoli Disruption and weakening of alveolar walls perivascular and peribronchial tissue Resultant Ventilation-Perfusion mismatch
Air embolism from pulmonary disruption Other injuries may add to haemodynamic instability
G I SYSTEM:
GI blast injury more commonly occurs after blast wave propagation in water. GI hemorrhage and perforation is most common in
HEAD INJURY:
Loss of consciousness Headache, seizures, dizziness, memory problems Gait/balance problems, nausea/vomiting, difficulty concentrating. Visual disturbances, tinnitus, slurred speech. Disoriented, irritability, confusion. Extremity weakness or numbness
CRUSH INJURY:
results when muscle reperfusion injury occurs as a result of the release of compressive forces on the tissues or compartment syndrome physiologic outcome - traumatic rhabdomyolysis myoglobin, potassium, and phosphorus leach into the circulation Clinically, compression of large skeletal muscle is necessary for this syndrome About 33% of the patients with rhabdomyolysis will develop acute renal failure
CRUSH INJURY:
GUNSHOT WOUNDS:
An explosive force is applied to a projectile that is propelled down a tube to fly towards its target
GUNSHOT WOUNDS:
Firearms
Low-velocity- shot gun, pistol High-velocity- rifle
Type of weapon
Caliber
Missile size Bullet construction Tumbling/yaw
Distance traveled
PROJECTILES:
RANGE OF FIRE:
Wound characteristics vary:
Contact The most devastation Close Range Arms length Distant Most handguns: significant decrease in KE at 100 m Most military rounds: retain large KE at 500m
MECHANISM OF INJURY:
2 areas of projectiletissue interaction in missile-caused wounds permanent cavity - localized area of cell necrosis, proportional to size of projectile temporary cavity - transient lateral displacement of tissue, after passage of the projectile. Elastic tissue skeletal muscle, blood vessels, and skin, may be pushed aside but then rebound Inelastic tissue bone or liver, may fracture.
MECHANISM OF INJURY:
GUNSHOT WOUNDS:
Entry wound Smaller May be darkened, burned Exit wound One, none, or many Larger May be ragged Imp to know to determine: Anatomy damaged Type of surgical procedure Entry and exit wounds can lie ! ! ! ! ! ! Projectiles do not have to follow a straight line !
PATHOPHYSIOLOGY:
Internal wound
Tissue contact damage High-velocity transfer of energy Shock waves Temporary cavity
Distal embolization can occur when a projectile slows enough and enters the vascular system
PATHOPHYSIOLOGY:
50 % of deaths are due to exsanguination require rapid pressure application and evacuation exception Gun Shot Wound to head large bore IVs are needed for fluid replacement 10 % from CNS injury
GUNSHOT INJURIES:
MANAGEMENT:
Prehospital trauma care: For severely injured patients, survival is time-dependent! Golden Hour From moment of injury To definitive treatment EMS platinum 10 minutes scoop & run OR stay & play
MANAGEMENT:
Scene Size-up
Standard precautions
Scene safety Initial triage (total number of patients)
TRAUMA SYSTEM:
DEFINITION:
an organized approach to acutely injured
patients in a defined geographical area that provides full and optimal care and that is integrated with the local or regional Emergency Medical Service (EMS) system.
TRIAGE:
French word meaning to separate, sort, sift or select the sorting of allocation of treatment to pts esp. battle and disaster victims acc. to a system of priorities designed to maximize the no of survivors
TRIAGE UNIT:
Determine location of triage areas Clear and assemble the walking wounded
TREATMENT UNIT:
Determine location for treatment area Coordinate with the Triage unit
areas
TRANSPORTATION UNIT:
Management of patient movement from the scene to the receiving Hospitals Establishes adequately sized, easily identifiable patient loading area
STAGING AREA:
Location designated to collect available resources near incident area Several staging areas may be required
TRIAGE TAG:
Alerts care providers to patient priority Prevents re-triage of the same patient Serves as a tracking system
TRIAGE TAG:
carried with Diagnostic Equipment in all EMS kits should be considered on all calls involving 3 pts general placement location for tags
neck.
TRIAGE CATEGORIES:
IMMEDIATE:
DELAYED:
Potentially serious injuries, but are stable enough to wait a short while for medical treatment
TRIAGE CATEGORIES:
MINIMUM
/ MINOR: MORGUE/EXPECTANT:
Minor injuries that can Death or lack of wait for longer period spontaneous respiration of time prior to after airway is opened treatment
MNEMONIC: 30 2 CAN DO
REVERSE TRIAGE:
conditions where less wounded are treated in preference to more severely wounded such as:
war - where military setting may require soldiers be
returned to combat as quickly as possible disaster situations - where medical resources are limited where significant numbers of medical personnel are among the affected patients
CAUTION:
Personal protective equipment is always needed at trauma scenes
Do not approach until Scene Size-up is complete!
MANAGEMENT:
Primary
survey
MANAGEMENT: AIRWAY
Airway Suction
Blood Mucus Dental fragments
Open Airway
Head Tilt-Chin Lift Jaw Thrust (if Cervical Spine Injury is suspected)
Maintain Airway
Oropharyngeal Airway Nasopharyngeal Airway
MANAGEMENT: BREATHING
Assess
Breathing Ventilation Oxygenation
MANAGEMENT: BREATHING
Nasotracheal intubation:
in breathing patient without major facial trauma
Surgical airways
jet insufflation
Retrograde intubation
cricothyrotomy tracheostomy
BREATHING: PITFALLS
Tension Pneumothorax Rib Fractures
High risk injury if Fractured ribs 1-3 Associated with significant cardiopulmonary injury Flail chest Pulmonary Contusion
MANAGEMENT: CIRCULATION
Level of Consciousness Skin color Central Pulse
Chest Injury Abdominal Injury (especially retroperitoneal) Pelvic Injury Extremity Injury (especially femur)
MANAGEMENT: CIRCULATION
MANAGEMENT: DISABILITY
Unresponsive
EXPOSURE:
Undress patient do complete visual inspection Keep spine immobilized and log roll Prevent Hypothermia Warm crystalloid in microwave or bath to 39C Do not microwave Blood, Plasma or Dextrose
MANAGEMENT:
Resuscitation of vital functions Detailed secondary survey Definitive care
injury Auscultation of chest & chest X rays DPL / FAST- for unstable pts. CT Scan Abdomen/Pelvis for patients with appropriate signs and symptoms. Hearing in both ears should be tested at bedside. Limb X rays & examination
ABDOMINAL INJURIES:
Laparotomy - main stay of investigation and management Priorities of the Trauma Laparotomy Hemorrhage control Contamination control Detection of all injuries Missed injury - high mortality and morbidity Tetanus toxoid and Antibiotics initial blood loss on opening abdomen- can be brisk patient rapidly can become unstable Volume resuscitation & blood transfusion
RADIATION MANAGEMENT:
Radiation deaths are delayed. Management of conventional injuries and acute life threats takes precedence over radiation exposure. Treat injury first, then decontaminate.
Contamination issues
No medical personnel have ever received an
95% of decontamination occurs with: Removal of patients clothing Soap & water
Limb Stabilization
Vital signs, oxygen, EKG, IV Additional Rx & transport IS CRUSH SYNDROME OR COMPARTMENT SYNDROME SUSPECTED?
Look for injuries on Limbs, Pelvis, Gluteal region &
Abdominal muscles
TREATMENT HOSPITAL
Fluid resuscitation - Brisk diuresis (2 ml/kg/hr) Diagnose and treat other metabolic derangements
Mannitol - a nonosmotic diuretic Help augments diuresis effective radical scavenger Use of bicarbonate: alkalization of the urine cast formation direct toxic effects of myoglobin upon nephrons Hyperkalemia, severe acidosis, and hypervolemia continuous renal replacement therapy
If injury is open:
Antibiotics, tetanus, jet irrigation. Debridement of nonviable tissues. Early amputation for severely injured limbs may be required
Fasciotomy
NO
NO
YES
Management ventilatory failure- intubate Caution with PPV- BLI, embolism
HOSPITAL DIAGNOSTIC EVALUATION Chest radiography Arterial blood gases computed tomography doppler ultrasound to help diagnose BLI and air emboli. Testing conducted per resuscitation protocols Acc to nature of explosion (eg. confined space,fire etc) OXYGENATION High flow O2 via non-rebreather mask, CPAP,or endotracheal intubation.
CLOSE OBSERVATION Chest decompression- clinical presentation of tension pneumothorax. Fluid administration
enough fluid to ensure tissue perfusion & avoiding volume
overload.
AIR EMBOLISM Position in prone, semi-left lateral, or left lateral transport to a facility with a hyperbaric chamber.
TENSION PNEUMOTHORAX:
Treatment is decompression
needle into 2nd intercostal space of mid-clavicular line -
FLAIL CHEST:
Free-floating chest segment- multiple ribs # Pain and restricted movement paradoxical movement of chest wall with respiration Treatment :
Ventilate well Humidify oxygen Resuscitate with fluids Manage pain Stabilize chest ventilator
No definitive guidelines for observation, admission, discharge Patients diagnosed with BLI may need complex management should be admitted to an intensive care unit suspicious for BLI should be observed in the hospital. Discharge decisions will also depend on: associated injuries other issues related to the event, including the patients current social & mental situation. Patients with normal chest X Rays, blood gases & pulse oximetry no complaints suggesting a BLI can be considered for discharge after 4-6 hours of observation.
BURN INJURY:
Fluid resuscitation while avoiding fluid overload to prevent further pulmonary injury
guided by urine output.
WOUND MANAGEMENT:
Tetanus status. Local exploration. Delayed primary closure. IV followed by oral antibiotics for all but the most trivial wounds