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Pre-hospital and Emergency Department Management for Blast Injury
Nat Krairojananan MD FRCSTDepartment of Trauma and Emergency Medicine
Phramongkutklao Hospital
Physics of the explosive• Sudden rapid conversion from chemical
component to gas, heat, pressure, light and flame• Low-order explosive devices < 400 m/sec.• High-order explosive devices 1400-9000 m/sec.
Type of explosives
Manufactured explosives • Military: C4• Industrial: TNT
Improvise Explosive Devices (IED)• Pipe bomb• ANFO (Ammonium Nitrate Fuel Oil)
Type of explosives
Factors influence severity of injuries
• Size and amount of explosive• Distance from the detonation• Media (air VS water)• Detonation in the closed space
Blast injury categorization
Primary blast injurySecondary blast injury
Tertiary blast injuryQuaternary blast injury
Quinary blast injury
Primary blast injury• Caused by high order explosive only• Over pressure to air-filled organs
• Blast lung: PTX, pulmonary contusion, PE• Blast bowel: ruptured hollow viscus peritonitis• Blast ear: TM perforation• Blast brain: concussion• Blast eye
Secondary blast injury
• Penetrating injury/ laceration• Fragmentation of case/shell or Shrapnel • Secondary fragment
Secondary blast injury
Tertiary blast injury
• Blast wave• Propulsion of body onto hard surface• Propulsion of object onto individuals• Structural collapsed• Fall from height
• Blunt injury• crush syndrome• compartment syndrome
Quaternary blast injury
Not caused by primary, secondary or tertiary blast injury
• Fire (burn)• Inhalation injury• Asphyxia
Quinary blast injury
• Toxic fume • Chemical injury• Radiation • Biological agents
Part IScene Management
For EMS personnel
Scene management
• Scene sized up (scene safety)• Scene triage• Scene treatment• Evacuation
ICS in bombing event
• Commander • Security• Search and rescue• Treatment team• Evacuation team
Scene sized upRecognition of specific hazards with bombing• Secondary device• Environmental hazards (fires, toxin)• Structural instability• Other threat; sniper
Safe distance?
Scene Triage
• MASS triage• START triage
MASS Triage
M: Move A: Assess S: Sort S: Send
• Presence of threat
MOVE• Quickly evacuate all patients from scene• Move unresponsive patients first• Use of appropriate stabilization and equipment• Stretcher or SKED
MASS triage
ASSESS
• According to Pre-Hospital Trauma Life Support (PHTLS) protocol by assess life threatening injury first
Abv. Extend Action
A Airway and C-spine protection Open & clear airway, C-collar
B Breathing (chest injury) O2 supplement by face mask with bag, Rx for tension PTX
C Circulation (hemorrhagic shock) Stop bleeding, initiate iv fluid
D Disability (neurologic status) Check A-V-P-U
E Environmental control Keep warm
MASS triage
SORTCategorize and tag patients into groups for Rx and evacuation
Color code Severity Type of injuries
RED-immediate Life threatening injury - Airway obstruction- Chest injury- Hemorrhagic shock
YELLOW-delayed - Potential life threatening - Limb threatening injury
- Fracture- mild abdominal injury- PTSD*
GREEN-minimal Minor injury Wounds
BLACK or BLUEExpectant
Obvious signs of death - Severe injury- Extensive wounds
MASS triage
SEND
• Expedient patients to appropriate resources • Trauma center • En route care: monitors• Proper stabilization
MASS triage
START Triage
Simple Triage And Rapid Treatment
START triageScene Sized up
Ask patients to walk to your voice
GREEN (minimal)
Walk to assigned area
Unable to walk Able to walk
Ask patients to raise hand or leg
START Triage (cont.)
No response
Obey command
REDImmediate AW
treatment
YELLOW Delayed Rx possibility
BLACK or BLUESupportive treatment with limited resources
Ask patient to raise hand or leg
No breathing
Assess breathingBreathing
5 /min or more
Initial management
• Treat life threatening injuries• Prevent disability
START triage
Abv. Extend Action
A Airway and C-spine protection Open & clear airway, C-collar
B Breathing (chest injury) O2 supplement by face mask with bag, Rx for tension PTX
C Circulation (hemorrhagic shock) Stop bleeding, initiate iv fluid
D Disability (neurologic status) Check A-V-P-U
E Environmental control Keep warm
Evacuation
• Expedient patients to appropriate resources • Trauma center • En route care: monitors• Proper stabilization
START triage
Part IIEmergency Department Management
For clinicians, nurses
Emergency department management
• Triage and Patient categorization• Treatment zones by color code• follow Advance Trauma Life Support (ATLS) protocol
Primary blast injury treatmentSystem Possible injury Immediate Rx consultation
Blast lung
CXR in all cases*
Tension PTX Needle thoracocentesis, follow by ICD insertion and support ventilation
- Trauma surgeon- CVT surgeon
Air embolism Support ventilation Intensivist
Pulmonary contusion Support ventilation Intensivist
Blast GI Intra abdominal bleeding
iv fluid infusion, investigation
Trauma surgeon
Bowel perforation Investigation, observe Trauma surgeon
Blast brain Brain concussion, ICH Check GCS, lateralizing sign Neurosurgeon
Blast ear TM perforation Ear exam in all cases ENT
Blast eye Globe rupture Eye examination Opthalmologist
Secondary blast injury treatmentInjury Immediate Rx Definitive Rx consultation
Penetrating injury
- Bleeding control- iv fluid replacement- Film for foreign body
Explore lap. Trauma surgeon
Amputation - Bleeding control- Tourniquet if necessary- iv fluid replacement
Surgical debridement and control bleeding
- Trauma surgeon- Orthopedist
Laceration - Bleeding control- iv fluid replacement- Film for foreign body
Debridement and suture
Trauma surgeon
Opened fracture - Immobilization- Distal neurovascular check
- Debridement - Bone realignment
Orthopedist
Tertiary blast injury treatment
Injury Immediate Rx Definitive Rx consultation
Blunt chest / abdominal injury
- Bleeding control- iv fluid replacement- FAST / DPL
Explore lap. Trauma surgeon
Crush syndrome - iv fluid load to force diuresis- ECG monitoring- Looking for compartment syndrome
- Alkalinize urine- Dialysis if necessary
Trauma surgeon
Compartment syndrome
Fasciotomy - Trauma surgeon- Orthopedist
Quaternary blast injury treatment
Injury Immediate Rx Definitive RxInhalation injury - Airway management
- Oxygen supplement
Asphyxia - Airway management- Oxygen supplement
Burn - Keep warm- Wound care- iv fluid resuscitation
- Wound debridement- Grafting for skin coverage
Quinary blast injury treatment
Injury Immediate Rx Definitive RxToxic fume Airway and ventilation support Antidote?Chemical injury Decontamination Wound careRadiation Supportive treatment sameBiological agents - Isolation
- Medical personnel PPEAntibiotics ?
Special consideration
• ‘upside down’ or ‘reverse’ triage
• Estimated incoming patient
Total number of patient = Number in first hour x 2
Special consideration
CBRNE event
• Decontamination• Personal Protective Equipment
EMS personnel
preparation
Decontaminating station
Thank youComments and question are welcome
Three suspected
injured
captured