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Blast injury

Dr Vincent Ioos Medical ICU PIMS

Introduction
Area affected: Irak, Israel, Pakistan, Madrid, 9/11, Beirut Main publications: civilian (Israel), military (Irak) Particularities of blast injury Management of mass casualty events

Classification of explosives (1)


Explosives are categorized as high-order explosives (HE) or low-order explosives (LE). HE produce a defining supersonic overpressurization shock wave. Examples of HE: TNT, C-4,
Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil (ANFO).

LE create a subsonic explosion and lack HEs over-pressurization wave. Examples of LE: pipe bombs,
gunpowder, and most pure petroleum-based bombs such as Molotov cocktails or aircraft improvised as guided missiles.

HE and LE cause different injury patterns.

Classification of explosives (2)


Manufactured implies standard military-issued, mass produced, and quality-tested weapons. Improvised describes weapons produced in small quantities (IED), or use of a device outside its intended purpose, such as converting a commercial aircraft into a guided missile. Manufactured (military) explosive weapons are exclusively HE-based. Terrorists will use whatever is available Manufactured and improvised bombs cause markedly different injuries.

Particularities of suicide blast


High-grade explosive material used by the attackers; Ability of the attackers to detonate the explosive device in proximity to the victims by concealing the explosive device and mingling within a crowd; Ability of the attacker to precisely time the explosion at his or her discretion; Large load of heavy shrapnel that accompany the explosive material.

Blast wave
The HE blast wave (over-pressure component) should be distinguished from blast wind (forced super-heated air flow), encountered with both HE and LE. Expansion of gas creating a shock wave: supersonic speed 3000 to 8000m/s Blast wave rapidly looses pressure and velocity with distance and time

Blast wave (2)


Brisance: shattering ability of the blast front If closed space: overpressure magnified by reflection off solid structures Open space: little primary blast injury because of rapid decay of the blast wave

Enhanced blast weapons


A primary blast from these devices disseminates the explosive and then triggers it to cause a secondary explosion Air delivery, guided missiles, handheld weaponry Designed to enhance blast wave + thermal effect Lower peak pressure but longer sustained time of blast overpressure Greater damage to soft structures and personnel

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Action of blast wave on the body


Stress waves:
Longitudinal pressure forces, supersonic speed Spalling effect at air-tissue interfaces Severe microvascular damage and tissue disruption

Shear waves:
Transversal waves Asynchronous movement of tissue Possible disruption of attachments ear, lungs, colon, gas-filled organs affected with the damage initiating at the tissue-gas interface

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Primary blast injury


Body armor does not protect against the barotrauma of primary blast injury Pulmonary barotrauma is the most common critical injury to people close to a blast center, whether civilian or military Systemic acute gas embolism from pulmonary disruption is believed to occlude the blood vessels of the brain or spinal cord Primary blast injuries are notorious for their delayed onset

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Closed versus open space (greater primary blast injury)

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Blast Injuries: Bus Versus Open-Air Bombings-A Comparative Study of Injuries in Survivors of Open-Air Versus Confined-Space Explosions

J Trauma Volume 41(6), December 1996, pp 1030-1035

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Blast Injuries: Bus Versus Open-Air Bombings-A Comparative Study of Injuries in Survivors of Open-Air Versus Confined-Space Explosions
An overall increased mortality rate with explosions in confined spaces. Immediate survivors of explosions within confined spaces suffer more severe injuries and present to the ED in a less favorable physiologic condition. Confined spaces: higher incidence of primary blast injuries, with a predominance of the more severe pulmonary injuries rather than perforation of tympanic membranes. Burns sustained by victims of explosions in confined spaces affect a larger BSA. No difference in the incidence of significant penetrating trauma, burns, or traumatic amputations between the two settings.
J Trauma Volume 41(6), December 1996, pp 1030-1035

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Blast lung (1)


Direct consequence of the HE over-pressurization wave. Most common fatal primary blast injury among initial survivors. Signs of blast lung usually present at the time of initial evaluation, but reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical triad of apnea, bradycardia, and hypotension.

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Blast lung (2)


Pulmonary injuries vary from scattered petechae to confluent hemorrhages Blast lung should be suspected for anyone with dyspnea, cough, hemoptysis, or chest pain following blast exposure. Characteristic butterfly pattern on chest X-ray. A chest Xray is recommended for all exposed persons

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Ear blast injury


Significant morbidity, but are easily overlooked. Dependent on the orientation of the ear to the blast. TM perforation is the most common injury to the middle ear. Signs of ear injury are usually present at time of initial evaluation: hearing loss, tinnitus, otalgia, vertigo, bleeding from the external canal, TM rupture, or mucopurulent otorhea. All patients exposed to blast should have an otologic assessment and audiometry.

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Blast abdominal injury


Gas-containing sections of the GI tract most vulnerable to primary blast effect. Bowel perforation, hemorrhage (ranging from small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture. abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicularpain, unexplained hypovolemia, or any findings suggestive of an acute abdomen. Clinical findings may be absent until the onset of complications.

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Blast brain injury


Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Primary blast injury can also result in cranial fractures around air-filled sinuses and focal neurologic deficits as a result of air embolism Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms. the signs and symptoms of postconcussion syndrome overlap with those of PTSD

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In the field (1)


Scoop and run approach Needle thoracostomy or endotracheal intubation, early use of tourniquet may be life saving Victims with amputated body parts and no sign of movement + those with no pulse and fixed dilated pupils are considered dead: no further effort

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In the field (2)


Objects that are impaling a person should be removed or manipulated only in an operating room. To facilitate the transport of impaled patients, the objects can be cut or shortened. Transporting patients with long-bone fractures requires temporary splinting to manage pain and also to avert further soft-tissue damage

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Injury Severity Score / AIS


Abbreviated injury scale: categorize the injuries of victims of motor vehicle collisions. Severity from 1 (least severe) to 5 (survival uncertain) within six body regions: head/neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. Nonsurvivable conditions are assigned an AIS of 6. The AIS does not accurately measure the effects of multiple injuries. It is used in coding injuries for other scoring systems or for outcome analysis systems Injury Severity Score The ISS is calculated from the AIS for the three most severely injured regions : ISS = (AIS1) squared + (AIS2) squared + (AIS3) squared

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ISS / other scoring system


ISS limited by: its inability to adjust for the cumulative effect of coexisting injuries in one region (eg, subdural hematoma and intraparenchymal hemorrhage), the lack of a direct linear relationship between increasing score and severity, the lack of consideration of preexisting conditions that may affect trauma outcomes. ISS is a valid predictor of mortality, length of stay in the hospital or intensive care unit, and cost of trauma care. RTS (systolic BP, respiratory rate, GCS) TRISS (ISS +RTS) START: Simple Triage and Rapid Treatment

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Damage control surgery


Surgical concept: the best operation for a patient is one, definite procedure Multiple trauma patients die from coagulopathy, hypothermia, meabolic acidosis DCS: control of haemorrhage, prevention of contamination and protection from further injury ICU: warming, correction of acidosis and coagulopathy Staged procedure (definitie surgical procedure)

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White phosphorus burns (1)


Copious lavage of the area, removing identifiable particles (which should be placed in water to prevent further combustion), and covering the area with saline-soaked gauze to prevent further combustion. Use of a Wood lamp in a darkened resuscitation suite or operating room may help identify WP particles in the wound. Rinse the contaminated burn with copper sulfate solution 1%, remove WP particles, and then use copious saline lavage to rinse off the copper sulfate. Copper sulfate combines with phosphorous particles to create a blue-black cupric phosphide coating. This impedes further WP combustion and makes particles easier to find.

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White phosphorus burns (2)


Never apply copper sulfate as a dressing. Excess copper sulfate absorption can cause intravascular hemolysis and renal failure. WP injury can lead to hypokalemia and hyperphosphatemia with ECG changes, cardiac arrhythmias, and death. Place the patient on a cardiac monitor and closely track serum calcium levels. Intravenous (IV) calcium may be required. Moistened face masks and good ventilation help protect patients and medical personnel from the pulmonary effects of phosphorous pentoxide gas. Naturally, avoid the use of flammable anesthetic agents and excessive oxygen around WP

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Administration of multiple-casualty event


Analysis of blast incidents indicates that "upsidedown" triage is common; less injured patients typically arrive at the hospital, via ambulance or private vehicle, before the most severely injured victims First, peri-incident intensive care management (forward deployment) and second, maintaining a chain of command with efficient triage Patient identification, tracking and documentation

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In the ER
Senior most trauma surgeon take the lead and should define prorities for access to OT Avoid heroic procedures compromising delivery of efficient care to the salvageable victims Risk of undertriage, so repeated assessment should be performed

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Control and coordination: Accordion approach

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Challenges
Many hours and sometimes days are required for the situation to stabilize and eventually normalize Treating teams are physically and emotionally exhausted from the continuous workload, especially when repeat attacks occur within days; Repeated reassessment by the treating teams and SIC to ascertain that all patients receive optimal care is fundamental. In these circumstances, a strong personal commitment by the treating teams and SIC is pivotal to success.
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