Bombings: Injury Patterns and Care
This project was funded by the Centers for Disease Control and Prevention (CDC) under Cooperative Agreement U 17/CCU 524163 -01, “Linkages of Acute Care and EMS to State and Local Injury Prevention Programs for Terrorism Preparedness and Response. ” Bombings: Injury Patterns and Care
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: n n n 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) Bombings: Injury Patterns and Care 3
A task force was established with representative experts from emergency medicine including physicians, surgeons, nursing, 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 allhazards 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 4
n American College of Emergency Physicians (ACEP) Grant Staff – – – – n 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 and Development Manager Kathryn Mensah, MS, Grants Administrator Mary Whiteside, Ph. D, 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 5
Discussion Topics n n n Background Explosive Events Blast Injuries – Primary, Secondary, Tertiary, Quaternary n n Crush Injuries and Compartment Syndrome Military Experience Special Considerations Psychological Issues Bombings: Injury Patterns and Care 6
Background Bombings: Injury Patterns and Care 7
Background n 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 8
Background n n n 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 9
Background: Historical Perspective n 1968 -1999 – 7000 international terrorist bombings n 1969 -1980 – 187 bombings in Northern Ireland n 1980 -2001 – 324 criminal bombing events in the US n 2001 -2003 – 500 International terrorist bombings n 2005 – 399 International terrorist bombings Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre Bombings: Injury Patterns and Care 10
Background: Blast Devices Photo used with permission of MAJ Benjamin Gonzalez, MD Bombings: Injury Patterns and Care 11
Background: Blast Devices n Improvised explosive devices (IEDs) – – n 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) n n n Rocket propelled grenades (RPGs) Surface to air missiles (SAMs) Enhanced blast devices Bombings: Injury Patterns and Care 12
Background: Blast Devices IEDs n Improvised/“homemade” explosive devices n Made from explosives, commercial blasting supplies, or fertilizer and household ingredients n Designed to cause injury and death n 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 13
Background: Blast Agents High-order explosive: HE Low-order explosive: LE n Nitroglycerin (NTG) n Petroleum products (“Molotov cocktail”) n Dynamite n Gunpowder n Plastic (“black” powder) n Ammonium nitrate/ n Can become HE, if fuel oil (ANFO) contained (e. g. , pipe n Trinitrotoluene (TNT) bomb) n Triacetone triperoxide (TAPT) Bombings: Injury Patterns and Care 14
Explosive Events Bombings: Injury Patterns and Care 15
Explosive Events n Incident command – Entire area = crime scene → evidence preservation – Multi-jurisdictional response n Scene safety – Dirty bombs, secondary devices, building collapse, high dust environment (possibly contaminated), bomb fragments Bombings: Injury Patterns and Care 16
Explosive Events: Criminal Investigation n 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 17
Scene Safety Bombings: Injury Patterns and Care
Scene Safety: Common Hazards n n n n Secondary devices Shrapnel Building collapse Air-borne contaminants Contaminated patients Contaminated scene/environment Perpetrators Terrorist patients Bombings: Injury Patterns and Care 19
Scene Safety: Common Hazards n n n n 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 20
Scene Safety: Appropriate PPE for blasts n n n n 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 21
Scene Safety: Common Principles n Contain the incident – Deny entry to all but responders – Set up zones n n 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 22
Scene Safety: Common Principles n n n Cause no further injury or destruction Protect yourself Activate command hazard response (ICS) Limit access Contain the incident Photo used with permission of Kathryn Brinsfield, MD, FACEP Bombings: Injury Patterns and Care 23
Scene Safety: Common Principles n n n 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 24
Triage Bombings: Injury Patterns and Care 25
Triage n n n 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 26
Triage n n n 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 27
Triage n 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 28
Blast Injuries Bombings: Injury Patterns and Care 29
Blast Injuries: Unique Aspects n n n Inflict multi-system injuries on large groups of people Cause many simultaneous life-threatening injuries Hidden pattern of injury Bombings: Injury Patterns and Care 30
Blast Injuries: Blast Physics n n 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 31
Blast Injuries: Blast Physics Importance of Injury Types vs. Distance Emergency War Surgery, 3 rd Edition Bombings: Injury Patterns and Care Diagram used with permission of John-Phillipe Dionne. Ph. D 32
Background: Physics of Blasts Bombings: Injury Patterns and Care Click to view animation. 33
Blast Injury: Severity n n n 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 34
Murrah Building Bombings: Injury Patterns and Care Photo Courtesy of the City Of Oklahoma City 35
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 36
Russell Square, London bombing, 2005 Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London Bombings: Injury Patterns and Care 37
Mumbai, India: July 2006 Reuters/Prashanth Vishwanathan Bombings: Injury Patterns and Care 38
Blast Injuries: Pathophysiology Proposed mechanisms* n Spalling – Caused by shock wave moving through tissues of different densities → molecular disruption n Implosion – Caused by entrapped gases in hollow organs compressing then expanding → visceral disruption Bombings: Injury Patterns and Care 39
Blast Injuries: Pathophysiology n Shearing – Caused by tissues of different densities moving at different speeds → visceral tearing n 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 40
Blast Injuries: Categories n Primary injury – Caused by blast wave → over pressure n Secondary injury – Caused by flying debris → shrapnel wounds n Tertiary injury – Caused by blast wind → forceful impact n Quaternary injury – Caused by other vectors → heat, radiation Bombings: Injury Patterns and Care 41
Blast Injuries: Primary n Blunt trauma from over pressure wave – Unique to high-order explosives – Results from the impact of the overpressurization wave with body surfaces – Blunt force injuries – Produces barotrauma Bombings: Injury Patterns and Care 42
Diagram used with permission of LTC John Mc. Manus, Jr. , MD, FACEP Bombings: Injury Patterns and Care 43
Blast Injuries: Primary n 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 44
Blast Injuries: Secondary n 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 45
Diagram used with permission of LTC John Mc. Manus, Jr. , MD, FACEP Bombings: Injury Patterns and Care 46
Blast Injuries: Secondary n 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 47
Blast Injuries: Secondary n 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 48
Secondary Injury Used with permission of American Journal of Roentgenology 2006; 187: 609 -616 Bombings: Injury Patterns and Care 49
Blast Injuries: Tertiary n n 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 n Treatment for most tertiary blast injuries follows established protocols for that specific injury. Bombings: Injury Patterns and Care 50
Diagram used with permission of LTC John Mc. Manus, Jr. , MD, FACEP Bombings: Injury Patterns and Care 51
Blast Injuries: Quaternary n 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 52
Blast Injuries: Quaternary n 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 53
Blast Injuries: Blast Lung Used with permission of CHEST, December 1999; 116(6): 1683 -1688 Bombings: Injury Patterns and Care 54
Blast Injuries: Blast Lung Bombings: Injury Patterns and Care Reprinted from American Journal of Surgery, V 190: 945 -950, Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc. 55
Blast Injuries: Blast Lung n Clinical manifestations – – – Tachypnea Hypoxia Cyanosis Apnea Wheezing Decreased breath sounds Hemoptysis Cough Chest pain Dyspnea Hemodynamic instability Bombings: Injury Patterns and Care 56
Blast Injuries: Blast Lung n 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 57
Blast Injuries: Head n Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head Bombings: Injury Patterns and Care 58
Blast Injuries: Head n 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 59
Blast Injuries: TM Rupture n 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 60
Blast Injuries: TM Rupture Used with permission of NEJM, April 2005; 352: 1335 -1342 Bombings: Injury Patterns and Care 61
Blast Injuries: Ear n Ear injuries may include not only TM rupture, but also ossicular disruption, cochlear damage, and foreign bodies. Bombings: Injury Patterns and Care 62
Blast Injuries: Ear n n n 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 63
Blast Injuries: Abdomen n Abdominal injuries (also called blast abdomen) include abdominal hemorrhage and abdominal organ perforation Bombings: Injury Patterns and Care 64
Blast Injuries: Abdomen n 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 65
Blast Injuries: Combined Injuries n Combined injuries, especially blast and burn injury or blast and crush injury, are common during an explosive event. Bombings: Injury Patterns and Care 66
Blast Injuries: Combined Injuries n n Avoid tunnel vision during initial assessment Treatment protocols are often contradictory – Blast lung vs. burn injury, blast lung vs. crush injury n 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 67
Blast Injury: Combined Injuries Typical confined space (e. g. , a bus) injuries n Primary—blast lung, intestinal rupture, TM rupture n Secondary—penetrating injury to head, eye, chest, abdomen n Tertiary—traumatic amputation, fractures to the face, pelvis, ribs, spine n Quaternary— crush injuries, superficial and partial to full thickness burns Bombings: Injury Patterns and Care 68
Military Experience Bombings: Injury Patterns and Care
Military Experience n n n 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 70
Military Experience n Death Rates After Wounding – – – Revolutionary War WWII Korean War Vietnam War Persian Gulf War Global War on Terror (GWOT) Bombings: Injury Patterns and Care 42% 30 ~25 ~25 <10 71
Military Experience n Medical Advances from the GWOT – – – Expanded use of Damage Control Surgery Whole blood Tourniquets Hemostatic agents Hemostatic dressings Bombings: Injury Patterns and Care 72
Military Experience Photo used courtesy of Cybernetics International Bombings: Injury Patterns and Care 73
Military Experience n Damage Control Surgery – Technique known for 20 years, but slow to be accepted – Central tenet: Avoid the “Deadly Triad” n n n Hypothermia Coagulopathy Metabolic acidosis Each condition worsens both of the others Bombings: Injury Patterns and Care 74
Military Experience n Damage Control Surgery – – – Stop the bleeding Remove major contaminants Wounds left open to avoid abdominal compartment syndrome n “Pack ‘em and wrap ‘em” – Transfer to ICU Bombings: Injury Patterns and Care 75
Military Experience n Damage Control Surgery – Resuscitate in ICU: n n n Normalize blood pressure Normalize body temperature Normalize coagulation factors – Return to OR 12 -18 hours for definitive surgery Bombings: Injury Patterns and Care 76
Military Experience n IV Hemostasis – INR>1. 5 on arrival predictive of need for massive transfusion (MT) – Fresh thawed plasma best resuscitation fluid in MT n Optimum ratio of plasma to crystalloid 1: 1 to avoid clotting factor dilution >50% – Less crystalloid (acidotic, inflammatory, adverse effects on coagulation) n Hextend (a colloid) preferable Bombings: Injury Patterns and Care 77
Military Experience n IV Hemostasis – – – Use of fresh whole blood Early use of cryoprecipitate Recombinant Factor VIIa (r. FVlla) Bombings: Injury Patterns and Care 78
Military Experience n 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 79
Military Experience n 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 80
Military Experience n Hem. Con (chitosan) – Originally available as a bandage – Now available in roll that can be stuffed into wound n Quik. Clot – – – Very exothermic (up to 147 deg F) Difficult to debride New Advanced Clotting Sponge (ACS) n Gauze sack – easily removed from wound Bombings: Injury Patterns and Care 81
Special Considerations Bombings: Injury Patterns and Care
Special Considerations n n n Pregnancy Children Elderly Disabled Language barriers Bombings: Injury Patterns and Care 83
Special Considerations: Pregnancy n n 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 84
Special Considerations: Children n n 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 85
Special Considerations: Elderly n n n May be at a higher risk of mortality and the inhospital 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 86
Special Considerations: Disabled n n 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 87
Special Considerations: Language Barriers n n Diverse population speaking multiple languages may be an unforeseen obstacle Interaction with the deaf, hard of hearing, latedeafened 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 88
Photo used courtesy of Kwikpoint Bombings: Injury Patterns and Care 89
Psychological Issues Bombings: Injury Patterns and Care
Psychological Issues n Sequelae from an explosive event – – Anger Frustration Helplessness Desire to seek revenge Bombings: Injury Patterns and Care 91
Psychological Issues n 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 92
Psychological Issues n Tips for Responders – – – Promotion of safety Promote calm Promote connectedness Promote self-efficacy Promote hope Bombings: Injury Patterns and Care 93
Discussion Topics: Review n n n Background Explosive Events Blast Injuries – Primary, Secondary, Tertiary, Quaternary n n Crush Injuries and Compartment Syndrome Military Experience Special Considerations Psychological Issues Bombings: Injury Patterns and Care 94
Discussion Topics Surge Capacity Issues n Hospital after Madrid bombing saw 312 patients in 2. 5 hours n Need to surge: CT, OR suites, staff, and supplies (blood, etc. ) n Hidden nature of injuries can lead to dangerous overtriage and undertriage Bombings: Injury Patterns and Care 95
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