Blast/Explosion Event Introduction to: Blast/Explosion Event The University of South Alabama Center for Strategic Health Innovation © University of South Alabama Center For Strategic Health Innovation. All Rights Reserved. These slides are a part of the ARRTC program and cannot be reproduced for commercial purposes.

Objectives Develop a basic understanding of explosions and blast injuries to include: Types of explosives Mechanism of blast injuries Overview of types of injuries Patterns of patient flow to health care facilities overview of injury assessment and treatment concepts I changed the order of objectives and the lead sentence

Blast and Bombing Events United States April 19, 1995 Oklahoma City Bombing- Murrah Building Madrid, Spain- March 1, 2004 Other recent major attacks: India, Pakistan, United Kingdom Most common type of terrorist attack globally. 168 Killed (including 19 children, > 680 Injured 191 Killed, 1800 Injured

Classification of Explosives by Type High-order explosives (HE) Produce a supersonic over- pressurization shock wave (examples: TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil Low-order explosives (LE) Create a subsonic explosion and over pressurization wave. (examples include: pipe bombs, gunpowder, most pure petroleum-based bombs (Molotov cocktails) or aircraft improvised guided missiles From: http://www.cdc.gov/masstrauma/preparedness/primer.pdf Explosive and incendiary (fire) bombs are further characterized based on their source. “Manufactured” implies standard military-issued, mass produced, and quality-tested weapons. “Improvised” describes weapons produced in small quantities, 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 – illegally obtained manufactured weapons or improvised explosive devices (also known as “IEDs”) that may be composed of HE, LE, or both. Manufactured and improvised bombs cause markedly different injuries. Blast

Bomb and Explosion Injury Patterns More serious injuries than usual MVA trauma Higher Injury Severity Score-(ISS) Lower Glasgow Coma Scale- (GCS) Greater ICU need-longer stay Higher hospital mortality Longer rehabilitation

Explosion Injury Profiles Terror Casualties RTA Casualties Penetrating 61% 1.75% Penetrating & Blunt 12% Penetrating, Blunt, Burn 4% Blunt 18% 97.4% Blunt & Burn 2% 0.1% RTA= road taffic associated casualties—Info from article by Peleg—comparing Israeli terrorist attack casualties and RTA’s over 5 year period

Explosion Injuries: Body Regions and Severity Explosions RTA Trauma % ISS 16 + 1 43 9.4% ** 53 6% 2 26 24 % ** 15% 3 15 49% ** 12.5 35% 4 8.6 5.3 5 + 4.6 2.8 For patients with 1, 2 or 3 body regions injured the % of ISS 16 or greater is much higher than RTA patients with same number of body regions involved Above 3 regions injured the % of ISS 16 or greater is more nearly equal

Patterns of Patient Flow to Hospitals Half of all initial casualties will seek medical care over a one hour period These will usually bypass EMS and transport selves to hospital More severely injured will arrive after less severely injured These may require prolonged extrication Will usually be transported via emergency response personnel Took out the patterns of injury statement– it needs a ppt of its own

Blast Injury Mechanisms Primary Secondary Tertiary Quarternary Unique to HE, results from the impact of the over pressurization wave with body surfaces. Gas filled structures are most susceptible: lungs, GI tract and middle ear Blast lung (pulmonary barotrauma) TM rupture and middle ear damage Abdominal hemorrhage and perforation - Globe (eye) rupture Concussion (TBI without physical signs of head injury) Results from flying debris and bomb fragments. Any body part may be affected: Penetrating ballistic (fragmentation) or blunt injuries -Eye penetration (can be occult) Results from individuals being thrown by the blast wind. Any body part may be affected: Fracture and traumatic amputation Closed and open brain injury All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms. - Includes exacerbation or complications of existing conditions. Any body part may be Affected Burns (flash, partial, and full thickness) - Crush injuries Asthma, COPD, or other breathing problems from dust, smoke, or toxic fumes - Angina Hyperglycemia, hypertension

Basic Assessment Focus for Blast Injuries Important: Full impact and scope of injuries may not be immediately visible and may be delayed in onset Key types of injuries and issues to monitor for with blast events: -Trauma related to projectiles, blunt force or impact Potential for fractures Foreign body impalement (glass, shrapnel, nails, etc) Tympanic membrane rupture Can be a ‘red flag’ to monitor for CNS injuries Blast lung/Abdomen Airway obstruction/ compromise Delayed onset of acute abdomen Projectiles of all types and sizes---TM rupture is most common blast injury, but absence does not preclude blast injury in another region– TM rupture may reduce hearing and make patient appear confused on un responsive in the absence of head injury— Blast injury to lung or abdomen may evolve slowly requiring frequent reassessment Air way must be secured early if any sign of respiratory difficulty—air embolism may occur suddenly Industrial and terrorist explosions may be accompanied with exposure to toxic material inhalation

Overview of Explosive-related Injuries System Injury or Condition Auditory TM rupture, ossicular disruption, cochlear damage, foreign body Eye, Orbit, Face Perforated globe, foreign body, air embolism, fractures Respiratory Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of air embolism), airway epithelial damage, aspiration pneumonitis, sepsis Digestive Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism Circulatory Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury CNS injury Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism-induced injury Renal Injury Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia Extremity injury Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism-induced injury http://www.cdc.gov/masstrauma/preparedness/primer.pdf

Basic Overview of Treatment Concepts for Blast Injuries Perform Trauma Assessment Focus on Airway, Breathing and Circulation Airway, oxygen, CPR as indicated; control bleeding and hemorrhage; maintain hemodynamic status with fluid replacement as appropriate** Monitor for trauma- occult injury Stabilize injuries, control bleeding Early imaging– CT scan— head, chest, abdomen Early interventions with appropriate MD specialists ( i.e. Trauma Surgeons) ** Caution: Fluid replacement can be a fine balance between therapeutic and overload depending on injury IV therapy for hemorrhage with hypotension may be complicated by blast injury to lungs--- ventilation of patient may worsen lung injury if high pressures are used

Explosion and Blast Casualties Explosions create instant MCE’s-rapid surge demand at scene and hospital Complex multi-system injuries rarely seen outside of military operations Unique and difficult patient care demands Blasts in closed environments produce increased injury severity***** Importance of history –inside or outside blast Surge requirement for EMS, ED, ICU, Radiology, Trauma Surgery Risk of secondary explosions at hospital in terrorist settings

In Conclusion: Explosions and blast events can be high energy or low energy events Critical patients will arrive to hospitals AFTER the ‘walking well’ Health effects and injuries from blast/explosions may have delayed onset Injuries will be rated as trauma Trauma assessment and interventions is best treatment concepts to implement!

Blasts and Explosions

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