Bombings: Injury Patterns and Care

This project was funded by the Centers for Disease Control and Prevention (CDC) under Cooperative Agreement U17/CCU , “Linkages of Acute Care and EMS to State and Local Injury Prevention Programs for Terrorism Preparedness and Response.”

Bombings: Injury Patterns and Care3 American Medical Association (AMA) American Medical Association (AMA) American Trauma Society (ATS) American Trauma Society (ATS) National Association of EMS Physicians (NAEMSP) National Association of EMS Physicians (NAEMSP) National Association of EMT’s (NAEMT) National Association of EMT’s (NAEMT) National Association of State EMS Officials (NASEMSO) National Association of State EMS Officials (NASEMSO) National Native American EMS Association (NNAEMSA) National Native American EMS Association (NNAEMSA) 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:

Bombings: Injury Patterns and Care4 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 all- hazards 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 Care5 American College of Emergency Physicians (ACEP) Grant Staff – –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, PhD, 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 Care6 Discussion Topics Background Background Explosive Events Explosive Events Blast Injuries Blast Injuries –Primary, Secondary, Tertiary, Quaternary Crush Injuries and Compartment Syndrome Crush Injuries and Compartment Syndrome Military Experience Military Experience Special Considerations Special Considerations Psychological Issues Psychological Issues

Bombings: Injury Patterns and Care7 Background

8 Background Terrorism can be defined as containing four key elements: Terrorism can be defined as containing four key elements: –Premeditated –Political –Aimed at civilians –Carried out by sub-national groups

Bombings: Injury Patterns and Care9 Background Explosive use increasing in terrorist events Explosive use increasing in terrorist events Result in mass casualty incidents Result in mass casualty incidents Recent examples Recent examples –Mumbai (2006) –Tel Aviv (2006) –London subway (2005) –Madrid subway (2004) –Tel Aviv (2001)

Bombings: Injury Patterns and Care10 Background: Historical Perspective –7000 international terrorist bombings –187 bombings in Northern Ireland –324 criminal bombing events in the US –500 International terrorist bombings –399 International terrorist bombings Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre

Bombings: Injury Patterns and Care11 Background: Blast Devices Photo used with permission of MAJ Benjamin Gonzalez, MD

Bombings: Injury Patterns and Care12 Background: Blast Devices Improvised explosive devices (IEDs) Improvised explosive devices (IEDs) –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 Incendiary bombs –Airplane bombs (World Trade Center II, Pentagon) Rocket propelled grenades (RPGs) Rocket propelled grenades (RPGs) Surface to air missiles (SAMs) Surface to air missiles (SAMs) Enhanced blast devices Enhanced blast devices

Bombings: Injury Patterns and Care13 Background: Blast Devices IEDs Improvised/“homemade” explosive devices Improvised/“homemade” explosive devices Made from explosives, commercial blasting supplies, or fertilizer and household ingredients Made from explosives, commercial blasting supplies, or fertilizer and household ingredients Designed to cause injury and death Designed to cause injury and death Often packed with metal objects such as nails or ball bearings; could contain toxic chemicals or radiological materials (dirty bomb) Often packed with metal objects such as nails or ball bearings; could contain toxic chemicals or radiological materials (dirty bomb)

Bombings: Injury Patterns and Care14 Background: Blast Agents High-order explosive: HE Nitroglycerin (NTG) Nitroglycerin (NTG) Dynamite Dynamite Plastic Plastic Ammonium nitrate/ fuel oil (ANFO) Ammonium nitrate/ fuel oil (ANFO) Trinitrotoluene (TNT ) Trinitrotoluene (TNT ) Triacetone triperoxide (TAPT) Triacetone triperoxide (TAPT) Low-order explosive: LE Petroleum products Petroleum products (“Molotov cocktail”) Gunpowder Gunpowder (“black” powder) Can become HE, if contained (e.g., pipe bomb) Can become HE, if contained (e.g., pipe bomb)

Bombings: Injury Patterns and Care15 Explosive Events

Bombings: Injury Patterns and Care16 Explosive Events Incident command Incident command –Entire area = crime scene → evidence preservation –Multi-jurisdictional response Scene safety Scene safety –Dirty bombs, secondary devices, building collapse, high dust environment (possibly contaminated), bomb fragments

Bombings: Injury Patterns and Care17 Explosive Events: Criminal Investigation Principles of criminal investigation and evidence preservation 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

Scene Safety

Bombings: Injury Patterns and Care19 Scene Safety: Common Hazards Secondary devices Secondary devices Shrapnel Shrapnel Building collapse Building collapse Air-borne contaminants Air-borne contaminants Contaminated patients Contaminated patients Contaminated scene/environment Contaminated scene/environment Perpetrators Perpetrators Terrorist patients Terrorist patients

Bombings: Injury Patterns and Care20 Scene Safety: Common Hazards Victims with no soft tissue injuries Victims with no soft tissue injuries Vehicles coming or leaving scene (out of place) Vehicles coming or leaving scene (out of place) People acting oddly People acting oddly Packages or containers at scene (out of place) Packages or containers at scene (out of place) Vehicles not damaged or out of place Vehicles not damaged or out of place Structural damage Structural damage Weather Weather Possible places for secondary devices Possible places for secondary devices

Bombings: Injury Patterns and Care21 Scene Safety: Appropriate PPE for blasts Coveralls Coveralls Heavy coat Heavy coat Heavy gloves Heavy gloves Steel-toed boots Steel-toed boots Hard hat Hard hat Eye protection Eye protection Dust particle mask Dust particle mask Breathing apparatus for toxic fumes Breathing apparatus for toxic fumes

Bombings: Injury Patterns and Care22 Scene Safety: Common Principles Contain the incident Contain the incident –Deny entry to all but responders –Set up zones Hot Hot Warm Warm Cold Cold Contain the people 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 Care23 Scene Safety: Common Principles Cause no further injury or destruction Cause no further injury or destruction Protect yourself Protect yourself Activate command and hazard response (ICS) Activate command and hazard response (ICS) Limit access Limit access Contain the incident Contain the incident Photo used with permission of Kathryn Brinsfield, MD, FACEP

Bombings: Injury Patterns and Care24 Scene Safety: Common Principles Worker safety Worker safety Protection of uninvolved public and volunteers Protection of uninvolved public and volunteers Protection of injured Protection of injured Treatment of injured Treatment of injured Surveillance of patients and workers for long-term effects Surveillance of patients and workers for long-term effects

Bombings: Injury Patterns and Care25 Triage

Bombings: Injury Patterns and Care26 Triage Unique patterns, multiple and occult injuries Unique patterns, multiple and occult injuries Death often result of combined blast, ballistic, and thermal effect injuries (multidimensional injury) Death often result of combined blast, ballistic, and thermal effect injuries (multidimensional injury) Walking wounded Walking wounded Hidden/internal injuries Hidden/internal injuries Many non-critical patients who require time intensive workups Many non-critical patients who require time intensive workups

Bombings: Injury Patterns and Care27 Triage Nature of injuries may lead to overtriage Nature of injuries may lead to overtriage Up to 75% of victims self-refer to hospital; arrive by private transportation Up to 75% of victims self-refer to hospital; arrive by private transportation Field triage Field triage –Dynamic process

Bombings: Injury Patterns and Care28 Triage Factors that determine when needs exceed resources 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 Care29 Blast Injuries

Bombings: Injury Patterns and Care30 Blast Injuries: Unique Aspects Inflict multi-system injuries on large groups of people Inflict multi-system injuries on large groups of people Cause many simultaneous life-threatening injuries Cause many simultaneous life-threatening injuries Hidden pattern of injury Hidden pattern of injury

Bombings: Injury Patterns and Care31 Blast Injuries: Blast Physics Rapid chemical conversion of a solid or liquid into highly pressurized gases Rapid chemical conversion of a solid or liquid into highly pressurized gases Gases expand rapidly and compress the surrounding air Gases expand rapidly and compress the surrounding air Pressure wave and blast wind are generated and spread in all directions 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 Is affected by the medium through which it travels, i.e., air vs. water

Bombings: Injury Patterns and Care32 Blast Injuries: Blast Physics Emergency War Surgery, 3rd Edition Importance of Injury Types vs. Distance Diagram used with permission of John-Phillipe Dionne. PhD

Bombings: Injury Patterns and Care33 Background: Physics of Blasts Click to view animation.

Bombings: Injury Patterns and Care34 Blast Injury: Severity Nature of device – agent, amount Nature of device – agent, amount Method of delivery – incendiary, explosive Method of delivery – incendiary, explosive Nature of environment – open, closed Nature of environment – open, closed Distance from device Distance from device Intervening protective barrier Intervening protective barrier Other environmental hazards Other environmental hazards

Bombings: Injury Patterns and Care35 Murrah Building Photo Courtesy of the City Of Oklahoma City

Bombings: Injury Patterns and Care36 Murrah Federal Building, Oklahoma City (1993) – distribution of injuries JAMA, August 1996, 276 (5): © 1996 American Medical Association

Bombings: Injury Patterns and Care37 Russell Square, London bombing, 2005 Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London

Bombings: Injury Patterns and Care38 Mumbai, India: July 2006 Reuters/Prashanth Vishwanathan

Bombings: Injury Patterns and Care39 Blast Injuries: Pathophysiology Proposed mechanisms* Spalling Spalling –Caused by shock wave moving through tissues of different densities → molecular disruption Implosion Implosion –Caused by entrapped gases in hollow organs compressing then expanding → visceral disruption

Bombings: Injury Patterns and Care40 Blast Injuries: Pathophysiology Shearing Shearing –Caused by tissues of different densities moving at different speeds → visceral tearing Irreversible Work 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 Care41 Blast Injuries: Categories Primary injury Primary injury –Caused by blast wave → over pressure Secondary injury Secondary injury –Caused by flying debris → shrapnel wounds Tertiary injury Tertiary injury –Caused by blast wind → forceful impact Quaternary injury Quaternary injury –Caused by other vectors → heat, radiation

Bombings: Injury Patterns and Care42 Blast Injuries: Primary Blunt trauma from over pressure wave Blunt trauma from over pressure wave –Unique to high-order explosives –Results from the impact of the over- pressurization wave with body surfaces –Blunt force injuries –Produces barotrauma

Bombings: Injury Patterns and Care43 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

Bombings: Injury Patterns and Care44 Blast Injuries: Primary Most common injuries: 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 Care45 Blast Injuries: Secondary 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. 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 Care46 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

Bombings: Injury Patterns and Care47 Blast Injuries: Secondary The most common types of secondary blast injuries are: 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 Care48 Blast Injuries: Secondary Penetrating trauma (shrapnel wounds) 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 Care49 Secondary Injury Used with permission of American Journal of Roentgenology 2006; 187:

Bombings: Injury Patterns and Care50 Blast Injuries: Tertiary Tertiary injuries result from individuals being thrown by the blast wind. Tertiary injuries result from individuals being thrown by the blast wind. The most common types of tertiary blast injuries are: The most common types of tertiary blast injuries are: –Head injuries –Skull fractures –Bone fractures Treatment for most tertiary blast injuries follows established protocols for that specific injury. Treatment for most tertiary blast injuries follows established protocols for that specific injury.

Bombings: Injury Patterns and Care51 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

Bombings: Injury Patterns and Care52 Blast Injuries: Quaternary 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. 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 Care53 Blast Injuries: Quaternary The most common quaternary blast injuries include: The most common quaternary blast injuries include: –Burns –Head injuries –Asthma –COPD –Other breathing problems –Angina –Hyperglycemia –Hypertension –Crush injuries

Bombings: Injury Patterns and Care54 Blast Injuries: Blast Lung Used with permission of CHEST, December 1999; 116(6):

Bombings: Injury Patterns and Care55 Blast Injuries: Blast Lung Reprinted from American Journal of Surgery, V190: , Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc.

Bombings: Injury Patterns and Care56 Blast Injuries: Blast Lung Clinical manifestations Clinical manifestations –Tachypnea –Hypoxia –Cyanosis –Apnea –Wheezing –Decreased breath sounds –Hemoptysis –Cough –Chest pain –Dyspnea –Hemodynamic instability

Bombings: Injury Patterns and Care57 Blast Injuries: Blast Lung Treatment 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 Care58 Blast Injuries: Head Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head

Bombings: Injury Patterns and Care59 Blast Injuries: Head Consider the proximity of the victim to the blast particularly when given complaints of: 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 Care60 Blast Injuries: TM Rupture 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. 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 Care61 Blast Injuries: TM Rupture Used with permission of NEJM, April 2005; 352:

Bombings: Injury Patterns and Care62 Blast Injuries: Ear Ear injuries may include not only TM rupture, but also ossicular disruption, cochlear damage, and foreign bodies. Ear injuries may include not only TM rupture, but also ossicular disruption, cochlear damage, and foreign bodies.

Bombings: Injury Patterns and Care63 Blast Injuries: Ear Presentation: acute hearing loss (conductive, sensorineural) Presentation: acute hearing loss (conductive, sensorineural) Findings: auditory canal debris, tympanic membrane rupture, ossicular disruption, cochlear damage 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 Treatment: observation; 50-80% of ruptured tympanic membranes heal; sensorineural hearing loss often permanent

Bombings: Injury Patterns and Care64 Blast Injuries: Abdomen Abdominal injuries (also called blast abdomen) include abdominal hemorrhage and abdominal organ perforation Abdominal injuries (also called blast abdomen) include abdominal hemorrhage and abdominal organ perforation

Bombings: Injury Patterns and Care65 Blast Injuries: Abdomen Clinical manifestations include: 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 Care66 Blast Injuries: Combined Injuries Combined injuries, especially blast and burn injury or blast and crush injury, are common during an explosive event. Combined injuries, especially blast and burn injury or blast and crush injury, are common during an explosive event.

Bombings: Injury Patterns and Care67 Blast Injuries: Combined Injuries Avoid tunnel vision during initial assessment Avoid tunnel vision during initial assessment Treatment protocols are often contradictory Treatment protocols are often contradictory –Blast lung vs. burn injury, blast lung vs. crush injury Judicious fluid administration for adequate tissue perfusion without volume overload may be required in the multiple injured patient with blast lung 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 Care68 Blast Injury: Combined Injuries Typical confined space (e.g., a bus) injuries Primary—blast lung, intestinal rupture, TM rupture Primary—blast lung, intestinal rupture, TM rupture Secondary—penetrating injury to head, eye, chest, abdomen Secondary—penetrating injury to head, eye, chest, abdomen Tertiary—traumatic amputation, fractures to the face, pelvis, ribs, spine Tertiary—traumatic amputation, fractures to the face, pelvis, ribs, spine Quaternary— crush injuries, superficial and partial to full thickness burns Quaternary— crush injuries, superficial and partial to full thickness burns

Military Experience

Bombings: Injury Patterns and Care70 Military Experience U.S. Military has significant experience in dealing with blast and explosive injuries 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 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 Mortality rates dramatically lower for the current conflict

Bombings: Injury Patterns and Care71 Military Experience Death Rates After Wounding Death Rates After Wounding –Revolutionary War 42% –WWII 30 –KoreanWar~25 –Vietnam War~25 –Persian Gulf War~25 –Global War on Terror (GWOT)<10

Bombings: Injury Patterns and Care72 Military Experience Medical Advances from the GWOT Medical Advances from the GWOT –Expanded use of Damage Control Surgery –Whole blood –Tourniquets –Hemostatic agents –Hemostatic dressings

Bombings: Injury Patterns and Care73 Military Experience Photo used courtesy of Cybernetics International

Bombings: Injury Patterns and Care74 Military Experience Damage Control Surgery Damage Control Surgery –Technique known for 20 years, but slow to be accepted –Central tenet: Avoid the “Deadly Triad” Hypothermia Hypothermia Coagulopathy Coagulopathy Metabolic acidosis Metabolic acidosis Each condition worsens both of the others

Bombings: Injury Patterns and Care75 Military Experience Damage Control Surgery Damage Control Surgery –Stop the bleeding –Remove major contaminants –Wounds left open to avoid abdominal compartment syndrome “Pack ‘em and wrap ‘em” “Pack ‘em and wrap ‘em” –Transfer to ICU

Bombings: Injury Patterns and Care76 Military Experience Damage Control Surgery Damage Control Surgery –Resuscitate in ICU: Normalize blood pressure Normalize blood pressure Normalize body temperature Normalize body temperature Normalize coagulation factors Normalize coagulation factors –Return to OR hours for definitive surgery

Bombings: Injury Patterns and Care77 Military Experience IV Hemostasis IV Hemostasis –INR>1.5 on arrival predictive of need for massive transfusion (MT) –Fresh thawed plasma best resuscitation fluid in MT Optimum ratio of plasma to crystalloid 1:1 to avoid clotting factor dilution >50% Optimum ratio of plasma to crystalloid 1:1 to avoid clotting factor dilution >50% –Less crystalloid (acidotic, inflammatory, adverse effects on coagulation) Hextend (a colloid) preferable Hextend (a colloid) preferable

Bombings: Injury Patterns and Care78 Military Experience IV Hemostasis IV Hemostasis –Use of fresh whole blood –Early use of cryoprecipitate –Recombinant Factor VIIa (rFVlla)

Bombings: Injury Patterns and Care79 Military Experience Tourniquets 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 Care80 Military Experience Hemostatic Dressings 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 Care81 Military Experience HemCon (chitosan) HemCon (chitosan) –Originally available as a bandage –Now available in roll that can be stuffed into wound QuikClot QuikClot –Very exothermic (up to 147 deg F) –Difficult to debride –New Advanced Clotting Sponge (ACS) Gauze sack – easily removed from wound Gauze sack – easily removed from wound

Special Considerations

Bombings: Injury Patterns and Care83 Special Considerations Pregnancy Pregnancy Children Children Elderly Elderly Disabled Disabled Language barriers Language barriers

Bombings: Injury Patterns and Care84 Special Considerations: Pregnancy Injuries to the placenta are possible and must be detected Injuries to the placenta are possible and must be detected Second or third trimester of pregnancy should be admitted for continuous fetal monitoring Second or third trimester of pregnancy should be admitted for continuous fetal monitoring The placental attachment is at risk for primary blast injury The placental attachment is at risk for primary blast injury Screening test for fetal-maternal hemorrhage in second or third trimester of pregnancy 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 Care85 Special Considerations: Children History of event or patient’s complaints may be difficult to obtain. 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. 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 Specialized equipment Identification of regional pediatric trauma facilities Identification of regional pediatric trauma facilities

Bombings: Injury Patterns and Care86 Special Considerations: Elderly May be at a higher risk of mortality and the in- hospital stay may be longer and more complicated May be at a higher risk of mortality and the in- hospital stay may be longer and more complicated Orthopedic injuries may be more prevalent Orthopedic injuries may be more prevalent Blunt chest trauma should be of special consideration Blunt chest trauma should be of special consideration Decontamination methods may need modification due to limited mobility 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 Technical decontamination of medical equipment such as wheelchairs, walkers and other walking aides may be needed

Bombings: Injury Patterns and Care87 Special Considerations: Disabled Consideration should be given to patients with underlying medical conditions Consideration should be given to patients with underlying medical conditions Untreated or inadequately treated fractures may lead to severe and long lasting disabilities Untreated or inadequately treated fractures may lead to severe and long lasting disabilities

Bombings: Injury Patterns and Care88 Special Considerations: Language Barriers Diverse population speaking multiple languages may be an unforeseen obstacle Diverse population speaking multiple languages may be an unforeseen obstacle Interaction with the deaf, hard of hearing, late- deafened and the deaf-blind Interaction with the deaf, hard of hearing, late- deafened and the deaf-blind History of the event maybe difficult to obtain as well as the individual history for the patient. History of the event maybe difficult to obtain as well as the individual history for the patient. Translation Translation –On scene resources –Pool of medical interpreters including sign language –Telephone translation services

Bombings: Injury Patterns and Care89 Photo used courtesy of Kwikpoint

Psychological Issues

Bombings: Injury Patterns and Care91 Psychological Issues Sequelae from an explosive event Sequelae from an explosive event –Anger –Frustration –Helplessness –Desire to seek revenge

Bombings: Injury Patterns and Care92 Psychological Issues Events that affect mental health 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 Care93 Psychological Issues Tips for Responders Tips for Responders –Promotion of safety –Promote calm –Promote connectedness –Promote self-efficacy –Promote hope

Bombings: Injury Patterns and Care94 Discussion Topics: Review Background Background Explosive Events Explosive Events Blast Injuries Blast Injuries –Primary, Secondary, Tertiary, Quaternary Crush Injuries and Compartment Syndrome Crush Injuries and Compartment Syndrome Military Experience Military Experience Special Considerations Special Considerations Psychological Issues Psychological Issues

Bombings: Injury Patterns and Care95 Discussion Topics Surge Capacity Issues Hospital after Madrid bombing saw 312 patients in 2.5 hours Hospital after Madrid bombing saw 312 patients in 2.5 hours Need to surge: CT, OR suites, staff, and supplies (blood, etc.) Need to surge: CT, OR suites, staff, and supplies (blood, etc.) Hidden nature of injuries can lead to dangerous overtriage and undertriage Hidden nature of injuries can lead to dangerous overtriage and undertriage