1. Bombings: Injury Patterns and Care

2. This project was funded by the Centers for Disease Control and Prevention (CDC) under Cooperative Agreement U17/CCU524163-01, “Linkages of Acute Care and EMS to State and Local Injury Prevention Programs for Terrorism Preparedness and Response.”

3. 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:

4. 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.

5. 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

6. 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

7. Bombings: Injury Patterns and Care7 Background

8. 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

9. 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)

10. Bombings: Injury Patterns and Care10 Background: Historical Perspective 1968-1999 1968-1999 –7000 international terrorist bombings 1969-1980 1969-1980 –187 bombings in Northern Ireland 1980-2001 1980-2001 –324 criminal bombing events in the US 2001-2003 2001-2003 –500 International terrorist bombings 2005 2005 –399 International terrorist bombings Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre

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

12. 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

13. 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)

14. 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) Trinitrotolue (TNT ) Trinitrotolue (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)

15. Bombings: Injury Patterns and Care15 Explosive Events

16. 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

17. 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

18. Scene Safety

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Bombings: Injury Patterns and Care25 Triage

26. 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

27. 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

28. 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

29. Bombings: Injury Patterns and Care29 Blast Injuries

30. 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

31. 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

32. 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

33. Bombings: Injury Patterns and Care33 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

34. Bombings: Injury Patterns and Care34 Murrah Building Photo Courtesy of the City Of Oklahoma City

35. Bombings: Injury Patterns and Care35 Murrah Federal Building, Oklahoma City (1993) – distribution of injuries JAMA, August 1996, 276 (5): 382-387 © American Medical Association

36. Bombings: Injury Patterns and Care36 Russell Square, London bombing, 2005 Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London

37. Bombings: Injury Patterns and Care37 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

38. Bombings: Injury Patterns and Care38 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.

39. Bombings: Injury Patterns and Care39 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

40. Bombings: Injury Patterns and Care40 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

41. Bombings: Injury Patterns and Care41 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

42. Bombings: Injury Patterns and Care42 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

43. Bombings: Injury Patterns and Care43 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.

44. Bombings: Injury Patterns and Care44 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

45. Bombings: Injury Patterns and Care45 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

46. Bombings: Injury Patterns and Care46 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

47. Bombings: Injury Patterns and Care47 Secondary Injury Used with permission of American Journal of Roentgenology 2006; 187:609-616

48. Bombings: Injury Patterns and Care48 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.

49. Bombings: Injury Patterns and Care49 Diagram used with permission of LTC John McManus, Jr., MD, FACEP

50. Bombings: Injury Patterns and Care50 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.

51. Bombings: Injury Patterns and Care51 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

52. Bombings: Injury Patterns and Care52 Blast Injuries: Blast Lung Used with permission of CHEST, December 1999; 116(6): 1683-1688

53. Bombings: Injury Patterns and Care53 Blast Injuries: Blast Lung Reprinted from American Journal of Surgery, V190: 945-950, Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc.

54. Bombings: Injury Patterns and Care54 Blast Injuries: Blast Lung Clinical manifestations Clinical manifestations –Tachypnea –Hypoxia –Cyanosis –Apnea –Wheezing –Decreased breath sounds –Hemoptysis –Cough –Chest pain –Dyspnea –Hemodynamic instability

55. Bombings: Injury Patterns and Care55 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)

56. Bombings: Injury Patterns and Care56 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

57. Bombings: Injury Patterns and Care57 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

58. Bombings: Injury Patterns and Care58 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.

59. Bombings: Injury Patterns and Care59 Blast Injuries: TM Rupture Used with permission of NEJM, April 2005; 352: 1335-1342

60. Bombings: Injury Patterns and Care60 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.

61. Bombings: Injury Patterns and Care61 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

62. Bombings: Injury Patterns and Care62 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

63. Bombings: Injury Patterns and Care63 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

64. Bombings: Injury Patterns and Care64 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.

65. Bombings: Injury Patterns and Care65 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

66. Bombings: Injury Patterns and Care66 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

67. Crush Injury

68. Bombings: Injury Patterns and Care68 Crush Injury: Definition An injury sustained when a body part is subjected to a high degree, or prolonged presence, of force or pressure An injury sustained when a body part is subjected to a high degree, or prolonged presence, of force or pressure –Usually applied to both regional (e.g. body part) effects and systemic effects. Acute traumatic ischemia, with or without associated injuries, describes actual insult to tissues Acute traumatic ischemia, with or without associated injuries, describes actual insult to tissues

69. Bombings: Injury Patterns and Care69 Crush Injury: Crush Syndrome Term used to describe the systems manifestations of crush injury after reperfusion of affected body part(s) Term used to describe the systems manifestations of crush injury after reperfusion of affected body part(s) Reprinted with permission of OrthoWorld.com

70. Bombings: Injury Patterns and Care70 Crush Injury: Compartment Syndrome Is a collection of localized signs and symptoms that result when the perfusion pressure falls below the tissue pressure in a closed anatomic space for sufficient time that compromise of circulation and function of tissues involved occurs Is a collection of localized signs and symptoms that result when the perfusion pressure falls below the tissue pressure in a closed anatomic space for sufficient time that compromise of circulation and function of tissues involved occurs

71. Bombings: Injury Patterns and Care71 Crush Injury: Incidence 5-15% of mass casualty situations 5-15% of mass casualty situations –Natural disasters, especially earthquakes and tornadoes –Structural collapse, with or without victim entrapment –Industrial, farm or transportation accidents –Blast injury (all types) –Combat –Prolonged immobilization with major vascular or microvascular circulation compromise

72. Bombings: Injury Patterns and Care72 Crush Injury: Examples of events Tyre, Lebanon (1982) Tyre, Lebanon (1982) –Building collapse Beirut, Lebanon (1983) Beirut, Lebanon (1983) –Marine barracks bombed Oklahoma City (1995) Oklahoma City (1995) –Murrah Federal Building bombed Khobar, Saudi Arabia (1996) Khobar, Saudi Arabia (1996) –Khobar Towers bombed Used with permission of AP Photo/KM Chaudhry

73. Bombings: Injury Patterns and Care73 Crush Injury: Pathophysiology Areas most affected Areas most affected –Lower extremities –Upper extremities –Pelvis –Gluteal region –Abdominal muscles Reprinted with permission of OrthoWorld.com

74. Crush Syndrome

75. Bombings: Injury Patterns and Care75 Crush Syndrome May occur in absence of trauma and evolve in the absence of early signs or symptoms May occur in absence of trauma and evolve in the absence of early signs or symptoms –Arterial thrombosis or embolism –Severe anemia –Toxins –Legitimate medications and drugs of abuse Systemic effects due to rhabdomyolysis and reperfusion of hypoxic and damaged tissues and is the major cause of early mortality Systemic effects due to rhabdomyolysis and reperfusion of hypoxic and damaged tissues and is the major cause of early mortality

76. Bombings: Injury Patterns and Care76 Crush Syndrome: Pathophysiology Rhabdomyolysis Efflux from damaged muscle cells of: Efflux from damaged muscle cells of: –Potassium –Purines –Lactic Acid –Phosphate –Myoglobin –Thromboplastin –Creatine

77. Bombings: Injury Patterns and Care77 Crush Syndrome : Pathophysiology Reperfusion Reperfusion –Skeletal muscle damage greatest after reperfusion –Superoxide radicals produced during reperfusion attacks free fatty acids, producing cellular edema, death, and necrosis –Na-K-ATP pump exchanges intracellular sodium for calcium with further derangement of intracellular metabolism

78. Bombings: Injury Patterns and Care78 Crush Syndrome: Pathophysiology Resultant effects of derangements due to rhabdomyolysis and reperfusion Resultant effects of derangements due to rhabdomyolysis and reperfusion Potassium  Hyperkalemia  Arrythmias Potassium  Hyperkalemia  Arrythmias Calcium  Hypocalcemia  Arrythmias Calcium  Hypocalcemia  Arrythmias Phosphate  Hyperphosphatemia  Renal damage Phosphate  Hyperphosphatemia  Renal damage Myoglobin  Myoglobinemia  Renal damage Myoglobin  Myoglobinemia  Renal damage Fluid shifts  Hypovolemia  Renal failure Fluid shifts  Hypovolemia  Renal failure Reperfusion  Free radicals  Renal damage Reperfusion  Free radicals  Renal damage Purines  Hyperuricemia  Renal damage Purines  Hyperuricemia  Renal damage Hypoxemia  Lactic acid  Acidosis Hypoxemia  Lactic acid  Acidosis Thromboplastin  Complement system  DIC Thromboplastin  Complement system  DIC Creatinine  Elevated serum levels Creatinine  Elevated serum levels Sodium  Azotemia Sodium  Azotemia

79. Bombings: Injury Patterns and Care79 Crush Syndrome: Clinical Presentation General condition of a patient with crush injury dictated by other injuries, delay in extrication, environmental conditions General condition of a patient with crush injury dictated by other injuries, delay in extrication, environmental conditions Common presentations Common presentations –Hypothermia or hyperthermia –Dehydration/shock –Mental status varies from alert to comatose

80. Bombings: Injury Patterns and Care80 Crush Syndrome: Clinical Presentation Affected part (usually limb) Affected part (usually limb) –Tense edema and decreased sensation –Overlying skin may be shiny, contused, necrotic May have penetrating wounds (worse diagnosis) May have penetrating wounds (worse diagnosis)

81. Bombings: Injury Patterns and Care81 Crush Syndrome: Potential Complications Hyperkalemia Hyperkalemia Hypocalcemia Hypocalcemia Hyperphosphatemia Hyperphosphatemia Metabolic acidosis Metabolic acidosis Hypothermia Hypothermia Acute Renal failure Acute Renal failure

82. Bombings: Injury Patterns and Care82 Crush Syndrome: Treatment Greatest initial danger is after release of crushed limb from entrapment with restoration of circulation Greatest initial danger is after release of crushed limb from entrapment with restoration of circulation Mainstay of treatment is aggressive fluid resuscitation and brisk diuresis Mainstay of treatment is aggressive fluid resuscitation and brisk diuresis Amount of tissue damage correlates with need for dialysis Amount of tissue damage correlates with need for dialysis –Cannot determine actual tissue damage based on area of affected body part

83. Bombings: Injury Patterns and Care83 Crush Syndrome: Treatment Delay in treatment associated with greater morbidity and mortality Delay in treatment associated with greater morbidity and mortality –50% renal failure at 6 hours –100% renal failure at 12 hours –Rhabdomyolysis induced renal failure has 40% mortality

84. Bombings: Injury Patterns and Care84 Crush Syndrome: Treatment Pre-hospital Primary survey and initial stabilization (ABCs) Primary survey and initial stabilization (ABCs) Fluid resuscitation before patient is extricated with severe or prolonged entrapment of limb or pelvis (more than a hand or foot) Fluid resuscitation before patient is extricated with severe or prolonged entrapment of limb or pelvis (more than a hand or foot)

85. Bombings: Injury Patterns and Care85 Crush Syndrome: Treatment Hospital Fluid resuscitation Fluid resuscitation Brisk diuresis Brisk diuresis Diagnose and treat other metabolic derangements Diagnose and treat other metabolic derangements –Hyperkalemia –Hypocalcemia Treat tissue damage Treat tissue damage Pain control Pain control Agitation Agitation

86. Compartment Syndrome

87. Bombings: Injury Patterns and Care87 Compartment Syndrome Is a collection of localized signs and symptoms that result when the perfusion pressure falls below the tissue pressure in a closed anatomic space for sufficient time that compromise of circulation and function of tissues involved occurs Is a collection of localized signs and symptoms that result when the perfusion pressure falls below the tissue pressure in a closed anatomic space for sufficient time that compromise of circulation and function of tissues involved occurs

88. Bombings: Injury Patterns and Care88 Compartment Syndrome Can lead to crush syndrome systemic effects if left untreated or inadequately treated. Can lead to crush syndrome systemic effects if left untreated or inadequately treated. Photo used with permission of The Institute for Foot and Ankle Reconstruction at Mercy, Baltimore, MD

89. Bombings: Injury Patterns and Care89 Compartment Syndrome Suggestive clinical findings Similar settings to crush injury, but may also occur with subacute trauma Similar settings to crush injury, but may also occur with subacute trauma Bone fractures Bone fractures High velocity penetrating injury to muscles in closed compartment with extensive tissue disruption High velocity penetrating injury to muscles in closed compartment with extensive tissue disruption Can also occur in subacute fashion due to prolonged immobilization on hard surface Can also occur in subacute fashion due to prolonged immobilization on hard surface

90. Bombings: Injury Patterns and Care90 Compartment Syndrome: Pathophysiology Significance of muscle mass damage Significance of muscle mass damage Only occurs in major muscle groups enclosed by inelastic, fibrous sheaths Only occurs in major muscle groups enclosed by inelastic, fibrous sheaths Tissue/muscle damage results in edema in a closed volume space Tissue/muscle damage results in edema in a closed volume space –Progressive cycle of edema, perfusion compromise, tissue hypoxia and cellular derangement, further edema, etc. –Untreated, will produce same effects as crush injury

91. Bombings: Injury Patterns and Care91 Compartment Syndrome: Clinical Presentation The 5 P’s The 5 P’s –Pain –Pallor –Paresthesia –Paralysis –Pressure Progression of systems Progression of systems – (sometimes the 6 th P)

92. Bombings: Injury Patterns and Care92 Compartment Syndrome: Treatment Pre-hospital Primary survey and initial stabilization (ABC’s) Primary survey and initial stabilization (ABC’s) Suspect compartment syndrome Suspect compartment syndrome Immobilize affected part Immobilize affected part Treat other injuries Treat other injuries

93. Bombings: Injury Patterns and Care93 Compartment Syndrome: Treatment Hospital Primary survey, stabilization and resuscitation, secondary survey Primary survey, stabilization and resuscitation, secondary survey Diagnosis through examination Diagnosis through examination Treat systemic effects of compartment syndrome similar to crush injury treatment Treat systemic effects of compartment syndrome similar to crush injury treatment

94. Bombings: Injury Patterns and Care94 Compartment Syndrome: Extremity Injuries Management of extremity injuries Management of extremity injuries –Indication for field amputation –Appropriate use of tourniquet application –Appropriate use of hemostatic dressings –Appropriate anesthesia/analgesic

95. Bombings: Injury Patterns and Care95 Compartment Syndrome: Procedural Skills Measuring compartment pressures Measuring compartment pressures Use of Ketamine Use of Ketamine Fasciotomies Fasciotomies Photo used with permission of Immediate Action Services

96. Bombings: Injury Patterns and Care96 Compartment Syndrome: Procedural Skills Fasciotomies are a definitive treatment, but tissue pressure at which it is required is controversial. Fasciotomies are a definitive treatment, but tissue pressure at which it is required is controversial. Varying views include: Varying views include: –Early fasciotomy when pressures >45 mm Hg or when within 20 mm Hg of diastolic pressure –Avoid fasciotomy if distal pulses are present to prevent conversion to open compartment syndrome, which carries greater risk of sepsis –Delayed fasciotomy (beyond 48-72 hours) increases risk of sepsis and death due to extensive necrotic tissues

97. Bombings: Injury Patterns and Care97 Compartment Syndrome: Procedural Skills Fasciotomy Fasciotomy –Provide adequate analgesia and anesthesia –Pre-operative broad spectrum antibiotics –Ensure ALL compartments in extremity checked for pressures (multiple compartments may be affected) –Check compartment pressures before and after fasciotomy –Ensure adequate hemostasis –Pack wound open and use large bulky dressings

98. Bombings: Injury Patterns and Care98 Entrapped Patient Treatment Treatment Treatment –Fluid resuscitation before victim extricated –1 L NS bolus, followed by 1-1.5 L per hour infusion –Limb stabilization –Minimize potential systemic effects of reperfusion –Consider use of tourniquets prior to release –Consider alkalinization by giving 1 ampule of sodium bicarbonate (50 mEq) immediately prior to extrication, followed by adding 1 ampule of sodium bicarbonate to each liter of NS infused at 1-1.5 L per hour as above; keep second IV line open without sodium bicarbonate

99. Bombings: Injury Patterns and Care99 Field Amputation Indications: Indications: –Unable to safely extricate –Continued environmental toxins pose hazard to victim and rescuers –Grossly prolonged time until definitive treatment even after extrication

100. Bombings: Injury Patterns and Care100 Field Amputation Best performed by trauma or orthopedic surgeon Best performed by trauma or orthopedic surgeon Few EMS systems have protocols Few EMS systems have protocols Ensure adequate analgesia and anesthesia Ensure adequate analgesia and anesthesia –Ketamine (dissociative anesthetic) Decreases or only minimally increases serum potassium levels Decreases or only minimally increases serum potassium levels Patient maintains airway despite adequate anesthesia Patient maintains airway despite adequate anesthesia

101. Bombings: Injury Patterns and Care101 Photo used with permission of Immediate Action Services

102. Military Experience

103. Bombings: Injury Patterns and Care103 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

104. Bombings: Injury Patterns and Care104 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

105. Bombings: Injury Patterns and Care105 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

106. Bombings: Injury Patterns and Care106 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

107. Bombings: Injury Patterns and Care107 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

108. Bombings: Injury Patterns and Care108 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 12-18 hours for definitive surgery

109. Bombings: Injury Patterns and Care109 Military Experience IV Hemostatsis IV Hemostatsis –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

110. Bombings: Injury Patterns and Care110 Military Experience IV Hemostatsis IV Hemostatsis –Use of fresh whole blood –Early use of cryoprecipitate –Recombinant Factor VIIa (rFVlla)

111. Bombings: Injury Patterns and Care111 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

112. Bombings: Injury Patterns and Care112 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

113. Bombings: Injury Patterns and Care113 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

114. Special Considerations

115. Bombings: Injury Patterns and Care115 Special Considerations Pregnancy Pregnancy Children Children Elderly Elderly Disabled Disabled Language barriers Language barriers

116. Bombings: Injury Patterns and Care116 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.

117. Bombings: Injury Patterns and Care117 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

118. Bombings: Injury Patterns and Care118 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

119. Bombings: Injury Patterns and Care119 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

120. Bombings: Injury Patterns and Care120 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

121. Psychological Issues

122. Bombings: Injury Patterns and Care122 Psychological Issues Sequelae from an explosive event Sequelae from an explosive event –Anger –Frustration –Helplessness –Desire to seek revenge

123. Bombings: Injury Patterns and Care123 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

124. Bombings: Injury Patterns and Care124 Psychological Issues Tips for Responders Tips for Responders –Promotion of safety –Promote calm –Promote connectedness –Promote self-efficacy –Promote hope

125. Bombings: Injury Patterns and Care125 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

126. Bombings: Injury Patterns and Care126 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