Blast Injuries & Gunshot Wounds

8/3/2019 Blast Injuries & Gunshot Wounds

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PREET IGEHLAUT


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BLAST:

Explosions are physical, chemical,

or nuclear reactions involving a

large, rapid release of energy


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BLAST PHYSIOLOGY:

Blast injury

Based on mechanism of tissue injury &physical tissue damage

defined and broken into 4 categories

Primary

SecondaryTertiary

quaternary


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BLAST PHYSIOLOGY:


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PRIMARY BLAST INJURY:

Result of the physical properties of the blastwave

occurs as a function of an increase in atmospheric

pressure over time, referred to as blast overpreassure

Measure of over pressure is dependent upon: energy of the explosion

distance from detonation

distance from detonation


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Molecules in air are constantly in a state ofmotion referred to as the state of the gas

Due to blast / explosion this state is disturbed

from normal conditions resulting in: escalation of molecular speed

increase in the no of molecules occupying a definedspace

density, pressure & temperature of gas increases a shock wave, or blast wave, develops moving at

supersonic speeds (3000 to 8000 m/sec)

loses its pressure and velocity as distance

increases


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blast front- leading edge of the blast wave

creates a high-pressure region, or positive phase,called blast wind

Leaves behind a negative pressure area whichreverses the movement of gas

damage can occur from both

In nuclear blast- precursor shock wave isobserved.

shock front near the ground of heated air and movesahead of the blast wave.6


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victim positioning relative to the primary waveresults in varied damage:

perpendicular fashion to blast wave - greatest

amount of impact and injury

horizontal fashion - less direct surface contact forimpact

underwater detonations: force of blast wavegreatest at the deepest depths & begins to dissipateas blast wave approaches the surface


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Essentially barotrauma little or no effect on

solid or fluid-filled organs

maximal destruction - air-containing organs

Hallmarks : Perforation of eardrums (overpressure 15-50 psi)

pneumothoraces (over[ressure 50-100 psi)

At psi 65 fatality rate approaches 99%

Other injuries: Intestinal /hollow viscus injury

Brain injuries

Paucity of obvious external signs


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Factors potentiating outcome to blast injuries magnitude of the explosion

potential building collapse

open air versus enclosed space (6 fold in pulmonary

injuries in confines spaces) Enhanced wounding measures

Ball bearings, nails, incendiary

Other pathognomonic findings : presence of air emboli in pulmonary & coronary vessels

Representing leading cause of death in victims of pulmonaryblast injury


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SECONDARY INJURIES:

Injury from flying debris

Classic shrapnel injuries

Of various velocities

Primary bomb fragments

Secondary fragments or missiles

Inert from inanimate objects

Biological allogenic bone fragments etc may beHIV, HBSAg infected

Potential for pathogen transmission

Cases seen in israel n iraq


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SECONDARY INJURIES:

Environmental debris such as glass, splinters,soil, and various structural particles may bemajor cause.

Interface of debris with skin characteristic skin pattern called spalling

More common than primary injury:

Reason - Victim doesnt have to be near blastsite

No 1 military killer in 20th century


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TERTIARY BLAST INJURIES:

Injuries from deceleration and structural collapse Axial load injuries

Wide range blunt injuries:

Spine Orthopedic

Head

Solid & hollow organ Crush syndrome - time delay

to recovery and weight of

falling debris


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QUATERNARY BLAST INJURY:

result of the byproducts of explosion

Inhalational injuries:

From dust and gases

Burns : Thermal

Radiation

Chemical describes the sequela of reflective of dirty bomb

in which chemical or radiologic-laden detonations mayoccur


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HUMAN SUICIDE BOMB:


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HUMAN SUICIDE BOMB:

walking smart bomb. High grade explosive material used

Ability to precisely time the explosion

Ability to detonate in close proximity to victims

Large load of heavy shrapnel as well as explosivematerial

body parts acting as missile fragments and projectiles

may carry with them HIV, hepatitis, and otherserious and yet to be identified threats

Suicide Bomb victims suffer with the worst of both

ie Explosion and Penetrating shrapnel


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SPECIAL CONSIDERATIONS IN PREGNANCY

Fetus' hollow organs are void of air offering protection from primary blast injury

However, amniotic fluid, potentially amplifies 3-foldthe blast wave, as in underwater detonations

concern of potential maternal-fetal injury

Penetrating shrapnel (2 injuries)

concern for possible fetal injury

the closer to term greater potential for fetal injury


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Tertiary blast effects of deceleration - blunt traumain pregnancy

Women with previous history of C-sections greater riskfor uterine rupture

risk of (40-50% ) abruptio placenta

Chemical injuries:

Spontaneous abortions (about 4 fold in bhopaldisaster)

Teratogenicity not proved


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Radiation injuries depend on: gestational age at time of the exposure

period between the 2-8 weeks - extremely

sensitive At significant risk is the central nervous system

fetal dose of absorption.

low birth weight

best chance for fetal survival is that of the stabilityof the mother suffering traumatic injury


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BLAST LUNG INJURY ( BLI ):

Second most susceptible organ (1st TM) Direct consequence of blast wave on the body

Overpressure needed - about 40 psi (40 psi being

produced by 20Kg TNT exploding 6 meters away) Most common CRITICAL Injury in victims close to

bomb

Can be life threatening

May not have obvious external injury to chest


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Other pulmonary injuries include:

Pneumothorax

Hemothorax

Pneumomediastinum

Subcutaneous emphysema

Air emboli


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Results in tearing, hemorrhage, contusion andedema

Micro -hemorrhages in alveoli

Disruption and weakening of

alveolar walls

perivascular and peribronchial tissue Resultant Ventilation-Perfusion mismatch


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Symptoms: Dyspnoea, Haemoptysis, cough, chest pain

Signs:

Tachypnoeic, hypoxic, cynosis, wheezing X-Ray features

similar to pulmonary contusion, bihilar (butterflypattern) shadows

pneumothorax, haemothorax

Can have bronchopleural fistula

Air embolism from pulmonary disruption

Other injuries may add to haemodynamic instability


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Tension pneumothorax of the right lung afterblunt chest trauma


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G I SYSTEM:

Most commonly results in

tissue tearing

hemorrhage.

GI blast injury more commonly occurs after blastwave propagation in water.

GI hemorrhage and perforation is most common in

lower small intestine or cecum, where gas accumulates.

Perforations can be delayed

May develop 24 to 48 hrs post blast

Manifestations of peritonitis can occur hours or days later


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HEAD INJURY:

Loss of consciousness

Headache, seizures, dizziness, memory problems

Gait/balance problems, nausea/vomiting, difficultyconcentrating.

Visual disturbances, tinnitus, slurred speech.

Disoriented, irritability, confusion. Extremity weakness or numbness


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CRUSH INJURY:

results when muscle reperfusion injury occurs as aresult of the release of compressive forces on thetissues or compartment syndrome

physiologic outcome - traumatic rhabdomyolysis

myoglobin, potassium, and phosphorus leach intothe circulation

Clinically, compression of large skeletal muscle is

necessary for this syndrome About 33% of the patients with rhabdomyolysis will

develop acute renal failure mortality rate of 30-50%


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CRUSH INJURY:

General cond. of pt with crush injury dictated by: other injuries

delay in extrication

environmental conditions SIGNS OF COMPARTMENT SYNDROME

Pain, Pallor, Paresthesia, Paralysis, PulselessnessProgression of symptoms (the 6th P)


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GUNSHOT WOUNDS:

An explosive force is applied to a projectile that ispropelled down a tube to fly towards its target


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GUNSHOT WOUNDS:

Firearms Type of weapon

Low-velocity- shot gun, pistol

High-velocity- rifle

Caliber

Missile size

Bullet construction

Tumbling/yaw Distance traveled


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PROJECTILES:


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RANGE OF FIRE:

Wound characteristics vary:

Contact

The most devastation

Close Range

Arms length

Distant

Most handguns: significant decrease in KE at 100 m

Most military rounds: retain large KE at 500m


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MECHANISM OF INJURY:

2 areas of projectiletissue interaction in missile-causedwounds

permanent cavity -localized area of cell necrosis,proportional to size of projectile

temporary cavity- transient lateral displacement oftissue, after passage of the projectile.

Elastictissue

skeletal muscle, blood vessels, and skin, may be pushed

aside but then rebound

Inelastic tissue

bone or liver, may fracture.


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MECHANISM OF INJURY:


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GUNSHOT WOUNDS: Entry wound Smaller

May be darkened, burned Exit wound One, none, or many Larger May be ragged

Imp to know to determine: Anatomy damaged

Type of surgical procedure

Entry and exit wounds can lie ! ! ! ! ! ! Projectiles do nothave to follow a straight line !


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PATHOPHYSIOLOGY:

Internal wound

Tissue contact damage

High-velocity transfer of energy Shock waves

Temporary cavity

Damage proportional to tissue density

Highly dense tissue sustains more damage

Distal embolization can occur when a projectile slowsenough and enters the vascular system


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PATHOPHYSIOLOGY:

50 % of deaths are due to exsanguination require rapid pressure application and evacuation

exception Gun Shot Wound to head

large bore IVs are needed for fluid replacement

10 % from CNS injury

Do not delay transport for ANY REASON ! ! ! ! ! ! !


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GUNSHOT INJURIES:


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MANAGEMENT:

Prehospital trauma care:For severely injured patients,survival is time-dependent!

Golden Hour

From moment of injury To definitive treatment

EMS platinum 10 minutes scoop & run OR stay & play

Assessment and management Every action must have lifesaving purpose

Organized, detail-oriented, selective, rapid


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MANAGEMENT:

Scene Size-up

Standard precautions

Scene safety

Initial triage (total number of patients) Need for more help or equipment?

Mechanism of injury?

Expect combined injuries


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TRAUMA SYSTEM:

DEFINITION:

an organized approach to acutely injuredpatients in a defined geographical area that

provides full and optimal care and that isintegrated with the local or regionalEmergency Medical Service (EMS) system.

provide the full range of care (from prehospital torehabilitation).


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TRAUMA SYSTEM GOAL:

To get the right patient

to the right hospital

at the right time


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TRIAGE:

French wordmeaning to separate, sort, sift orselect

the sorting of allocation of treatment to pts esp.

battle and disaster victims acc. to a system ofpriorities designed to maximize the no of survivors


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TRIAGE UNIT:

Determine location of triage areas Clear and assemble the walking wounded

using verbal instructions

Conduct Primary triage ensure all pts. are assessed & sorted

Communicate resources required

Secondary triage more in-depth assessment

usually conducted in treatment Unit


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TREATMENT UNIT:

Determine location for treatment area

Coordinate with the Triage unit

to move patients from the triage treatmentareas

Establish communication withIncident Command

Reassess patients

conduct secondary triage to matchpatient with resources


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TRANSPORTATION UNIT:

Management of patient movement from the sceneto the receiving Hospitals

Establishes adequately sized, easily identifiablepatient loading area


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STAGING AREA:

Location designated to collect available resourcesnear incident area

Several staging areas may be required


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TRIAGE TAG:

Alerts care providers to patient priority Prevents re-triage of the same patient

Serves as a tracking system


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TRIAGE TAG:

carried with Diagnostic Equipment in all EMS kits

should be considered on all calls involving 3 pts

general placement location for tags

one of the patients arms or hung around the patientsneck.


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TRIAGE CATEGORIES:

IMMEDIATE:Life-threatening buttreatable injuries

requiring rapidmedical attention

DELAYED:Potentially seriousinjuries, but are stable

enough to wait a shortwhile for medicaltreatment


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TRIAGE CATEGORIES:

MINIMUM / MINOR:Minor injuries that canwait for longer period

of time prior totreatment

MORGUE/EXPECTANT:Death or lack ofspontaneous respiration

after airway is opened


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TRIAGE SCORING SYSTEMS


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START TRIAGE METHOD:

Simple Triage And Rapid Transport Triage assessment based on 3 criteria

RPM

Respirations ( > or < 30/min) Perfusion (Capillary Refill > or< 2/ sec)

Mental Status (Follow ssimple commands)

MNEMONIC: 30 2 CAN DO


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REVERSE TRIAGE: conditions where less wounded are treated in

preference to more severely wounded such as:

war - where military setting may require soldiers bereturned to combat as quickly as possible

disaster situations - where medical resources arelimited

where significant numbers of medical personnel are

among the affected patients


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CAUTION:

Personal protective equipment is alwaysneeded at trauma scenes

Do not approach until Scene Size-up iscomplete!


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ASK SOME QUESTIONS.

What type of explosive and how much?

Where was victim located with respect to theblast?

Were fire/fumes present to cause inhalationalinjury?

What was orientation of head and torso to theblast?


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You see what you look for Stephen Sondheim


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MANAGEMENT:

Primary survey

Many components are assessed simultaneously

Airway- maintenance with cervical spine protection

Breathing and ventilation

Circulation with hemorrhage control

Disability; neurologic status

Exposure/Environment (completely undress the pt

and prevent hypothermia)


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MANAGEMENT: AIRWAY Assume Cervical Spine Injury Maintain inline cervical spine stabilization

Airway Suction Blood

Mucus Dental fragments

Open Airway Head Tilt-Chin Lift

Jaw Thrust (if Cervical Spine Injury is suspected)

Maintain Airway Oropharyngeal Airway

Nasopharyngeal Airway
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MANAGEMENT: BREATHING

Assess Breathing Ventilation

Oxygenation

Awake with spontaneous breathing Supplemental 100% Oxygen Delivery

Infants under 1 year old: Oxygen Hood

Children/Adults: Non rebreather mask with reservoir

Conscious with respiratory failure Bag Valve Mask with 100% Oxygen

Unresponsive or respiratory failure

Orotracheal intubation
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MANAGEMENT: BREATHING

Nasotracheal intubation: in breathing patient without major facial trauma

Surgical airways

jet insufflation Retrograde intubation

cricothyrotomy

tracheostomy


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BREATHING: PITFALLS

Tension Pneumothorax

Rib Fractures

High risk injury if Fractured ribs 1-3

Associated with significant cardiopulmonaryinjury

Flail chest

Pulmonary Contusion

Open Pneumothorax

Massive hemothorax
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MANAGEMENT: CIRCULATION

Level of Consciousness Skin color

Central Pulse

Child or adult: Carotid pulse or femoral pulse Infant: Brachial Pulse

Sites of rapid blood loss Chest Injury

Abdominal Injury (especially retroperitoneal) Pelvic Injury

Extremity Injury (especially femur)
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MANAGEMENT: CIRCULATION

Correct Hypovolemia: Fluid Replacement in Trauma Two large bore IVs (14 or 16 gauge)

Shorter tubing provides faster IV rate

Replace fluid deficit

Infuse Lactated Ringers 2-3 Liters until response

Consider blood transfusion Unmatched Type-specific blood may be used OR

Low titer O, or Rh- O if other not available

Hemorrhage Evaluation

Avoid potentially harmful measures Vasopressors

Steroids

Sodium Bicarbonate
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MANAGEMENT: DISABILITY

Level of Consciousness: (AVPU system)

Alert

Vocal Stimuli

Painful stimuli Unresponsive

GCS

Pupil response
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EXPOSURE:

Undress patient do complete visual inspection

Keep spine immobilized and log roll

Prevent Hypothermia Warm crystalloid in microwave or bath to 39C

Do not microwave Blood, Plasma or Dextrose

Minimize 2 injury

RAPID TRANSPORT to Surgical Facility


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MANAGEMENT:

Resuscitation of vital functions Detailed secondary survey Definitive care

Consider abdominal films in all pts with significant blast

injury Auscultation of chest & chest X rays DPL / FAST- for unstable pts. CT Scan Abdomen/Pelvis for patients with appropriate signs

and symptoms.

Hearing in both ears should be tested at bedside. Limb X rays & examination

Avoid tunnel vision on one injury.


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ABDOMINAL INJURIES:

Laparotomy - main stay of investigation andmanagement

Priorities of the Trauma Laparotomy

Hemorrhage control

Contamination control

Detection of all injuries

Missed injury - high mortality and morbidity

Tetanus toxoid and Antibiotics

initial blood loss on opening abdomen- can be brisk

patient rapidly can become unstable

Volume resuscitation & blood transfusion


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RADIATION MANAGEMENT: Radiation deaths are delayed. Management of conventional injuries and acute life

threats takes precedence over radiation exposure.

Treat injury first, then decontaminate.

Contamination issues No medical personnel have ever received an

exposure anywhere near the degree to cause

radiation effects 95% of decontamination occurs with:

Removal of patients clothing

Soap & water


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ENTRAPPED PATIENT TREATMENT

Volume resuscitation before extrication maintain a euvolemic state with brisk urine output (2ml/kg/hr)

Limb Stabilization

Vital signs, oxygen, EKG, IVAdditional Rx &transport

IS CRUSH SYNDROME OR COMPARTMENTSYNDROME SUSPECTED?

Look for injuries on Limbs, Pelvis, Gluteal region &Abdominal muscles


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ENTRAPPED PATIENT TREATMENT:

Crush / compartment injury signs & symptoms ifpresent:

TREATMENT PREHOSPITAL ABCs

Treat other injuries Immobilize affected part-dont use constricting bandages

TREATMENT HOSPITAL Fluid resuscitation - Brisk diuresis (2 ml/kg/hr)

Diagnose and treat other metabolic derangementsHyperkalemia, Hypocalcemia

Pain control

Anxiolysis


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ENTRAPPED PATIENT TREATMENT: Mannitol - a nonosmotic diuretic

Help augments diuresis effective radical scavenger

Use of bicarbonate:

alkalization of the urine cast formation

direct toxic effects ofmyoglobin upon nephrons Hyperkalemia, severe acidosis, and hypervolemia

continuous renal replacement therapy

If injury is open: Antibiotics, tetanus, jet irrigation.

Debridement of nonviable tissues.

Early amputation for severely injured limbs may be required

Fasciotomy

BLAST LUNG INJURY


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BLAST LUNG INJURYWas the Bombing in Open or Closed Space?

higher incidence of blast lung injury in enclosed spaces Signs/symptoms suggestive of BLI or resp distress??

NO

NO YES

Management

ventilatory failure- intubate

Caution with PPV- BLI, embolism

Appropriate Rx & transport

BLAST LUNG INJURY


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BLAST LUNG INJURY

HOSPITAL DIAGNOSTIC EVALUATION

Chest radiography

Arterial blood gases

computed tomography

doppler ultrasound to help diagnose BLI and air emboli.

Testing conducted per resuscitation protocols

Acc to nature of explosion (eg. confined space,fire etc)

OXYGENATION High flow O2 via non-rebreather mask, CPAP,or

endotracheal intubation.

BLAST LUNG INJURY


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BLAST LUNG INJURY:

CLOSE OBSERVATION Chest decompression- clinical presentation of tension

pneumothorax.

Fluid administration

enough fluid to ensure tissue perfusion & avoiding volumeoverload.

AIR EMBOLISM

Position in prone, semi-left lateral, or left lateral

transport to a facility with a hyperbaric chamber.

TENSION PNEUMOTHORAX


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TENSION PNEUMOTHORAX:

Tension pneumothorax is not an x-raydiagnosis

it MUST be recognized clinically

Treatment is decompression needle into 2nd intercostal space of mid-clavicular line -

followed by thoracotomy tube

Insert needle here

MASSIVE HEMOTHORAX TREATMENT


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MASSIVE HEMOTHORAX: TREATMENT

Large-bore (32 to 36 F) tube to drain blood

If moderate sized (500 to 1500 ml) and stops bleeding

closed drainage usually sufficient

If initial drainage >1500 ml OR continuous bleeding>200 ml / hr

OPEN THORACOTOMY

FLAIL CHEST


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FLAIL CHEST: Free-floating chest segment- multiple ribs #

Pain and restricted movement

paradoxical movement of chest wall with

respiration

Treatment :

Ventilate well

Humidify oxygen

Resuscitate with fluids Manage pain

Stabilize chest

ventilator

DISPOSITION AND OUTCOME


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DISPOSITION AND OUTCOME: No definitive guidelines for observation, admission, discharge

Patients diagnosed with BLI may need complex management

should be admitted to an intensive care unit

suspicious for BLI should be observed in the hospital.

Discharge decisions will also depend on:

associated injuries

other issues related to the event, including the patients

current social & mental situation.

Patients with normal chest X Rays, blood gases & pulse oximetry

no complaints suggesting a BLI

can be considered for discharge after 4-6 hours of

observation.


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BURN INJURY:

Fluid resuscitation while avoiding fluid overload toprevent further pulmonary injury

guided by urine output. Consider monitoring central venous pressure

systemic vascular resistance when indicated.

Standard burn management

WOUND MANAGEMENT


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WOUND MANAGEMENT: Tetanus status.

Local exploration.

Delayed primary closure.

IV followed by oral antibiotics for all but the mosttrivial wounds


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Blast Injuries & Gunshot Wounds

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