Pre-hospital and Emergency Department Management for Blast Injury

Nat Krairojananan MD FRCSTDepartment of Trauma and Emergency Medicine

Phramongkutklao Hospital

Physics of the explosive• Sudden rapid conversion from chemical

component to gas, heat, pressure, light and flame• Low-order explosive devices < 400 m/sec.• High-order explosive devices 1400-9000 m/sec.

Type of explosives

Manufactured explosives • Military: C4• Industrial: TNT

Improvise Explosive Devices (IED)• Pipe bomb• ANFO (Ammonium Nitrate Fuel Oil)

Type of explosives

Factors influence severity of injuries

• Size and amount of explosive• Distance from the detonation• Media (air VS water)• Detonation in the closed space

Blast injury categorization

Primary blast injurySecondary blast injury

Tertiary blast injuryQuaternary blast injury

Quinary blast injury

Primary blast injury• Caused by high order explosive only• Over pressure to air-filled organs

• Blast lung: PTX, pulmonary contusion, PE• Blast bowel: ruptured hollow viscus peritonitis• Blast ear: TM perforation• Blast brain: concussion• Blast eye

Secondary blast injury

• Penetrating injury/ laceration• Fragmentation of case/shell or Shrapnel • Secondary fragment

Secondary blast injury

Tertiary blast injury

• Blast wave• Propulsion of body onto hard surface• Propulsion of object onto individuals• Structural collapsed• Fall from height

• Blunt injury• crush syndrome• compartment syndrome

Quaternary blast injury

Not caused by primary, secondary or tertiary blast injury

• Fire (burn)• Inhalation injury• Asphyxia

Quinary blast injury

• Toxic fume • Chemical injury• Radiation • Biological agents

Part IScene Management

For EMS personnel

Scene management

• Scene sized up (scene safety)• Scene triage• Scene treatment• Evacuation

ICS in bombing event

• Commander • Security• Search and rescue• Treatment team• Evacuation team

Scene sized upRecognition of specific hazards with bombing• Secondary device• Environmental hazards (fires, toxin)• Structural instability• Other threat; sniper

Safe distance?

Scene Triage

• MASS triage• START triage

MASS Triage

M: Move A: Assess S: Sort S: Send

• Presence of threat

MOVE• Quickly evacuate all patients from scene• Move unresponsive patients first• Use of appropriate stabilization and equipment• Stretcher or SKED

MASS triage

ASSESS

• According to Pre-Hospital Trauma Life Support (PHTLS) protocol by assess life threatening injury first

Abv. Extend Action

A Airway and C-spine protection Open & clear airway, C-collar

B Breathing (chest injury) O2 supplement by face mask with bag, Rx for tension PTX

C Circulation (hemorrhagic shock) Stop bleeding, initiate iv fluid

D Disability (neurologic status) Check A-V-P-U

E Environmental control Keep warm

MASS triage

SORTCategorize and tag patients into groups for Rx and evacuation

Color code Severity Type of injuries

RED-immediate Life threatening injury - Airway obstruction- Chest injury- Hemorrhagic shock

YELLOW-delayed - Potential life threatening - Limb threatening injury

- Fracture- mild abdominal injury- PTSD*

GREEN-minimal Minor injury Wounds

BLACK or BLUEExpectant

Obvious signs of death - Severe injury- Extensive wounds

MASS triage

SEND

• Expedient patients to appropriate resources • Trauma center • En route care: monitors• Proper stabilization

MASS triage

START Triage

Simple Triage And Rapid Treatment

START triageScene Sized up

Ask patients to walk to your voice

GREEN (minimal)

Walk to assigned area

Unable to walk Able to walk

Ask patients to raise hand or leg

START Triage (cont.)

No response

Obey command

REDImmediate AW

treatment

YELLOW Delayed Rx possibility

BLACK or BLUESupportive treatment with limited resources

Ask patient to raise hand or leg

No breathing

Assess breathingBreathing

5 /min or more

Initial management

• Treat life threatening injuries• Prevent disability

START triage

Abv. Extend Action

A Airway and C-spine protection Open & clear airway, C-collar

B Breathing (chest injury) O2 supplement by face mask with bag, Rx for tension PTX

C Circulation (hemorrhagic shock) Stop bleeding, initiate iv fluid

D Disability (neurologic status) Check A-V-P-U

E Environmental control Keep warm

Evacuation

• Expedient patients to appropriate resources • Trauma center • En route care: monitors• Proper stabilization

START triage

Part IIEmergency Department Management

For clinicians, nurses

Emergency department management

• Triage and Patient categorization• Treatment zones by color code• follow Advance Trauma Life Support (ATLS) protocol

Primary blast injury treatmentSystem Possible injury Immediate Rx consultation

Blast lung

CXR in all cases*

Tension PTX Needle thoracocentesis, follow by ICD insertion and support ventilation

- Trauma surgeon- CVT surgeon

Air embolism Support ventilation Intensivist

Pulmonary contusion Support ventilation Intensivist

Blast GI Intra abdominal bleeding

iv fluid infusion, investigation

Trauma surgeon

Bowel perforation Investigation, observe Trauma surgeon

Blast brain Brain concussion, ICH Check GCS, lateralizing sign Neurosurgeon

Blast ear TM perforation Ear exam in all cases ENT

Blast eye Globe rupture Eye examination Opthalmologist

Secondary blast injury treatmentInjury Immediate Rx Definitive Rx consultation

Penetrating injury

- Bleeding control- iv fluid replacement- Film for foreign body

Explore lap. Trauma surgeon

Amputation - Bleeding control- Tourniquet if necessary- iv fluid replacement

Surgical debridement and control bleeding

- Trauma surgeon- Orthopedist

Laceration - Bleeding control- iv fluid replacement- Film for foreign body

Debridement and suture

Trauma surgeon

Opened fracture - Immobilization- Distal neurovascular check

- Debridement - Bone realignment

Orthopedist

Tertiary blast injury treatment

Injury Immediate Rx Definitive Rx consultation

Blunt chest / abdominal injury

- Bleeding control- iv fluid replacement- FAST / DPL

Explore lap. Trauma surgeon

Crush syndrome - iv fluid load to force diuresis- ECG monitoring- Looking for compartment syndrome

- Alkalinize urine- Dialysis if necessary

Trauma surgeon

Compartment syndrome

Fasciotomy - Trauma surgeon- Orthopedist

Quaternary blast injury treatment

Injury Immediate Rx Definitive RxInhalation injury - Airway management

- Oxygen supplement

Asphyxia - Airway management- Oxygen supplement

Burn - Keep warm- Wound care- iv fluid resuscitation

- Wound debridement- Grafting for skin coverage

Quinary blast injury treatment

Injury Immediate Rx Definitive RxToxic fume Airway and ventilation support Antidote?Chemical injury Decontamination Wound careRadiation Supportive treatment sameBiological agents - Isolation

- Medical personnel PPEAntibiotics ?

Special consideration

• ‘upside down’ or ‘reverse’ triage

• Estimated incoming patient

Total number of patient = Number in first hour x 2

Special consideration

CBRNE event

• Decontamination• Personal Protective Equipment

EMS personnel

preparation

Decontaminating station

Thank youComments and question are welcome

Three suspected

injured

captured