04 strt battlefield injury patterns

8/9/2019 04 STRT Battlefield Injury Patterns

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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008

I n t e g r i t y - S e r v i c e - E x c e l l e n c e

Strengthening Partner Nation Medical Capacity And Consequence Management Capabilities Through Education And Training

Defense Institute for Medical

Operations (DIMO)

BATTLEFIELD INJURY PATTERNS

Surgical Trauma Response

Techniques(STRT)


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OBJECTIVES

Differentiate blast injury types, their associated

injury management and complications.

Describe depleted uranium exposure, the toxiceffects, and patient issues.

Identify combustible chemical injuries, theirtoxic effects, and patient management issues.


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Battlefield Wounding

Mechanisms

Blast injuries

Mines

Unexploded Ordinance

Phosgene-like Combustion Products

White Phosphorus


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Blast Injuries

In addition to

fragmentation

(missiles), explosive

ordinance causes injuryby blast effects

Three types of blast

injury:

Primary

Secondary

Tertiary


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Blast Wave


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Primary Blast Injury

Direct effect of the blast

wave

Distance dependent

Lethal radius tripled inwater and increased at

reflecting surface

Almost exclusively

injures air filledstructures


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Ear

Most sensitive

Respiratory system

Cause of most morbidity and mortality

GI Tract

Most common cause of delayed morbidity and

mortality


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Israeli experience from suicide bombings:

Butterfly Pattern on chest radiograph associated with high

mortality due to severe pulmonary blast injury.


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Care is as for any injury to that organ system

Pulmonary

Supportive. Avoid positive pressure ventilation if possible

(increased air embolism risk)

GI injuries

Cause of delayed morbidity of early survivors. Maintain

high index of suspician.

Possible risks with aeromedical evacuation.


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Secondary/Tertiary Blast

Injury

Secondary Blast Injury

Injuries fragments from the explosive device orby secondary missiles being energized by the

blastSame principles of diagnosis and care as

shown earlier for missile injuries

Tertiary Blast Injury

Occurs when the casualty is thrown againstthe ground or against solid objects

Injuries similar to blunt trauma or falls and carefollows blunt trauma guidelines


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Blast Injury-Summary

Remember, casualty can suffer all

three components of blast injury in

varying degrees at once

Plus-- can get thermal, chemical, and

biological injuries


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Mines


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Mines

Severe world-wide problem

Millions exist from previous and current conflicts

Estimated 100 million mines in 64 countries

No maps of mine fields; terrorist type use is quite common

Still produced and laid today

Removal slow, difficult, and expensive

Weapon of mass destruction in slow motion


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Modern mines are high tech and

cheap.

May be plastic to avoid usual

detection methods.Sown by helicopters.

Indiscriminate

in whom they

injure.

Estimated 15,000 victims

per year (probably

more).

80% civilian

30% children



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Mines

Patterns of injurydepend on multiplefactors Type of mine

Position of victim

Characteristics of theenvironment

Most wounds cause

extensive and complexsoft tissue and bonyinjury


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Mines

Surgery is complex and challenging

Aggressive, serial debridement

Amputation, external fixation

Save non-involved tissue to maximize stump length

Be wary of trunk/perineal involvement

Complex, reconstruction frequent

(Scientific American, May 1996, G. Strada)


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Embedded in casualty without exploding

Rockets, grenades, mortar rounds

Must travel distance prior to arming (50-70m)

Fuses triggered by different stimuli (ie impact,electromagnetic, laser)

Notify Explosive Ordinance Disposal (EOD)

Available to civilian community

Work with them on formulating a plan


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Triage Category

Traditionally victims were expectant

31/31 victims lived after removal from recent

review

Triage as delayed, moved far from others andoperated on last


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Transportation

If by rotary wing aircraft, ground victim to chopper-

large electrostatic charge from rotors

Move into safe area Revetment, parking lot, back building

Operate there, not in main OR area

Triage them to delayed category


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Unexploded OrdinanceOperative Management

Precautions for you andstaff Sand bag operative area

Wear flak vests, eye

protectionAvoid triggering stimuli

Electromagnetic (no defib,monitors, bovie, bloodwarmers, ultrasound, or

CT) No metal to metal contact

Plain X-ray safe - helpsID type


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Operative Management

Anesthesia

Regional/spinal/local preferred

No oxygen in operating area

Anesthesiologist leaves after induction

OPERATION

Surgeon alone with patient

Gentle techniqueRemove en-bloc if possible (may require

amputation)


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Decision to remove Chem-Bio is COMMAND

decision

Immediately after removal, hand to EOD for

disposal


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DepletedUranium

Used extensively by US and foreign militaries

Armor piercing munition and shielding in

armored vehicles

Uranium depleted of most radioactive isotopes 40% less radioactive than natural uranium

Heavy metal toxicity

Toxic when internalized in large quantities

(eg lead, tungsten)


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DepletedUranium

Gulf War veterans with retained DU fragments

are being followed by the Veterans

Administration

Higher levels of uranium in urine

Actual long term effects of DU exposure

remain unknown

No renal effects yet noted

No congenital effects in offspring


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DepletedUranium

Care of Exposed Casualties

DU may be on clothing and/or skin

NEITHER patient NOR contamination is

hazardous to medical personnel

NEVER DELAY CARE to them Use standard universal precautions only


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DepletedUranium


Wounds/burns treatment generally follows

standard surgical procedure

Radiation meter can be used to assist-B

UT UNDE

R NOCIRCUMSTANCES SHOULD TREATMENT BE

DELAYED TO FACILITATE MONITORING

Manage embedded fragments as for any

shrapnel wound EXCEPT any DU fragments >

1cm should be removed unless the medical risk ofremoval is too great

NEVER AMPUTATE TO REMOVE FRAGMENTS


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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008I n t e g r i t y - S e r v i c e - E x c e l l e n c e


DepletedUranium


Monitor renal function

Kidney is sensitive to heavy metals

Chelation therapy not recommended

Reassure that victim is not risk to others No risk to family, no body fluid risk, no special

precautions necessary

Document exposure to allow follow-up


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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008I n t e g r i t y - S e r v i c e - E x c e l l e n c e


Phosgene-Like Combustion

Products

Perfluoroisobutylene

(PFIB)

Combustion product of

Teflon

Found in military/armored

vehicles

Similar toxicity as

Phosgene Damages moist tissues

by direct contact through

release of HCl


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Products

Physiologic Effects

Irritation of mucous membranes, laryngospasm

Latent pulmonary edema depends on intensity

of exposure and physical activityFluid sequestration can lead to shock

Death due to hypoxia, hypoventilation, or

hypovolemia


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Products

Initial Management

Terminate exposure

A,B,Cs

Manage airway secretions & bronchospasm

Enforce rest

Consider methylprednisolone 700-1000mg IV


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Immediate - signs of pulmonary edema, ICU

capability/available

Delayed - dyspnea w/o pulmonary edema,

reevaluate q 2 hoursMinimal - asymptomatic

Expectant - pulmonary edema, cyanosis, and

hypotension

Phosgene-Like Combustion ProductsTriage Category


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White Phosphorous

Incendiary agent used

in anti-personnel

weapons

Fragments can bedriven deep into tissues

Ignites (exothermic) in

presence of oxygen

Suspect casualtiesinvolved in explosions


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White Phosphorous

Initial Management

Remove all clothing

Thorough irrigation with

water or saline

Remove easilyidentified particles

Cover wounds with

saline or water soaked

dressings and keepmoist during transport


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White Phosphorous

Definitive Management

Surgically debride fragments

Look for the smoking wound Dense white smoke and yellow

flame

Garlic odor

Identify fragments 0.5% copper sulfate solution

rinse->forms cupric phosphide,a blue black film, and preventsfurther oxidation

Woods lamp

Immerse fragments in waterto avoid further ignition


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White Phosphorous

Complications

Hypocalcemia and hypophosphatemia

Serial electrolyte measurements

Cardiac arrhythmias

Reverses Ca2+ : PO42- ratio May need cardiac monitoring

Hemolysis and renal failure due to copper

sulfate solution rinse

Must be immediately removed by water lavage

04 strt battlefield injury patterns

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