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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PRIMARY BLAST INJURY:
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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PRIMARY BLAST INJURY:
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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PRIMARY BLAST INJURY:
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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PRIMARY BLAST INJURY:
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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PRIMARY BLAST INJURY:
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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SPECIAL CONSIDERATIONS IN PREGNANCY
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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SPECIAL CONSIDERATIONS IN PREGNANCY
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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BLAST LUNG INJURY ( BLI ):
Other pulmonary injuries include:
Pneumothorax
Hemothorax
Pneumomediastinum
Subcutaneous emphysema
Air emboli
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BLAST LUNG INJURY ( BLI ):
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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BLAST LUNG INJURY ( BLI ):
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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