bombings 3 h

7/25/2019 Bombings 3 h

1/130

Bombings:Bombings:

Injury Patterns andInjury Patterns andCareCare


2/130

This project was funded by the Centers forThis project was funded by the Centers for

Disease Control and Prevention (CDC) underDisease Control and Prevention (CDC) under

Cooperative Agreement U!"CCU#$%&'*Cooperative Agreement U!"CCU#$%&'*

+,in-ages of Acute Care and ./0 to 0tate and+,in-ages of Acute Care and ./0 to 0tate and

,ocal 1njury Prevention Programs for Terrorism,ocal 1njury Prevention Programs for Terrorism

Preparedness and 2esponse34Preparedness and 2esponse34


3/130

Bombings: Injury Patterns 3

American /edical Association (A/A)American /edical Association (A/A) American Trauma 0ociety (AT0)American Trauma 0ociety (AT0) 5ational Association of ./0 Physicians (5A./0P)5ational Association of ./0 Physicians (5A./0P) 5ational Association of ./T6s (5A./T)5ational Association of ./T6s (5A./T) 5ational Association of 0tate ./0 78cials (5A0./07)5ational Association of 0tate ./0 78cials (5A0./07) 5ational 5ative American ./0 Association (55A./0A)5ational 5ative American ./0 Association (55A./0A)

TheThe Bombings: Injury Patterns and CareBombings: Injury Patterns and Care curriculum wascurriculum was

developed through the Linkages of cute Care and !"#developed through the Linkages of cute Care and !"#

to #tate and Local Injury Prevention Programs projectto #tate and Local Injury Prevention Programs project

that was funded by the Centers for $isease Control andthat was funded by the Centers for $isease Control and

Prevention %C$C&' The merican College of !mergencyPrevention %C$C&' The merican College of !mergencyPhysicians %C!P& served as the lead grantee for thePhysicians %C!P& served as the lead grantee for the

project along with the following si( other organi)ations:project along with the following si( other organi)ations:


4/130


task force was established with representative e(perts from task force was established with representative e(perts from

emergency medicine including physicians* surgeons* nursing*emergency medicine including physicians* surgeons* nursing*

and !"#' Core competencies and knowledge objectives wereand !"#' Core competencies and knowledge objectives were

developed using a consensus approach' writing group thendeveloped using a consensus approach' writing group then

developed teaching objectives and course content based on thedeveloped teaching objectives and course content based on thecore competencies'core competencies'

TheThe Bombings: Injury Patterns and CareBombings: Injury Patterns and Care curriculum is designedcurriculum is designed

to be the minimum content that should be included in any all+to be the minimum content that should be included in any all+

ha)ards disaster response training program' This content isha)ards disaster response training program' This content is

designed to update the student with the latest clinicaldesigned to update the student with the latest clinical

information regarding blast related injuries from terrorism'information regarding blast related injuries from terrorism'


5/130


merican College of !mergency Physicians %C!P& ,rant #ta-9 .athryn /' Brins0eld* "$* "P/* 1C!P* Chair* Curriculum on Traumatic

Injuries from Terrorism Task 1orce %C2+TI1T&9 3ick "urray* !"T+P* !"# and $isaster Preparedness $irector* Principle3ick "urray* !"T+P* !"# and $isaster Preparedness $irector* Principle

InvestigatorInvestigator9 "arshall ,ardner* !"T+P* !"# and $isaster Preparedness "anager"arshall ,ardner* !"T+P* !"# and $isaster Preparedness "anager

9 $iana #' 4ester* !"# and $isaster 3esponse Coordinator$iana #' 4ester* !"# and $isaster 3esponse Coordinator9 Cynthia #ingh* "#* ,rants and $evelopment "anagerCynthia #ingh* "#* ,rants and $evelopment "anager9 .athryn "ensah* "#* ,rants dministrator.athryn "ensah* "#* ,rants dministrator9 "ary 5hiteside* Ph$* Curriculum $evelopment Consultant"ary 5hiteside* Ph$* Curriculum $evelopment Consultant

Centers for $isease Control and Prevention %C$C& #ta-9 3ichard C' /unt* "$* 1C!P* $irector* $ivision of Injury 3esponse* 6ational3ichard C' /unt* "$* 1C!P* $irector* $ivision of Injury 3esponse* 6ational

Center forCenter for Injury Prevention and ControlInjury Prevention and Control9 #cott "' #asser* "$* 1C!P* Consultant* $ivision of Injury 3esponse*#cott "' #asser* "$* 1C!P* Consultant* $ivision of Injury 3esponse*

6ational Center6ational Center for Injury Prevention and Controlfor Injury Prevention and Control9 !rnest !' #ullivent* III* "$* "edical 27cer* $ivision of Injury 3esponse*!rnest !' #ullivent* III* "$* "edical 27cer* $ivision of Injury 3esponse*

6ational6ational Center for Injury Prevention and ControlCenter for Injury Prevention and Control9 Paula Burgess* "$* "P/* Team Leader* $ivision of Injury 3esponse* 6ationalPaula Burgess* "$* "P/* Team Leader* $ivision of Injury 3esponse* 6ational

CenterCenter for Injury Prevention and Controlfor Injury Prevention and Control9 4ane "itchko* "!d* C/!#* /ealth Communications #pecialist* $ivision of4ane "itchko* "!d* C/!#* /ealth Communications #pecialist* $ivision of

InjuryInjury 3esponse* 6ational Center for Injury Prevention and Control3esponse* 6ational Center for Injury Prevention and Control

89;


6/130


$iscussion$iscussionTopicsTopics

:ac-ground:ac-ground

.;plosive .vents.;plosive .vents

:last 1njuries:last 1njuries9 Primary* 0econdary* Tertiary*


7/130Bombings: Injury Patterns 7

BackgroundBackground




Terrorism can be de=ned as containingTerrorism can be de=ned as containing

four -ey elements>four -ey elements>

9 PremeditatedPremeditated9 PoliticalPolitical

9 Aimed at civiliansAimed at civilians

9 Carried out by subnational groupsCarried out by subnational groups




.;plosive use increasing in terrorist.;plosive use increasing in terrorist

eventsevents

2esult in mass casualty incidents2esult in mass casualty incidents 2ecent e;amples2ecent e;amples

9 /umbai ($&)/umbai ($&)

9 Tel Aviv ($&)Tel Aviv ($&)

9 ,ondon subway ($#),ondon subway ($#)

9 /adrid subway ($%)/adrid subway ($%)

9 Tel Aviv ($)Tel Aviv ($)



BackgroundBackground: /istorical: /istorical

PerspectivePerspective

?&@????&@???9 ! international terrorist bombings! international terrorist bombings

?&??@?&??@9 @! bombings in 5orthern 1reland@! bombings in 5orthern 1reland

?@$?@$9 '$% criminal bombing events in the U0'$% criminal bombing events in the U0

$$'$$'9 # 1nternational terrorist bombings# 1nternational terrorist bombings

$#$#9 '?? 1nternational terrorist bombings'?? 1nternational terrorist bombings

0ources> ry-berg .2* Tepas BB U0 Departments of 0tate* Bustice Terrorism 2esearch

Centre


11/130


Background: Blast $evicesBackground: Blast $evices

Photo used with permission of "4 Benjamin ,on)ale)* "$


12/130


Background: Blast $evicesBackground: Blast $evices

1mprovised e;plosive devices (1.Ds)1mprovised e;plosive devices (1.Ds)9 Car and truc- bombs (7-lahoma City* orld Trade Center 1)Car and truc- bombs (7-lahoma City* orld Trade Center 1)

9 ,etter and parcel bombs (1daho +Unabomber4),etter and parcel bombs (1daho +Unabomber4)

9 Pipe bombs (Atlanta 7lympics)Pipe bombs (Atlanta 7lympics)

9 :ac-pac- and satchel bombs (1srael* ,ondon):ac-pac- and satchel bombs (1srael* ,ondon)

1ncendiary bombs1ncendiary bombs9 Airplane bombs (orld Trade Center 11* Pentagon)Airplane bombs (orld Trade Center 11* Pentagon)

2oc-et propelled grenades (2PEs)2oc-et propelled grenades (2PEs) 0urface to air missiles (0A/s)0urface to air missiles (0A/s)

.nhanced blast devices.nhanced blast devices


13/130


BackgroundBackground: Blast $evices: Blast $evices

1.Ds1.Ds

1mprovised"+homemade4 e;plosive devices1mprovised"+homemade4 e;plosive devices

/ade from e;plosives* commercial blasting/ade from e;plosives* commercial blastingsupplies* or fertiliFer and householdsupplies* or fertiliFer and household

ingredientsingredients

Designed to cause injury and deathDesigned to cause injury and death

7ften pac-ed with metal objects such as nails7ften pac-ed with metal objects such as nailsor ball bearings could contain to;ic chemicalsor ball bearings could contain to;ic chemicals

or radiological materials (dirty bomb)or radiological materials (dirty bomb)


14/130


BackgroundBackground: Blast gents: Blast gents

Gighorder e;plosive> G.Gighorder e;plosive> G.

5itroglycerin (5TE)5itroglycerin (5TE)

DynamiteDynamite PlasticPlastic

Ammonium nitrate"Ammonium nitrate"

fuel oil fuel oil(A57)(A57)

Trinitrotoluene (T5TTrinitrotoluene (T5T)) Triacetone tripero;ideTriacetone tripero;ide

(TAPT) (TAPT)

,oworder e;plosive>,oworder e;plosive>

,.,.

Petroleum productsPetroleum products(+/olotov coc-tail4)(+/olotov coc-tail4)

EunpowderEunpowder

(+blac-4 powder)(+blac-4 powder)

Can become G.* ifCan become G.* if

contained (e3g3*contained (e3g3*

pipe bomb)pipe bomb)


15/130


!(plosive!(plosive !vents!vents


16/130


!(plosive!(plosive!vents!vents

1ncident command1ncident command

9 .ntire area H crime scene I evidence.ntire area H crime scene I evidence

preservationpreservation9 /ultijurisdictional response/ultijurisdictional response

0cene safety0cene safety

9 Dirty bombs* secondary devices* buildingDirty bombs* secondary devices* building

collapse* high dust environment (possiblycollapse* high dust environment (possiblycontaminated)* bomb fragmentscontaminated)* bomb fragments


17/130


!(plosive !vents:!(plosive !vents:

Criminal InvestigationCriminal Investigation

Principles of criminal investigation andPrinciples of criminal investigation and

evidence preservationevidence preservation

9 1ndicators for crime scene1ndicators for crime scene9 .vidence and chain of custody.vidence and chain of custody

9 Avoid disturbing or compromising evidenceAvoid disturbing or compromising evidence

9 Detection of possible suspects"perpetratorsDetection of possible suspects"perpetrators

9


18/130

#cene#cene#afety#afety


19/130


#cene #afety: Common /a)ards#cene #afety: Common /a)ards

0econdary devices0econdary devices

0hrapnel0hrapnel

:uilding collapse:uilding collapse Airborne contaminantsAirborne contaminants

Contaminated patientsContaminated patients

Contaminated scene"environmentContaminated scene"environment

PerpetratorsPerpetrators Terrorist patientsTerrorist patients


20/130


#cene #afety: Common /a)ards#cene #afety: Common /a)ards

Jictims with no soft tissue injuriesJictims with no soft tissue injuries Jehicles coming or leaving scene (out ofJehicles coming or leaving scene (out of

place)place) People acting oddlyPeople acting oddly Pac-ages or containers at scene (out ofPac-ages or containers at scene (out of

place)place) Jehicles not damaged or out of placeJehicles not damaged or out of place

0tructural damage0tructural damage eathereather Possible places for secondary devicesPossible places for secondary devices


21/130


#cene #afety:#cene #afety:

ppropriate PP! for blastsppropriate PP! for blasts

CoverallsCoveralls

Geavy coatGeavy coat

Geavy glovesGeavy gloves 0teeltoed boots0teeltoed boots

Gard hatGard hat

.ye protection.ye protection Dust particle mas-Dust particle mas-

:reathing apparatus for to;ic fumes:reathing apparatus for to;ic fumes


22/130


#cene #afety: Common#cene #afety: Common

PrinciplesPrinciples

Contain the incidentContain the incident

9 Deny entry to all but respondersDeny entry to all but responders

9 0et up Fones0et up Fones GotGot armarm

ColdCold

Contain the peopleContain the people

9 Do not let anyone leaveDo not let anyone leave

scene until chec-ed scene until chec-ed

9 Decontaminate if necessaryDecontaminate if necessaryPhoto used with permission of Connie $oyle* "$*1C!P


23/130




Cause no further injury or destructionCause no further injury or destruction

Protect yourselfProtect yourself

Activate command andActivate command andhaFard response (1C0)haFard response (1C0)

,imit access,imit access

Contain the incidentContain the incident

Photo used with permission of .athryn Brins0eld* "$* 1C!P


24/130




or-er safetyor-er safety

Protection of uninvolved public andProtection of uninvolved public and

volunteersvolunteers Protection of injuredProtection of injured

Treatment of injuredTreatment of injured

0urveillance of patients and wor-ers0urveillance of patients and wor-ersfor longterm eKectsfor longterm eKects


25/130


TriageTriage


26/130


TriageTriage

UniLue patterns* multiple and occultUniLue patterns* multiple and occult

injuriesinjuries

Death often result of combined blast*Death often result of combined blast*ballistic* and thermal eKect injuriesballistic* and thermal eKect injuries

(multidimensional injury)(multidimensional injury)

al-ing woundedal-ing wounded

Gidden"internal injuriesGidden"internal injuries /any noncritical patients who reLuire/any noncritical patients who reLuire

time intensive wor-upstime intensive wor-ups


27/130


TriageTriage

5ature of injuries may lead to5ature of injuries may lead to

overtriageovertriage

Up to !#M of victims selfrefer toUp to !#M of victims selfrefer tohospital arrive by privatehospital arrive by private

transportationtransportation ield triageield triage

9 Dynamic processDynamic process


28/130


TriageTriage

actors that determine when needsactors that determine when needs

e;ceed resourcese;ceed resources

9 ,arge number of patients ma-e rapid,arge number of patients ma-e rapidtriage impossibletriage impossible

9 ,arge number of patients cause delay in,arge number of patients cause delay in

transport to hospitalstransport to hospitals

9 ,arge number of patients e;ceed,arge number of patients e;ceedresponder treatment capabilitiesresponder treatment capabilities

9 0urge at local hospitals0urge at local hospitals


29/130


BlastBlast InjuriesInjuries


30/130


Blast Injuries: =ni>ue spectsBlast Injuries: =ni>ue spects

1nNict multisystem injuries on large1nNict multisystem injuries on large

groups of peoplegroups of people

Cause many simultaneous lifeCause many simultaneous lifethreatening injuriesthreatening injuries

Gidden pattern of injuryGidden pattern of injury


31/130


Blast Injuries: Blast PhysicsBlast Injuries: Blast Physics

2apid chemical conversion of a solid or2apid chemical conversion of a solid or

liLuid into highly pressuriFed gasesliLuid into highly pressuriFed gases

Eases e;pand rapidly and compressEases e;pand rapidly and compressthe surrounding airthe surrounding air

Pressure wave and blast wind arePressure wave and blast wind are

generated and spread in all directionsgenerated and spread in all directions

1s aKected by the medium through1s aKected by the medium through

which it travels* i3e3* air vs3 waterwhich it travels* i3e3* air vs3 water


32/130


Blast Injuries: Blast PhysicsBlast Injuries: Blast Physics

Emergency War Surgery, 3rd Edition

1mportance of 1njury Types vs3Distance

$iagram used with permission of 4ohn+Phillipe $ionne' Ph$


33/130


Background: Physics of BlastsBackground: Physics of Blasts

Clic- to viewanimation3


34/130


Blast Injury: #everityBlast Injury: #everity

5ature of device 9 agent* amount5ature of device 9 agent* amount

/ethod of delivery 9 incendiary*/ethod of delivery 9 incendiary*

e;plosivee;plosive 5ature of environment 9 open* closed5ature of environment 9 open* closed

Distance from deviceDistance from device

1ntervening protective barrier1ntervening protective barrier 7ther environmental haFards7ther environmental haFards


35/130


"urrah"urrah

BuildingBuilding

Photo Courtesy of the City 2f 2klahoma City


36/130


"urrah 1ederal Building* 2klahoma City %8??@& A distribution ofinjuries

4"* ugust 8??


37/130


3ussell #>uare* London bombing*9;;

$iagram used with permission of $irectorate of Public -airs* "etropolitan Police

#ervice* London


38/130


"umbai* India: 4uly 9;;


39/130


Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology

Proposed mechanismsOProposed mechanismsO

0palling0palling

9 Caused by shoc- wave moving throughCaused by shoc- wave moving throughtissues of diKerent densitiestissues of diKerent densities II molecularmolecular

disruptiondisruption

1mplosion1mplosion

9 Caused by entrapped gases in hollowCaused by entrapped gases in holloworgans compressing then e;pandingorgans compressing then e;panding II

visceral disruptionvisceral disruption


40/130


Blast Injuries: PathophysiologyBlast Injuries: Pathophysiology

0hearing0hearing

9 Caused by tissues of diKerent densitiesCaused by tissues of diKerent densities

moving at diKerent speedsmoving at diKerent speeds II visceral tearingvisceral tearing

1rreversible or-1rreversible or-

9 Caused by forces e;ceeding the tensileCaused by forces e;ceeding the tensile

strength of the tissuestrength of the tissue

O0palling* implosion and shearing are thought to be threeO0palling* implosion and shearing are thought to be three

mechanisms that cause blast injuries3 1rreversible wor- ismechanisms that cause blast injuries3 1rreversible wor- is

currently being researched as a more li-ely mechanism ofcurrently being researched as a more li-ely mechanism of

injury3injury3


41/130


Blast Injuries: CategoriesBlast Injuries: Categories

Primary injuryPrimary injury

9 Caused by blast waveCaused by blast wave II over pressureover pressure

0econdary injury0econdary injury9 Caused by Nying debrisCaused by Nying debris I shrapnel woundsI shrapnel wounds

Tertiary injuryTertiary injury

9 Caused by blast windCaused by blast wind II forceful impactforceful impact


42/130


Blast Injuries: PrimaryBlast Injuries: Primary

:lunt trauma from over pressure wave:lunt trauma from over pressure wave

9 UniLue to highorder e;plosivesUniLue to highorder e;plosives

9 2esults from the impact of the over2esults from the impact of the overpressuriFation wave with body surfacespressuriFation wave with body surfaces

9 :lunt force injuries:lunt force injuries

9 Produces barotraumaProduces barotrauma


43/130


$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$*1C!P


44/130


Blast Injuries: PrimaryBlast Injuries: Primary

/ost common injuries>/ost common injuries>9 :last lungpulmonary barotraumas:last lungpulmonary barotraumas

9 Traumatic brain injury (T:1)* concussionTraumatic brain injury (T:1)* concussion9 Tympanic membrane (eardrum) ruptureTympanic membrane (eardrum) rupture

9 /iddle ear damage/iddle ear damage

9 Abdominal hemorrhageAbdominal hemorrhage

9 Abdominal organ perforationAbdominal organ perforation


45/130


Blast Injuries: #econdaryBlast Injuries: #econdary

The most common cause of death in aThe most common cause of death in a

blast event is secondary blast injuries3blast event is secondary blast injuries3

These injuries are caused by NyingThese injuries are caused by Nyingdebris generated by the e;plosion3debris generated by the e;plosion3

Terrorists often add screws* nails* andTerrorists often add screws* nails* and

other sharp objects to bombs toother sharp objects to bombs to

increase injuries3increase injuries3


46/130


$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$* 1C!P


47/130



The most common types of secondaryThe most common types of secondary

blast injuries are>blast injuries are>

9 Trauma to the head* nec-* chest*Trauma to the head* nec-* chest*abdomen* and e;tremities in the form ofabdomen* and e;tremities in the form of

penetrating and blunt traumapenetrating and blunt trauma

9 racturesractures

9 Traumatic amputationsTraumatic amputations9 0oft tissue injuries0oft tissue injuries


48/130



Penetrating trauma (shrapnel wounds)Penetrating trauma (shrapnel wounds)

9 oreign bodies follow unpredictable pathsoreign bodies follow unpredictable paths

through bodythrough body

9 /ay have only mild e;ternal signs/ay have only mild e;ternal signs

9 Gave a low threshold for imaging studiesGave a low threshold for imaging studies

(plain radiographs* computed tomograms)(plain radiographs* computed tomograms)

9 Consider all wounds contaminatedConsider all wounds contaminated


49/130


#econdaryInjury

=sed with permission of merican 4ournal of 3oentgenology 9;;


50/130


Blast Injuries: TertiaryBlast Injuries: Tertiary

Tertiary injuries result from individuals beingTertiary injuries result from individuals being

thrown by the blast wind3thrown by the blast wind3

The most common types of tertiary blastThe most common types of tertiary blast

injuries are>injuries are>9 Gead injuriesGead injuries

9 0-ull fractures0-ull fractures

9 :one fractures:one fractures

Treatment for most tertiary blast injuriesTreatment for most tertiary blast injuriesfollows established protocols for that speci=cfollows established protocols for that speci=c

injury3injury3


51/130


$iagram used with permission of LTC 4ohn "c"anus* 4r'* "$* 1C!P


52/130


Blast Injuries: HuaternaryBlast Injuries: Huaternary

All e;plosionrelated injuries* illnesses*All e;plosionrelated injuries* illnesses*

or diseases not due to primary*or diseases not due to primary*

secondary* or tertiary mechanisms aresecondary* or tertiary mechanisms areconsidered Luaternary blast injuries3considered Luaternary blast injuries3

This includes e;acerbation orThis includes e;acerbation or

complications of e;isting conditions3complications of e;isting conditions3


53/130


Blast Injuries: HuaternaryBlast Injuries: Huaternary

The most common Luaternary blastThe most common Luaternary blastinjuries include>injuries include>9 :urns:urns

9 Gead injuriesGead injuries9 AsthmaAsthma

9 C7PDC7PD

9 7ther breathing problems7ther breathing problems

9 AnginaAngina

9 GyperglycemiaGyperglycemia

9 GypertensionGypertension

9 Crush injuriesCrush injuries


54/130


Blast Injuries: Blast LungBlast Injuries: Blast Lung

=sed with permission of C/!#T* $ecember 8???G 88


55/130



3eprinted from merican 4ournal of #urgery* F8?;: ?+?;*

vidan F et al: Blast Lung #urgeryJwith permission from E !(cerpta"edica Inc'


56/130



Clinical manifestationsClinical manifestations9 TachypneaTachypnea

9 Gypo;iaGypo;ia

9 CyanosisCyanosis9 ApneaApnea

9 heeFingheeFing

9 Decreased breath soundsDecreased breath sounds

9 GemoptysisGemoptysis

9 CoughCough

9 Chest painChest pain

9 DyspneaDyspnea

9 Gemodynamic instabilityGemodynamic instability


57/130



TreatmentTreatment

9 Gigh Now o;ygen su8cient to preventGigh Now o;ygen su8cient to prevent

hypo;emia via nonrebreather mas-hypo;emia via nonrebreather mas-

9 CPAPCPAP

9 .ndotracheal intubation.ndotracheal intubation

9 Budicious Nuid administration (similar toBudicious Nuid administration (similar to

that of pulmonary contusion)that of pulmonary contusion)


58/130


Blast Injuries: /eadBlast Injuries: /ead

Primary blast waves can causePrimary blast waves can cause

concussions or mild traumatic brainconcussions or mild traumatic brain

injury (/T:1) without a direct blow toinjury (/T:1) without a direct blow to

the headthe head


59/130


Blast Injuries: /eadBlast Injuries: /ead

Consider the pro;imity of the victim toConsider the pro;imity of the victim to

the blast particularly when giventhe blast particularly when given

complaints of>complaints of>

9 ,oss of consciousness,oss of consciousness

9 GeadacheGeadache

9 atigueatigue

9 Poor concentration* lethargy* amnesia* orPoor concentration* lethargy* amnesia* or

other constitutional symptomsother constitutional symptoms

9 0ymptoms of concussion and post traumatic0ymptoms of concussion and post traumatic

stress disorder (PT0D) can be similarstress disorder (PT0D) can be similar


60/130


Blast Injuries: T" 3uptureBlast Injuries: T" 3upture

Tympanic membrane rupture indicatesTympanic membrane rupture indicates

e;posure to an over pressuriFatione;posure to an over pressuriFation

wave3 1t may be found in victims withwave3 1t may be found in victims with

severe pulmonary* intestinal* or othersevere pulmonary* intestinal* or other

injuries* or it may be found in isolation3injuries* or it may be found in isolation3

1ts presence does not indicate that1ts presence does not indicate that

more sinister blast injuries e;ist3more sinister blast injuries e;ist3


61/130


Blast Injuries: T" 3uptureBlast Injuries: T" 3upture

=sed with permission of 6!4"* pril 9;;G @9: 8@@+8@9


62/130


Blast Injuries: !arBlast Injuries: !ar

.ar injuries may include not only T/.ar injuries may include not only T/

rupture* but also ossicular disruption*rupture* but also ossicular disruption*

cochlear damage* and foreign bodies3cochlear damage* and foreign bodies3


63/130


Blast Injuries: !arBlast Injuries: !ar

Presentation> acute hearing lossPresentation> acute hearing loss

(conductive* sensorineural)(conductive* sensorineural)

indings> auditory canal debris*indings> auditory canal debris*tympanic membrane rupture* ossiculartympanic membrane rupture* ossicular

disruption* cochlear damagedisruption* cochlear damage

Treatment> observation #@M ofTreatment> observation #@M of

ruptured tympanic membranes healruptured tympanic membranes healsensorineural hearing loss oftensensorineural hearing loss often

permanentpermanent


64/130


Blast Injuries: bdomenBlast Injuries: bdomen

Abdominal injuries (also called blastAbdominal injuries (also called blast

abdomen) include abdominalabdomen) include abdominal

hemorrhage and abdominal organhemorrhage and abdominal organ

perforationperforation


65/130


Blast Injuries: bdomenBlast Injuries: bdomen

Clinical manifestations include>Clinical manifestations include>9 Abdominal or testicular painAbdominal or testicular pain

9 TenesmusTenesmus

9 2ectal bleeding2ectal bleeding9 0olid organ lacerations0olid organ lacerations

9 2ebound tenderness2ebound tenderness

9 EuardingEuarding

9 Absent bowel soundsAbsent bowel sounds

9 0igns of hypovolemia0igns of hypovolemia

9 5ausea5ausea

9 JomitingJomiting


66/130


Blast Injuries: CombinedBlast Injuries: Combined

InjuriesInjuries

Combined injuries* especially blast andCombined injuries* especially blast and

burn injury or blast and crush injury*burn injury or blast and crush injury*

are common during an e;plosiveare common during an e;plosive

event3event3


67/130


Blast Injuries: CombinedBlast Injuries: Combined

InjuriesInjuries

Avoid tunnel vision during initial assessmentAvoid tunnel vision during initial assessment

Treatment protocols are often contradictoryTreatment protocols are often contradictory

9 :last lung vs3 burn injury* blast lung vs3 crush injury:last lung vs3 burn injury* blast lung vs3 crush injury

Budicious Nuid administration for adeLuateBudicious Nuid administration for adeLuate

tissue perfusion without volume overload maytissue perfusion without volume overload may

be reLuired in the multiple injured patient withbe reLuired in the multiple injured patient with

blast lungblast lung

9 Presence of additional injuries complicatesPresence of additional injuries complicatesadministration* rate* selection of Nuidsadministration* rate* selection of Nuids


68/130


Blast Injury: Combined InjuriesBlast Injury: Combined Injuries

Typical con=ned space (e3g3* a bus) injuriesTypical con=ned space (e3g3* a bus) injuries

Primaryblast lung* intestinal rupture* T/Primaryblast lung* intestinal rupture* T/

rupturerupture

0econdary0econdarypenetrating injury to head*penetrating injury to head*

eye* chest* abdomeneye* chest* abdomen

Tertiarytraumatic amputation* fracturesTertiarytraumatic amputation* fractures

to the face* pelvis* ribs* spineto the face* pelvis* ribs* spine


69/130

Crush InjuryCrush Injury


70/130


Crush Injury: $e0nitionCrush Injury: $e0nition

An injury sustained when a body part isAn injury sustained when a body part is

subjected to a high degree* or prolongedsubjected to a high degree* or prolonged

presence* of force or pressurepresence* of force or pressure

9 Usually applied to both regional (e3g3 bodyUsually applied to both regional (e3g3 body

part) eKects and systemic eKects3part) eKects and systemic eKects3

Acute traumatic ischemia* with or withoutAcute traumatic ischemia* with or without

associated injuries* describes actual insultassociated injuries* describes actual insultto tissuesto tissues


71/130


Crush Injury: Crush #yndromeCrush Injury: Crush #yndrome

Term used to describe the systemsTerm used to describe the systems

manifestations of crush injury aftermanifestations of crush injury after

reperfusion of aKected body part(s)reperfusion of aKected body part(s)

3eprinted with permission of 2rtho5orld'com


72/130


Crush Injury:Crush Injury:

Compartment #yndromeCompartment #yndrome

1s a collection of localiFed signs and1s a collection of localiFed signs and

symptoms that result when thesymptoms that result when the

perfusion pressure falls below theperfusion pressure falls below the

tissue pressure in a closed anatomictissue pressure in a closed anatomic

space for su8cient time thatspace for su8cient time that

compromise of circulation and functioncompromise of circulation and function

of tissues involved occursof tissues involved occurs


73/130


Crush Injury: IncidenceCrush Injury: Incidence

##M of mass casualty situations##M of mass casualty situations9 5atural disasters* especially earthLua-es5atural disasters* especially earthLua-es

and tornadoesand tornadoes

9 0tructural collapse* with or without victim0tructural collapse* with or without victimentrapmententrapment

9 1ndustrial* farm or transportation accidents1ndustrial* farm or transportation accidents

9 :last injury (all types):last injury (all types)

9 CombatCombat9 Prolonged immobiliFation with majorProlonged immobiliFation with major

vascular or microvascular circulationvascular or microvascular circulationcompromisecompromise


74/130


Crush Injury: !(amples ofCrush Injury: !(amples of

eventsevents

Tyre* ,ebanon (?@$)Tyre* ,ebanon (?@$)9 :uilding collapse:uilding collapse

:eirut* ,ebanon (?@'):eirut* ,ebanon (?@')

9 /arine barrac-s bombed/arine barrac-s bombed

7-lahoma City (??#)7-lahoma City (??#)9 /urrah ederal :uilding/urrah ederal :uilding

bombedbombed

Qhobar* 0audi ArabiaQhobar* 0audi Arabia(??&)(??&)9 Qhobar Towers bombedQhobar Towers bombed =sed with permission of P Photo." Chaudhry


75/130


Crush Injury: PathophysiologyCrush Injury: Pathophysiology

Areas most aKectedAreas most aKected

9 ,ower e;tremities,ower e;tremities

9Upper e;tremitiesUpper e;tremities

9 PelvisPelvis

9 Eluteal regionEluteal region

9 Abdominal musclesAbdominal muscles

3eprinted with permission of 2rtho5orld'com


76/130

Crush #yndromeCrush #yndrome


77/130


Crush #yndromeCrush #yndrome

/ay occur in absence of trauma and evolve/ay occur in absence of trauma and evolve

in the absence of early signs or symptomsin the absence of early signs or symptoms

9 Arterial thrombosis or embolismArterial thrombosis or embolism

9 0evere anemia0evere anemia9 To;insTo;ins

9 ,egitimate medications and drugs of abuse,egitimate medications and drugs of abuse

0ystemic eKects due to rhabdomyolysis and0ystemic eKects due to rhabdomyolysis and

reperfusion of hypo;ic and damaged tissuesreperfusion of hypo;ic and damaged tissuesand is the major cause of early mortalityand is the major cause of early mortality

h dC h # d


78/130


Crush #yndrome:Crush #yndrome:

PathophysiologyPathophysiology

2habdomyolysis2habdomyolysis

.Ru; from damaged muscle cells of>.Ru; from damaged muscle cells of>

9 PotassiumPotassium9 PurinesPurines

9 ,actic Acid,actic Acid

9 PhosphatePhosphate

9 /yoglobin/yoglobin9 ThromboplastinThromboplastin

9 CreatineCreatine

C h # dC h # d


79/130


Crush #yndrome :Crush #yndrome :


2eperfusion2eperfusion

9 0-eletal muscle damage greatest after0-eletal muscle damage greatest after

reperfusionreperfusion

9 0upero;ide radicals produced during reperfusio0upero;ide radicals produced during reperfusioattac-s free fatty acids* producing cellularattac-s free fatty acids* producing cellular

edema* death* and necrosisedema* death* and necrosis

9 5aQATP pump e;changes intracellular sodium5aQATP pump e;changes intracellular sodium

for calcium with further derangement offor calcium with further derangement ofintracellular metabolismintracellular metabolism

C h # dC h # d


80/130




3esultant e-ects of derangements due to rhabdomyolysis3esultant e-ects of derangements due to rhabdomyolysis andandreperfusionreperfusion

PotassiumPotassium Gyper-alemiaGyper-alemia ArrhythmiasArrhythmias

CalciumCalcium GypocalcemiaGypocalcemia ArrhythmiasArrhythmias PhosphatePhosphate GyperphosphatemiaGyperphosphatemia 2enal damage2enal damage /yoglobin/yoglobin /yoglobinemia/yoglobinemia 2enal damage2enal damage luid shiftsluid shifts GypovolemiaGypovolemia 2enal failure2enal failure 2eperfusion2eperfusion ree radicalsree radicals 2enal damage2enal damage PurinesPurines GyperuricemiaGyperuricemia 2enal damage2enal damage Gypo;emiaGypo;emia ,actic acid,actic acid AcidosisAcidosis ThromboplastinThromboplastin Complement systemComplement system D1CD1C CreatinineCreatinine .levated serum levels.levated serum levels 0odium0odium AFotemiaAFotemia


81/130

C h # d Cli i lC h # d Cli i l


82/130


Crush #yndrome: ClinicalCrush #yndrome: Clinical

PresentationPresentation

AKected part (usually limb)AKected part (usually limb)

9 Tense edema and decreased sensationTense edema and decreased sensation

9 7verlying s-in may be shiny* contused*7verlying s-in may be shiny* contused*

necroticnecrotic

/ay have penetrating wounds (worse/ay have penetrating wounds (worse

diagnosis)diagnosis)

C h # dC h # d


83/130



Potential ComplicationsPotential Complications

Gyper-alemiaGyper-alemia

GypocalcemiaGypocalcemia

GyperphosphatemiaGyperphosphatemia /etabolic acidosis/etabolic acidosis

GypothermiaGypothermia

Acute 2enal failureAcute 2enal failure


84/130


Crush #yndrome: TreatmentCrush #yndrome: Treatment

Ereatest initial danger is after releaseEreatest initial danger is after releaseof crushed limb from entrapment withof crushed limb from entrapment withrestoration of circulationrestoration of circulation

/ainstay of treatment is aggressive/ainstay of treatment is aggressiveNuid resuscitation and bris- diuresisNuid resuscitation and bris- diuresis

Amount of tissue damage correlatesAmount of tissue damage correlateswith need for dialysiswith need for dialysis9 Cannot determine actual tissue damageCannot determine actual tissue damage

based on area of aKected body partbased on area of aKected body part


85/130



Delay in treatment associated withDelay in treatment associated with

greater morbidity and mortalitygreater morbidity and mortality

9 #M renal failure at & hours#M renal failure at & hours

9 M renal failure at $ hoursM renal failure at $ hours

9 2habdomyolysis induced renal failure has2habdomyolysis induced renal failure has

%M mortality%M mortality


86/130



PrehospitalPrehospital

Primary survey and initial stabiliFationPrimary survey and initial stabiliFation

(A:Cs)(A:Cs) luid resuscitation before patient isluid resuscitation before patient is

e;tricated with severe or prolongede;tricated with severe or prolonged

entrapment of limb or pelvis (moreentrapment of limb or pelvis (more

than a hand or foot)than a hand or foot)


87/130



GospitalGospital luid resuscitationluid resuscitation

:ris- diuresis:ris- diuresis

Diagnose and treat other metabolicDiagnose and treat other metabolic

derangementsderangements9 Gyper-alemiaGyper-alemia

9 GypocalcemiaGypocalcemia

Treat tissue damageTreat tissue damage Pain controlPain control

AgitationAgitation


88/130



89/130



1s a collection of localiFed signs and1s a collection of localiFed signs and

symptoms that result when thesymptoms that result when the

perfusion pressure falls below theperfusion pressure falls below the

tissue pressure in a closed anatomictissue pressure in a closed anatomic

space for su8cient time thatspace for su8cient time that

compromise of circulation and functioncompromise of circulation and function

of tissues involved occursof tissues involved occurs


90/130



Can lead to crush syndrome systemicCan lead to crush syndrome systemic

eKects if left untreated or inadeLuatelyeKects if left untreated or inadeLuately

treated3treated3

Photo used with permission of The Institute for 1ootand nkle 3econstruction at "ercy* Baltimore* "$
http://footandankle.mdmercy.com/conditions/trauma/images/compartment_1.jpg


91/130



0uggestive clinical =ndings0uggestive clinical =ndings 0imilar settings to crush injury* but may also0imilar settings to crush injury* but may also

occur with subacute traumaoccur with subacute trauma

:one fractures:one fractures

Gigh velocity penetrating injury to muscles inGigh velocity penetrating injury to muscles in

closed compartment with e;tensive tissueclosed compartment with e;tensive tissue

disruptiondisruption

Can also occur in subacute fashion due toCan also occur in subacute fashion due to

prolonged immobiliFation on hard surfaceprolonged immobiliFation on hard surface

Compartment #yndrome:Compartment #yndrome:


92/130




0igni=cance of muscle mass damage0igni=cance of muscle mass damage Typically occurs in major muscle groupsTypically occurs in major muscle groups

enclosed by inelastic* =brous sheathsenclosed by inelastic* =brous sheaths Tissue"muscle damage results in edemaTissue"muscle damage results in edema

in a closed volume spacein a closed volume space9 Progressive cycle of edema* perfusionProgressive cycle of edema* perfusion

compromise* tissue hypo;ia and cellularcompromise* tissue hypo;ia and cellular

derangement* further edema* etc3derangement* further edema* etc39 Untreated* will produce same eKects asUntreated* will produce same eKects as

crush injurycrush injury



93/130


Compartment #yndrome:p y

Clinical PresentationClinical Presentation

The # P6sThe # P6s

9 PainPain

9 PallorPallor

9 ParesthesiaParesthesia

9 ParalysisParalysis

9 PressurePressure

Progression of symptomsProgression of symptoms9 (sometimes the &(sometimes the &ththP)P)



94/130



TreatmentTreatment

PrehospitalPrehospital

Primary survey and initial stabiliFationPrimary survey and initial stabiliFation

(A:C6s)(A:C6s) 0uspect compartment syndrome0uspect compartment syndrome

1mmobiliFe aKected part1mmobiliFe aKected part

Treat other injuriesTreat other injuries



95/130



TreatmentTreatment

GospitalGospital

Primary survey* stabiliFation andPrimary survey* stabiliFation and

resuscitation* secondary surveyresuscitation* secondary survey Diagnosis through e;aminationDiagnosis through e;amination

Treat systemic eKects of compartmentTreat systemic eKects of compartment

syndrome similar to crush injurysyndrome similar to crush injury

treatmenttreatment


96/130



97/130



Procedural #killsProcedural #kills

/easuring compartment pressures/easuring compartment pressures

Use of QetamineUse of Qetamine

asciotomiesasciotomies

Photo used with permission of Immediate ction #ervices



98/130




asciotomies are a de=nitiveasciotomies are a de=nitive

treatment* but tissue pressure attreatment* but tissue pressure at

which it is reLuired is controversial3which it is reLuired is controversial3

Jarying views include>Jarying views include>9 .arly fasciotomy when pressures S%# mm Gg.arly fasciotomy when pressures S%# mm Gg

or when within $ mm Gg of diastolic pressureor when within $ mm Gg of diastolic pressure

9 Delayed fasciotomy (beyond %@!$ hours)Delayed fasciotomy (beyond %@!$ hours)increases ris- of sepsis and death due toincreases ris- of sepsis and death due to

e;tensive necrotic tissuese;tensive necrotic tissues



99/130




asciotomyasciotomy9 Provide adeLuate analgesia and anesthesiaProvide adeLuate analgesia and anesthesia

9 Preoperative broad spectrum antibioticsPreoperative broad spectrum antibiotics

9 .nsure A,, compartments in e;tremity.nsure A,, compartments in e;tremitychec-ed for pressures (multiplechec-ed for pressures (multiplecompartments may be aKected)compartments may be aKected)

9 Chec- compartment pressures before andChec- compartment pressures before andafter fasciotomyafter fasciotomy

9 .nsure adeLuate hemostasis.nsure adeLuate hemostasis

9 Pac- wound open and use large bul-yPac- wound open and use large bul-ydressingsdressings


100/130


!ntrapped Patient Treatment!ntrapped Patient Treatment

TreatmentTreatment9 luid resuscitation before victim e;tricatedluid resuscitation before victim e;tricated

, 50 bolus* followed by 3# , per hour infusion , 50 bolus* followed by 3# , per hour infusion

9 ,imb stabiliFation,imb stabiliFation9 /inimiFe potential systemic eKects of reperfusion/inimiFe potential systemic eKects of reperfusion

Consider use of tourniLuets prior to releaseConsider use of tourniLuets prior to release

9 Consider al-aliniFation by giving ampule ofConsider al-aliniFation by giving ampule ofsodium bicarbonate (# m.L) immediately priorsodium bicarbonate (# m.L) immediately prior

to e;trication* followed by adding ampule ofto e;trication* followed by adding ampule ofsodium bicarbonate to each liter of 50 infused atsodium bicarbonate to each liter of 50 infused at3# , per hour as above -eep second 1J line3# , per hour as above -eep second 1J lineopen without sodium bicarbonateopen without sodium bicarbonate


101/130


1ield mputation1ield mputation

1ndications>1ndications>

9 Unable to safely e;tricateUnable to safely e;tricate

9 Continued environmental to;ins poseContinued environmental to;ins pose

haFard to victim and rescuershaFard to victim and rescuers

9 Erossly prolonged time until de=nitiveErossly prolonged time until de=nitive

treatment even after e;tricationtreatment even after e;trication


102/130


1ield mputation1ield mputation

:est performed by trauma or orthopedic:est performed by trauma or orthopedic

surgeonsurgeon

ew ./0 systems have protocolsew ./0 systems have protocols

.nsure adeLuate analgesia and.nsure adeLuate analgesia and

anesthesiaanesthesia

9 Qetamine (dissociative anesthetic)Qetamine (dissociative anesthetic)

Decreases or only minimally increases serumDecreases or only minimally increases serumpotassium levelspotassium levels

Patient maintains airway despite adeLuatePatient maintains airway despite adeLuate

anesthesiaanesthesia


103/130


Photo used with permission of Immediate ction#ervices


104/130

"ilitary !(perience"ilitary !(perience


105/130



106/130



Death 2ates After oundingDeath 2ates After ounding

9 2evolutionary ar2evolutionary ar %$M%$M

9 1111 ''

9 QoreanQoreanarar $#$#

9 Jietnam arJietnam ar $#$#

9 Persian Eulf arPersian Eulf ar $#$#

9 Elobal ar on Terror (E7T)Elobal ar on Terror (E7T)



107/130



/edical Advances from the E7T/edical Advances from the E7T

9 .;panded use of Damage Control 0urgery.;panded use of Damage Control 0urgery

9 hole bloodhole blood

9 TourniLuetsTourniLuets

9 Gemostatic agentsGemostatic agents

9 Gemostatic dressingsGemostatic dressings



108/130



Photo used courtesy of Bio Cybernetics International



109/130



Damage Control 0urgeryDamage Control 0urgery

9 TechniLue -nown for $ years* but slow toTechniLue -nown for $ years* but slow to

be acceptedbe accepted

9 Central tenet> Avoid the +Deadly Triad4Central tenet> Avoid the +Deadly Triad4 GypothermiaGypothermia

CoagulopathyCoagulopathy

/etabolic acidosis/etabolic acidosis

.ach condition worsens both of the others.ach condition worsens both of the others


110/130

"ilit ! i"ilit ! i


111/130



Damage Control 0urgeryDamage Control 0urgery

9 2esuscitate in 1CU>2esuscitate in 1CU> 5ormaliFe blood pressure5ormaliFe blood pressure

5ormaliFe body temperature5ormaliFe body temperature 5ormaliFe coagulation factors5ormaliFe coagulation factors

9 2eturn to 72 $@ hours for de=nitive2eturn to 72 $@ hours for de=nitive

surgerysurgery



112/130


"ilitary !(periencey p

1J Gemostasis1J Gemostasis

9 152S3# on arrival predictive of need for152S3# on arrival predictive of need for

massive transfusion (/T)massive transfusion (/T)

9 resh thawed plasma best resuscitationresh thawed plasma best resuscitationNuid in /TNuid in /T 7ptimum ratio of plasma to crystalloid > to7ptimum ratio of plasma to crystalloid > to

avoid clotting factor dilution S#Mavoid clotting factor dilution S#M

9 ,ess crystalloid (acidotic* inNammatory*,ess crystalloid (acidotic* inNammatory*adverse eKects on coagulation)adverse eKects on coagulation) Ge;tend (a colloid) preferableGe;tend (a colloid) preferable



113/130


"ilitary !(periencey p

1J Gemostasis1J Gemostasis

9 Use of fresh whole bloodUse of fresh whole blood

9 .arly use of cryoprecipitate.arly use of cryoprecipitate

9 2ecombinant actor J11a (rJlla)2ecombinant actor J11a (rJlla)



114/130


a y pe e cey p

TourniLuetsTourniLuets

9 ,iberal use encouraged for any signi=cant,iberal use encouraged for any signi=cant

e;tremity hemorrhagee;tremity hemorrhage

9 5o adverse events seen in cases when5o adverse events seen in cases whenapplied inappropriatelyapplied inappropriately

9 Apply early (+=rst resort not last resort4)Apply early (+=rst resort not last resort4)

9 .very soldier carries at least one at all.very soldier carries at least one at all

timestimes


115/130



116/130



GemCon (chitosan)GemCon (chitosan)

9 7riginally available as a bandage7riginally available as a bandage

9 5ow available in roll that can be stuKed5ow available in roll that can be stuKed

into woundinto wound


117/130

#pecial Considerations#pecial Considerations



118/130



PregnancyPregnancy

ChildrenChildren

.lderly.lderly DisabledDisabled

,anguage barriers,anguage barriers

#pecial Considerations:#pecial Considerations:


119/130


pp

PregnancyPregnancy

1njuries to the placenta are possible and must1njuries to the placenta are possible and mustbe detectedbe detected

0econd or third trimester of pregnancy should0econd or third trimester of pregnancy should

be admitted for continuous fetal monitoringbe admitted for continuous fetal monitoring

The placental attachment is at ris- for primaryThe placental attachment is at ris- for primaryblast injuryblast injury

0creening test for fetalmaternal hemorrhage0creening test for fetalmaternal hemorrhagein second or third trimester of pregnancyin second or third trimester of pregnancy

9 Positive test reLuires mandatory pelvic ultrasound*Positive test reLuires mandatory pelvic ultrasound*fetal nonstress test monitoring* andfetal nonstress test monitoring* andobstetrics"gynecology (7:"EW5) consultation3obstetrics"gynecology (7:"EW5) consultation3



120/130


pp

ChildrenChildren

Gistory of event or patient6s complaints may beGistory of event or patient6s complaints may be

di8cult to obtain3di8cult to obtain3

Pulmonary contusion is one of the most commonPulmonary contusion is one of the most common

injuries from blunt thoracic trauma3 The injuryinjuries from blunt thoracic trauma3 The injury

may not be clinically apparent initially and shouldmay not be clinically apparent initially and should

be suspected when abrasions* contusions* or ribbe suspected when abrasions* contusions* or rib

fractures are present3 A chest ;ray is essential infractures are present3 A chest ;ray is essential in

diagnosis especially when blast lung is suspected3diagnosis especially when blast lung is suspected3

0pecialiFed eLuipment0pecialiFed eLuipment 1denti=cation of regional pediatric trauma1denti=cation of regional pediatric trauma

facilitiesfacilities


121/130



122/130


p$isabled$isabled

Consideration should be given toConsideration should be given to

patients with underlying medicalpatients with underlying medical

conditionsconditions

Untreated or inadeLuately treatedUntreated or inadeLuately treated

fractures may lead to severe and longfractures may lead to severe and long

lasting disabilitieslasting disabilities


123/130


124/130


Photo used courtesy of .wikpoint


125/130

Psychological IssuesPsychological Issues



126/130



0eLuelae from an e;plosive event0eLuelae from an e;plosive event

9 AngerAnger

9 rustrationrustration

9 GelplessnessGelplessness

9 Desire to see- revengeDesire to see- revenge



127/130



.vents that aKect mental health.vents that aKect mental health

9 ,ittle or no warning,ittle or no warning

9 Un-nown duration of the eventUn-nown duration of the event

9 Potential threat to personal safetyPotential threat to personal safety

9 Un-nown health ris-sUn-nown health ris-s



128/130



Tips for 2espondersTips for 2esponders

9 Promotion of safetyPromotion of safety

9 Promote calmPromote calm

9 Promote connectednessPromote connectedness

9 Promote selfe8cacyPromote selfe8cacy

9 Promote hopePromote hope

$iscussion Topics: 3eview$iscussion Topics: 3eview


129/130


$iscussion Topics: 3eview$iscussion Topics: 3eview

:ac-ground:ac-ground

.;plosive .vents.;plosive .vents

:last 1njuries:last 1njuries

9 Primary* 0econdary* Tertiary*


130/130

$iscussion Topics$iscussion Topics

0urge Capacity 1ssues0urge Capacity 1ssues

Gospital after /adrid bombing saw '$Gospital after /adrid bombing saw '$

patients in $3# hourspatients in $3# hours

5eed to surge> CT* 72 suites* staK* and5eed to surge> CT* 72 suites* staK* and

supplies (blood* etc3)supplies (blood* etc3)

Gidden nature of injuries can lead toGidden nature of injuries can lead to

dangerous overtriage and undertriagedangerous overtriage and undertriage

bombings 3 h

Documents