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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008
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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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Primary Blast Injury
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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Primary Blast Injury
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
Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008
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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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Unexploded Ordinance
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Unexploded Ordinance
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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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008
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Unexploded Ordinance
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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Unexploded Ordinance
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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Unexploded Ordinance
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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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008
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Distribution Statement A: Approved for public release; distribution is unlimited. 311 HSW/PA No. 08-044, 20 February 2008
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Unexploded Ordinance
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
Care of Exposed Casualties
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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DepletedUranium
Care of Exposed Casualties
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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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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Phosgene-Like Combustion
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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Phosgene-Like Combustion
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