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Explosive events, burn patient management

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Explosion in Cyprus Naval Base Kills 12 and injures >60

•Mass trauma related to explosions can produce unique patterns of injury•They have the potential to inflict multi-organ, life-threatening injuries on many victims simultaneously•Blast-related injuries can present unique triage, diagnostic, and management challenges•The medical consequences from the detonation of a conventional explosive include death and acute injury, as well as destruction of critical infrastructure such as buildings, roads, and utilities

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The impact of an explosive event depends largely on :

• the composition and amount of explosive materials involved,

• the surrounding environment,

• delivery method (if a bomb),

• distance between the victim and the blastv and

•any intervening protective barriers or environmental

hazards.

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•Α predominant post explosion injuries among survivors involve standard penetrating and blunt trauma. Blast lung is the most common fatal injury among initial survivors.

•Explosions in confined spaces (mines, buildings, or large vehicles) and/or structural collapse are associated with greater morbidity and mortality.

•Half of all initial casualties will seek medical care over a one-hour period. This can be useful to predict demand for care and resource needs.

•Expect an “upside-down” triage - the most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals.

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Categories Characteristics Body Part Affected

Types of Injuries

Primary Unique to HE, results from the impact of the over-pressurization wave with body surfaces.

Gas filled structures are most susceptible - lungs, GI tract, and middle ear.

Blast lungTM rupture and middle ear damage Abdominal hemorrhage and perforation – Globe (eye) rupture- Concussion (TBI without physical signs of head injury)

Secondary Results from flying debris and bomb fragments.

Any body part may be affected.

Penetrating ballistic or blunt injuries Eye penetration (can be occult)

Tertiary Results from individuals being thrown by the blast wind.

Any body part may be affected.

Fracture and traumatic amputation Closed and open brain injury

Quaternary All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms. Includes exacerbation or complications of existing conditions.

Any body part may be affected.

Burns (flash, partial, and full thickness) Crush injuriesClosed and open brain injuryAsthma, COPD, or other breathing problems from dust, smoke, or toxic fumesAnginaHyperglycemia, hypertension

Mechanisms of Blast Injury

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Overview of Explosive-Related InjuriesSystem Injury or Condition

Auditory TM rupture, ossicular disruption, cochlear damage, foreign body

Eye, Orbit, Face

Perforated globe, foreign body, air embolism, fractures

Respiratory Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of air embolism), airway epithelial damage, aspiration pneumonitis, sepsis

Digestive Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism

Circulatory Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury

CNS Injury Concussion, closed and open brain injury, stroke, spinal cord injury, air embolism-induced injury

Renal Injury Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia

Extremity Injury

Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism-induced injury

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• Follow your hospital’s and regional disaster system’s plan.

• Expect an “upside-down” triage - the most severely injured arrive after

the less injured, who by-pass EMS triage and go directly to the closest

hospitals.

• Double the first hour’s casualties for a rough prediction of total “first

wave” of casualties.

Emergency Management Options :

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• Obtain and record details about the nature of the explosion, potential

toxic exposures and environmental hazards, and casualty location from

police, fire, EMS, ICS Commander, regional EMA, health department,

and reliable news sources.

• If structural collapse occurs, expect increased severity and delayed

arrival of casualties.

Emergency Management Options :

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Blast injuries should always be considered for any victim exposed to an

explosive force.  Primary blast lung and blast abdomen are associated with

a high mortality rate. “Blast Lung” is the most common fatal injury among

initial survivors.

Clinical signs of blast-related abdominal injuries can be initially silent until

signs of acute abdomen or sepsis are advanced.

Medical Management Options

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Standard penetrating and blunt trauma to any body surface is the most

common injury seen among survivors.

Blast lung presents soon after exposure. It can be confirmed by finding

a “butterfly” pattern on chest X-ray. Prophylactic chest tubes

(thoracostomy) are recommended prior to general anesthesia and/or air

transport.

Auditory system injuries and concussions are easily overlooked. The

symptoms of mild TBI and post traumatic stress disorder can be

identical. 

Isolated TM rupture is not a marker of morbidity; however, traumatic

amputation of any limb is a marker for multi-system injuries.

Medical Management Options

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Medical Management Options

Air embolism is common, and can present as stroke, MI, acute abdomen,

blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen

therapy may be effective in some cases.

Compartment syndrome, rhabdomyolysis, and acute renal failure are

associated with structural collapse, prolonged extrication, severe burns, and

some poisonings. 

Consider the possibility of exposure to inhaled toxins and poisonings (e.g.,

CO, CN, MetHgb) in both industrial and criminal explosions.

Wounds can be grossly contaminated. Consider delayed primary closure and

assess tetanus status. Ensure close follow- up of wounds, head injuries, eye,

ear, and stress- related complaints.

Communications and instructions may need to be written because of tinnitus

and sudden temporary or permanent deafness.

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Burn victim in precarious situations

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Date References Location Cause No of injured survivors

No of on-scene dead

1970 (6) Osaka,Japan Natural gas pipeline 428 79 1978 (7) LosAlfaques,Spain Liquid propyleneg as 140 102

1980 (8) LasVegas,Nevada,USA Hotel fire(‘MGMGrand’) 726 84 1981 (70,71) Dublin,Ireland Nightclub fire(‘Stardust’) 44 48 1981 (72) Bangalore,India Circus fire 169 92 1982 (73) Cardowan,UK Coalmine explosion 40 0 1984 (9) SanJuanico,Mexico Liquid propane gas 7230 300 1985 (10) BradfordCity,UK Football stadium fire 256 52 1985 (74) Manchester,UK Aeroplane fire 79 52 1988 (11) PiperAlphaplatform, Oilrigfire 25 167 NorthSea,UK 1988 (41) Ramstein,Germany Aeroplane crash 400 45 1989 (13) Bashkiria,Russia Naturalgaspipeline 800 400

1990 (75) Va¨dero¨arna,Sweden Fire on ferryboat (Scandinavian 30 158

Star) 1994 (14,76) PopeAirForceBase, Aeroplane crash 119 11 NorthCarolina,USA 1998 (16) Gothenburg,Sweden Discotheque fire 213 60

2001 (17) Volendam,NL Cafe´fire 245 4

2001 (1,21,77) NewYorkCity,USA Aeroplane attacks 790 2713 2002 (2,23,24) Bali,Indonesia Nightclubbombings 155(78) 202{(79) 2003 West Warwick, USA Nightclubfire(‘Station’) 215 96

Selected recent burn mass casualty disasters.

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The Los Alfaques Disaster was a road accident and tanker explosion which occurred on 11 July 1978 in Alcanar, near Tarragona, in Spain.

the importance of controlling both the routes and types of conveyances used for evacuation

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principles are similar to those applicable to other mass casualty events, modified as needed for the unique features of thermal injury and any unique features of a

given disaster

Order in chaos. A Burn disaster is inherently chaotic

Establish command and control of casualty care activities ASAP, integrating the burn centres into the regional disaster response system EARLY

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Arturson G. Analysis of severe fire disasters. In: Masselis M, Gunn SWA, editors. The Management of Mass Burn Casualties and Fire Disasters: Proceedings of the First International Conference on Burns and Fire Disasters. Dordrecht, The Netherlands: Kluwer Academic, 1992:24–33. Only 1 out 14 burn disasters had disaster plans in place

Rapid triage for the severity of the injury, by considering total extent of burn, age of patient and the presence or absence of inhalation injury or associated severe mechanical trauma . Burn injury. In: Bowen TE, Bellamy RF, editors. Emergency War Surgery: Second United States Revision of the Emergency War Surgery NATO Handbook. Washington, DC: US Government Printing Office, 1988:35–56

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What constitutes a non-survivable burn?

LA50, half of young adults with burns of 80% of the total body surface area can be expected to survive.

The presence of inhalation injury, or of severe mechanical trauma, should add 10% to the burn size for this calculation

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Patients with burns of 20% or less (10% or less at the extremes of age) can be Triaged as , T2 or T3

Triage on site at 3 Levels by an experienced burn surgeon or a plastic surgeon

Organized transport by a centralized system

NOT the usual ICU model of one nurse / patient, BUT of teams focusing on specific functions, airway management, fluid resuscitation, pain management and wound and extremity care Phillips WJ, Reynolds PC, Lenczyk M, Walton S, Ciresi S. Anesthesia during a mass-casualty disaster: the Army’s experience at Fort Bragg, North Carolina, March 23, 1994. Mil Med. 1997;162:371–3.It is disputed

formation

Experienced personnel in more managerial roles and innexperienced in providing the proper care under supervision

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Magnitude of Injury

The rule of “nines” The depth of burn

+/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs

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Magnitude of Injury

The rule of “nines” The depth of burn

+/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs

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Superficial or 1st degree

Deep partial thickness or 2nd degree

Full thickness or 3rd degree

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Fluid Resuscitation

• Large bore IV (s)• Non - burn site if possible

• Best tool , Urine Output . . . .• 0 . 5 cc / kg / hr adult

• 1 . 0 cc / kg / hr child [ < 30 kg ]

• Too much fluids can be just as bad as too little ! ! !

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Parkland Formula

•% BSA x Kg x 4 cc = 24 hour totalneed

• 1 / 2 over the first eight hours• 1 / 2 over the next sixteen hours

• Lactate Ringers is the fluid of choice !

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Modified Brooke Formula

•% BSA x Kg x 2 cc = 24 hour totalNeed

• 1 / 2 over the first eight hours• 1 / 2 over the next sixteen hours

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Escharotomy and / or Fasciotomy

Primary Escharectomy

Secondary Escharectomy

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Burn Center Transport Guidelines

• Partial thickness over 15 %• Full thickness over 5 %

• Involvement of hands , perineum , face , feet• Inhalation

• All high voltage• All chemical

• Patients with significant pre – existing disease

Standards lowered if enormous number of severe burn victims

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International Co-operationBurn Teams Classification of Burn Care Facilities according to ISBI• Level A, for 24–48 hours, and consists of triage, initiation of resuscitation, preparation of patients for transfer and care of patients with minor injuries• Level B, resuscitation, wound care including grafting, and initial rehabilitation• Level C, existing tertiary burn centres which provide

definitive care including invasive monitoring, management of inhalation injury, early wound excision, complete rehabilitation, infection control and metabolic support

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Rehabilitation and long-term follow-up

Incorporation of occupational, physical and psychological rehabilitation of the survivors

Debriefing

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Thank You