10/2/2015

Clinical Manifestation of Blast InjuriesADVANCED EXPLOSIONS & BLAST INJURIES

Outline

• Types of injuries seen• Injury characterization• Specific Injuries

- Primary- Secondary- Tertiary- Quaternary- Quinary

Madrid Bombing - Injuries

• Ruplure of the ty nipanic membranes occurred in99 of 243 victims

• Chest injuries in 97/243 victims• Shrapnel wounds in 89/243• Fracture in 44• Burns in 45• Eye injuries in 41• Abdominal injuries in 12• Traumatic amputations in 5

1

10/2/2015

Boston Marathon Bombing-April 15, 2013

• 3 deaths prior toreaching the hospital

• 264 injuries• More than 20 with

critical injuries• Amputations, soft

tissue injuries• TM rupture

■‘t 1M,mMn;1:

Trauma Activations at Mass General Hospital

*«• u- *»*ÿ> * u>

USnlmi t SONs* c.. a<N4l li.■>#*•'“b <• ‘j.t» nu> •SO

•« MVtH4 nrjlt t StWl I' Of-** x»irTi *SO*W**»m> rnrjn* 10

.ai a>!nt»c t.j CM j»(O IUUL **•» , so

r Li) pn r*r.« »rds..i iQl <3:1

II. SE."S# MWA0S0O14U0 M»Q»Y lift

JJ®’* «MUS.n4«ntWilk'fh»l»« tUUT..<««rt«lMk«pictlln

iliiii;if:s

»y)**«;pnof Mtrr> •i*<■xv�niK Mm> « rvi

«-*.»• -<31-01

Tertiary BlastInjury Jlnjuiescbc to tTiportWtl* arvothcr

obinctlHi L/ÿ// y'V./ '

A <rPrimary Blast InjuryOnjuies due ro the

I'ftunes die ti nuss.les benypropelled by oleÿt furÿej

Secondary Blast Injury

2

10/2/2015

Primary Blast Injuries

♦ Affect air-filled organs or air-fluidinterfaces

• Rupture of tympanic membranes,

pulmonary injury, air embolization and

rupture of hollow viscera are the most

common patterns

Tympanic Membrane Rupture

• Occurs at the lowest pressure (5 psi)• May be bilateral• May be the earliest sign to look for

- Deafness, tinnitus and vertigo• If more severe, may cause dislocation of the

oval, round window or the ossicles- Permanent hearing loss

• Other organs need higher pressures (56-76psi) so if the TM is intact, they are unlikely

ncopyright Michael Hawke MD_

3

10/2/2015

Normal and Perforated RightTympanic Membranes

4

The drawing of a traumatic perforation shows an irregularmargin or rim with blood or a blood clot, and the draw ing of apermanent central perforation shows a tvmpanocele

Pulmonary Injuries

• Second most common primary blast injury• Hemorrhage

- Pulmonary contusion (appearing as a bihilar"butterfly" pattern on chest radiographs)

- Pneumothorax- Hemothorax- Pneumomediastinum- Subcutaneous emphysema

i7*jA • / ,

4

10/2/2015

'W w,

1 -i, *1'

mi

,,tt>

BHlKopvnghi 2<>1’-2uU H

Pulmonary Injuries

• Onset of symptoms is commonly w ithin minutes

- Controversial

Body Armor

• Protects fromsecondary blastinjuries

• Does not protectfrom primary blastinjury

* 552;

-JCK

|3«

f'SSw“ass

-sx~

5

10/2/2015

Kevlar Helmet

D |fTM Perforation - Pulmonary Injury• Among 17 critically ill victims with

pulmonary injuries from the blast:- 13 had ruptured tympanic membranes and 4 did

not

• Rupture of tympanic membranes occurredin 18 of 27 critically injured victims- 17 of these were bilateral

Data from Madrid

Screening

• 647 survivors of explosions on buses usedimmediate radiography of the chest toscreen for pulmonary injuries from theblasts

• Primary injuries, in some form, were foundin 193 persons:- 142 had isolated perforation of the eardrum

Data from Israel

6

10/2/2015

Screening

• 51 had other forms of primary blast injuries:

- 1 8 with isolated pulmonary injuries

- 31 with combined otic and pulmonary injuries

-Two with intestinal injuries

Visceral Injury

■ Visceral injury is third most commonprimary blast injury

• Rupture of the colon and, less frequently,the small intestine may occur as animmediate result of a blast

• Mesenteric ischemia or infarct can causedelayed rupture of the large or the smallintestine; these injuries are difficult todetect initially_

f

7

10/2/2015

V'- t.1t' y, :vt *•

:C

V/

Visceral Injuries

• The ileocecal area isthe most vulnerable

Accumulates gas

• Observed findingsI lemorrhages

- Edema- Perforations

Lacerations

f\i

V-

I*i

Other Injuries

• Serous retinitis

• Concussion

• Air embolism may be seenand can present as stroke.MI. acute abdomen.blindness, deafness, spinalcord injury, orclaudication

8

10/2/2015

Ruptured Globes

'1 lb•%.

Secondary Injuries• Penetrating injuries

from:-Primary fragments

(fragments that arepart of the weapon)

-Secondary fragments(those that resultfrom the explosion)

j

11

9

10/2/2015

HNv «C-

Df

w% IOIMFlgur*1—Photographcf th» patents abflorwn aho»inga vnar auM$Mdantry Mwnd

Flgura >— Cha«raaogrsphaiminga na«ifl» paDanrsk«!ung

zr -%. \*4

.N<--

■KM: - H

10

10/2/2015

«SL -A.-. •

# *irrjI 1

wl ■/� frrar\ [.

,

11

10/2/2015

Tertiary Injuries• Caused by trauma from

falling objects or frombodies being thrown againstother objects

Blunt and penetrating injuries

- Crush syndrome andsecondary rhabdonivolvsis

- Open or closed head injuries

1.U

.jt

Crush Syndrome

• Rhabdomyolysis:

I♦ Myoglobinuric renal

failureAu Electrocardiographic Sine Wave

in Hyperkalemia- ■:•y -vy-."S 4.y-

1

VWÿVÿWv'V\5-'• Hyperkalemia

‘..or.v M IMiUhl ViUj-umioiu

Pelvic Fractures

Hit

■ J

12

10/2/2015

Crush Syndrome-Earthquakes

Y»bU 1. StatistKi Related to Ma|srCirth<|uab(t In th« Pait 18 Y«»rt.’

Crush Syndrom*

WfM'l n irr.bt' cfcrj\b ytcbm*

600

DiatydtLocation and Year 0*»lh

Sp wit. A,*rt*nia. WBl1’"17Northern (ran. 199C**Kobe, japan )995,,x'

Mamiara rcgiOr'.T-rt(N 199$>]

ChnChi. Ta.wan, 1999u

G.|a'.t •ndta, 2001i!Bouroe'CW. A!ge> t 2002**Bam, |rarL 200)”

fatf-rur. PaUsunTo!a'

28,000

>40.0005 000

225-285156

»2 122>17,000 6)9

52 2?2,405

20.021 25 ))

20? IS?2.26626,002

>80.000>217.000

9*1241)8

-1200.1900

Rhabdomyolysis

♦ Secondary complication of crush syndrome

* Myoglobinurea and CK. elevation

Quaternary Injuries• Bums (chemical or thermal)

• Toxic inhalation of carbon monoxide orhydrogen cyanide gas

* Exposure to radiation: ARS and InternalContamination

• Inhalation of dust containing coal orasbestos

• Exacerbation of chronic illnesses

13

10/2/2015

Exacerbation of Chronic Illnesses

• Asthma and COPD• Diabetes Mellitus• Hypertension♦ Coronary artery disease• Peptic ulcer disease• Alcohol and substance abuse♦ Mental health

Quinary Blast Injuries

■ SIRS manifestations- Fever-Tachycardia- Hypotension

• No infectious source recognized• BAL reveals eosinophil ia• Management supportive +/- steroids

Any Questions or Comments?

14