Bombings:
Injury Patterns and Care
This project was funded by the Centers for Disease
Control and Prevention (CDC) under Cooperative
Agreement U17/CCU524163-01, “Linkages of Acute
Care and EMS to State and Local Injury Prevention
Programs for Terrorism Preparedness and Response.”
The Bombings: Injury Patterns and Care curriculum was
developed through the Linkages of Acute Care and EMS to State
and Local Injury Prevention Programs project that was funded
by the Centers for Disease Control and Prevention (CDC). The
American College of Emergency Physicians (ACEP) served as the
lead grantee for the project along with the following six other
organizations:
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American Medical Association (AMA)
American Trauma Society (ATS)
National Association of EMS Physicians (NAEMSP)
National Association of EMT’s (NAEMT)
National Association of State EMS Officials (NASEMSO)
National Native American EMS Association (NNAEMSA)
Bombings: Injury Patterns and Care
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A task force was established with representative experts from
emergency medicine including physicians, surgeons, nursing,
and EMS. Core competencies and knowledge objectives were
developed using a consensus approach. A writing group then
developed teaching objectives and course content based on the
core competencies.
The Bombings: Injury Patterns and Care curriculum is designed
to be the minimum content that should be included in any allhazards disaster response training program. This content is
designed to update the student with the latest clinical
information regarding blast related injuries from terrorism.
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American College of Emergency Physicians (ACEP) Grant Staff
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Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic Injuries from
Terrorism Task Force (CO-TIFT)
Rick Murray, EMT-P, EMS and Disaster Preparedness Director, Principle Investigator
Marshall Gardner, EMT-P, EMS and Disaster Preparedness Manager
Diana S. Jester, EMS and Disaster Response Coordinator
Cynthia Singh, MS, Grants and Development Manager
Kathryn Mensah, MS, Grants Administrator
Mary Whiteside, PhD, Curriculum Development Consultant
Centers for Disease Control and Prevention (CDC) Staff
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Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National Center for
Injury Prevention and Control
Scott M. Sasser, MD, FACEP, Consultant, Division of Injury Response, National Center
for Injury Prevention and Control
Ernest E. Sullivent, III, MD, Medical Officer, Division of Injury Response, National
Center for Injury Prevention and Control
Paula Burgess, MD, MPH, Team Leader, Division of Injury Response, National Center
for Injury Prevention and Control
Jane Mitchko, MEd, CHES, Health Communications Specialist, Division of Injury
Response, National Center for Injury Prevention and Control
12/06
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Discussion Topics
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Background
Explosive Events
Blast Injuries
– Primary, Secondary, Tertiary, Quaternary
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Crush Injuries and Compartment Syndrome
Military Experience
Special Considerations
Psychological Issues
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Background
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Background
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Terrorism can be defined as containing four
key elements:
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Premeditated
Political
Aimed at civilians
Carried out by sub-national groups
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Background
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Explosive use increasing in terrorist events
Result in mass casualty incidents
Recent examples
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Mumbai (2006)
Tel Aviv (2006)
London subway (2005)
Madrid subway (2004)
Tel Aviv (2001)
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Background: Historical Perspective
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1968-1999
– 7000 international terrorist bombings
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1969-1980
– 187 bombings in Northern Ireland
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1980-2001
– 324 criminal bombing events in the US
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2001-2003
– 500 International terrorist bombings
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2005
– 399 International terrorist bombings
Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research Centre
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Background: Blast Devices
Photo used with permission of MAJ Benjamin Gonzalez, MD
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Background: Blast Devices
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Improvised explosive devices (IEDs)
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Car and truck bombs (Oklahoma City, World Trade Center I)
Letter and parcel bombs (Idaho “Unabomber”)
Pipe bombs (Atlanta Olympics)
Backpack and satchel bombs (Israel, London)
Incendiary bombs
– Airplane bombs (World Trade Center II, Pentagon)
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Rocket propelled grenades (RPGs)
Surface to air missiles (SAMs)
Enhanced blast devices
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Background: Blast Devices
IEDs
 Improvised/“homemade” explosive devices
 Made from explosives, commercial blasting
supplies, or fertilizer and household
ingredients
 Designed to cause injury and death
 Often packed with metal objects such as nails
or ball bearings; could contain toxic chemicals
or radiological materials (dirty bomb)
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Background: Blast Agents
High-order explosive: HE Low-order explosive: LE
 Nitroglycerin (NTG)
 Petroleum products
(“Molotov cocktail”)
 Dynamite
 Gunpowder
 Plastic
(“black” powder)
 Ammonium nitrate/
 Can become HE, if
fuel oil (ANFO)
contained (e.g., pipe
 Trinitrotoluene (TNT)
bomb)
 Triacetone triperoxide
(TAPT)
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Explosive Events
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Explosive Events
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Incident command
– Entire area = crime scene → evidence
preservation
– Multi-jurisdictional response
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Scene safety
– Dirty bombs, secondary devices, building
collapse, high dust environment (possibly
contaminated), bomb fragments
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Explosive Events:
Criminal Investigation
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Principles of criminal investigation and
evidence preservation
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Indicators for crime scene
Evidence and chain of custody
Avoid disturbing or compromising evidence
Detection of possible suspects/perpetrators
Quick identification and note taking
Documentation of statements by victims and
witnesses
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Scene Safety
Scene Safety: Common Hazards
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Secondary devices
Shrapnel
Building collapse
Air-borne contaminants
Contaminated patients
Contaminated scene/environment
Perpetrators
Terrorist patients
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Scene Safety: Common Hazards
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Victims with no soft tissue injuries
Vehicles coming or leaving scene (out of place)
People acting oddly
Packages or containers at scene (out of place)
Vehicles not damaged or out of place
Structural damage
Weather
Possible places for secondary devices
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Scene Safety:
Appropriate PPE for blasts
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Coveralls
Heavy coat
Heavy gloves
Steel-toed boots
Hard hat
Eye protection
Dust particle mask
Breathing apparatus for toxic fumes
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Scene Safety: Common Principles
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Contain the incident
– Deny entry to all but responders
– Set up zones
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Hot
Warm
Cold
Contain the people
– Do not let anyone leave
scene until checked
– Decontaminate if necessary
Bombings: Injury Patterns and Care
Photo used with permission of Connie Doyle, MD, FACEP
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Scene Safety: Common Principles
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Cause no further injury or destruction
Protect yourself
Activate command and
hazard
response (ICS)
Limit access
Contain the incident
Photo used with permission of Kathryn Brinsfield, MD, FACEP
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Scene Safety: Common Principles
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Worker safety
Protection of uninvolved public and
volunteers
Protection of injured
Treatment of injured
Surveillance of patients and workers for
long-term effects
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Triage
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Triage
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Unique patterns, multiple and occult injuries
Death often result of combined blast,
ballistic, and thermal effect injuries
(multidimensional injury)
Walking wounded
Hidden/internal injuries
Many non-critical patients who require time
intensive workups
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Triage
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Nature of injuries may lead to overtriage
Up to 75% of victims self-refer to hospital;
arrive by private transportation
Field triage
– Dynamic process
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Triage
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Factors that determine when needs exceed
resources
– Large number of patients make rapid triage
impossible
– Large number of patients cause delay in
transport to hospitals
– Large number of patients exceed responder
treatment capabilities
– Surge at local hospitals
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Blast Injuries
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Blast Injuries: Unique Aspects
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Inflict multi-system injuries on large groups
of people
Cause many simultaneous life-threatening
injuries
Hidden pattern of injury
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Blast Injuries: Blast Physics
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Rapid chemical conversion of a solid or
liquid into highly pressurized gases
Gases expand rapidly and compress the
surrounding air
Pressure wave and blast wind are generated
and spread in all directions
Is affected by the medium through which it
travels, i.e., air vs. water
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Blast Injuries: Blast Physics
Importance of Injury Types vs. Distance
Emergency War Surgery, 3rd Edition
Bombings: Injury Patterns and Care
Diagram used with permission of John-Phillipe Dionne. PhD
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Background: Physics of Blasts
Bombings: Injury Patterns and Care
Click to view animation.
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Blast Injury: Severity
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Nature of device – agent, amount
Method of delivery – incendiary, explosive
Nature of environment – open, closed
Distance from device
Intervening protective barrier
Other environmental hazards
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Murrah Building
Bombings: Injury Patterns and Care
Photo Courtesy of the City Of Oklahoma City
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Murrah Federal Building, Oklahoma City (1993) – distribution of injuries
JAMA, August 1996, 276 (5): 382-387 © 1996 American Medical Association
Bombings: Injury Patterns and Care
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Russell Square, London bombing, 2005
Diagram used with permission of Directorate of Public Affairs, Metropolitan Police Service, London
Bombings: Injury Patterns and Care
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Mumbai, India: July 2006
Reuters/Prashanth Vishwanathan
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Blast Injuries: Pathophysiology
Proposed mechanisms*
 Spalling
– Caused by shock wave moving through tissues
of different densities → molecular disruption
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Implosion
– Caused by entrapped gases in hollow organs
compressing then expanding → visceral
disruption
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Blast Injuries: Pathophysiology
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Shearing
– Caused by tissues of different densities moving
at different speeds → visceral tearing
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Irreversible Work
– Caused by forces exceeding the tensile strength
of the tissue
*Spalling, implosion and shearing are thought to be three
mechanisms that cause blast injuries. Irreversible work is
currently being researched as a more likely mechanism of injury.
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Blast Injuries: Categories
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Primary injury
– Caused by blast wave → over pressure
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Secondary injury
– Caused by flying debris → shrapnel wounds
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Tertiary injury
– Caused by blast wind → forceful impact
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Quaternary injury
– Caused by other vectors → heat, radiation
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Blast Injuries: Primary
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Blunt trauma from over pressure wave
– Unique to high-order explosives
– Results from the impact of the overpressurization wave with body surfaces
– Blunt force injuries
– Produces barotrauma
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Diagram used with permission of LTC John McManus, Jr., MD, FACEP
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Blast Injuries: Primary
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Most common injuries:
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Blast lung—pulmonary barotraumas
Traumatic brain injury (TBI), concussion
Tympanic membrane (eardrum) rupture
Middle ear damage
Abdominal hemorrhage
Abdominal organ perforation
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Blast Injuries: Secondary
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The most common cause of death in a blast
event is secondary blast injuries. These
injuries are caused by flying debris
generated by the explosion. Terrorists often
add screws, nails, and other sharp objects
to bombs to increase injuries.
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Diagram used with permission of LTC John McManus, Jr., MD, FACEP
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Blast Injuries: Secondary
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The most common types of secondary blast
injuries are:
– Trauma to the head, neck, chest, abdomen, and
extremities in the form of penetrating and blunt
trauma
– Fractures
– Traumatic amputations
– Soft tissue injuries
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Blast Injuries: Secondary
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Penetrating trauma (shrapnel wounds)
– Foreign bodies follow unpredictable paths
through body
– May have only mild external signs
– Have a low threshold for imaging studies (plain
radiographs, computed tomograms)
– Consider all wounds contaminated
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Secondary Injury
Used with permission of American Journal of Roentgenology 2006; 187:609-616
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Blast Injuries: Tertiary
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Tertiary injuries result from individuals being thrown
by the blast wind.
The most common types of tertiary blast injuries
are:
– Head injuries
– Skull fractures
– Bone fractures
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Treatment for most tertiary blast injuries follows
established protocols for that specific injury.
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Diagram used with permission of LTC John McManus, Jr., MD, FACEP
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Blast Injuries: Quaternary
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All explosion-related injuries, illnesses, or
diseases not due to primary, secondary, or
tertiary mechanisms are considered
quaternary blast injuries. This includes
exacerbation or complications of existing
conditions.
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Blast Injuries: Quaternary
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The most common quaternary blast injuries
include:
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Burns
Head injuries
Asthma
COPD
Other breathing problems
Angina
Hyperglycemia
Hypertension
Crush injuries
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Blast Injuries: Blast Lung
Used with permission of CHEST, December 1999; 116(6): 1683-1688
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Blast Injuries: Blast Lung
Bombings: Injury Patterns and Care
Reprinted from American Journal of Surgery, V190: 945-950,
Avidan V et al: Blast Lung Surgery…with permission from © Excerpta Medica Inc.
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Blast Injuries: Blast Lung
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Clinical manifestations
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Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability
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Blast Injuries: Blast Lung
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Treatment
– High flow oxygen sufficient to prevent
hypoxemia via non-rebreather mask
– CPAP
– Endotracheal intubation
– Judicious fluid administration (similar to that of
pulmonary contusion)
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Blast Injuries: Head
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Primary blast waves can cause concussions
or mild traumatic brain injury (MTBI)
without a direct blow to the head
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Blast Injuries: Head
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Consider the proximity of the victim to the
blast particularly when given complaints of:
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Loss of consciousness
Headache
Fatigue
Poor concentration, lethargy, amnesia, or other
constitutional symptoms
– Symptoms of concussion and post traumatic
stress disorder (PTSD) can be similar
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Blast Injuries: TM Rupture
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Tympanic membrane rupture indicates
exposure to an over pressurization wave. It
may be found in victims with severe
pulmonary, intestinal, or other injuries, or it
may be found in isolation. Its presence does
not indicate that more sinister blast injuries
exist.
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Blast Injuries: TM Rupture
Used with permission of NEJM, April 2005; 352: 1335-1342
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Blast Injuries: Ear
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Ear injuries may include not only TM
rupture, but also ossicular disruption,
cochlear damage, and foreign bodies.
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Blast Injuries: Ear
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Presentation: acute hearing loss
(conductive, sensorineural)
Findings: auditory canal debris, tympanic
membrane rupture, ossicular disruption,
cochlear damage
Treatment: observation; 50-80% of
ruptured tympanic membranes heal;
sensorineural hearing loss often permanent
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Blast Injuries: Abdomen
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Abdominal injuries (also called blast
abdomen) include abdominal hemorrhage
and abdominal organ perforation
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Blast Injuries: Abdomen
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Clinical manifestations include:
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Abdominal or testicular pain
Tenesmus
Rectal bleeding
Solid organ lacerations
Rebound tenderness
Guarding
Absent bowel sounds
Signs of hypovolemia
Nausea
Vomiting
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Blast Injuries: Combined Injuries
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Combined injuries, especially blast and burn
injury or blast and crush injury, are common
during an explosive event.
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Blast Injuries: Combined Injuries
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Avoid tunnel vision during initial assessment
Treatment protocols are often contradictory
– Blast lung vs. burn injury, blast lung vs. crush
injury
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Judicious fluid administration for adequate
tissue perfusion without volume overload
may be required in the multiple injured
patient with blast lung
– Presence of additional injuries complicates
administration, rate, selection of fluids
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Blast Injury: Combined Injuries
Typical confined space (e.g., a bus) injuries
 Primary—blast lung, intestinal rupture, TM
rupture
 Secondary—penetrating injury to head, eye,
chest, abdomen
 Tertiary—traumatic amputation, fractures to
the face, pelvis, ribs, spine
 Quaternary— crush injuries, superficial and
partial to full thickness burns
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Crush Injury
Crush Injury: Definition
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An injury sustained when a body part is
subjected to a high degree, or prolonged
presence, of force or pressure
– Usually applied to both regional (e.g. body part)
effects and systemic effects.
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Acute traumatic ischemia, with or without
associated injuries, describes actual insult to
tissues
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Crush Injury: Crush Syndrome
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Term used to describe the systems
manifestations of crush injury after reperfusion
of affected body part(s)
Reprinted with permission of OrthoWorld.com
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Crush Injury:
Compartment Syndrome
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Is a collection of localized signs and
symptoms that result when the perfusion
pressure falls below the tissue pressure in a
closed anatomic space for sufficient time
that compromise of circulation and function
of tissues involved occurs
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Crush Injury: Incidence
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5-15% of mass casualty situations
– Natural disasters, especially earthquakes and
tornadoes
– Structural collapse, with or without victim
entrapment
– Industrial, farm or transportation accidents
– Blast injury (all types)
– Combat
– Prolonged immobilization with major vascular or
microvascular circulation compromise
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Crush Injury: Examples of events
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Tyre, Lebanon (1982)
– Building collapse
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Beirut, Lebanon (1983)
– Marine barracks bombed
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Oklahoma City (1995)
– Murrah Federal Building
bombed
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Khobar, Saudi Arabia
(1996)
– Khobar Towers bombed
Bombings: Injury Patterns and Care
Used with permission of AP Photo/KM Chaudhry
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Crush Injury: Pathophysiology
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Areas most affected
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Lower extremities
Upper extremities
Pelvis
Gluteal region
Abdominal muscles
Reprinted with permission of OrthoWorld.com
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Crush Syndrome
Crush Syndrome
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May occur in absence of trauma and evolve
in the absence of early signs or symptoms
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Arterial thrombosis or embolism
Severe anemia
Toxins
Legitimate medications and drugs of abuse
Systemic effects due to rhabdomyolysis and
reperfusion of hypoxic and damaged tissues
and is the major cause of early mortality
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Crush Syndrome: Pathophysiology
Rhabdomyolysis
 Efflux from damaged muscle cells of:
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Potassium
Purines
Lactic Acid
Phosphate
Myoglobin
Thromboplastin
Creatine
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Crush Syndrome : Pathophysiology
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Reperfusion
– Skeletal muscle damage greatest after reperfusion
– Superoxide radicals produced during reperfusion
attacks free fatty acids, producing cellular edema,
death, and necrosis
– Na-K-ATP pump exchanges intracellular sodium for
calcium with further derangement of intracellular
metabolism
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Crush Syndrome: Pathophysiology
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Resultant effects of derangements due to rhabdomyolysis and
reperfusion
Potassium
Calcium
Phosphate
Myoglobin
Fluid shifts
Reperfusion
Purines
Hypoxemia
Thromboplastin
Creatinine
Sodium
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Bombings: Injury Patterns and Care
Hyperkalemia
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Hypocalcemia
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Hyperphosphatemia 
Myoglobinemia
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Hypovolemia
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Free radicals
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Hyperuricemia
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Lactic acid
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Complement system
Elevated serum levels
Azotemia
Arrhythmias
Arrhythmias
Renal damage
Renal damage
Renal failure
Renal damage
Renal damage
Acidosis
DIC
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Crush Syndrome: Clinical Presentation
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General condition of a patient with crush
injury dictated by other injuries, delay in
extrication, environmental conditions
Common presentations
– Hypothermia or hyperthermia
– Dehydration/shock
– Mental status varies from alert to comatose
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Crush Syndrome: Clinical Presentation
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Affected part (usually limb)
– Tense edema and decreased sensation
– Overlying skin may be shiny, contused, necrotic
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May have penetrating wounds (worse
diagnosis)
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Crush Syndrome:
Potential Complications
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Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Hypothermia
Acute Renal failure
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Crush Syndrome: Treatment
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Greatest initial danger is after release of
crushed limb from entrapment with
restoration of circulation
Mainstay of treatment is aggressive fluid
resuscitation and brisk diuresis
Amount of tissue damage correlates with
need for dialysis
– Cannot determine actual tissue damage based
on area of affected body part
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Crush Syndrome: Treatment
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Delay in treatment associated with greater
morbidity and mortality
– 50% renal failure at 6 hours
– 100% renal failure at 12 hours
– Rhabdomyolysis induced renal failure has 40%
mortality
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Crush Syndrome: Treatment
Prehospital
 Primary survey and initial stabilization
(ABCs)
 Fluid resuscitation before patient is
extricated with severe or prolonged
entrapment of limb or pelvis (more than a
hand or foot)
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Crush Syndrome: Treatment
Hospital
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Fluid resuscitation
Brisk diuresis
Diagnose and treat other metabolic derangements
– Hyperkalemia
– Hypocalcemia
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Treat tissue damage
Pain control
Agitation
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Compartment Syndrome
Compartment Syndrome
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Is a collection of localized signs and
symptoms that result when the perfusion
pressure falls below the tissue pressure in a
closed anatomic space for sufficient time
that compromise of circulation and function
of tissues involved occurs
Bombings: Injury Patterns and Care
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Compartment Syndrome
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Can lead to crush syndrome systemic effects
if left untreated or inadequately treated.
Photo used with permission of The Institute for Foot
and Ankle Reconstruction at Mercy, Baltimore, MD
Bombings: Injury Patterns and Care
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Compartment Syndrome
Suggestive clinical findings
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Similar settings to crush injury, but may also occur
with subacute trauma
Bone fractures
High velocity penetrating injury to muscles in closed
compartment with extensive tissue disruption
Can also occur in subacute fashion due to
prolonged immobilization on hard surface
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Compartment Syndrome:
Pathophysiology
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

Significance of muscle mass damage
Typically occurs in major muscle groups
enclosed by inelastic, fibrous sheaths
Tissue/muscle damage results in edema in a
closed volume space
– Progressive cycle of edema, perfusion
compromise, tissue hypoxia and cellular
derangement, further edema, etc.
– Untreated, will produce same effects as crush
injury
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Compartment Syndrome:
Clinical Presentation

The 5 P’s
–
–
–
–
–

Pain
Pallor
Paresthesia
Paralysis
Pressure
Progression of symptoms
– (sometimes the 6th P)
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Compartment Syndrome:
Treatment
Prehospital
 Primary survey and initial stabilization
(ABC’s)
 Suspect compartment syndrome
 Immobilize affected part
 Treat other injuries
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Compartment Syndrome:
Treatment
Hospital
 Primary survey, stabilization and
resuscitation, secondary survey
 Diagnosis through examination
 Treat systemic effects of compartment
syndrome similar to crush injury treatment
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Compartment Syndrome:
Extremity Injuries

Management of extremity injuries
–
–
–
–
Indication for field amputation
Appropriate use of tourniquet application
Appropriate use of hemostatic dressings
Appropriate anesthesia/analgesic
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Compartment Syndrome:
Procedural Skills



Measuring compartment pressures
Use of Ketamine
Fasciotomies
Photo used with permission of Immediate Action Services
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Compartment Syndrome:
Procedural Skills


Fasciotomies are a definitive
treatment, but tissue pressure at
which it is required is controversial.
Varying views include:
– Early fasciotomy when pressures >45 mm Hg or
when within 20 mm Hg of diastolic pressure
– Delayed fasciotomy (beyond 48-72 hours)
increases risk of sepsis and death due to
extensive necrotic tissues
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Compartment Syndrome:
Procedural Skills

Fasciotomy
– Provide adequate analgesia and anesthesia
– Pre-operative broad spectrum antibiotics
– Ensure ALL compartments in extremity checked
for pressures (multiple compartments may be
affected)
– Check compartment pressures before and after
fasciotomy
– Ensure adequate hemostasis
– Pack wound open and use large bulky dressings
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Entrapped Patient Treatment

Treatment
– Fluid resuscitation before victim extricated

1 L NS bolus, followed by 1-1.5 L per hour infusion
– Limb stabilization
– Minimize potential systemic effects of reperfusion

Consider use of tourniquets prior to release
– Consider alkalinization by giving 1 ampule of sodium
bicarbonate (50 mEq) immediately prior to
extrication, followed by adding 1 ampule of sodium
bicarbonate to each liter of NS infused at 1-1.5 L
per hour as above; keep second IV line open
without sodium bicarbonate
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Field Amputation

Indications:
– Unable to safely extricate
– Continued environmental toxins pose hazard to
victim and rescuers
– Grossly prolonged time until definitive treatment
even after extrication
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Field Amputation



Best performed by trauma or orthopedic
surgeon
Few EMS systems have protocols
Ensure adequate analgesia and anesthesia
– Ketamine (dissociative anesthetic)


Decreases or only minimally increases serum
potassium levels
Patient maintains airway despite adequate anesthesia
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Photo used with permission of Immediate Action Services
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Military Experience
Military Experience



U.S. Military has significant experience in
dealing with blast and explosive injuries
Military has been quick to seek and adopt
new strategies in treating hemorrhage, the
leading cause of preventable death
Mortality rates dramatically lower for the
current conflict
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Military Experience

Death Rates After Wounding
–
–
–
–
–
–
Revolutionary War
WWII
Korean War
Vietnam War
Persian Gulf War
Global War on Terror (GWOT)
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42%
30
~25
~25
~25
<10
106
Military Experience

Medical Advances from the GWOT
–
–
–
–
–
Expanded use of Damage Control Surgery
Whole blood
Tourniquets
Hemostatic agents
Hemostatic dressings
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Military Experience
Photo used courtesy of Bio Cybernetics International
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Military Experience

Damage Control Surgery
– Technique known for 20 years, but slow to be
accepted
– Central tenet: Avoid the “Deadly Triad”



Hypothermia
Coagulopathy
Metabolic acidosis
Each condition worsens both of the others
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Military Experience

Damage Control Surgery
– Stop the bleeding
– Remove major contaminants
– Wounds left open to avoid abdominal
compartment syndrome

“Pack ‘em and wrap ‘em”
– Transfer to ICU
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Military Experience

Damage Control Surgery
– Resuscitate in ICU:



Normalize blood pressure
Normalize body temperature
Normalize coagulation factors
– Return to OR 12-18 hours for definitive surgery
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Military Experience

IV Hemostasis
– INR>1.5 on arrival predictive of need for
massive transfusion (MT)
– Fresh thawed plasma best resuscitation fluid in
MT

Optimum ratio of plasma to crystalloid 1:1 to avoid
clotting factor dilution >50%
– Less crystalloid (acidotic, inflammatory, adverse
effects on coagulation)

Hextend (a colloid) preferable
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Military Experience

IV Hemostasis
– Use of fresh whole blood
– Early use of cryoprecipitate
– Recombinant Factor VIIa (rFVlla)
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Military Experience

Tourniquets
– Liberal use encouraged for any significant
extremity hemorrhage
– No adverse events seen in cases when applied
inappropriately
– Apply early (“first resort not last resort”)
– Every soldier carries at least one at all times
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Military Experience

Hemostatic Dressings
– Key to avoiding coagulopathy from MT is to
control bleeding in the first place
– Primarily used for non-extremity hemorrhage
– Dressings applied with pressure x 5 minutes;
patient wrapped and transported
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Military Experience

HemCon (chitosan)
– Originally available as a bandage
– Now available in roll that can be stuffed into
wound

QuikClot
– Very exothermic (up to 147 deg F)
– Difficult to debride
– New Advanced Clotting Sponge (ACS)

Gauze sack – easily removed from wound
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Special Considerations
Special Considerations





Pregnancy
Children
Elderly
Disabled
Language barriers
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Special Considerations: Pregnancy




Injuries to the placenta are possible and must be
detected
Second or third trimester of pregnancy should be
admitted for continuous fetal monitoring
The placental attachment is at risk for primary blast
injury
Screening test for fetal-maternal hemorrhage in
second or third trimester of pregnancy
– Positive test requires mandatory pelvic ultrasound, fetal
non-stress test monitoring, and obstetrics/gynecology
(OB/GYN) consultation.
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Special Considerations: Children




History of event or patient’s complaints may be
difficult to obtain.
Pulmonary contusion is one of the most common
injuries from blunt thoracic trauma. The injury may
not be clinically apparent initially and should be
suspected when abrasions, contusions, or rib
fractures are present. A chest x-ray is essential in
diagnosis especially when blast lung is suspected.
Specialized equipment
Identification of regional pediatric trauma facilities
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Special Considerations: Elderly





May be at a higher risk of mortality and the inhospital stay may be longer and more complicated
Orthopedic injuries may be more prevalent
Blunt chest trauma should be of special
consideration
Decontamination methods may need modification
due to limited mobility
Technical decontamination of medical equipment
such as wheelchairs, walkers and other walking
aides may be needed
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Special Considerations: Disabled


Consideration should be given to patients
with underlying medical conditions
Untreated or inadequately treated fractures
may lead to severe and long lasting
disabilities
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Special Considerations:
Language Barriers




Diverse population speaking multiple languages
may be an unforeseen obstacle
Interaction with the deaf, hard of hearing, latedeafened and the deaf-blind
History of the event maybe difficult to obtain as
well as the individual history for the patient.
Translation
– On scene resources
– Pool of medical interpreters including sign language
– Telephone translation services
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Photo used courtesy of Kwikpoint
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Psychological Issues
Psychological Issues

Sequelae from an explosive event
–
–
–
–
Anger
Frustration
Helplessness
Desire to seek revenge
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Psychological Issues

Events that affect mental health
–
–
–
–
Little or no warning
Unknown duration of the event
Potential threat to personal safety
Unknown health risks
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Psychological Issues

Tips for Responders
–
–
–
–
–
Promotion of safety
Promote calm
Promote connectedness
Promote self-efficacy
Promote hope
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Discussion Topics: Review



Background
Explosive Events
Blast Injuries
– Primary, Secondary, Tertiary, Quaternary




Crush Injuries and Compartment Syndrome
Military Experience
Special Considerations
Psychological Issues
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Discussion Topics
Surge Capacity Issues
 Hospital after Madrid bombing saw 312
patients in 2.5 hours
 Need to surge: CT, OR suites, staff, and
supplies (blood, etc.)
 Hidden nature of injuries can lead to
dangerous overtriage and undertriage
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130
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Bombings: Injury Patterns and Care