Bombings 3 H

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:
American Medical Association (AMA)

American Trauma Society (ATS)
National Association of EMS Physicians (NAEMSP)
National Association of EMTs (NAEMT)
National Association of State EMS Officials (NASEMSO)
National Native American EMS Association (NNAEMSA)
Bombings: Injury Patterns
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.
American College of Emergency Physicians (ACEP) Grant Staf
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) Staf
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
Discussion Topics
Background
Explosive Events
Blast Injuries
Primary, Secondary, Tertiary, Quaternary
Crush Injuries and Compartment Syndrome

Military Experience
Special Considerations
Psychological Issues
Background
Background
Terrorism can be defined as containing

four key elements:
Premeditated
Political
Aimed at civilians
Carried out by sub-national groups
Background
Explosive use increasing in terrorist

events
Result in mass casualty incidents
Recent examples
Mumbai (2006)
Tel Aviv (2006)
London subway (2005)
Madrid subway (2004)
Tel Aviv (2001)
Background: Historical
Perspective
1968-1999
7000 international terrorist bombings
1969-1980
187 bombings in Northern Ireland
1980-2001
324 criminal bombing events in the US
2001-2003
500 International terrorist bombings
2005
399 International terrorist bombings
Sources: Frykberg ER, Tepas JJ; US Departments of State, Justice; Terrorism Research
Centre
10
Background: Blast Devices
Photo used with permission of MAJ Benjamin Gonzalez, MD
11
Improvised explosive devices (IEDs)
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)
Rocket propelled grenades (RPGs)

Surface to air missiles (SAMs)
Enhanced blast devices
12

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)
13
Background: Blast Agents

High-order explosive: HE Low-order explosive:
Nitroglycerin (NTG)
LE
Petroleum products
Dynamite
Plastic
(Molotov cocktail)
Gunpowder
Ammonium nitrate/
fuel oil (ANFO)
(black powder)
Trinitrotoluene (TNT)
Can become HE, if
Triacetone triperoxide
contained (e.g.,
(TAPT)
pipe bomb)
14
Explosive Events
15
Explosive Events
Incident command
Entire area = crime scene evidence
preservation
Multi-jurisdictional response
Scene safety
Dirty bombs, secondary devices, building
collapse, high dust environment (possibly
contaminated), bomb fragments
16
Explosive Events:
Criminal Investigation
Principles of criminal investigation and

evidence preservation
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
17
Scene Safety
Scene Safety: Common Hazards
Secondary devices
Shrapnel
Building collapse
Air-borne contaminants
Contaminated patients
Contaminated scene/environment
Perpetrators
Terrorist patients
19
Scene Safety: Common Hazards
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
20
Scene Safety:
Appropriate PPE for blasts
Coveralls
Heavy coat
Heavy gloves
Steel-toed boots
Hard hat
Eye protection
Dust particle mask
Breathing apparatus for toxic fumes
21
Scene Safety: Common

Principles
Contain the incident

Deny entry to all but responders
Set up zones
Hot
Warm
Cold
Contain the people

Do not let anyone leave
scene until checked
Decontaminate if necessary
Photo used with permission of Connie Doyle, MD,

FACEP
22

Principles
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
23

Principles
Worker safety
Protection of uninvolved public and
volunteers
Protection of injured
Treatment of injured
Surveillance of patients and workers
for long-term effects
24
Triage
25
Triage
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
26
Triage
Nature of injuries may lead to

overtriage
Up to 75% of victims self-refer to
hospital; arrive by private
transportation
Field triage
Dynamic process
27
Triage
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
28
Blast Injuries
29
Blast Injuries: Unique Aspects
Inflict multi-system injuries on large

groups of people
Cause many simultaneous lifethreatening injuries
Hidden pattern of injury
30
Blast Injuries: Blast Physics
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
31
Blast Injuries: Blast Physics

Importance of Injury Types vs.
Distance
Emergency War Surgery, 3rd Edition
32
Diagram used with permission of John-Phillipe Dionne. PhD
Background: Physics of Blasts
Click to view
animation.
33
Blast Injury: Severity
Nature of device agent, amount

Method of delivery incendiary,
explosive
Nature of environment open, closed
Distance from device
Intervening protective barrier
Other environmental hazards
34
Murrah
Building
Photo Courtesy of the City Of Oklahoma City
35
Murrah Federal Building, Oklahoma City (1993) distribution of

injuries
JAMA, August 1996, 276 (5): 382-387 1996 American Medical

Association
36
Russell Square, London bombing,

2005
Diagram used with permission of Directorate of Public Afairs, Metropolitan Police

Service, London
37
Mumbai, India: July 2006
Reuters/Prashanth Vishwanathan
38
Blast Injuries: Pathophysiology

Proposed mechanisms*
Spalling
Caused by shock wave moving through
tissues of different densities molecular
disruption
Implosion
Caused by entrapped gases in hollow
organs compressing then expanding
visceral disruption
39
Blast Injuries: Pathophysiology
Shearing
Caused by tissues of different densities
moving at different speeds visceral tearing
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.
40
Blast Injuries: Categories
Primary injury
Caused by blast wave over pressure
Secondary injury
Caused by flying debris shrapnel wounds
Tertiary injury
Caused by blast wind forceful impact
Quaternary injury
Caused by other vectors heat, radiation
41
Blast Injuries: Primary
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
42
Diagram used with permission of LTC John McManus, Jr., MD,

FACEP
43
Blast Injuries: Primary
Most common injuries:
Blast lungpulmonary barotraumas

Traumatic brain injury (TBI), concussion
Tympanic membrane (eardrum) rupture
Middle ear damage
Abdominal hemorrhage
Abdominal organ perforation
44
Blast Injuries: Secondary
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.
45
Diagram used with permission of LTC John McManus, Jr., MD, FACEP
46
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
47
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
48
Secondary
Injury
Used with permission of American Journal of Roentgenology 2006;

187:609-616
49
Blast Injuries: Tertiary
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
Treatment for most tertiary blast injuries

follows established protocols for that specific
injury.
50
Diagram used with permission of LTC John McManus, Jr., MD, FACEP
51
Blast Injuries: Quaternary
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.
52
Blast Injuries: Quaternary
The most common quaternary blast

injuries include:
Burns
Head injuries
Asthma
COPD
Other breathing problems
Angina
Hyperglycemia
Hypertension
Crush injuries
53
Blast Injuries: Blast Lung
Used with permission of CHEST, December 1999; 116(6): 1683-1688
54
Reprinted from American Journal of Surgery, V190: 945-950,

Avidan V et al: Blast Lung Surgerywith permission from Excerpta
Medica Inc.
55
Clinical manifestations
Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability
56
Treatment
High flow oxygen sufficient to prevent
hypoxemia via non-rebreather mask
CPAP
Endotracheal intubation
Judicious fluid administration (similar to
that of pulmonary contusion)
57
Blast Injuries: Head
Primary blast waves can cause

concussions or mild traumatic brain
injury (MTBI) without a direct blow to
the head
58
Blast Injuries: Head
Consider the proximity of the victim to

the blast particularly when given
complaints of:
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
59
Blast Injuries: TM Rupture
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.
60
Blast Injuries: TM Rupture
Used with permission of NEJM, April 2005; 352: 1335-1342
61
Blast Injuries: Ear
Ear injuries may include not only TM

rupture, but also ossicular disruption,
cochlear damage, and foreign bodies.
62
Blast Injuries: Ear
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
63
Blast Injuries: Abdomen
Abdominal injuries (also called blast

abdomen) include abdominal
hemorrhage and abdominal organ
perforation
64
Blast Injuries: Abdomen
Clinical manifestations include:
Abdominal or testicular pain

Tenesmus
Rectal bleeding
Solid organ lacerations
Rebound tenderness
Guarding
Absent bowel sounds
Signs of hypovolemia
Nausea
Vomiting
65
Blast Injuries: Combined

Injuries
Combined injuries, especially blast and

burn injury or blast and crush injury,
are common during an explosive
event.
66
Blast Injuries: Combined

Injuries
Avoid tunnel vision during initial assessment

Treatment protocols are often contradictory
Blast lung vs. burn injury, blast lung vs. crush injury
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
67
Blast Injury: Combined Injuries

Typical confined space (e.g., a bus) injuries
Primaryblast lung, intestinal rupture, TM
rupture
Secondarypenetrating injury to head,
eye, chest, abdomen
Tertiarytraumatic amputation, fractures
to the face, pelvis, ribs, spine
Quaternary crush injuries, superficial and
partial to full thickness burns
68
Crush Injury
Crush Injury: Definition
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.
Acute traumatic ischemia, with or without

associated injuries, describes actual insult
to tissues
70
Crush Injury: Crush Syndrome
Term used to describe the systems

manifestations of crush injury after
reperfusion of affected body part(s)
Reprinted with permission of OrthoWorld.com
71
Crush Injury:
Compartment Syndrome
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
72
Crush Injury: Incidence
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
73
Crush Injury: Examples of

events
Tyre, Lebanon (1982)

Building collapse
Beirut, Lebanon (1983)

Marine barracks bombed
Oklahoma City (1995)

Murrah Federal Building
bombed
Khobar, Saudi Arabia

(1996)
Khobar Towers bombed
Used with permission of AP Photo/KM Chaudhry
74
Crush Injury: Pathophysiology
Areas most affected
Lower extremities
Upper extremities
Pelvis
Gluteal region
Abdominal muscles
Reprinted with permission of OrthoWorld.com
75
Crush Syndrome
Crush Syndrome
May occur in absence of trauma and evolve

in the absence of early signs or symptoms
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
77
Crush Syndrome:
Pathophysiology
Rhabdomyolysis
Efflux from damaged muscle cells of:
Potassium
Purines
Lactic Acid
Phosphate
Myoglobin
Thromboplastin
Creatine
78
Crush Syndrome :
Pathophysiology
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
79
Crush Syndrome:
Pathophysiology
Resultant efects of derangements due to rhabdomyolysis and

reperfusion
Potassium
Calcium
Phosphate
Myoglobin
Fluid shifts
Reperfusion
Purines
Hypoxemia
Thromboplastin
Creatinine
Sodium
Hyperkalemia
Arrhythmias
Hypocalcemia
Arrhythmias
Hyperphosphatemia
Renal damage
Myoglobinemia
Renal damage
Hypovolemia
Renal failure
Free radicals
Renal damage
Hyperuricemia
Renal damage
Lactic acid
Acidosis
Complement system
DIC
Elevated serum levels
Azotemia
80
Crush Syndrome: Clinical

Presentation
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
81
Crush Syndrome: Clinical

Presentation
Affected part (usually limb)

Tense edema and decreased sensation
Overlying skin may be shiny, contused,
necrotic
May have penetrating wounds (worse

diagnosis)
82
Crush Syndrome:
Potential Complications
Hyperkalemia
Hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Hypothermia
Acute Renal failure
83
Crush Syndrome: Treatment
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
84
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
85

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)
86

Hospital
Fluid resuscitation
Brisk diuresis
Diagnose and treat other metabolic
derangements
Hyperkalemia
Hypocalcemia
Treat tissue damage

Pain control
Agitation
87
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
89
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
90
Suggestive clinical findings
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
91
Compartment Syndrome:
Pathophysiology
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
92
Clinical Presentation
The 5 Ps
Pain
Pallor
Paresthesia
Paralysis
Pressure
Progression of symptoms
(sometimes the 6th P)
93
Treatment
Prehospital
Primary survey and initial stabilization
(ABCs)
Suspect compartment syndrome
Immobilize affected part
Treat other injuries
94
Treatment
Hospital
Primary survey, stabilization and
resuscitation, secondary survey
Diagnosis through examination
Treat systemic effects of compartment
syndrome similar to crush injury
treatment
95
Extremity Injuries
Management of extremity injuries
Indication for field amputation

Appropriate use of tourniquet application
Appropriate use of hemostatic dressings
Appropriate anesthesia/analgesic
96
Procedural Skills
Measuring compartment pressures

Use of Ketamine
Fasciotomies
Photo used with permission of Immediate Action Services
97
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
98
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
99
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
100
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
101
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
102
Photo used with permission of Immediate Action

Services
103
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
105
Military Experience
Death Rates After Wounding
Revolutionary War
WWII
Korean War
Vietnam War
Persian Gulf War
Global War on Terror (GWOT)
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
107
Military Experience
Photo used courtesy of Bio Cybernetics International
108
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

109
Military Experience
Stop the bleeding

Remove major contaminants
Wounds left open to avoid abdominal
compartment syndrome
Pack em and wrap em
Transfer to ICU
110
Military Experience

Resuscitate in ICU:
Normalize blood pressure

Normalize body temperature
Normalize coagulation factors
Return to OR 12-18 hours for definitive

surgery
111
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
112
Military Experience
IV Hemostasis
Use of fresh whole blood

Early use of cryoprecipitate
Recombinant Factor VIIa (rFVlla)
113
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
114
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
115
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
116
Pregnancy
Children
Elderly
Disabled
Language barriers
118
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.
119
Children
History of event or patients 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 lungis suspected.
Specialized equipment
Identification of regional pediatric trauma
facilities
120
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
121
Disabled
Consideration should be given to

patients with underlying medical
conditions
Untreated or inadequately treated
fractures may lead to severe and long
lasting disabilities
122
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
123
Photo used courtesy of Kwikpoint
124
Sequelae from an explosive event
Anger
Frustration
Helplessness
Desire to seek revenge
126
Events that affect mental health
Little or no warning
Unknown duration of the event
Potential threat to personal safety
Unknown health risks
127
Tips for Responders
Promotion of safety
Promote calm
Promote connectedness
Promote self-efficacy
Promote hope
128
Discussion Topics: Review
Background
Explosive Events
Blast Injuries
Primary, Secondary, Tertiary, Quaternary
Crush Injuries and Compartment Syndrome

Military Experience
129
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
130

Bombings 3 H

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Bombings 3 H

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Bombings:

Injury Patterns and

This project was funded by the Centers for

The Bombings: Injury Patterns and Care curriculum was

American Medical Association (AMA)

Bombings: Injury Patterns

A task force was established with representative experts from

Bombings: Injury Patterns

American College of Emergency Physicians (ACEP) Grant Staf

Kathryn H. Brinsfield, MD, MPH, FACEP, Chair, Curriculum on Traumatic

Centers for Disease Control and Prevention (CDC) Staf

Richard C. Hunt, MD, FACEP, Director, Division of Injury Response, National

Bombings: Injury Patterns

Crush Injuries and Compartment Syndrome

Bombings: Injury Patterns

Bombings: Injury Patterns

Terrorism can be defined as containing

Bombings: Injury Patterns

Explosive use increasing in terrorist

Bombings: Injury Patterns

Bombings: Injury Patterns

Background: Blast Devices

Photo used with permission of MAJ Benjamin Gonzalez, MD

Bombings: Injury Patterns

Background: Blast Devices

Improvised explosive devices (IEDs)

Car and truck bombs (Oklahoma City, World Trade Center I)

Rocket propelled grenades (RPGs)

Bombings: Injury Patterns

Background: Blast Devices

Background: Blast Agents

Bombings: Injury Patterns

Bombings: Injury Patterns

Principles of criminal investigation and

Indicators for crime scene

Bombings: Injury Patterns

Scene Safety: Common Hazards

Bombings: Injury Patterns

Scene Safety: Common Hazards

Victims with no soft tissue injuries

Bombings: Injury Patterns

Bombings: Injury Patterns

Scene Safety: Common

Contain the incident

Contain the people

Photo used with permission of Connie Doyle, MD,

Bombings: Injury Patterns

Scene Safety: Common

Cause no further injury or destruction

Photo used with permission of Kathryn Brinsfield, MD, FACEP

Bombings: Injury Patterns

Scene Safety: Common

Bombings: Injury Patterns

Bombings: Injury Patterns

Unique patterns, multiple and occult

Bombings: Injury Patterns

Nature of injuries may lead to

Bombings: Injury Patterns

Factors that determine when needs

Bombings: Injury Patterns

Bombings: Injury Patterns

Blast Injuries: Unique Aspects

Inflict multi-system injuries on large