Emergency Medicine Book

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Blast Injury

Aka: Blast Injury, Explosion Related Injury, Explosive Agents, Bombing Injury
  1. See Also
    1. Pulmonary Blast Injury
    2. Trauma Team Activation (TTA)
    3. Trauma Primary Survey
    4. Trauma Secondary Survey
    5. Pediatric Trauma
    6. ABC Management (Cardiopulmonary Resuscitation)
    7. Emergency Procedure
    8. Penetrating Trauma
    9. Trauma Center
    10. Trauma Triage in the Field
    11. JumpSTART Pediatric Multiple Casualty Incident Triage
    12. SALT Mass Casualty Triage Algorithm
    13. Simple Triage and Rapid Treatment (START Triage)
    14. Mass Casualty Incident
    15. Decontamination
    16. Contaminated Casualty Management
    17. Decontamination in Children
    18. Chemical Weapon
    19. Biological Weapon (Bioterrorism)
    20. Biological Neurotoxin
    21. Toxin Antidotes
    22. Violence in the Hospital
    23. Personal Protection Equipment
    24. Respiratory Personal Protective Equipment
  2. Causes: Explosive types (based on rate of burn)
    1. High order explosives (detonate)
      1. Result in a supersonic over-pressurization shock wave, expanding rapidly from detonation point
      2. Agents include Ammonium nitrate (ANFO), dynamite (TNT), Semtex
    2. Low-order explosives (deflagrate)
      1. Rapidly burns, but advances more slowly subsonic (<1000 m/s) than a high order explosive
      2. Devices and agents include pipe bombs, gun powder, and molotov cocktails (or other petroleum based bombs)
  3. Risk Factors: Greatest Injury
    1. Enclosed space blasts (e.g. building, bus), underground or underwater blast
    2. Proximity to the explosive
    3. High order explosive
    4. Bombs encased with projectiles
  4. Mechanism
    1. Explosive detonation results in rapid conversion of solid or liquid to a gas, with a subsequent sudden release of energy
    2. Pressure peaks initially and then rapidly loses pressure
      1. Pressure falls below sub-atmospheric pressure
      2. Finally pressure returns to normal
    3. Fragmentation occurs when projectiles (e.g. nails, bolts, nuts) are housed within the bomb
      1. Typically result in most significant secondary injuries
    4. Pressure and fragmentation effects fall off exponentially with distance from the blast
      1. Doubling the distance from the blast, results in a 9 fold drop in experienced force
  5. Adverse Effects: Primary Blast Injury
    1. Mechanism
      1. Injuries result from blast's direct pressure effects (especially high order explosives)
      2. Greatest injuries are to gas containing organs (middle ear, lungs, bowel)
    2. Associated injuries
      1. Pulmonary Barotrauma (Blast Lung)
        1. Most common lethal injury
      2. Pulmonary Contusion
      3. Arterial Gas Embolism
        1. Results in Occlusion of the spinal cord or brain most commonly
      4. Gastrointestinal barotrauma
        1. Most common in underwater blast injuries
        2. May include mesenteric shear injury, liver Laceration, Splenic Rupture, intestinal rupture
      5. Genitourinary barotrauma
        1. Testicular rupture may occur
      6. Globe Rupture
      7. Tympanic Membrane Rupture (or hemotympanum)
        1. Most susceptible to even low level blast injuries (5 PSI above barometric pressure)
        2. Ear barotrauma is not a reliable indicator of greater internal injuries (e.g. lung, bowel)
      8. Traumatic Brain Injury
        1. Distinguish from Arterial Gas Embolism related CVA
  6. Adverse Effects: Secondary Blast Injury
    1. Mechanism
      1. Most common form of blast-related injury
        1. Most common form of lethal injury aside from building collapse
        2. Radius of potential injury from epicenter is much greater than the blast pressure force itself
        3. Injured body parts are widely dispersed and often unpredictable
      2. Projectiles directly strike the blast victim
        1. Nails, bolts or nuts within the bomb casing
        2. Damaged people or materials are propelled by the blast force
    2. Precaution
      1. Deeper, serious injuries may exist despite relatively mild external wounds
      2. Treat all wounds as contaminated (avoid primary closure)
    3. Associated injuries
      1. Penetrating Trauma
      2. Blunt Trauma
      3. Fractures
      4. Soft Tissue Injury
      5. Traumatic amputation
      6. Compartment Syndrome
  7. Adverse Effects: Tertiary Blast Injury
    1. Mechanism
      1. Blast victim is propelled by the blast force against another object
      2. May result in blunt or Penetrating Trauma
    2. Associated Injuries
      1. Fractures
      2. Joint dislocations
      3. Compartment Syndrome
      4. Traumatic amputations
      5. Closed Head Injury
  8. Adverse Effects: Quaternary Blast Injury
    1. Mechanism
      1. Environmental injuries and exposures related to the blast
    2. Associated injuries
      1. Burn Injury
      2. Inhalation Injury
      3. Toxin exposures (Carbon Monoxide Poisoning, Cyanide Poisoning)
      4. Chemical Weapon, Biological Weapon or Radiological Weapon exposure
      5. Exacerbation of chronic disease (e.g. Asthma Exacerbation or COPD exacerbation, Acute Coronary Syndrome)
  9. Adverse Effects: Late
    1. Acute Respiratory Distress Syndrome (ARDS)
    2. Disseminated Intravascular Coagulation (DIC)
  10. History: Blast Injury specific
    1. Background
      1. See AMPLE History
      2. Details of injury Mechanisms and catastrophe
    2. Hearing Loss, Ear Pain, Tinnitus, Ear Drainage
      1. Ear barotrauma (e.g. Tympanic Membrane Rupture)
    3. Dyspnea, cough or Hemoptysis
      1. See Pulmonary Blast Injury
      2. Pulmonary Barotrauma (most common lethal injury)
      3. Pulmonary Contusion
      4. Hemothorax or Pneumothorax
      5. Hemorrhagic Shock
    4. Chest Pain
      1. Chest blunt or Penetrating Trauma
      2. Hemothorax or Pneumothorax
      3. Pneumomediastinum
      4. Arterial Gas Embolism
    5. Nausea or Vomiting, Hematemesis, Abdominal Pain or bloody stools
      1. Abdominal blunt or Penetrating Trauma
      2. Bowel perforation
      3. Testicular rupture
    6. Eye Pain or vision changes
      1. Globe Rupture
  11. Exam
    1. See Trauma Primary Survey
    2. See Trauma Secondary Survey
    3. Head and Neurologic Exam
      1. Blood or drainage from auditory canal or nose
      2. Hemotympanum
      3. Globe injury
    4. Respiratory Exam
      1. Cyanosis
      2. Respiratory distress
      3. Hypoxia
      4. Apnea
      5. Rales or rhonchi
      6. Asymmetric breath sounds or chest movement
      7. Subcutaneous Emphysema
    5. Cardiovascular exam
      1. Arrhythmia
      2. Hypotension
        1. Hypotension compensatory Mechanisms may be paradoxically absent in blast Trauma
        2. Systemic vascular resistance and Heart Rate may remain normal despite profoun Hypotension, blood loss
      3. Severe Bradycardia
        1. Seen especially with higher intensity blast injuries
    6. Abdominal exam
      1. Abominal tenderness, rigidity or guarding
    7. Neurologic Exam
      1. Glascow Coma Scale
      2. Focal neurologic deficit
      3. Seizures
  12. Labs: Initial
    1. Comprehensive metabolic panel
    2. Complete Blood Count (CBC) with platelets
    3. Blood Type and screen (consider cross-match)
    4. ProTime (PT/INR)
    5. Activated Partial Thromboplastin Time (aPTT)
    6. Urinalysis
    7. Urine Pregnancy Test
  13. Labs: As Indicated
    1. DIC considered
      1. Thrombin Time
      2. Fibrinogen
      3. Fibrin split products
    2. Rhabdomyolysis considered (structure collapse, prolonged extrication, severe burns)
      1. Creatine Phosphokinase (CPK)
    3. Structural fire
      1. Carboxyhemoglobin
      2. Cyanide Level
  14. Imaging
    1. See FAST Exam
    2. Chest XRay
    3. Advanced imaging as indicated
      1. CT Head and CT Cervical Spine
      2. CT Chest (with or without Abdomen and Pelvis)
      3. CT Abdomen and Pelvis
        1. May miss intestinal Contusions and mesenteric injury
        2. Consider repeat imaging at 8 hours if persistent symptoms
  15. Evaluation
    1. Initial Trauma Evaluation
      1. See Trauma Primary Survey
      2. See Trauma Secondary Survey
      3. See ABC Management (Cardiopulmonary Resuscitation)
      4. See AMPLE History
      5. See FAST Exam
    2. Blast Injury specific evaluation (in order of highest lethality first)
      1. See History and Exam above
      2. Multiple Trauma
      3. Head Trauma
      4. Thoracic Trauma
      5. Abdominal Trauma
  16. Management: Preparation after initial notification of catastrophe
    1. See Mass Casualty Incident
    2. Activate hospital disaster plan
      1. Activate available medical and surgical staff, nursing staff and allied health
      2. Use appropriate Personal Protection Equipment
    3. Obtain details of catastrophe
      1. Explosion cause and type
      2. Toxin exposures
      3. Casualty location
    4. Expect "upside-down" triage
      1. Victims who are less injured (typically walking wounded) present before those more injured (due to self triage)
      2. Walking wounded self-triage themselves outside of EMS system, presenting individually to local hospitals
    5. Anticipate total casualties
      1. Expect 50% of casualties in the first hour after an incident
      2. Double the number presenting in hour one, to estimate total casualties
      3. Structural collapse is associated with greater injuries, toxins (e.g. Carbon Monoxide), delayed presentations
    6. Stage and staff areas based on triage categories (typically assigned by EMS at scene)
      1. See Trauma Triage in the Field
      2. See JumpSTART Pediatric Multiple Casualty Incident Triage
      3. See SALT Mass Casualty Triage Algorithm
      4. Simple Triage and Rapid Treatment (START Triage)
        1. Patients are categorized into minor (green), delayed (yellow), immediate (red) and deceased/expected (black)
        2. Those in delayed group should be frequently reassessed for decompensation
    7. Prepare for expected injuries
      1. Closed Head Injury
      2. Chest Trauma
      3. Musculoskeletal Trauma
      4. Abdominal Trauma
      5. Open wounds
  17. Management: Blast specific injury management
    1. See Pulmonary Blast Injury
    2. See Arterial Gas Embolism
    3. Abdominal Trauma
      1. Abdominal complications may be delayed 2-14 days
      2. Observe symptomatic patients for 6-8 hours regardless of normal CT Abdomen results
      3. Consider repeat imaging at 6-8 hours
    4. Mild Traumatic Brain Injury
      1. Seemingly mild head injuries can have longstanding effects
    5. Tympanic Membrane Rupture
      1. Risk of longterm Hearing Loss (one third of patients)
      2. Consider evaluation with otolaryngology
      3. May evaluate for ossicle disruption, or increased risk of Perilymphatic Fistula or Cholesteatoma
    6. Eye Injury
      1. Serious Eye Injury is common in blast survivors
      2. Evaluate foreign body sensation, vision change
    7. Traumatic amputation
      1. Very high mortality (due to rapid Exsanguination)
      2. Associated with multi-system injury
      3. Lower extremities are most commonly involved
      4. Immediate Tourniquet application at scene, followed by emergent surgical evaluation
    8. Wound contamination
      1. Consider all blast wounds contaminated
      2. Debride foreign material and non-viable tissue
      3. Extensive isotonic saline irrigation
      4. Tetanus prophlaxis (Td or Tdap and consider tetanus Immunoglobulin)
      5. Consider blood bourne pathogen exposure in specific cases (Hepatitis B Vaccine, HIV Postexposure Prophylaxis)
      6. Consider empiric antibiotic coverage
        1. Clostridium perfringens
          1. First-Line: Penicillin
          2. Alternatives: Erythromycin, Chloramphenicol, Cephalosporins
        2. Pseudomonas aeruginosa (severely contaminated blast wounds)
          1. First-Line: Amioglycosides
          2. Alternatives: Carbapenems (e.g. Imipenem), Zosyn
        3. Open Fractures
          1. First-Line: Cefazolin
          2. Alternatives: Clindamycin, Vancomycin, Aminoglycoside
  18. Management: Specific Cohorts
    1. Pregnancy (second and third trimester)
      1. Evaluate for Placental Abruption
      2. Obtain Fetal Monitoring and Ultrasound
      3. Consider RhoGAM in Rh negative women
      4. Consider obstetrics Consultation
    2. Extremes of age (increased mortality risk)
      1. Children
        1. High risk of Pulmonary Barotrauma (Blast Lung, Pulmonary Contusion)
        2. Have high index of suspicion if Rib Fractures or Chest Contusions
        3. Chest XRay in most Pediatric Trauma
      2. Elderly
        1. High index of suspicion for orthopedic injury
        2. Chest Trauma is associated with greater morbidity
  19. Management: Disposition
    1. Emergent surgical Consultation for TTA Level I patients, positive FAST Scan or other immediate surgical emergency
    2. Consider transfer of multiple Trauma or significant Trauma to the head, chest, or Abdomen to Level I Trauma Center
    3. Admit those with significant, but non-surgical findings on exam or diagnostics
      1. Significant Burn Injury
      2. Suspected arterial air embolism (or risk)
      3. Chemical Weapon exposure
      4. Radiation exposure
      5. White phosphorus contamination (risk of calcium and phosphorus abnormalities)
      6. Abdominal Pain despite normal CT Abdomen
      7. Vital Sign, chest or Abdomen abnormalities
      8. Non-extremity penetrating injuries
      9. Pregnant women beyond first trimester (risk of Placental Abruption)
    4. Observe for 6-8 hours (with Oxygen Saturation) those with positive history or exam findings (see above)
      1. Closed-space or under-water blast exposures
      2. Isolated Tympanic Membrane exposures
    5. Observe for 4 hours, patients exposed to open-space blasts without significant findings
    6. Communication may be difficult after Blast Injury (due to deafness, Tinnitus)
      1. Written communication and instructions may be needed
  20. Prognosis
    1. Closed Head Injury is the most common cause of death
    2. Bimodal mortality distribution
      1. Greatest mortality immediately after blast
      2. Second peak in mortality is delayed affecting the most severely injured
    3. Blast victims (contrasted with other Trauma victims)
      1. More severe injuries
      2. Require extended ICU, hospital, and rehab stays
  21. Resources
    1. CDC
      1. http://www.cdc.gov/masstrauma/preparedness/primer.pdf
    2. American Trauma Society (ATS)
      1. http://www.amtrauma.org/?page=BlastPrimer
    3. ACEP
      1. http://www.acep.org/blastinjury/
  22. References
    1. (2016) CALS Manual, 14th edition 1: 42-3
    2. Jagminas (2015) Crit Dec Emerg Med 29(5): 2-11
    3. DePalma (2005) N Engl J Med 352(13): 1335-42 [PubMed]

Struck by explosion (C0337252)

Concepts Injury or Poisoning (T037)
SnomedCT 39826003
Spanish golpe por explosión (evento), golpe por explosión (hallazgo), golpe por explosión
English Struck by explosion, Struck by explosion, NOS, Struck by explosion (finding), Struck by explosion (event)
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Explosive Agents (C1721090)

Definition (MSH) Substances that are energetically unstable and can produce a sudden expansion of the material, called an explosion, which is accompanied by heat, pressure and noise. Other things which have been described as explosive that are not included here are explosive action of laser heating, human performance, sudden epidemiological outbreaks, or fast cell growth.
Concepts Chemical Viewed Functionally (T120)
MSH D053834
English Agents, Explosive, Explosives, Explosive Agents
Italian Esplosivi
German Explosivstoffe, Explosive Stoffe, Sprengstoffe, Sprengstoff
French Explosifs, Agents explosifs
Swedish Sprängämnen
Finnish Räjähtävät aineet
Russian VZRYVCHATYE VESHCHESTVA, ВЗРЫВЧАТЫЕ ВЕЩЕСТВА
Czech trhaviny, výbušné látky, výbušniny
Japanese 爆薬, 炸薬, 火薬, 爆破薬, 爆裂薬
Polish Materiały wybuchowe
Portuguese Substâncias Explosivas, Explosivos, Agentes Explosivos
Spanish Sustancias Explosivas, Agentes Explosivos, Explosivos
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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