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Explosive events, burn patient management 1. Explosion in Cyprus Naval Base Kills 12 and injures >60 Mass trauma related to explosions can produce unique.

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Presentation on theme: "Explosive events, burn patient management 1. Explosion in Cyprus Naval Base Kills 12 and injures >60 Mass trauma related to explosions can produce unique."— Presentation transcript:

1 Explosive events, burn patient management 1

2 Explosion in Cyprus Naval Base Kills 12 and injures >60 Mass trauma related to explosions can produce unique patterns of injury They have the potential to inflict multi-organ, life-threatening injuries on many victims simultaneously Blast-related injuries can present unique triage, diagnostic, and management challenges The medical consequences from the detonation of a conventional explosive include death and acute injury, as well as destruction of critical infrastructure such as buildings, roads, and utilities 2

3 The impact of an explosive event depends largely on : the composition and amount of explosive materials involved, the surrounding environment, delivery method (if a bomb), distance between the victim and the blastv and any intervening protective barriers or environmental hazards. 3

4 Α predominant post explosion injuries among survivors involve standard penetrating and blunt trauma. Blast lung is the most common fatal injury among initial survivors. Explosions in confined spaces (mines, buildings, or large vehicles) and/or structural collapse are associated with greater morbidity and mortality. Half of all initial casualties will seek medical care over a one-hour period. This can be useful to predict demand for care and resource needs. Expect an “upside-down” triage - the most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals. 4

5 CategoriesCharacteristicsBody Part Affected Types of Injuries Primary Unique to HE, results from the impact of the over- pressurization wave with body surfaces. Gas filled structures are most susceptible - lungs, GI tract, and middle ear. Blast lung TM rupture and middle ear damage Abdominal hemorrhage and perforation – Globe (eye) rupture- Concussion (TBI without physical signs of head injury) Secondary Results from flying debris and bomb fragments. Any body part may be affected. Penetrating ballistic or blunt injuries Eye penetration (can be occult) Tertiary Results from individuals being thrown by the blast wind. Any body part may be affected. Fracture and traumatic amputation Closed and open brain injury Quaternary All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms. Includes exacerbation or complications of existing conditions. Any body part may be affected. Burns (flash, partial, and full thickness) Crush injuries Closed and open brain injury Asthma, COPD, or other breathing problems from dust, smoke, or toxic fumes Angina Hyperglycemia, hypertension Mechanisms of Blast Injury 5

6 Overview of Explosive-Related Injuries SystemInjury or Condition AuditoryTM rupture, ossicular disruption, cochlear damage, foreign body Eye, Orbit, Face Perforated globe, foreign body, air embolism, fractures RespiratoryBlast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of air embolism), airway epithelial damage, aspiration pneumonitis, sepsis DigestiveBowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric ischemia from air embolism CirculatoryCardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury CNS InjuryConcussion, closed and open brain injury, stroke, spinal cord injury, air embolism- induced injury Renal InjuryRenal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia Extremity Injury Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism-induced injury 6

7 Follow your hospital’s and regional disaster system’s plan. Expect an “upside-down” triage - the most severely injured arrive after the less injured, who by-pass EMS triage and go directly to the closest hospitals. Double the first hour’s casualties for a rough prediction of total “first wave” of casualties. Emergency Management Options : 7

8 8 Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty location from police, fire, EMS, ICS Commander, regional EMA, health department, and reliable news sources. If structural collapse occurs, expect increased severity and delayed arrival of casualties. Emergency Management Options :

9  Blast injuries should always be considered for any victim exposed to an explosive force. Primary blast lung and blast abdomen are associated with a high mortality rate. “Blast Lung” is the most common fatal injury among initial survivors.  Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute abdomen or sepsis are advanced. Medical Management Options 9

10 10  Standard penetrating and blunt trauma to any body surface is the most common injury seen among survivors.  Blast lung presents soon after exposure. It can be confirmed by finding a “butterfly” pattern on chest X-ray. Prophylactic chest tubes (thoracostomy) are recommended prior to general anesthesia and/or air transport.  Auditory system injuries and concussions are easily overlooked. The symptoms of mild TBI and post traumatic stress disorder can be identical.  Isolated TM rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries. Medical Management Options

11  Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases.  Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings.  Consider the possibility of exposure to inhaled toxins and poisonings (e.g., CO, CN, MetHgb) in both industrial and criminal explosions.  Wounds can be grossly contaminated. Consider delayed primary closure and assess tetanus status. Ensure close follow- up of wounds, head injuries, eye, ear, and stress- related complaints.  Communications and instructions may need to be written because of tinnitus and sudden temporary or permanent deafness. 11

12 12 Burn victim in precarious situations

13 Date References Location Cause No of injured survivors No of on- scene dead 1970 (6) Osaka,Japan Natural gas pipeline (7) LosAlfaques,Spain Liquid propyleneg as (8) LasVegas,Nevada,USA Hotel fire(‘MGMGrand’) (70,71) Dublin,Ireland Nightclub fire(‘Stardust’) (72) Bangalore,India Circus fire (73) Cardowan,UK Coalmine explosion (9) SanJuanico,Mexico Liquid propane gas (10) BradfordCity,UK Football stadium fire (74) Manchester,UK Aeroplane fire (11) PiperAlphaplatform, Oilrigfire NorthSea,UK 1988 (41) Ramstein,Germany Aeroplane crash (13) Bashkiria,Russia Naturalgaspipeline (75) Va¨dero¨arna,Sweden Fire on ferryboat (Scandinavian Star) 1994 (14,76) PopeAirForceBase, Aeroplane crash NorthCarolina,USA 1998 (16) Gothenburg,Sweden Discotheque fire (17) Volendam,NL Cafe´fire (1,21,77) NewYorkCity,USA Aeroplane attacks (2,23,24) Bali,Indonesia Nightclubbombings 155(78) 202{(79) 2003 West Warwick, USA Nightclubfire(‘Station’) Selected recent burn mass casualty disasters. 13

14 The Los Alfaques Disaster was a road accident and tanker explosion which occurred on 11 July 1978 in Alcanar, near Tarragona, in Spain. 14 the importance of controlling both the routes and types of conveyances used for evacuation

15 principles are similar to those applicable to other mass casualty events, modified as needed for the unique features of thermal injury and any unique features of a given disaster  Order in chaos. A Burn disaster is inherently chaotic  Establish command and control of casualty care activities ASAP, integrating the burn centres into the regional disaster response system EARLY 15

16 16  Arturson G. Analysis of severe fire disasters. In: Masselis M, Gunn SWA, editors. The Management of Mass Burn Casualties and Fire Disasters: Proceedings of the First International Conference on Burns and Fire Disasters. Dordrecht, The Netherlands: Kluwer Academic, 1992:24–33. Only 1 out 14 burn disasters had disaster plans in place  Rapid triage for the severity of the injury, by considering total extent of burn, age of patient and the presence or absence of inhalation injury or associated severe mechanical trauma. Burn injury. In: Bowen TE, Bellamy RF, editors. Emergency War Surgery: Second United States Revision of the Emergency War Surgery NATO Handbook. Washington, DC: US Government Printing Office, 1988:35–56

17 What constitutes a non-survivable burn?  LA50, half of young adults with burns of 80% of the total body surface area can be expected to survive.  The presence of inhalation injury, or of severe mechanical trauma, should add 10% to the burn size for this calculation 17

18  Patients with burns of 20% or less (10% or less at the extremes of age) can be Triaged as, T2 or T3  Triage on site at 3 Levels by an experienced burn surgeon or a plastic surgeon  Organized transport by a centralized system  NOT the usual ICU model of one nurse / patient, BUT of teams focusing on specific functions, airway management, fluid resuscitation, pain management and wound and extremity care Phillips WJ, Reynolds PC, Lenczyk M, Walton S, Ciresi S. Anesthesia during a mass- casualty disaster: the Army’s experience at Fort Bragg, North Carolina, March 23, Mil Med. 1997;162:371–3. It is disputed formation  Experienced personnel in more managerial roles and innexperienced in providing the proper care under supervision 18

19 Magnitude of Injury  The rule of “nines”  The depth of burn  +/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs 19

20 Magnitude of Injury  The rule of “nines”  The depth of burn  +/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs 20

21 Superficial or 1 st degree Deep partial thickness or 2 nd degree Full thickness or 3 rd degree 21

22 Fluid Resuscitation Large bore IV (s) Non - burn site if possible Best tool, Urine Output cc / kg / hr adult 1. 0 cc / kg / hr child [ < 30 kg ] Too much fluids can be just as bad as too little ! ! ! 22

23 Parkland Formula % BSA x Kg x 4 cc = 24 hour total need 1 / 2 over the first eight hours 1 / 2 over the next sixteen hours Lactate Ringers is the fluid of choice ! 23

24 Modified Brooke Formula % BSA x Kg x 2 cc = 24 hour total Need 1 / 2 over the first eight hours 1 / 2 over the next sixteen hours 24

25 25 Escharotomy and / or Fasciotomy Primary Escharectomy Secondary Escharectomy

26 Burn Center Transport Guidelines Partial thickness over 15 % Full thickness over 5 % Involvement of hands, perineum, face, feet Inhalation All high voltage All chemical Patients with significant pre – existing disease Standards lowered if enormous number of severe burn victims 26

27 27 International Co-operation  Burn Teams  Classification of Burn Care Facilities according to ISBI Level A, for 24–48 hours, and consists of triage, initiation of resuscitation, preparation of patients for transfer and care of patients with minor injuries Level B, resuscitation, wound care including grafting, and initial rehabilitation Level C, existing tertiary burn centres which provide definitive care including invasive monitoring, management of inhalation injury, early wound excision, complete rehabilitation, infection control and metabolic support

28 28 Rehabilitation and long-term follow-up Incorporation of occupational, physical and psychological rehabilitation of the survivors Debriefing

29 29 Thank You


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