1. Pre-hospital and Emergency Department Management for Blast Injury Nat Krairojananan MD FRCST Department of Trauma and Emergency Medicine Phramongkutklao Hospital

2. Physics of the explosive Sudden rapid conversion from chemical component to gas, heat, pressure, light and flame Low-order explosive devices < 400 m/sec. High-order explosive devices 1400-9000 m/sec.

3. Type of explosives Manufactured explosives Military:C4 Industrial:TNT

4. Improvise Explosive Devices (IED) Pipe bomb ANFO (Ammonium Nitrate Fuel Oil) Type of explosives

5. Factors influence severity of injuries Size and amount of explosive Distance from the detonation Media (air VS water) Detonation in the closed space

6. Blast injury categorization Primary blast injury Secondary blast injury Tertiary blast injury Quaternary blast injury Quinary blast injury

7. Primary blast injury Caused by high order explosive only Over pressure to air-filled organs Blast lung: PTX, pulmonary contusion, PE Blast bowel: ruptured hollow viscus  peritonitis Blast ear: TM perforation Blast brain: concussion Blast eye

9. Secondary blast injury Penetrating injury/ laceration Fragmentation of case/shell or Shrapnel Secondary fragment

10. Secondary blast injury

11. Tertiary blast injury Blast wave Propulsion of body onto hard surface Propulsion of object onto individuals Structural collapsed Fall from height Blunt injury crush syndrome compartment syndrome

12. Quaternary blast injury Not caused by primary, secondary or tertiary blast injury Fire (burn) Inhalation injury Asphyxia

13. Quinary blast injury Toxic fume Chemical injury Radiation Biological agents

14. Part I Scene Management For EMS personnel

15. Scene management Scene sized up (scene safety) Scene triage Scene treatment Evacuation

16. ICS in bombing event Commander Security Search and rescue Treatment team Evacuation team

17. Scene sized up Recognition of specific hazards with bombing Secondary device Environmental hazards (fires, toxin) Structural instability Other threat; sniper

18. Safe distance?

19. Scene Triage MASS triage START triage

20. MASS Triage M: Move A: Assess S: Sort S: Send Presence of threat

21. MOVE Quickly evacuate all patients from scene Move unresponsive patients first Use of appropriate stabilization and equipment Stretcher or SKED MASS triage

24. ASSESS According to Pre-Hospital Trauma Life Support (PHTLS) protocol by assess life threatening injury first Abv.ExtendAction AAirway and C-spine protectionOpen & clear airway, C-collar BBreathing (chest injury)O 2 supplement by face mask with bag, Rx for tension PTX CCirculation (hemorrhagic shock)Stop bleeding, initiate iv fluid DDisability (neurologic status)Check A-V-P-U EEnvironmental controlKeep warm MASS triage

25. SORT Categorize and tag patients into groups for Rx and evacuation Color codeSeverityType of injuries RED-immediateLife threatening injury- Airway obstruction - Chest injury - Hemorrhagic shock YELLOW-delayed- Potential life threatening - Limb threatening injury - Fracture - mild abdominal injury - PTSD* GREEN-minimalMinor injuryWounds BLACK or BLUE Expectant Obvious signs of death- Severe injury - Extensive wounds MASS triage

26. SEND Expedient patients to appropriate resources Trauma center En route care: monitors Proper stabilization MASS triage

27. START Triage Simple Triage And Rapid Treatment

28. START triage Scene Sized up Ask patients to walk to your voice GREEN (minimal) Walk to assigned area Unable to walkAble to walk Ask patients to raise hand or leg

29. START Triage (cont.) No response Obey command RED Immediate AW treatment YELLOW Delayed Rx possibility BLACK or BLUE Supportive treatment with limited resources Ask patient to raise hand or leg No breathing Assess breathing Breathing 5 /min or more

30. Initial management Treat life threatening injuries Prevent disability START triage Abv.ExtendAction AAirway and C-spine protectionOpen & clear airway, C-collar BBreathing (chest injury)O 2 supplement by face mask with bag, Rx for tension PTX CCirculation (hemorrhagic shock)Stop bleeding, initiate iv fluid DDisability (neurologic status)Check A-V-P-U EEnvironmental controlKeep warm

31. Evacuation Expedient patients to appropriate resources Trauma center En route care: monitors Proper stabilization START triage

32. Part II Emergency Department Management For clinicians, nurses

33. Emergency department management Triage and Patient categorization Treatment zones by color code follow Advance Trauma Life Support (ATLS) protocol

34. Primary blast injury treatment SystemPossible injuryImmediate Rxconsultation Blast lung CXR in all cases* Tension PTXNeedle thoracocentesis, follow by ICD insertion and support ventilation - Trauma surgeon - CVT surgeon Air embolismSupport ventilationIntensivist Pulmonary contusionSupport ventilationIntensivist Blast GIIntra abdominal bleeding iv fluid infusion, investigation Trauma surgeon Bowel perforationInvestigation, observeTrauma surgeon Blast brainBrain concussion, ICHCheck GCS, lateralizing signNeurosurgeon Blast earTM perforationEar exam in all casesENT Blast eyeGlobe ruptureEye examinationOpthalmologist

35. Secondary blast injury treatment InjuryImmediate RxDefinitive Rxconsultation Penetrating injury - Bleeding control - iv fluid replacement - Film for foreign body Explore lap.Trauma surgeon Amputation- Bleeding control - Tourniquet if necessary - iv fluid replacement Surgical debridement and control bleeding - Trauma surgeon - Orthopedist Laceration- Bleeding control - iv fluid replacement - Film for foreign body Debridement and suture Trauma surgeon Opened fracture- Immobilization - Distal neurovascular check - Debridement - Bone realignment Orthopedist

36. Tertiary blast injury treatment InjuryImmediate RxDefinitive Rxconsultation Blunt chest / abdominal injury - Bleeding control - iv fluid replacement - FAST / DPL Explore lap.Trauma surgeon Crush syndrome- iv fluid load to force diuresis - ECG monitoring - Looking for compartment syndrome - Alkalinize urine - Dialysis if necessary Trauma surgeon Compartment syndrome Fasciotomy- Trauma surgeon - Orthopedist

37. Quaternary blast injury treatment InjuryImmediate RxDefinitive Rx Inhalation injury- Airway management - Oxygen supplement Asphyxia- Airway management - Oxygen supplement Burn- Keep warm - Wound care - iv fluid resuscitation - Wound debridement - Grafting for skin coverage

38. Quinary blast injury treatment InjuryImmediate RxDefinitive Rx Toxic fumeAirway and ventilation supportAntidote? Chemical injuryDecontaminationWound care RadiationSupportive treatmentsame Biological agents- Isolation - Medical personnel PPE Antibiotics ?

39. Special consideration ‘upside down’ or ‘reverse’ triage Estimated incoming patient Total number of patient = Number in first hour x 2

40. Special consideration CBRNE event Decontamination Personal Protective Equipment

41. EMS personnel preparation

42. Decontaminating station

45. Thank you Comments and question are welcome

46. Three suspected injured captured