1. Blast Trauma Scenario Simulation Debriefing Blast Trauma Scenario

2. Blast Injuries Sudden force Sudden force Rapid acceleration Rapid acceleration High peak velocity High peak velocity “Shock waves” stretch & tear soft tissues, shatter bones “Shock waves” stretch & tear soft tissues, shatter bones

3. Injuries from Explosions Blunt trauma (blast force, flying objects, falls) Blunt trauma (blast force, flying objects, falls) Penetrating trauma Penetrating trauma Barotrauma Barotrauma

4. Secondary Injuries Crush injuries Crush injuries Amputations Amputations Burns Burns Toxic inhalations Toxic inhalations Contaminants (chemical & radiation) Contaminants (chemical & radiation)

5. Primary Blast Injury Hemotympanum or rupture Hemotympanum or rupture Hearing loss Hearing loss

6. Primary Blast Injury Pulmonary lacerations Pulmonary lacerations Hemo- or pneumothorax Hemo- or pneumothorax Bronchopleural fistulas Bronchopleural fistulas Pulmonary contusions Pulmonary contusions Systemic arterial air embolism Systemic arterial air embolism Distal ischemia Distal ischemia Massive hemoptysis Massive hemoptysis

7. Primary Blast Injury GI hemorrhage GI hemorrhage Gastrointestinal ischemia Gastrointestinal ischemia Transmural gastric & bowel tears Transmural gastric & bowel tears Peritonitis Peritonitis May be occult May be occult

8. Primary Blast Injury Shattering of bone Shattering of bone

9. Treatment Caveats Stop exanguinating hemorrhage. Stop exanguinating hemorrhage. Pneumothorax is common. Pneumothorax is common. Pulmonary venous air embolism is possible. Pulmonary venous air embolism is possible. PPV worsens both. PPV worsens both. Exertion may worsen blast lung injury. Exertion may worsen blast lung injury.

10. Treatment Caveats Shock & burn injuries require large volumes of IV fluids. Shock & burn injuries require large volumes of IV fluids. Continued fluid resuscitation for burn injury: Continued fluid resuscitation for burn injury: ~23% BSA x 70 kg x 2 cc/kg = 3220 cc ~23% BSA x 70 kg x 2 cc/kg = 3220 cc One half in first 8 hrs = 1610 cc One half in first 8 hrs = 1610 cc Rate per hour = 200 cc Rate per hour = 200 cc

11. Treatment Caveats Rapid infusion of IV crystalloids may worsen pulmonary contusions. Rapid infusion of IV crystalloids may worsen pulmonary contusions. Use small boluses; reevaluate frequently. Use small boluses; reevaluate frequently.

12. Treatment Caveats Consider crush injury, rhabdomyolysis, & compartment syndrome if entrapment. Consider crush injury, rhabdomyolysis, & compartment syndrome if entrapment. Consider toxic gas inhalation from fires. Consider toxic gas inhalation from fires. Consider deliberate radiation or chemical contamination. Consider deliberate radiation or chemical contamination. Otherwise, follow standard management strategy for blunt & penetrating trauma. Otherwise, follow standard management strategy for blunt & penetrating trauma.

13. Optimal Management Strategy Setting affects strategy: Setting affects strategy: Small community hospital Small community hospital with limited resources & staff with limited resources & staff Extent of stabilization may vary. Extent of stabilization may vary.

14. Optimal Management Strategy See “Blast Trauma Simulation Skill Sets.” See “Blast Trauma Simulation Skill Sets.” Basic or advanced Basic or advanced

15. Credits Project funded by: Regional Bioterrorism Prepardedness Project Michigan Department of Community Health & Health Resources and Services Administration Project Director: William Fales, MD MSU/KCMS Simulation development: Richard Lammers, MD MSU/KCMS With technical assistance from: Stu Myers, BS, EMT-P Jason Schlautman, MD