Copy of Blast Facts CDC.pdf

7/28/2019 Copy of Blast Facts CDC.pdf

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U.S. Department of Health and Human Services

Centers or Disease Control and Prevention

BLAST INJURIESFact Sheets or Proessionals

National Center for Injury Prevention and Control

Division or Injury Response

8119-A


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Blast Injuries

In an instant, an explosion or blast can wreck havoc; producing numerous casualties with complex,

technically challenging injuries not commonly seen ater natural disasters such as oods or hurricanes.

To address this issue, Centers or Disease Control and Prevention (CDC), in collaboration with partners

rom the Terrorism Injuries Inormation, Dissemination and Exchange (TIIDE) Project, as well as other

experts in the feld, have developed act sheets or health care providers that provide detailed inormation

on the treatment o blast injuries.

These act sheets address background, clinical presentation, diagnostic evaluation, management and

disposition o blast injury topics and are available in many languages including Arabic, Bengali, Spanish,

French, Chinese, Hindi, Marathi, Russian, and Urdu.

Additional terrorist bombing and mass casualty event preparedness and response inormation or

proessionals including act sheets, multimedia tools, and communication messages are available or

download and order rom CDCs website at http://emergency.cdc.gov/BlastInjuries.

Post these act sheets in emergency departments where visible and accessible to

sta only and include the act sheets in your hospital emergency plan binders.

Note: Please use caution with posting these act sheets in public areas,

such as hospital waiting rooms, as this inormation may cause alarm.


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E t i l F t

Key Concepts Bombs and explosions can cause unique patterns o injury seldom seen outside combat

Expect hal o all initial casualties to seek medical care over a one-hour period

Most severely injured arrive ater the less injured, who bypass EMS triage and go directly to the closest hospitals

Predominant injuries involve multiple penetrating injuries and blunt trauma

Explosions in confned spaces (buildings, large vehicles, mines) and/or structural collapse are associatedwith greater morbidity and mortality

Primary blast injuries in survivors are predominantly seen in confned space explosions

Repeatedly examine and assess patients exposed to a blast

All bomb events have the potential or chemical and/or radiological contamination

Triage and lie saving procedures should never be delayed because o the possibility o radioactivecontamination o the victim; the risk o exposure to caregivers is small

Universal precautions eectively protect against radiological secondary contamination o frst respondersand frst receivers

For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization(within 7 days) and age-appropriate tetanus toxoid vaccine (i not current)

Blast Injuries Primary: Injury rom over-pressurization orce (blast wave) impacting the body surace TM rupture, pulmonary damage and air embolization, hollow viscus injury

Secondary: Injury rom projectiles (bomb ragments, ying debris) Penetrating trauma, ragmentation injuries, blunt trauma

Tertiary: Injuries rom displacement o victim by the blast wind Blunt/penetrating trauma, ractures, and traumatic amputations

Quaternary: All other injuries rom the blast Crush injuries, burns, asphyxia, toxic exposures, exacerbations o chronic illness

Primary Blast Injury

Lung Injury Signs usually present at time o initial evaluation, but may be delayed up to 48 hours

Reported to be more common in patients with skull ractures, >10% BSA burns, and penetrating injuryto the head or torso

Varies rom scattered petechiae to conuent hemorrhages

Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain ollowing blast

CXR: buttery pattern

High ow O2 sufcient to prevent hypoxemia via NRB mask, CPAP, or ET tube

BLAST INJURIESEssential Facts




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EssentialFacts

Primary Blast Injury (continued) Fluid management similar to pulmonary contusion; ensure tissue perusion but avoid volume overload

Endotracheal intubation or massive hemoptysis, impending airway compromise or respiratory ailure Consider selective bronchial intubation or signifcant air leaks or massive hemoptysis

Positive pressure may risk alveolar rupture or air embolism Prompt decompression or clinical evidence o pneumothorax or hemothorax

Consider prophylactic chest tube beore general anesthesia or air transport

Air embolism can present as stroke, MI, acute abdomen, blindness, deaness, spinal cord injury, claudication High ow O2; prone, semi-let lateral, or let lateral position Consider transer or hyperbaric O2 therapy

Abdominal Injury Gas-flled structures most vulnerable (esp. colon)

Bowel peroration, hemorrhage (small petechiae to large hematomas), mesenteric shear injuries, solidorgan lacerations, and testicular rupture

Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicularpain, unexplained hypovolemia

Clinical signs can be initially subtle until acute abdomen or sepsis is advanced

Ear Injury Tympanic membrane most common primary blast injury

Signs o ear injury usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, bleeding romexternal canal, otorrhea)

Other Injury

Traumatic amputation o any limb is a marker or multi-system injuries Concussions are common and easily overlooked

Consider delayed primary closure or grossly contaminated wounds, and assess tetanus immunization status

Compartment syndrome, rhabdomyolysis, and acute renal ailure are associated with structural collapse,prolonged extrication, severe burns, and some poisonings

Consider possibility o exposure to inhaled toxins (CO, CN, MetHgb) in both industrial and terrorist explosions

Signifcant percentage o survivors will have serious eye injuries

Disposition No defnitive guidelines or observation, admission, or discharge

Discharge decisions will also depend upon associated injuries

Admit 2nd and 3rd trimester pregnancies or monitoring

Close ollow-up o wounds, head injury, eye, ear, and stress-related complaints

Patients with ear injury may have tinnitus or deaness; communications and instructions may need to be written

This act sheet is part o a series o materials developed by the Centers or Disease Control and Prevention(CDC) on blast injuries. For more inormation on blast injuries and to order ree copies

o the blast act sheets,visithttp://emergency.cdc.gov/BlastInjuries


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BackgroundAbdominal blast injuries are a signifcant cause o injury and death. The actual incidence o abdominalblast injury is unknown. Incidence and clinical presentation o abdominal blast injury will vary signifcantlydepending upon the patient and the nature o the blast. Underwater blasts carry a signifcantly greater risko abdominal injury. Children are more prone to abdominal injuries in blast situations due to their uniqueanatomy. (For urther inormation please reer to CDCs Blast Injuries: Pediatrics act sheet.)

Clinical PresentationGas-containing sections o the GI tract are most vulnerable to primary blast eect. This can cause immediatebowel peroration, hemorrhage (ranging rom small petechiae to large hematomas), mesenteric shear injuries,

solid organ lacerations, and testicular rupture. Blast abdominal injury should be suspected in anyone exposedto an explosion with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain,unexplained hypovolemia, or any fndings suggestive o an acute abdomen. Clinical fndings may be absentuntil the onset o complications:

Clinical presentation o abdominal blast injury may be overt, or subtle and variable, and may include:abdominal pain, rebound tenderness, guarding, absent bowel sounds, nausea and vomiting, ever, andsigns and symptoms o hypovolemia or hemorrhage. Victims o closed space bombings are at risk or moreprimary blast injuries, including abdominal injury.

Predominant post-explosion abdominal injuries among survivors involve standard penetrating andblunt trauma (secondary and tertiary blast injury), but include primary blast injuries, including ischemiasecondary to arterial gas embolism.

Abdominal injuries are particularly severe in underwater blasts; the lethal radius o an underwaterexplosion is about three times that o a similar explosion in air because waves propagate aster and areslower to lose energy with distance due to the relative incompressibility o water.

Children are more prone to abdominal blast injury smaller and more pliable walls oer less protection thin abdominal walls oer less protection proportionately larger organs render children more vulnerable to injuries, especially to liver and spleen

Most common abdominal blast injuries include: Primary: abdominal hemorrhage and peroration (colon most vulnerable to peroration) Secondary: penetrating and blunt abdominal trauma

Tertiary: blunt and penetrating abdominal trauma Quaternary: crush injury to abdomen and abdominal wall

Diagnostic Evaluation Work-up similar to standard blunt and penetrating abdominal trauma

Serial abdominal examinations, as presentation may be delayed; serial exams may be difcult in young children Laboratory studies Radiological studies: ree air, unexplained ileus, intra-abdominal hematoma/hemorrhage, solid organ

contusion/laceration, intra-abdominal abscess

BLAST INJURIESAbdominal Blast Injuries




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AbdominalBlastInjuries

Initial Management ABCs (airway, breathing, circulation) as or all trauma patients

Nothing by mouth

Avoid removal o penetrating objects in emergency room (operative intervention due to risk o hemorrhage)

Antibiotics and tetanus immunization

Serial exams and laboratory monitoring

Radiological studies: plain abdominal flms, computed tomography [CT] scan, Focused AbdominalSonography or Trauma (FAST)

Disposition High degree o suspicion or missed or delayed abdominal injuries, including serial exams, close ollow-up,

and strict return instructions should signs or symptoms o abdominal injury maniest ater discharge

Appropriate reerral to trauma center as needed

This act sheet is part o a series o materials developed by the Centers or Disease Control and Prevention (CDC)on blast injuries. For more inormation on blast injuries and to order ree copies



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BackgroundIn a terrorist attack, crush injury and crush syndrome may result rom structural collapse ater a bombing orexplosion. Crush injury is defned as compression o extremities or other parts o the body that causes muscleswelling and/or neurological disturbances in the aected areas o the body. Typically aected areas o thebody include lower extremities (74%), upper extremities (10%), and trunk (9%). Crush syndrome is localizedcrush injury with systemic maniestations. These systemic eects are caused by a traumatic rhabdomyolysis(muscle breakdown) and the release o potentially toxic muscle cell components and electrolytes intothe circulatory system. Crush syndrome can cause local tissue injury, organ dysunction, and metabolicabnormalities, including acidosis, hyperkalemia, and hypocalcemia.

Previous experience with earthquakes that caused major structural damage has demonstrated that theincidence o crush syndrome is 2-15% with approximately 50% o those with crush syndrome developingacute renal ailure and over 50% needing asciotomy. O those with renal ailure, 50% need dialysis.

Clinical PresentationSudden release o a crushed extremity may result in reperusion syndromeacute hypovolemia and metabolicabnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release o toxins romnecrotic muscle into the circulatory system leads to myoglobinuria, which causes renal ailure i untreated.

Hypotension Massive third spacing occurs, requiring considerable uid replacement in the frst 24 hours; patients may

sequester (third space) >12 L o uid in the crushed area over a 48-hour period

Third spacing may lead to secondary complications such as compartment syndrome, which is swellingwithin a closed anatomical space; compartment syndrome oten requires asciotomy

Hypotension may also contribute to renal ailure

Renal Failure Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation

Myoglobinuria may result in renal tubular necrosis i untreated

Release o electrolytes rom ischemic muscles causes metabolic abnormalities

Metabolic Abnormalities Calcium ows into muscle cells through leaky membranes, causing systemic hypocalcemia

Potassium is released rom ischemic muscle into systemic circulation, causing hyperkalemia

Lactic acid is released rom ischemic muscle into systemic circulation, causing metabolic acidosis

Imbalance o potassium and calcium may cause lie-threatening cardiac arrhythmias, including cardiacarrest; metabolic acidosis may exacerbate this situation

Secondary Complications Compartment syndrome may occur, which will urther worsen vascular compromise

BLAST INJURIESCrush Injury and Crush Syndrome




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CrushSyndrome

Initial ManagementPrehospital setting:

Administer intravenous uids beore releasing the crushed body part. (This step is especially important incases o prolonged crush [>4 hours]; however, crush syndrome can occur in crush scenarios o 12 hours may increase the incidence o renal ailure; delayed maniestations o renalailure can occur

DispositionPatients with acute renal ailure may require up to 60 days o dialysis treatment; unless sepsis is present,patients are likely to regain normal kidney unction.




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BackgroundPrimary blast injury to the organs o the body tends to occur in anatomical succession, depending on thepower o the blast and susceptibility o the tissues. The frst organ to sustain damage is typically the ear.Despite earlier reports to the contrary, isolated tympanic membrane peroration, without additional signs andsymptoms, does not appear to be a marker or occult primary blast injury.

The ear is the most susceptible organ to primary blast injury. Injury to the delicate and sensitive structures othe middle and inner ear represents the most common type o injury ater a blast. Blast injury to the ear mayresult in symptoms o tinnitus, earache, hearing loss, or vertigo.

As highest priority is directed toward diagnosis and treatment o lie-threatening injuries, otologic injury is

oten missed. However, with simple screening protocols, limited management, and appropriate otolaryngologicreerral, poor outcome and morbidity can be minimized.

Clinical PresentationExternal Ear Injury to the external ear is caused most oten by ying debris (secondary blast injury)

Degloving o the cartilage may occur; considered to be a serious injury

Tympanic Membrane (TM) The TM is exquisitely sensitive to variations o atmospheric pressure as it unctions to transmit minute

pressure oscillations encountered by impulsive and continuous sound waves

Blast overpressure enters the external auditory canal, stretching and displacing the TM medially

A spectrum o injury may be seen, ranging rom intra-tympanic hemorrhage in minor cases to totaltympanic membrane peroration in powerul blasts

Perorations may be unilateral or bilateral, small or complete, and single or double

The shape o the laceration may be smooth and linear, punched out, or ragged with the edges inverted or everted

Middle Ear Disruption o the ossicular chain may occur, especially in larger blasts

Cholesteatoma within the middle ear and mastoid cavity may occur and are potentially destructive lesionsthat can erode and destroy important structures o the middle ear, temporal bone, and skull base

Sequelae o disease can cause conductive and sensorineural hearing loss, vestibular disturbances, cranialnerve palsy, as well as central nervous system complications such as brain abscess and meningitis,making the injury potentially atal

Inner Ear Damage to the auditory and vestibular components o the inner ear may also occur

The typical blast-injured patient will experience a temporary hearing threshold change; most regainhearing within hours, or others resolution may take days to weeks

BLAST INJURIESEar Blast Injuries




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Initial Management Standard trauma protocols and liesaving measures should always be addressed frst in the assessment

and management o the blast patient

Ater basic liesaving measures and severe injuries have been addressed, a ocused secondary examshould include otoscopic evaluation o the TM and external auditory canal

Tympanic membrane injury should raise clinical suspicion and evaluation or additional primary blastinjury, but isolated tympanic membrane peroration, without additional signs and symptoms, does notappear to be a marker or occult primary blast injury.

Treatment o External Ear Injuries Manage as other sot tissue injuries with attention to oreign body removal, cleaning and irrigation o

wounds, and closure

Cartilage must not be let exposed; wounds should be closed primarily; i the cartilage o the pinna isdegloved, it should be buried in the post auricular pouch (may require the expertise o an otolaryngologistor a plastic surgeon)

Treatment o Tympanic Membrane Rupture

Treatment o TM perorations is typically expectant; i cerumen or blood clots obscure view o the eardrum,these can be careully suctioned and cleaned by an otolaryngologist

The ear should be kept clean and dry, and the patient should be reerred to a specialist

Antibiotic eardrops to irrigate and clear the ear o debris or blood clots are indicated or TM perorations orear canal lacerations

Treatment o Middle and Inner Ear Injuries Treatment or middle and inner ear injuries typically can be deerred until an otolaryngologist is available

Baseline audiometry in all blast-injured patients has been advocated because hearing defcits are commonand not always noted by the patient; patients should be ollowed with interval audiometric evaluation toollow progress during recovery

Disposition TM perorations typically have an excellent prognosis with spontaneous resolution in the majority o cases

For irregular perorations with everted ap, realignment may improve chances o healing; perorationsresolve most requently in the frst three months ater injury

Tympanoplasty is indicated i spontaneous resolution is not observed ater close observation

Any TM peroration runs the risk o cholesteatoma ormation, especially those perorations that are largerand do not resolve; ollow-up is indicated biannually or a minimum o two years




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BackgroundThe sot tissue and musculoskeletal systems have the highest incidence o bodily injury in survivors o bombings.The most extreme o these injuries, the traumatic amputation, is reported to occur in 1%3% o blast victims.

Clinical PresentationTraumatic amputation rom primary blast injuryis oten considered a marker or a lethal injury. Blast-inducedamputations primarily occur through the bony shat rather than joint disarticulations and may result rom thecombination o the blast wave and blast wind.

Secondary blast injuryto the extremities is marked by penetrating trauma rom the bomb casing ragments,

materials implanted within the bomb (e.g., nails, screws), ying glass, or rom local materials made airborne byproximity to the explosion.

Wound contamination may occur rom the traumatic implantation o biologic material (e.g., bone ragments)rom the bomber or rom victims in proximity to the explosion

Irregular projectiles result in extensive tissue damage

Even with small entrance wounds, surgeons should maintain a low threshold or perorming a thoroughdebridement, as deep contamination and devitalized tissue can produce highly morbid inectious complications

Tertiary and quaternary blast injuryto extremities more closely resembles civilian trauma. Victims suer romblunt impact orces when propelled against surrounding structures.

Building collapse may produce crush injury and the potential or compartment syndrome. (For urther inormationplease reer to CDCs Crush Injury and Crush Syndrome: What Clinicians Need to Know act sheet)

Diagnostic Evaluation Document a systematic musculoskeletal, neurological, and vascular exam or each extremity

Extremities should be thoroughly evaluated rom a vascular perspective; physical examination is less reliable ordetecting vascular injuries rom blast than rom routine civilian trauma

Although diligence is warranted in assessing the vascular status o the blast-injured extremity, institutionalprotocols incorporating mandatory arteriogram have not been published

Each open wound should be well documentednoting size, exposed bone, and type o contaminationand,ideally, photographed

Radiological examination o injured extremities should be liberally utilized to identiy deep oreign bodies and tocharacterize bony injuries

The initial absence o plantar sensation in the blast-injured extremity is not predictive or amputation; 50% opatients will regain this protective sensation over time

Lower extremity injury scores do not accurately predict the need or amputation

BLAST INJURIESBlast Extremity Injuries




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BlastExtremityInjuries

Initial Management Even when blast victims have small entrance wounds, surgeons should maintain a low threshold or perorming

thorough debridement

All open ractures are considered contaminated and should receive early antibiotic treatment (frst generationcephalosporin and/or aminoglycocide, extended spectrum penicillin)

Obviously contaminated wounds should be irrigated with sterile saline and dressed with iodophore (Betadine)-soaked sponges; once dressed, re-exposure should wait until operative exploration

Tetanus prophylaxis should be administered unless immunization within fve years can be documented

Extremity ractures should be splinted to provide mechanical stability and relieve pain

Surgical Management Initial debridement and bony stabilization should be done in the operating room to preserve lie and limb;

wounds should be enlarged with extensive longitudinal incisions and debrided in systematic ashion

The zone o injury will extend well beyond initial skin wounds and racture sites; aggressive debridement onecrotic and contaminated tissue is critical because there is a tendency to underestimate the sot tissue injury

Following debridement, low-pressure pulsatile lavage may be employed to thoroughly irrigate the wound

Bony stabilization is oten provided by external fxation with secondary conversion to defnitive plate orintramedullary fxation

When treating vascular injuries, avoiding prosthetic grats or repairs/reconstruction within contaminated zoneso injury is important; where vessels may not be ligated, autologous vein grats or critical reconstructions shouldbe used

Following debridement and bony stabilization, sot tissue injury is generally addressed with creation o anantibiotic bead pouch or application o a vacuum wound dressing

Cultures are generally not useul during this acute injury management

Repeat debridement is planned every 2472 hours, depending on the injury extent, until a stable sot tissue bedis attained

Literature on the management o small, imbedded oreign bodies is limited; it may be the case that smallragments involving sot tissue only, with small wounds and no active inection or gross contamination, may betreated expectantly

Beore and during each operative procedure, limb viability and easibility o continued eorts to save the limbmust be considered; the overall goal is to preserve potentially unctional limbs without jeopardizing the patientsoverall health




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BackgroundOcular injury is a requent cause o morbidity in terrorist blast victims, occurring in up to 28% o survivors.The eye, with its protective orbit, tarsal plates, and tough sclera, is resistant to traumatic rupture resultingrom a blast overpressure wave. Given enough orce, however, rupture can occur. Only one case o pureprimary blast injuryto the eye has been reported in the literature. Lesser orce can result in internal oculardisruption. Secondary blast injury, caused by ying debris or ragments, is a particular threat to exposed andunprotected heads and eyes. Rapidly accelerated sharp particles, large or small, can lacerate or rupture thecornea or sclera and enter the eye.

Glass is a major source o lacerations and oreign bodies (FBs) aecting the eye. Concrete, metal, wood, and

other materials rom explosions in buildings can create FB eye injuries. Explosions in open spaces tend toaccelerate metallic ragments rom the bomb and may also propel soil and organic matter. Ocular injuriesoccurring rom terrorist bombs may be extensive, and may involve blunt or penetrating trauma injury to thetissues o the globe, lids, orbit, or ocular adnexa. Frequently, injuries are bilateral and may range rom minorcorneal abrasions and oreign bodies to extensive eyelid lacerations, open globe injuries, intraocular oreignbodies (IOFB), or orbital ractures.

Clinical Presentation Blast eye injuries may present with a wide range o symptoms, rom minimal discomort to severe pain or

loss o vision

It is critical to appreciate that signifcant eye damage may be present with normal vision and minimalsymptoms; these may include eye irritation or pain, oreign body sensation, decreased or altered vision,bleeding, or periorbital swelling or bruising

Minor blast-related eye injuries include corneal abrasions, conjunctivitis, and superfcial oreign bodies

Open globe injuries, including penetrating and perorating injuries to the cornea or sclera, are the mostcommon serious blast-related eye injuries (up to 20%50% o those with eye injuries)

Eyelid lacerations, oten extensive, account or 20%60% o blast-related eye injuries

Serious non-penetrating eye injuries include hyphema, traumatic cataract, vitreous hemorrhage, retinaldetatchment, choroidal rupture, and optic nerve injuries

Diagnostic Evaluation

Assume all eye injuries harbor a rupture o the globe

Ruptured globes or IOFBs may be very subtlesigns o a ruptured globe include 360-degree conjunctivalhemorrhage; misshapen pupil; brown or pigmented tissue outside the globe; clear, gel-like tissue outsidethe globe; or abnormally deep or shallow anterior chamber

Intraocular oreign bodies may be large and obvious, or small and difcult to detect; may be located in anypart o the eye

BLAST INJURIESEye Blast Injuries




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EyeBlastInjurie

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Diagnostic Evaluation(continued) Obtain visual acuity o each eye i possible; test or light perception (LP), hand motion (HM), and

count fngers (CF)

Thin-cut computed tomography (CT) o the orbits may be helpul in identiying oreign bodies

Magnetic resonance imaging (MRI) is contraindicated until it is proven no metallic FBs are present; MRImay be helpul in identiying non-metallic (wood, plastic, organic) oreign bodies

Initial Management Do not orce the lids open to examine the eye; deer examining the eye i there is massive swelling or

hematoma o the lids

Assume all eye injuries harbor a ruptured globe; do not put any pressure on an eye that may be ruptured

Do not apply a patch or bandage to the eyeuse a convex plastic or metal shield, or the bottom o a cleanpaper or Styrooam cup be taped to the surrounding bones to protect the globe

Do not remove impaled oreign bodies; the distal aspect o the oreign body may be in a location thatrequires special extraction techniques

Administer tetanus i warranted

Administer anti-emetics to reduce nausea and vomiting

Administer intravenous (IV) broad-spectrum antibiotics i a ruptured globe is suspected; currentsuggestions include the combination cetazadime/vancomycin; consider IV clindamycin or dirty soil/organic material-contaminated wounds

Disposition The examination o blast victims should be approached with a high level o suspicion or occult eye injuries

and a low threshold or reerral; consult an ophthalmologist as early as possible

Ater initial stabilization o the patient and protection o the eye, rapid transport to acilities with ophthalmic

operating room (OR) capabilities should be the main goal




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BackgroundBlast lung injury (BLI) presents unique triage, diagnostic, and management challenges and is a directconsequence o the blast wave rom high explosive detonations upon the body. BLI is a major cause omorbidity and mortality or blast victims both at the scene and among initial survivors. The blast wavesimpact upon the lung results in tearing, hemorrhage, contusion, and edema with resultant ventilation-perusion mismatch. BLI is a clinical diagnosis and is characterized by respiratory difculty and hypoxia,which may occur without obvious external injury to the chest.

Current patterns in worldwide terrorist activity have increased the potential or casualties related toexplosions, yet ew civilian health care providers in the United States have experience treating patients withexplosion-related injuries. Emergency care providers are urged to learn more about the physics o explosionsand other types o injuries that can result. Basic clinical inormation is provided here to inorm practitioners othe presentation, evaluation, management, and outcomes o BLIs. Please see the reerence list below or moreinormation about how to treat injuries rom explosions.

Clinical Presentation Symptoms may include dyspnea, hemoptysis, cough, and chest pain.

Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds, andhemodynamic instability.

Associated pathology may include bronchopleural fstula, air emboli, and hemothoraces orpneumothoraces.

Other injuries may be present.

Diagnostic Evaluation Chest radiography is necessary or anyone who is exposed to a blast.

A characteristic buttery pattern may be revealed upon x-ray.

Arterial blood gases, computerized tomography, and dopplertechnology may be used.

Most laboratory and diagnostic testing can be conducted perresuscitation protocols and urther directed based upon the natureo the explosion (e.g. confned space, fre, prolonged entrapment

or extrication, suspected chemical or biologic event, etc).

Management Initial triage, trauma resuscitation, treatment, and transer should ollow standard protocols; however some

diagnostic or therapeutic options may be limited in a disaster or mass casualty situation.

In general, managing BLI is similar to caring or pulmonary contusion, which requires judicious uid useand administration ensuring tissue perusion without volume overload.

Clinical interventions

BLAST INJURIESBlast Lung Injury

Photo courtesy o Chest, 1999




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BlastLungInjury

Management(continued) All patients with suspected or confrmed BLI should receive supplemental high ow oxygen sufcient to

prevent hypoxemia (delivery may include non-rebreather masks, continuous positive airway pressure, orendotracheal intubation).

Impending airway compromise, secondary edema, injury, or massive hemoptysis requires immediateintervention to secure the airway. Patients with massive hemoptysis or signifcant air leaks may beneftrom selective bronchus intubation.

Clinical evidence o or suspicion or a hemothorax or pneumothorax warrants prompt decompression.

I ventilatory ailure is imminent or occurs, patients should be intubated; however, caution should be usedin the decision to intubate patients, as mechanical ventilation and positive end pressure may increase therisk o alveolar rupture and air embolism.

High ow oxygen should be administered i air embolism is suspected, and the patient should be placedin prone, semi-let lateral, or let lateral positions. Patients treated or air emboli should be transerred to ahyperbaric chamber.

Disposition and Outcome There are no defnitive guidelines or observation, admission, or discharge ollowing emergency

department evaluation or patients with possible BLI ollowing an explosion.

Patients diagnosed with BLI may require complex management and should be admitted to an intensivecare unit. Patients with any complaints or fndings suspicious or BLI should be observed in the hospital.

Discharge decisions will also depend upon associated injuries, and other issues related to the event,including the patients current social situation.

In general, patients with normal chest radiographs and ABGs, who have no complaints that would suggestBLI, can be considered or discharge ater 4-6 hours o observation.

Data on the short and long-term outcomes o patients with BLI is currently limited. However, in onestudy conducted on survivors one year post injury, no patients had pulmonary complaints, all had normalphysical examinations and chest radiographs, and most had normal lung unction tests.

Photo Source: Reprinted by permission rom Chest. X-ray Figure I in Recovery rom Blast Lung Injury: Oneyear ollow-up, by Hirshberg, Boaz, MD, et al. Dec 1999, Vol 116(6), p 1683-88.




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BackgroundCurrent patterns in worldwide terrorist activity have increased the potential or casualties related toexplosions, yet ew civilian emergency medical service providers in the United States have experience treatingpatients with these injuries. One direct consequence o high-explosive detonations upon the body is blast lunginjuryor, BLI. It is characterized by respiratory difculty and hypoxia. BLI can occur, although rarely, withoutobvious external chest injury. Persons in enclosed-space explosions or in close proximity to the explosion areat highest risk. BLI presents unique triage, diagnostic, and management challenges.

Clinical Presentation Symptoms may include dyspnea, hemoptysis, cough, and chest pain.

Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds, andhemodynamic instability.

Victims with skull ractures, injuries penetrating torso or head, or burns covering more than 10% bodysurace area (BSA) are more likely to have BLI.

Hemothoraces or pneumothoraces may occur.

Due to pulmonary or vascular tearing, air may enter the arterial circulation (air emboli) and result inembolic events involving the central nervous system, retinal arteries, or coronary arteries.

Clinical evidence o BLI is typically present at the initial evaluation; however, reports show that evidence oBLI can appear 24 to 48 hours ater an explosion.

Other injuries are oten present.

Prehospital Management Considerations Initial triage, trauma resuscitation, and transport o patients should ollow standard protocols or multiple

injured patients or mass casualties.

Explosions in confned spaces result in a higher incidence o primary blast injury, including lung injury.Note the patients location and the surrounding environment at the time o injury.

Patients with suspected or confrmed BLI should receive supplemental high-ow oxygen to preventhypoxemia.

A compromised airway requires immediate intervention.

I ventilatory ailure is imminent or occurs, patients should be intubated; however, prehospitalproviders must realize that mechanical ventilation and positive pressure may increase the risk oalveolar rupture, pneumothorax, and air embolism in BLI patients.

High-ow oxygen should be administered i air embolism is suspected, and the patient should beplaced in a prone, semi-let lateral, or let lateral position.

Clinical evidence or suspicion o a hemothorax or pneumothorax warrants close observation. Chestdecompression should be perormed or patients clinically presenting with a tension pneumothorax. Closeobservation is warranted or any patient suspected o BLI who is transported by air.

BLAST INJURIESBlast Lung Injury: An Overview or

Prehospital Care Providers




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Prehospital Management Considerations(continued) Fluids should be administered judiciously, as overzealous uid administration in the patient with BLI may

result in volume overload and worsen pulmonary status.

Patients with BLI should be transported rapidly to the nearest, appropriate acility, in accordance withcommunity response plans or mass casualty events.

Blast Lung Injury Management Protocol

*There is a higher incidence o BLI in enclosed spaces.

**High fow oxygen, airway management as appropriate, evaluate or additional injury and rapid transport.



No

No

Yes

Blast orexplosive event

Signs or symptomssuggestive o BLI orRespiratory Distress

CompromisedVentilation

Vital signs,** oxygen,monitor I.V.

Appropriate Treatmentand

** Transport

Transport rapidly to thenearest, appropriateacility in accordance

with communityresponse plans or

mass casualty events.

Suspicion or a hemothorax orpeumothorax warrants close

observation. Chest decompressionshould be preormed or patients

clinically presenting with a tensionpneumothorax. Close observationis warranted or any patient with

suspicion o BLI who is transportedby air.

Fluids shouldbe administeredjudiciously, irequired, as

administrating toomuch uid may result

in volume overloadand worsening opulmonary status.

I ventilatory ailure is imminent or occurs, patients should beintubated; however, caution should be used as mechanical ventilationand positive pressure may increase the risk o alveolar rupture and

air embolism.

Airwaymanagement

protocol

Initial triage, trauma resuscitation,and transport should ollow

standard protocols or multipleinjured patients

or mass casualties.* in an open or closed space?

Signs of BLIApnea, tachypnea or hypopnea,hypoxia and cyanosis, cough,wheezing, dullness to percussion,decreased breath sounds, orhemoptysis

Symptoms of BLIDyspnea, hemoptysis, cough, andchest pain

Clinical concernsBlast lung, hemothorax,pneumothorax, pulmonary contusionand hemorrhage, A-V fstulas(source o air embolism), penetratingchest trauma, and blunt chesttrauma. Evaluate patient or >10%BSA burns, skull ractures, andpenetrating torso or head injuries.


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B b i

d M t l H l t h

BackgroundIntentional mass casualty events such as bombings are designed to cause death, destruction, ear, andconusion. In comparison to natural disasters, intentional mass casualty events are associated with higherrates o long term psychological symptoms. The level o ear and distress ater a bombing depends on severalactors, including injury o sel and/or injury or death o amily members and riends; separation rom or lacko knowledge about loved ones; and the witnessing o horrifc and rightening scenes.

Emergency responders and other health care providers may also experience psychologicalsymptoms resulting rom continued exposure to death and devastation.

Most ear and distress reactions are normal, expected, and can be managed using principles o good psychologicalpatient care. Clinicians should take all reports o physical, emotional, cognitive, and behavioral reactions seriously.

Clinical Presentation Physical reactions: atigue/exhaustion, gastrointestinal distress, tightening in throat/chest/stomach,

headache, worsening chronic conditions, somatic complaints, or racing heartbeat.

Emotional reactions: depression/sadness, irritability/anger/resentment, anxiety/ear, despair/hopelessness,guilt/sel-doubt, unpredictable mood swings, emotional numbness, or inappropriately at aect.

Cognitive reactions: conusion/disorganization, recurring dreams or nightmares, preoccupation with the disaster,trouble concentrating/remembering things, difculty making decisions, questioning spiritual belies, disorientation,indecisiveness, worry, shortened attention span, memory loss, unwanted memories, or sel-blame.

Behavioral reactions: sleep problems, crying easily, excessive activity level, increased conicts with others,hypervigilance/startle reactions, isolation/social withdrawal, distrust, irritability, eeling rejected or abandoned,being distant, judgmental, or over-controlling. Abuse o substances and/or alcohol is also a common symptom.

Initial ManagementProvide psychological frst aid (PFA) to patients, amily members, and emergency responsepersonnel as needed: Establish contact and engagement

Provide/ensure saety and security

Stabilize, as necessary

Gather inormation regarding current needs and concerns

Avoid encouraging patient to talk about the event as this may intensiy symptoms

Provide practical assistance

Provide inormation and education regarding signs o distress and how to cope

Link with appropriate/needed ollow-up services

Provide amily members with accurate, timely, and credible inormation about patient status and what willbe happening next

BLAST INJURIESBombings and Mental Health




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Bombingsa

ndMentalHealth

Initial Management (continued) Provide amily members a quiet location away rom distressing signs and sounds

Minimize separation o pediatric and other patients where separation increases distress

Optimize services o hospital social services and chaplains

Reer to a behavioral health specialist when the ollowing signs occur: Disorientation: inability to know date, location, or recent events

High anxiety and hyper-arousal: highly agitated, unable to sleep, requent nightmares, ashbacks, orintrusive thoughts

Dissociation: emotional disconnection, sense o seeing sel rom another perspective, seeing theenvironment as unreal, or time distortion

Severe depression: hopelessness and despair, unrelenting eelings o worthlessness or guilt, requentcrying or no apparent reason, or withdrawal

Psychosis: hearing voices, seeing things that are not there, appearing out o touch with reality, or excessivepreoccupation with ideas or thoughts

Inability to care or one sel: does not eat or bathe, isolated rom others, or unable to manage tasks o daily living

Suicidal or homicidal thoughts or plans

Problematic use o alcohol or drugs

Domestic violence: child, spouse, elder, or animal abuse

Address emergency response personnel concerns as needed: Be aware o personal stress vulnerabilities in emergency responders

Identiy physical, emotional, cognitive, and behavioral signs in sel and coworkers, and practice sel-care

Enorce breaks

Use a buddy system to identiy stress

Provide PFA as needed

Seek help rom a mental health specialist i necessary

Be aware o stress and ears in your amily resulting rom your work/role

Disposition Most ear and distress reactions are normal and will resolve without the intervention o a mental health specialist;

however, reerral services should be made available to all patients, amilies, and emergency response personnel

Individuals who belong to strong social networks, such as amilies and aith communities, tend to do betterthan those who do not

Individuals and amilies that exhibit continuing signs o distress, and those exhibiting signs o mentalillness, including psychosis, severe anxiety, and depression, should be reerred to a mental healthspecialist or ongoing care




21/36

T

t

t

f O l d

A d

l t

BackgroundLimited research is available regarding treatment o blast injury in older patients. Nearly all data on the patternso injury and care o the victims o bombings are not ocused specifcally on older adults. However, lessonslearned rom day-to-day trauma and geriatrics care can provide insight into the treatment o blast injuries amongolder adults, including such considerations as the act that older patients are especially subject to:

An increased risk o ractures (e.g., hip, ribs, skull) as a result o decreased elasticity o tissues andorgans, in addition to the decreased ability o organs to withstand rapidly applied strain orces;

Traumatic brain injury; and

Post-traumatic complications.

Additionally, outcomes are aected by co-morbid conditions, physiologic reserve, multiple concurrent injuries,pre-hospital care, medical/surgical interventions, and rehabilitation services. Some potentially signifcantco-morbidities include: coronary artery disease, hypertension, chronic obstructive lung disease, diabetesmellitus, dementia, cerebrovascular disease, chronic renal ailure, arthritis, gastro-esophageal reux disease,and anemia o chronic disease. Each o these conditions, along with the medications used or them, need tobe taken into account when managing the care o an older blast victim.

Clinical Presentation Physiologic derangements in older adults can be occult. They need to be aggressively pursued.

Physiologic responses to hypovolemia seen in younger patients (e.g., tachycardia, hypotension) may not

be seen in the older patients due to medications and preexisting diseases; intravascular volume status omany older adults can be difcult to assess and may require the early use o invasive monitoring.

Diagnostic Evaluation The use o standard evaluation and resuscitation protocols (e.g., Advanced Trauma Lie Support) is

appropriate or initial evaluation and treatment o the older trauma patient.

Because o natural changes in brain size with aging, older patients can sustain a signifcant amount ointracranial bleeding rom a closed head injury beore symptoms o increased intracranial pressure occur;early use o computed tomography (CT) scanning should be considered i head injury is suspected.

A complete medication history, including use o prescription and non-prescription medications (herbal

supplements, etc.), should be obtained and assessed or possible adverse eects and interactions.Commonly prescribed medications in older adults (e.g., beta-blockers, calcium channel blockers) canmask or blunt the normal physiologic response to injury and stress or, in some cases (e.g., wararin), mayexacerbate an individuals injuries.

Flail chest (particularly anterior) may not be obvious in the older patient, and patients should be thoroughlyevaluated or ail chest along with other serious chest injuries. Fractured ribs and/or chest wall contusioncan be extremely painul and may be lethal i not managed aggressively.

BLAST INJURIESTreatment o Older Adults




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TreatmentofOlderAdults

Diagnostic Evaluation(continued) Delirium is not uncommon, and it may be due to medications (including prescription and nonprescription),

inections (e.g., pneumonia, urosepsis), or many other medical conditions, including: acute bloodloss,electrolyte imbalance, end organ ailure, hypoglycemia or hyperglycemia, hypoxia, arrhythmias,neurological conditions, dehydration, severe pain, immobility, sleep deprivation, ecal impaction, or urinary

retention. During initial evaluation, patients with delirium should be assumed to have a reversible etiologyuntil it is proven otherwise.

Decreased hearing and visual impairment are common in older adults. These conditions need to beevaluated as contributing actors in patients with altered consciousness or cognitive change.

Initial Management Pain, which can be maniested as delirium in older adults, should be optimally managed by balancing the

need or relie and unctional improvement with the potential or adverse events.

Non-emergent or other non-lie-threatening surgical procedures should be delayed or a brie period tomaximize physiologic reserve and to manage co-morbidities.

In the absence o any contraindications, perioperative beta-blocker use is appropriate or patients at highor intermediate risk o cardiac complications i such patients are undergoing emergent, vascular, headand neck, intrathoracic, intraperitoneal, or orthopedic surgery.

All surgical patients older than age 60 years are considered at high risk o postoperative deep venousthrombosis and should receive prophylaxis.

Disposition Social services, rehabilitation medicine, physical therapy, occupational therapy, nutrition, and

pharmacology should be consulted early in the hospitalization o older adults, and early mobility shouldbe encouraged post-operatively.

Family members should be queried regarding existing advanced directives, and health proessionalsshould assist amily members in understanding how these directives relate to the specifcs omedical care.

Unrecognized dementia is a risk actor or post-operative delirium.

Renal unction should be determined by creatinine clearance (reduced with increasing age) and notmerely by serum creatinine level. Medications that undergo renal excretion may need dosing adjustmentwhen creatinine clearance is less than 60 ml/min.

Measures to prevent skin breakdown should be evaluated on an ongoing basis.




23/36

P

d i t i

BackgroundAter a bomb blast or explosion, health care personnel with little or no pediatric experience could be calledupon to treat children. Although the general principles o emergency medicine apply when treating explosive-blast victims, all clinicians should understand there are important dierences between treating adults andtreating inants and children. The highlights o these treatment dierences ollow below.

Clinical PresentationBrain and Other Neurological Injuries

A traumatic brain injury (TBI) can occur without the patient losing consciousness. Consequently, children

who appear alert and awake when frst examined should be triaged to a hospital i they exhibit any othe ollowing: Abnormal behavior such as irritability or excessive sleepiness Persistent vomiting

Seizures Loss o consciousness Evidence o a cerebrospinal uid leak (CSF) leak

Chest Injuries Chest injuries, usually caused by blunt-orce impact, are a common cause o death in children subjected to

an explosive blast. Several anatomical eatures unique to children aect their injury patterns. For example: Children have a shorter trachea and so endotracheal intubation is more difcult, and unintentional

extubation occurs more commonly.

Children have narrower airways and as a result are more prone to bronchospasm and obstruction. Children have much more compliant chest walls; rib ractures are much less common and severe

thoracic injuries can occur without signifcant external evidence o injury. Children have more mobile mediastinal structures. Accordingly, a tension pneumothorax can shit

the mediastinum causing respiratory and cardiovascular compromise. Always consider tensionpneumothorax in the hypotensive, hypoxic child.

Abdominal Injuries Children exhibit many signifcant anatomical dierences rom adults with regard to the abdomen. These

can aect injury patterns as ollows: Children are more prone to abdominal injuries because their smaller and more pliable ribs oer less

protection than those in adults. Children have thin abdominal walls that oer them less protection. Children have proportionally larger organs that are more prone to injury. The spleen and liver are the organs most vulnerable to injury rom blunt- or penetrating-orce trauma.

BLAST INJURIESPediatrics




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Pe

diatrics

Clinical Presentation (continued)Orthopedic Injuries Common orthopedic injuries in children include: Plastic deormitybowed bone without evidence o cortical disruption. Torus (buckle) racturebending o the cortex. Greenstick ractureracture o one cortex at the side opposite o orce impact. Physeal ractureinvolving the physis (growth plate). Physeal ractures represent approximately 18%

o pediatric ractures. Forearm ractureinvolving radius and ulna and usually occurs ater alls. Supracondylar ractureinvolving distal humerus and elbow is considered an orthopedic emergency. A

careul neurovascular exam is necessary to detect potential damage to the brachial artery.

Critical Care Several actors unique to children aect their critical care. These include: Temperature regulation is important because children are more susceptible to heat loss by radiation,

convection, and evaporation. Young children have relatively large heads with immature neck musculature. This makes them more

susceptible to cervical spine injury caused by the ulcrum eect in the C1C3 area. Children under age 8 years also are susceptible to SCIWORA (spinal cord injury without radiographic

abnormality). Traumatic asphyxia occurs almost exclusively in children. It results rom sudden compression o the

abdomen or chest against a closed glottis. Treatment is supportive. Symptoms o traumatic asphyxiainclude:

Hyperemic sclera Seizures Disorientation Petechiae in upper body Respiratory ailure

Initial Management Consider possible cervical spine injury in children with head injury. Repeat examinations are essential because young children oten are not able to cooperate with their initial

examiner. Children have a remarkable cardiovascular reserve; even minimal signs o shock will not occur until 25% o

blood volume is lost. Recommended initial uid resuscitation is 2030 cc/kg o normal saline or Ringers lactate.

Other Considerations Decontaminate children in the presence o parents whenever possible to minimize disruption and reduce

the possibility o separation anxiety. Mental health issues are common in children who have experienced a traumatic event such as a bomb

blast. I parents are accessible, provide them with mental health reerral sources. For urther inormation on psychological frst aid or children and amilies, please reer to CDCs act sheet

Blast Injuries: Bombings and Mental Health.




25/36

P t E

P h l i f

B l d b P t h g

BackgroundVictims presenting rom the scene o an explosive event, as well as those participating in recovery andtransport eorts, including frst responders, are at risk o exposure to bloodborne pathogens via body uidsand oreign bodies such as bone, contaminated weapon ragments, or other debris. For victims near the sceneo an explosive event, biological oreign bodies such as bone can become projectiles that contribute to thespectrum o blast injury.

As noted in the U.S. Public Health Service guidelines or occupational exposure o health care workers,exposure to blood and other body uids increases the risk o exposure to hepatitis B virus (HBV), hepatitis Cvirus (HCV), and human immunodefciency virus (HIV).

Clinical PresentationIndividuals presenting rom the scene o a bombing can subsequently be categorized into one o three majorrisk categories or exposure to blood or bodily uids:

Category 1. Penetrating injuries or nonintact skin exposures

Category 2. Mucous membrane exposures

Category 3. Superfcial intact skin exposures without mucous membrane involvement

Initial Management

HBV post exposure prophylaxis (PEP) is recommended or individuals presenting rom the scene withnonintact skin or mucous membrane exposure (Categories 1 and 2). The hepatitis B vaccination series(age-appropriate dose and schedule) should be initiated as soon as possible, preerably within 24 hoursand not later than 7 days ater exposure. The vaccine should be administered to those who:

Lack a reliable history o immunization against HBV; and

Have no previous history o contraindication to immunization against HBV.

There is no prophylaxis recommended or HCV. Consider testing (immediately or during ollow-up reerral)i exposure is to a known or likely HCV-inected source or multiple sources. I testing is perormed, obtainbaseline (within 714 days) and ollow-up (46 months) anti-HCV and ALT (Category 1; generally no actionor Category 2).

Generally, no PEP is warranted or HIVconsider action ONLY i exposure is to a known or highly likelyHIV-inected source (Categories 1 and 2).

No PEP or testing is recommended or those individuals presenting rom the scene with possiblesuperfcial skin exposure (Category 3).

See Table 1 or summary.

BLAST INJURIESPost Exposure Prophylaxis or

Bloodborne Pathogens




26/36

PostExposu

reProphylaxisfor

BloodbornePathog

ens

Table 1. Recommended post exposure management by risk category and specifcpathogen

Risk Category HBV HCV HIV

Category 1. INTERVENE CONSIDER GENERALLYTESTING NO ACTION

Category 2. INTERVENE GENERALLY GENERALLYNO ACTION NO ACTION

Category 3. NO ACTION NO ACTION NO ACTION

Special Considerations regarding PEP Recommendations

Consultation rom health care specialists knowledgeable about HBV, HCV, and HIV is ideal, in particular orpediatric patients and pregnant women. Health care proessionals should be knowledgeable about consultingexisting guidelines and recommendations regarding contraindications and precautions, counseling andeducation, testing, medical ollow-up and, i PEP is initiated, management o adverse events. In addition,it should be recognized that ollowing these recommendations in response to a mass casualty event couldcreate a hepatitis vaccine demand that exceeds local resources.

Special Considerations regarding HIV PEP Recommendations

HIV PEP should be rarely indicated; i it is indicated, start as soon as possible ater exposure

I indicated, do not delay PEP or HIV test results

Collect specimens or baseline testing: HIV, CBC, LFTs, creatinine, pregnancy test

Test in accordance with applicable state/local laws

Consult experts: local inectious disease, hospital epidemiology, or occupational health consultant; local,

state, or ederal public health authorities PEPline 24-hours/day: 888-448-4911 (preerred) or http://www.ucs.edu/hivcntr/Hotlines/PEPline.html Or

HIV/AIDS Rx inormation service http://aidsino.nih.gov

Continue or 4 weeks

Discharge with written inormation, a 57 day supply o medication, and a ollow-up appointment

HIV specialist should reassess within 72 hours




27/36

P h

i t l C

BackgroundBecause a terrorist bombing can cause a large number o seriously injured persons, prehospital care systemsplay a critical role in managing the emergency medical response to this kind o mass casualty event. Thequality o prehospital emergency medical response will aect the quality o all subsequent clinical careactivities, and it may directly aect patient mortality and morbidity rates. The complexity and scope o a masscasualty event caused by an explosion requires that prehospital emergency medical care systems address theollowing issues:

Recognition o specifc hazards associated with a terrorist bombing, such as secondary devices,environmental hazards (e.g., toxins, fres) and structural instability.

Identifcation patients with signifcant blast related injuries. Eective communication with acute care medical resources and emergency management resources.

Expedient patient triage to match available resources with patient needs.

In the United States, the majority o emergency medical service (EMS) systems are organized and coordinatedat the local level. Nationwide, this results in an incredibly diverse prehospital emergency medical care systemthat is oten markedly dierent in operational and clinical approaches among jurisdictions. According to theInstitute o Medicine, EMS systems are challenged by the ollowing key issues: insufcient coordination,response time disparities, inconsistent quality o care, lack o disaster readiness, divided proessional identity,and limited evidence base or the proession.

Even though it aces these challenges, the prehospital medical care system will play a pivotal role in blastevent medical management by identifcation and transport o patients with potentially signifcant injuries toappropriate trauma centers, and direction o less injured patients to other medical acilities.

Challenges or EMS ProvidersNumerous challenges and potential concerns must be addressed by EMS providers.

Blast sites are dangerous; EMS personnel must be saety conscious and alert or hazards such as:

secondary device explosions; and

fre, environmental exposure, or structural collapse.

Exhaustive prehospital evaluations o survivors are impractical due to limited resources and potentialdangers at the bombing scene.

Patients with mild to moderate injuries may rapidly move on their own rom the explosion site to theclosest hospital(s).

Eective prehospital triage is an essential component o medical management or an explosive event.

Due to inrequent occurrence and the diversity o blast events, rigorous study o triage methodologiesis difcult.

A nationally standardized triage methodology does not currently exist.

BLAST INJURIESPrehospital Care




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Preh

ospitalCare

Challenges or EMS Providers(continued) Prehospital medical responders have adopted a variety o commercially available and locally created

methodologies, many o which possess similar processes and defnitions; however, subtle dierencesamong them may cause conusion during a chaotic situation.

Overtriage may deplete limited resources, thus degrading patient care and increasing mortality rates othose critically injured.

Improving Prehospital Care Ater Blast EventsIn the absence o a defned national prehospital triage methodology, agencies with responsibility or triage atmass casualty events should make every eort to standardize processes and defnitions at the local level. Aneective prehospital triage system includes:

common terminology and processes;

easily understood protocols or providers with varying amounts o medical education;

deployable tools and record keeping instruments or apparatus possibly used during an emergencyresponse; and

unctional exercises where prehospital medical providers demonstrate understanding o emergencyresponse processes and defnitions.

Eective management o the emergency medical response to a mass casualty bombing requires substantialpreparation by prehospital medical care systems. Integration into the local trauma system and understandingits emergency response methodology are critically important to ensuring that the most severely injuredbombing victims are transported to acilities that have the resources required to care or them. Prehospitalmedical system administrators should ocus on:

acilitating interagency collaboration by standardizing command structure, lines o communication, andtriage methodology.

ensuring that prehospital medical care providers have a basic understanding o blast pathophysiology andthe complex injury patterns produced by such an event.

training prehospital medical providers to recognize external signs o signifcant blast injury and designing triageguidelines that acilitates moving these patients to the highest level trauma center(s) in the local system.




29/36

R d i l

i l D i l D

i d R d i t i I j

BackgroundRadiological Dispersal Devices (RDDs) or dirty bombs consist o radioactive material combined with conventionalexplosives. Their orce is so powerul they can disperse such material over an area as large as multiple city blocks. Peoplein the immediate area may be killed or injured initially rom the eects o the blast and not rom radioactivity. RDDs areprimarily used to produce psychological rather than physical harm by inducing panic and terror in the target population.The clinical presentation o exposed casualties will mostly resemble conventional injuries. This is because the clinicaleects o all but the most severe radiation exposures are delayed.

A survey conducted with specialized radiological equipment is the only way to confrm the presence o radiation. Iradioactive material is used in a terrorist bombing, victims must be assessed or both exposure and contamination.People exposed to radiation can suer radiation illness i their dose is high enough, but they do not become radioactive.Contamination occurs externally when loose particles o radioactive material are deposited on suraces, skin, or

clothing. Internal contamination occurs when radioactive particles are inhaled, ingested, or lodged in an open wound.Contaminated patients should be decontaminated as soon as possible ater being treated or lie-threatening injuries. Theradioactivity levels o contaminated patients should not pose a health risk to care providers. Guidelines or protection andtreatment are provided below.

Triage and Sta Protection Establish an ad hoc triage area in a location based on the hospitals disaster plan and the anticipated number o

casualties. Stock a sufcient quantity o hospital-supplied gowns to replace contaminated clothing.

Establish both a contaminated area and a clean area and separate them by a buer zone.

Remove contaminated outer garments when leaving the contaminated area.

Using a radiation meter, survey the bodies o persons when they exit a contaminated area.

Follow standard guidelines or protection rom microbiological contamination.

Ensure surgical masks are adequate; N95 masks, i available, are recommended.

Survey hands and clothing with a radiation meter at requent intervals.

Decontaminating the Injured Survey the patient with a radiation meter using a consistent technique and trained personnel.

Note exceptionally large amounts o surace or imbedded radioactive material.

Handle easily-removable radioactive objects with orceps and store them in lead containers.

Use a standardized orm to record location and level o any contamination ound.

Remove patient clothing by careully cutting and rolling it away rom the ace toward the eet to contain thecontamination.

Double-bag clothing using radioactive hazardous waste guidelines and then label the bag.

Repeat the patient survey and record contamination levels.

Wash wounds with saline or warm water frst. Gently cleanse intact skin with soap and water, starting outside thecontaminated area and washing inward; do not irritate or abrade.

Flush eyes, nose, and ears, and rinse mouth i acial contamination occurred.

Survey and note radiation level again; repeat washing until survey indicates radiation level is no more than twice thebackground or the level remains unchanged.

BLAST INJURIESRadiological Dispersal Devices

and Radiation Injury




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Radiolo

gicalDispersalDe

vicesandRadiationInjury

Decontaminating the Injured(continued) Cover wounds with waterproo dressing.

For mass casualties, consider establishing separate shower areas or ambulatory and non-ambulatory patients.

Diagnosis and Treatment Perorm sequential CBCs with dierential to assess declines in lymphocyte levels.

Monitor or uid and electrolyte balance and or evidence o hemodynamic instability. Treat symptomatically and ocus on preventing inection; use antibiotics.

Consider cytokines, e.g., Neupogen and hematopoietic growth actors.

Perorm surgical interventions within 48 hours or delay them until ater hematopoietic recovery.

Radiation-related Illness/InjuryAcute Radiation Syndrome (ARS) is caused by high doses o radiation that are rapidly delivered to large portions o thebody. A dirty bomb will likely generate low levels o radiation exposure.

Symptoms can be immediate or delayed, mild or severe, based on radiation dose.

Nausea or vomiting may occur minutes to days ater exposure. The rapid onset o vomiting is a major actor indiagnosis and dose estimation o radiation.

Early onset o vomiting ollowed by symptoms o bone marrow suppression, gastrointestinal destruction, andcardiovascular/central nervous system eects are signs o acute illness.

Depending on the stage o illness, a patient may be asymptomatic.

Cutaneous Radiation Injury is acute radiation injury to the skin.

Transient itching, tingling, erythema, or edema may be seen within hours or days, and is usually ollowed by a latentperiod; lesions may not be seen or weeks to months post exposure.

The delay in occurrence dierentiates these lesions rom thermal burns.

Treat localized injuries symptomatically, ocusing on pain and inection control.

Internal Contamination should be considered i persistently high survey readings are noted ollowing

decontamination. It generally does not cause early symptoms. Nose or mouth contamination may indicateinhalation or ingestion.

Assessment may include analyzing urine, blood, and ecal samples or whole body counts.

Radiation experts may recommend early administration o radionuclide-specifc decorporation agents such asPrussian Blue, DTPA, or Bicarbonate.

Gastric lavage, antacids, and cathartics assist in clearing ingested contaminants.

Psychosocial Issues

In urban areas, hundreds to thousands may seek care. Many may seek radiological screening, many will needdecontamination, and many will simply seek reassurance.

Psychogenic illness symptoms, such as nausea or vomiting, may maniest.

Vomiting due to radiation exposure is usually recurrent rather than episodic.

Include mental health proessionals on the response team.



For more inormation about radiation emergencies, visit:www.bt.cdc.gov/radiation.


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R a d i o l o g i c a l D i a

g n o s i s

BackgroundExplosive events have the potential to inict numerous casualties with multiple injuries. The complexityo this scenario is exacerbated by the act that ew providers or medical acilities have experience withmass casualty events in which human and material resources can be rapidly overwhelmed. One signifcantdierence between explosion-related injury and other injury mechanisms are the number o patients andmultiplicity o injuries which require a higher allocation o resources. With this caveat, the appropriateutilization o radiology resources has the potential to impact in-hospital diagnosis and triage and is anessential element in the optimizing the management o the explosive injured patient.

Initial EvaluationPrimary Blast Injury is caused by the overpressure blast wave produced by high-order explosives, primarilyaecting air-flled organs and cavities such as the ear, lung, and abdomen. This blast wave is magnifed by thereection o suraces as seen in closed-space explosions (e.g., inside a building, bus, train).

Radiological diagnosis o primary blast injury ocuses on pulmonary and enteric barotrauma. Pulmonarybarotrauma is characterized by pulmonary opacifcation secondary to diuse pulmonary alveolar hemorrhageand pneumothorax. Patients with substantial pulmonary blast injury oten present with signifcant pulmonary symptoms which

may include dyspnea, tachypnea, and cyanosis. A chest radiograph is a confrmatory test.

In the absence o peritonitis or clinical signs, the role o radiological studies in assessing primary blastinjuries is to identiy enteric injury maniesting as intraperitoneal ree air. Computerized tomography(CT) has a much greater sensitivity or the detection o intraperitoneal ree air than does conventionalradiography.

Secondary Blast Injury is characterized by trauma due to impact rom bomb ragments, to include the casingo the bomb in addition to objects added to the device to increase lethality (e.g., screws, nails, nuts and bolts).It can also result rom debris external to the bomb that is secondarily propelled by the explosion. Secondaryblast injury primarily causes penetrating trauma, but may also cause blunt trauma. Patients can sustainpenetration o any region o the body, and typically have ragment penetrations in multiple body regions.

Radiological diagnosis o secondary blast injury helps to prioritize treatment by identiying lie-threateninginjury that may require timely intervention. For example, radiological imaging can be used as ollows: Portable biplanar x-ray can be used to defne basic penetration patterns.

Conventional x-ray can be used to identiy patients with ragment wounds suspicious or causing

intracavitary injury, who then will require more advance methods o imaging. (Conventional x-ray is notsensitive or body cavity penetration.)

The thoracoabdominal CT scan can be used to identiy unapparent injuries, including amonghemodynamically stable patients with blast ragment penetrations.

The CT scan can be used to identiy patients injured by ragments who do not need surgical therapy.

BLAST INJURIESRadiological Diagnosis




32/36

RadiologicalDia

gnosis

Initial Evaluation (continued)Tertiary blast injury results rom the victim being thrown by the orce o the blast wind. These injuriesprimarily involve blunt trauma, but may also be classifed as penetrating trauma (e.g., impalement onsharp object).

Radiological evaluation o tertiary blast injury primarily ocuses on identiying ractures, but also includes thedetection o other injuries. For example:

Plain flms are useul in evaluating the thorax or signs o pneumothorax, hemothorax, or pulmonarycontusion, as well as stigmata consistent with acute thoracic aortic injury.

Pelvic radiography is used to exclude or to determine the morphology o pelvis ractures.

Focused abdominal sonogram or trauma (FAST) can be used to rapidly diagnose the presence ointraperitoneal uid in patients with blunt-orce trauma injuries. In explosive events, this uid is presumedto be blood.

Similar to the diagnostic algorithm or the secondary blast injury, the CT scan is both sensitive and specifcor determining traumatic pathology.

Summary and Disposition

The severity and diversity o injuries caused by explosions provide treatment challenges or emergencymedical providers. Due to the potential or surge and nearby hospitals ollowing an explosion, eective use o radiology

resources is vitally important during patient triage and in identifcation o patients with the greatest needo lie-and-limb saving interventions.

I radiography resources permit, imaging should be used liberally in the acute diagnostic phase to increasethe accuracy o diagnosis and enhance treatment.

This act sheet is part o a series o materials developed by the Centers or Disease Control and Prevention (CDC)on blast injuries. For more inormation on blast injuries and to order ree copies



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T h l I j i

BackgroundThermal injuries rom explosions o conventional weapons are classifed as quaternary blast injuries. Therapidly expanding freball rom the explosion may cause ash burns over exposed body parts (e.g., hands,neck, and head). Confned space explosions can enhance thermal eects and increase the risk o inhalationinjury. Eectively managing thermal injuries associated with primary blast injury, particularly blast lung injury,may be challenging due to conicting uid requirements.

Clinical Presentation Most bomb-related burns cover


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ThermalInjuries

Initial Hospital Management(continued) At admission, consider evaluating the fber optic airway to determine i subsequent airway intervention or

aggressive pulmonary toilet is needed.

Among patients with primary blast injury to the lung, mechanical ventilation and positive pressure mayincrease the risk o alveolar rupture and air embolism. Patients with inhalational injury may be at a higherrisk o barotrauma.

Fluid Resuscitation

Fluid resuscitation is required or victims with burns that cover >15% o TBSA.

The goal is to replace the loss o intravascular volume and to maintain tissue perusion in the frst 48 hourspost-injury, when capillary leak and relative hypovolemia occur.

Inadequate uid resuscitation increases morbidity and mortality.

Fluid resuscitation or signifcant thermal injury that is initiated more than our hours post-injury isassociated with almost 100% mortality.

Give Lactated Ringers (LR):

4cc/kg/%TBSA in the frst 24 hours

Give hal in the frst eight hours starting rom the time o the burn insult itsel, and the remaining halduring the next 16 hours.

Eective uid resuscitation is demonstrated by adequate urine output.

Take care when treating burn victims who have also suered a blast lung injury. The risk o aggressivehydration to the blast injured lung must be balanced with the need to provide IV uids to manage the burn.

Pain Management

Give narcotics or pain.

Recognize when resources may be limited (e.g., a Rhode Island nightclub fre exhausted a three-monthnarcotic supply during the acute resuscitation phase at a Level I trauma and burn center).

Other Considerations

Administer tetanus toxoid i patient did not receive a booster in the last fve years, or i date o booster isunknown.

Full-thickness burns o thorax and extremities may cause the constriction o underlying structures andrequire an escharotomy.

Disposition Inhalation injury is an independent predictor o prolonged ICU care and mortality.

Burns covering >30% o TBSA are associated with increased death rates.

Death rom burns is dependent on: the percentage o TBSA aected, presence or absence o signifcant airway

and lung involvement, and the age o the victim.

Patients diagnosed with primary blast lung injury should be admitted to the hospital, regardless o the extent oany associated burn.




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BOMBINGS:INJURY PATTERNS AND CARE INTERACTIVEScenario-based Training 2.0

Free Blast Injury Products Available!

This course ocuses on the efects o explosive events and provides the latest clinical inormation regarding blast-related

injuries rom terrorism. It was developed to compliment all hazards disaster response training programs and also serve as an

independent training source or emergency responders and hospital staf.

The interactive scenario-based training includes:

Sixty minutes of instruction Practice scenarios and assessment situations with feedback used to provide context and realism

Visuals of several types including photos of actual blast events with patients, photos taken specically for the training,

charts, and diagrams

Final exam

The interactive scenario-based training, as well as curriculum guides and PowerPoint presentations for one and three

hour courses (CE and CECBEMS accredited), and the quick reference pocket guide are available free of charge at:

http://emergency.cdc.gov/BlastInjuries

Available Online Soon

Bombings Injury Patterns and Care: System Preparedness Course 1.0This course is designed to assist system administrators including public safety, healthcare, public health, emergency

management) and leadership in their preparation and response to terrorist bombings. The principles outlined in this course,

while focused on bombings, can be translated to any crisis or disaster. Specically, this course:

Discusses challenges to eective preparedness

Proposes solutions to systems preparedness

Reviews current resources available for preparedness and response

Developed under the Terrorism Injuries: Information, Dissemination, & Exchange (TIIDE) partnership agreement in with

American Trauma Society, this course focuses on the core competencies in eective leadership and crisis management,

challenge recognition, systems approach to preparedness, and best practices for saving lives in the event of terrorist bombings.


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For more inormation on blast injuriesand to order ree copies o the blast act sheets,

visit http://www.emergency.cdc.gov/blastinjuries

Helping all people live to their full potential

Documents

Copy of Blast Facts CDC.pdf