bomb and blast injuries - rochester, ny · 2017-06-06 · blast lung • wheezing can be from: o...
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Bomb and Blast Injuries
Heidi P. Cordi, MD, MPH, MS, EMTP, FACEP, FAADM
Associate Professor, Emergency Medicine
Albany Medical Center
EMS WEEK 2017
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• “The blast wave is a shot without a bullet, a
slash without a sword. It is present
everywhere within its range. Blast would be
as dreaded a weapon as chemical warfare,
if its range, when explosives are used were
not limited to small areas. However it would
be premature to believe that this situation
will always remain the same.”
• Theodor Benzinger 1950
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Global Disease• Bomb and blast injuries are becoming more
common in the civilian population
• Explosives are commonly used in terrorist
events
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Terrorism• Aimed at innocent civilians
• Premeditated
• Political
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Blast Injuries• Result from:
o Fireworks
o Household explosions
o Industrial accident
oMotor vehicular accidents
http://www.industrytap.com/5-chemical-plant-explosions-and-what-caused-them/16655
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Terrorism Blast Injuries• Result from:
o Suicide bombers
oMotor vehicle incidents
oAirplanes…
o Letter bombs
o Suitcase bombs
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Industrial Explosions
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Blast Injuries• Complex type of physical trauma resulting
from direct or indirect exposure to an
explosion.
• Blast injuries occur with the detonation of:
o high-order explosives
o deflagration of low order explosives
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Explosions• Single to multiple victims – mass casualties
• Explosions cause unique type of injuries
o Lungs
oCentral Nervous System
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Injury Patterns• Product of:
o Composition and amount of the materials
involved
o Surrounding environment
o Delivery method (if a bomb)
o Distance between the victim and the blast
o Any intervening protective barriers or
environmental hazards
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Explosive Devices
https://www.wibwnewsnow.com/possible-explosive-devices-found-junction-city-home/
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High-Order Explosive Devices
• Almost instantaneous high pressure rapidly
expanding gases which compress the surrounding
air resulting into supersonic over-pressurization
shock or blast wave followed by negative pressure
(suction)
• Detonation requires a chemical process that rapidly
decomposes nitrogenous compound producing
heat and gas as by-products
• Military
• Mass produced
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High-Order Explosives• TNT
• C-4
• Semtex
• Nitroglycerin
• Dynamite
• Ammonium Nitrate Fuel Oil (ANFO)
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Low-Order Explosives
• Pipe bombs
• Gunpowder
• Most pure petroleum based bombso Molotov cocktails
o Aircraft improvised (guided missiles
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Blast Devices• Characterized based on their source
• Explosive and Incendiary (fire) bombs
• Manufacturedo Standard military issued mass produced weapons
• Improvisedo Weapons produced in small quantities
o Use of a device outside its intended purpose
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Improvised Explosive Devices
• Improvised = homemade
• Made from explosives, commercial blasting
supplies, or fertilizer and household ingredients
• Designed to cause injury, mayhem and death
• Often packed with metal objects such as nails or
ball bearings
• Could contain toxic chemicals or radiological
materials (dirty bomb)
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Mechanism
• Implosion
• Shock wave travels through an organ containing
pockets of air/gas
• Pockets of air/gas are compressed by the
surrounding fluid
• The pockets of gas expand rapidly
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Mechanism
• Spalling
• Occurs at the interface between media of different
densities when the shock wave passes from a high
density to a lower density substance
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Mechanisms
• Acceleration-deceleration
• Blast wave accelerates tissues of different densities
at different rates
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Scene Hazards
• Secondary devices
• Shrapnel
• Building collapse
• Air-borne contaminants
• Contaminated patients
• Contaminated scene/environment
• Perpetrators
• Terrorist patients
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Scene Hazards• Victims with no soft tissue injuries
• Vehicles coming out or leaving the scene
• People acting oddly
• Packages or containers at scene (out of
place)
• Vehicles not damaged or out of place
• Structural damage
• Weather
• Possible places for secondary device
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Blast Injuries• Multi-system injuries
• Simultaneous life-threatening injuries
• Hidden patterns of injury
• Single or multiple victims
• Produce classic patterns from blunt and
penetrating trauma
• Unique injury patterns
• Occult injury patterns
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Blast Physics
http://lotuseat3r.blogspot.com/2015_05_01_archive.html
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Blast Injury Severity• Nature of the device
o Agent, amount
• Method of deliveryo Incendiary, explosive
• The environmento Open vs closed
• Distance from the device
• Intervening protective barrier
• Environmental hazard
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Blast Physics
Bowen et al
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Slow Motion Blast Wave
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Open Air Explosion• Air is a poor conductor of blast-wave energy
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Closed Space Explosion• Associated with greater morbidity and mortality
• Reflection of blast waves from walls and other
surface creates more complex waves, and lasts
longer
http://nypost.com/2016/03/24/second-attacker-believed-to-be-involved-in-brussels-subway-bombing-reports/
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Why Bomb Blasts Are More Dangerous…
https://www.youtube.com/watch?v=tCCL3wvcw7A
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Primary Blast Injury• Direct effect of the changes in the
atmospheric pressure caused by the blast
wave
• Occurs mostly in gas containing organs such
as:
o Lungs
oMiddle ear
o bowel
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Blast Lung
Brewer, LA et al
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Blast Lung
https://commons.wikimedia.org/wiki/File:Blast_lung-bilateral_pulmonary_hemorrhage.JPG
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Blast Lung
• Most common fatal primary blast injury
• Signs can be as late as 48 hours after initial injury
• Includes:
o Pulmonary contusion
o ARDS
o Systemic air embolism
• Brain
• Spinal cord
o Free radical associated injuries
• Thrombosis
• DIC
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Blast Lung
• Wheezing can be from:
o Pulmonary contusion
o Inhalation of gases
o Inhalation of dusts
o Pulmonary edema
o Adult Respiratory Distress Syndrome
• Apnea
• Cough
• Hemoptysis
• May need prophylactic chest tube if blast lung is suspected and need to fly patient
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Blast Lung
• Clinical triad
o Apnea
o Bradycardia
o Hypotension
• Suspect if:
o Dyspnea
o Cough
o Hemoptysis
o Chest pain
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Blast Thorax
• Decreased heart rate
• Hypotension
• Normal reflex to increase systemic vascular
resistance does not occur
• This is not observed anywhere else in medicine – PBI
that can cause death in the absence of any
demonstrable physical injury
• Pericardial tamponade
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Blast Ear
• Acoustic Barotrauma
• Tympanic rupture (most common)
o As low as 5 psi can rupture the TM
o Overpressure of 15 psi will cause TM ruputr
• Hemotympanum without perforation
• Ossicle fracture or dislocation
• May have other associated injuries
• May not be present if wearing some type of hearing
protection
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Blast Ear
• Suspect if:
o Hearing loss
o Tinnitus
oOtalgia
oVertigo
o Bleeding from external canal
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Blast Ear
Gadre, AK, et al
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Abdominal Injuries• Gas-containing portions are most vulnerable
• Bowel perforation
• Hemorrhage
• Shear injuries
• Look for:
o Abdominal pain, tenderness, rebound guarding,
absent bowel sounds
o Nausea, vomiting
o Rectal/testicular pain
o Tenesmus
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Traumatic Brain Injury
• Concussion
• Mild traumatic brain injury
• Consider:
• Proximity to explosion
• Headache
• Fatigue
• TBI can mimic Post-traumatic stress disorder
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Traumatic Brain Injury
http://www.yalescientific.org/2012/03/explosive-blast-induced-brain-injury-studies/
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Traumatic Brain Injury
• Physical Signs
o Headaches
o Dizziness
o Nausea, vomiting
o Blurred vision
o Insomnia
o Fatigue
o Unsteady gait
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Traumatic Brain Injury
• Behavioral Signs
• Irritability
• Depression
• Anxiety
• Problems with emotional control
• Social issues
• Memory issues
• Concentration issues
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Secondary Blast Injury
• Caused by flying objects that strike people:
• Shrapnel
• Debris from the blast
• Majority of casualties in many explosions
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Oklahoma Bombing 1995• Claimed 168 lives
• 19 children under the
age of 6
• Injured > 680 people
• Blast destroyed /
damaged 324
buildings within a 16
block radius
• Burned 86 cars
• Shattered glass in 258
nearby buildings
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Oklahoma Bombing 1995• 20 infants and children were seated by the window of
the second floor day care center
• 16 from the day care died
• Injury patterns:
• Skull fracture
• Cerebral evisceration
• Abdominal or thoracic injuries
• Amputations
• Arm fractures
• Leg fracture
• Burns
• Extensive cutaneous contusions, evulsions, lacerations
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Tertiary Blast Injury• Injuries from:
• High-energy explosions
• Or person was very close to the explosion source
• Collapsing buildingso Crush injuries
o Projectiles
• Body being displaced by the explosion
• Internal body organs being displaced by the
expanding gases
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Additional CNS Injuries• Concussion
• Closed or open brain injury
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Additional GI Injuries• Bowel perforation
• Ruptured liver
• Ruptured spleen
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Additional Renal Injuries• Renal contusion, laceration
• Acute renal failure:
• Rhabdomyolysis
o Hypotension
o Hypovolemia
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Additional Extremity Injuries
• Traumatic amputation
• Fractures
• Burns
• Lacerations
• Air embolism
• Acute arterial occlusion
• Compartment syndrome
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Traumatic Amputation
http://www.jems.com/articles/2016/10/prehospital-recognition-of-wounding-patterns-in-blast-injuries.html
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Additional: Ocular Injury• 10% of blast survivors have significant eye injuries
• Perforated globe
• Foreign body
• Air embolism
• Subconjunctival hemorrhage
• Lid lacerations
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Quaternary Blast Injury
• All other injuries caused by explosions
• Burnso Chemical
o Thermal
o Radiation
• Inhalation:
o Dust
o Smoke
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Thermal Injuries• Blast wind: forced superheated air flow generated
by the explosion
• Flash burns
• Varying degrees and depths of burns
• Necessitates adequate fluid resuscitation and
wound treatment
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Air China Explosion
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Inhaled Toxins
• Carbon Monoxide
• Cyanide
• Methemoglobinemia
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White Phosphorus Burns• Moistened face mask and good ventilation to protect
from pulmonary effects of phosphorous pentoxide gas
• Remove identifiable particleso Place in water to prevent further combustion
• Initial management includes copious lavage of the
area
• Cover area with saline-soaked gauze
• May lead to hypokalemia and hyperphosphatemia:o EKG changes
o Cardiac arrhythmia
o death
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https://simple.wikipedia.org/wiki/Blast_injury#cite_note-3
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Emergency Medical Services
• Scene safety
• Personnel Protect Equipment
• Determine nature and size of explosion
• Time of occurrence
• Proximity of victims to explosion
• Victim count
• Victim displacement
• Presence of
o Fire
o Smoke
o Dust
o Chemical contamination
o Radioactive contamination
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Emergency Medical Services
• Entrapment
• Activating disaster response
• Need for HazMat
• Screening for Radioactive contamination
• Early use of tourniquets for significant extremity
trauma and exsanguination for bleeding control
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THANK YOU
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References• Bowen TE, Bellamy RF eds 1988. Blast injuries. Idealized graph of a blast
pressure wave over time. Emergency War Surgery. Washington, DC: United States Government Printing Office, 1988.
• Gadre, Arun K. "Blast injury to the tympanic membrane." Ear, Nose and Throat Journal, Nov. 2005, p. 686. Academic OneFile,
• Horrocks, CL Blast Injuries: Biophysics, Pathophysiology and Management Principles J R Army Med Corps 2001; 147: 28 -40
• https://www.cdc.gov/masstrauma/preparedness/primer.pdf• http://emedicine.medscape.com/article/822587-overview• http://history.amedd.army.mil/booksdocs/wwii/thoracicsurgeryvolII/chap
ter1.htmo Brewer, LA, et all
• Ryan's Ballistic Trauma: A Practical Guide. Eds. Brooks A.J., Clasper J., Midwinter M., Hodgetts T. J., Mahoney P. F. Springer; 3rd Ed.(2011) p.52 ISBN 1848821239
• Quintana, DA et al 1997. The spectrum of pediatric injuries after a bomb blast. J Pediatr Surg. 1997; 32(2):307-10; discussion 310-1 (ISSN: 0022-3468)