Transcript Explosive events, burn patient management

Explosive events, burn patient
management
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Explosion in Cyprus Naval Base Kills 12
and injures >60
•Mass trauma related to explosions can produce unique patterns of injury
•They have the potential to inflict multi-organ, life-threatening injuries on many
victims simultaneously
•Blast-related injuries can present unique triage, diagnostic, and management
challenges
•The medical consequences from the detonation of a conventional explosive
include death and acute injury, as well as destruction of critical infrastructure
such as buildings, roads, and utilities
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The impact of an explosive event depends largely on :
• the composition and amount of explosive materials involved,
• the surrounding environment,
• delivery method (if a bomb),
• distance between the victim and the blastv and
•any intervening protective barriers or environmental
hazards.
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•Α predominant post explosion injuries among survivors involve standard
penetrating and blunt trauma. Blast lung is the most common fatal injury among
initial survivors.
•Explosions in confined spaces (mines, buildings, or large vehicles) and/or
structural collapse are associated with greater morbidity and mortality.
•Half of all initial casualties will seek medical care over a one-hour period. This
can be useful to predict demand for care and resource needs.
•Expect an “upside-down” triage - the most severely injured arrive after the less
injured, who bypass EMS triage and go directly to the closest hospitals.
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Mechanisms of Blast Injury
Categories
Characteristics
Body Part
Affected
Types of Injuries
Primary
Unique to HE, results from
the impact of the overpressurization wave with
body surfaces.
Gas filled
structures are
most susceptible
- lungs, GI tract,
and middle ear.
Blast lung
TM rupture and middle ear damage
Abdominal hemorrhage and perforation –
Globe (eye) rupture- Concussion (TBI
without physical signs of head injury)
Secondary
Results from flying debris
and bomb fragments.
Any body part
may be affected.
Penetrating ballistic or blunt injuries
Eye penetration (can be occult)
Tertiary
Results from individuals
being thrown by the blast
wind.
Any body part
may be affected.
Fracture and traumatic amputation
Closed and open brain injury
Quaternary
All explosion-related
injuries, illnesses, or
diseases not due to
primary, secondary, or
tertiary mechanisms.
Includes exacerbation or
complications of existing
conditions.
Any body part
may be affected.
Burns (flash, partial, and full thickness)
Crush injuries
Closed and open brain injury
Asthma, COPD, or other breathing
problems from dust, smoke, or toxic
fumes
Angina
Hyperglycemia, hypertension
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Overview of Explosive-Related Injuries
System
Injury or Condition
Auditory
TM rupture, ossicular disruption, cochlear damage, foreign body
Eye, Orbit,
Face
Perforated globe, foreign body, air embolism, fractures
Respiratory
Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage,
A-V fistulas (source of air embolism), airway epithelial damage, aspiration
pneumonitis, sepsis
Digestive
Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis, mesenteric
ischemia from air embolism
Circulatory
Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal
hypotension, peripheral vascular injury, air embolism-induced injury
CNS Injury
Concussion, closed and open brain injury, stroke, spinal cord injury, air embolisminduced injury
Renal Injury Renal contusion, laceration, acute renal failure due to rhabdomyolysis,
hypotension, and hypovolemia
Extremity
Injury
Traumatic amputation, fractures, crush injuries, compartment syndrome, burns,
cuts, lacerations, acute arterial occlusion, air embolism-induced injury
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Emergency Management Options :
• Follow your hospital’s and regional disaster system’s plan.
• Expect an “upside-down” triage - the most severely injured arrive after
the less injured, who by-pass EMS triage and go directly to the closest
hospitals.
• Double the first hour’s casualties for a rough prediction of total “first
wave” of casualties.
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Emergency Management Options :
• Obtain and record details about the nature of the explosion, potential
toxic exposures and environmental hazards, and casualty location from
police, fire, EMS, ICS Commander, regional EMA, health department,
and reliable news sources.
• If structural collapse occurs, expect increased severity and delayed
arrival of casualties.
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Medical Management Options
Blast injuries should always be considered for any victim exposed to an
explosive force. Primary blast lung and blast abdomen are associated with
a high mortality rate. “Blast Lung” is the most common fatal injury among
initial survivors.
Clinical signs of blast-related abdominal injuries can be initially silent until
signs of acute abdomen or sepsis are advanced.
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Medical Management Options
Standard penetrating and blunt trauma to any body surface is the most
common injury seen among survivors.
Blast lung presents soon after exposure. It can be confirmed by finding
a “butterfly” pattern on chest X-ray. Prophylactic chest tubes
(thoracostomy) are recommended prior to general anesthesia and/or air
transport.
Auditory system injuries and concussions are easily overlooked. The
symptoms of mild TBI and post traumatic stress disorder can be
identical.
Isolated TM rupture is not a marker of morbidity; however, traumatic
amputation of any limb is a marker for multi-system injuries.
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Medical Management Options
Air embolism is common, and can present as stroke, MI, acute abdomen,
blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen
therapy may be effective in some cases.
Compartment syndrome, rhabdomyolysis, and acute renal failure are
associated with structural collapse, prolonged extrication, severe burns, and
some poisonings.
Consider the possibility of exposure to inhaled toxins and poisonings (e.g.,
CO, CN, MetHgb) in both industrial and criminal explosions.
Wounds can be grossly contaminated. Consider delayed primary closure and
assess tetanus status. Ensure close follow- up of wounds, head injuries, eye,
ear, and stress- related complaints.
Communications and instructions may need to be written because of tinnitus
and sudden temporary or permanent deafness.
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Burn victim in precarious situations
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Selected recent burn mass casualty disasters.
Date
References
Location
Cause
1970
1978
(6)
(7)
Osaka,Japan
LosAlfaques,Spain
Natural gas pipeline
Liquid propyleneg as
1980
1981
1981
1982
1984
1985
1985
1988
(8)
(70,71)
(72)
(73)
(9)
(10)
(74)
(11)
LasVegas,Nevada,USA
Dublin,Ireland
Bangalore,India
Cardowan,UK
SanJuanico,Mexico
BradfordCity,UK
Manchester,UK
PiperAlphaplatform,
NorthSea,UK
Ramstein,Germany
Bashkiria,Russia
Hotel fire(‘MGMGrand’)
Nightclub fire(‘Stardust’)
Circus fire
Coalmine explosion
Liquid propane gas
Football stadium fire
Aeroplane fire
Oilrigfire
1988
1989
(41)
(13)
1990
(75)
1994
(14,76)
1998
(16)
Aeroplane crash
Naturalgaspipeline
Fire on ferryboat
Va¨dero¨arna,Sweden (Scandinavian
Star)
PopeAirForceBase,
Aeroplane crash
NorthCarolina,USA
Gothenburg,Sweden
Discotheque fire
2001
(17)
Volendam,NL
Cafe´fire
2001
2002
2003
(1,21,77)
(2,23,24)
NewYorkCity,USA
Bali,Indonesia
West Warwick, USA
Aeroplane attacks
Nightclubbombings
Nightclubfire(‘Station’)
No of injured
survivors
428
140
No of onscene dead
79
102
726
44
169
40
7230
256
79
25
84
48
92
0
300
52
52
167
400
800
45
400
30
158
119
11
213
60
245
4
790
155(78)
215
2713
202{(79)
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The Los Alfaques Disaster was a road
accident and tanker explosion which
occurred on 11 July 1978 in Alcanar,
near Tarragona, in Spain.
the importance of controlling both the routes and types of
conveyances used for evacuation
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principles are similar to those applicable to other mass casualty events, modified
as needed for the unique features of thermal injury and any unique features of a
given disaster
 Order in chaos. A Burn disaster is inherently chaotic
 Establish command and control of casualty care activities ASAP, integrating
the burn centres into the regional disaster response system EARLY
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Arturson G. Analysis of severe fire disasters. In: Masselis M, Gunn SWA,
editors. The Management of Mass Burn Casualties and Fire Disasters:
Proceedings of the First International Conference on Burns and Fire Disasters.
Dordrecht, The Netherlands: Kluwer Academic, 1992:24–33. Only 1 out 14
burn disasters had disaster plans in place
 Rapid triage for the severity of the injury, by considering total extent of
burn, age of patient and the presence or absence of inhalation injury or
associated severe mechanical trauma . Burn injury. In: Bowen TE, Bellamy RF,
editors. Emergency War Surgery: Second United States Revision of the
Emergency War Surgery NATO Handbook. Washington, DC: US Government
Printing Office, 1988:35–56
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What constitutes a non-survivable burn?
LA50, half of young adults with burns of 80% of the total
body surface area can be expected to survive.
The presence of inhalation injury, or of severe
mechanical trauma, should add 10% to the burn size for
this calculation
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Patients with burns of 20% or less (10% or less at the extremes of age)
can be Triaged as , T2 or T3
Triage on site at 3 Levels by an experienced burn surgeon or a plastic surgeon
Organized transport by a centralized system
 NOT the usual ICU model of one nurse / patient, BUT formation
of teams focusing on specific functions, airway management, fluid
resuscitation, pain management and wound and extremity care Phillips WJ,
Reynolds PC, Lenczyk M, Walton S, Ciresi S. Anesthesia during a masscasualty disaster: the Army’s experience at Fort Bragg, North Carolina,
March 23, 1994. Mil Med. 1997;162:371–3.
It is disputed
Experienced personnel in more managerial roles and innexperienced in
providing the proper care under supervision
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Magnitude of Injury
The rule of “nines”
 The depth of burn
 +/- Inhalation injury, circumferencial
burns, chemical or electrical burns,
children or W< 30 kgs
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Magnitude of Injury
The rule of “nines”
 The depth of burn
 +/- Inhalation injury,
circumferencial burns,
chemical or electrical burns,
children or W< 30 kgs
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Superficial or 1st degree
Deep partial thickness or 2nd degree
Full thickness or 3rd degree
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Fluid Resuscitation
• Large bore IV (s)
• Non - burn site if possible
• Best tool , Urine Output . . . .
• 0 . 5 cc / kg / hr adult
• 1 . 0 cc / kg / hr child [ < 30 kg ]
• Too much fluids can be just as bad as too little ! ! !
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Parkland Formula
•% BSA x Kg x 4 cc = 24 hour total
need
• 1 / 2 over the first eight hours
• 1 / 2 over the next sixteen hours
• Lactate Ringers is the fluid of choice !
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Modified Brooke Formula
•% BSA x Kg x 2 cc = 24 hour total
Need
• 1 / 2 over the first eight hours
• 1 / 2 over the next sixteen hours
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Escharotomy and / or Fasciotomy
Primary Escharectomy
Secondary Escharectomy
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Burn Center Transport Guidelines
• Partial thickness over 15 %
• Full thickness over 5 %
• Involvement of hands , perineum , face , feet
• Inhalation
• All high voltage
• All chemical
• Patients with significant pre – existing disease
Standards lowered if enormous number of severe burn victims
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International Co-operation
Burn Teams
Classification of Burn Care Facilities according to ISBI
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Level A, for 24–48 hours, and consists of triage,
initiation of resuscitation, preparation of
patients for transfer and care of patients with
minor injuries
•
Level B, resuscitation, wound care including
grafting, and initial rehabilitation
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Level C, existing tertiary burn centres which provide
definitive care including invasive monitoring,
management of inhalation injury, early wound
excision, complete rehabilitation, infection control
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and metabolic support
Rehabilitation and long-term follow-up
Incorporation of
occupational, physical and
psychological rehabilitation
of the survivors
Debriefing
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Thank You
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