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10/2/2015
Clinical Manifestation of Blast InjuriesADVANCED EXPLOSIONS & BLAST INJURIES
Outline
• Types of injuries seen• Injury characterization• Specific Injuries
- Primary- Secondary- Tertiary- Quaternary- Quinary
Madrid Bombing - Injuries
• Ruplure of the ty nipanic membranes occurred in99 of 243 victims
• Chest injuries in 97/243 victims• Shrapnel wounds in 89/243• Fracture in 44• Burns in 45• Eye injuries in 41• Abdominal injuries in 12• Traumatic amputations in 5
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10/2/2015
Boston Marathon Bombing-April 15, 2013
• 3 deaths prior toreaching the hospital
• 264 injuries• More than 20 with
critical injuries• Amputations, soft
tissue injuries• TM rupture
■‘t 1M,mMn;1:
Trauma Activations at Mass General Hospital
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Tertiary BlastInjury Jlnjuiescbc to tTiportWtl* arvothcr
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Secondary Blast Injury
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10/2/2015
Primary Blast Injuries
♦ Affect air-filled organs or air-fluidinterfaces
• Rupture of tympanic membranes,
pulmonary injury, air embolization and
rupture of hollow viscera are the most
common patterns
Tympanic Membrane Rupture
• Occurs at the lowest pressure (5 psi)• May be bilateral• May be the earliest sign to look for
- Deafness, tinnitus and vertigo• If more severe, may cause dislocation of the
oval, round window or the ossicles- Permanent hearing loss
• Other organs need higher pressures (56-76psi) so if the TM is intact, they are unlikely
ncopyright Michael Hawke MD_
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10/2/2015
Normal and Perforated RightTympanic Membranes
4
The drawing of a traumatic perforation shows an irregularmargin or rim with blood or a blood clot, and the draw ing of apermanent central perforation shows a tvmpanocele
Pulmonary Injuries
• Second most common primary blast injury• Hemorrhage
- Pulmonary contusion (appearing as a bihilar"butterfly" pattern on chest radiographs)
- Pneumothorax- Hemothorax- Pneumomediastinum- Subcutaneous emphysema
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10/2/2015
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Pulmonary Injuries
• Onset of symptoms is commonly w ithin minutes
- Controversial
Body Armor
• Protects fromsecondary blastinjuries
• Does not protectfrom primary blastinjury
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10/2/2015
Kevlar Helmet
D |fTM Perforation - Pulmonary Injury• Among 17 critically ill victims with
pulmonary injuries from the blast:- 13 had ruptured tympanic membranes and 4 did
not
• Rupture of tympanic membranes occurredin 18 of 27 critically injured victims- 17 of these were bilateral
Data from Madrid
Screening
• 647 survivors of explosions on buses usedimmediate radiography of the chest toscreen for pulmonary injuries from theblasts
• Primary injuries, in some form, were foundin 193 persons:- 142 had isolated perforation of the eardrum
Data from Israel
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10/2/2015
Screening
• 51 had other forms of primary blast injuries:
- 1 8 with isolated pulmonary injuries
- 31 with combined otic and pulmonary injuries
-Two with intestinal injuries
Visceral Injury
■ Visceral injury is third most commonprimary blast injury
• Rupture of the colon and, less frequently,the small intestine may occur as animmediate result of a blast
• Mesenteric ischemia or infarct can causedelayed rupture of the large or the smallintestine; these injuries are difficult todetect initially_
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10/2/2015
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Visceral Injuries
• The ileocecal area isthe most vulnerable
Accumulates gas
• Observed findingsI lemorrhages
- Edema- Perforations
Lacerations
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Other Injuries
• Serous retinitis
• Concussion
• Air embolism may be seenand can present as stroke.MI. acute abdomen.blindness, deafness, spinalcord injury, orclaudication
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10/2/2015
Ruptured Globes
'1 lb•%.
Secondary Injuries• Penetrating injuries
from:-Primary fragments
(fragments that arepart of the weapon)
-Secondary fragments(those that resultfrom the explosion)
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11
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10/2/2015
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10/2/2015
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10/2/2015
Tertiary Injuries• Caused by trauma from
falling objects or frombodies being thrown againstother objects
Blunt and penetrating injuries
- Crush syndrome andsecondary rhabdonivolvsis
- Open or closed head injuries
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Crush Syndrome
• Rhabdomyolysis:
I♦ Myoglobinuric renal
failureAu Electrocardiographic Sine Wave
in Hyperkalemia- ■:•y -vy-."S 4.y-
1
VWÿVÿWv'V\5-'• Hyperkalemia
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Pelvic Fractures
Hit
■ J
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10/2/2015
Crush Syndrome-Earthquakes
Y»bU 1. StatistKi Related to Ma|srCirth<|uab(t In th« Pait 18 Y«»rt.’
Crush Syndrom*
WfM'l n irr.bt' cfcrj\b ytcbm*
600
DiatydtLocation and Year 0*»lh
Sp wit. A,*rt*nia. WBl1’"17Northern (ran. 199C**Kobe, japan )995,,x'
Mamiara rcgiOr'.T-rt(N 199$>]
ChnChi. Ta.wan, 1999u
G.|a'.t •ndta, 2001i!Bouroe'CW. A!ge> t 2002**Bam, |rarL 200)”
fatf-rur. PaUsunTo!a'
28,000
>40.0005 000
225-285156
»2 122>17,000 6)9
52 2?2,405
20.021 25 ))
20? IS?2.26626,002
>80.000>217.000
9*1241)8
-1200.1900
Rhabdomyolysis
♦ Secondary complication of crush syndrome
* Myoglobinurea and CK. elevation
Quaternary Injuries• Bums (chemical or thermal)
• Toxic inhalation of carbon monoxide orhydrogen cyanide gas
* Exposure to radiation: ARS and InternalContamination
• Inhalation of dust containing coal orasbestos
• Exacerbation of chronic illnesses
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10/2/2015
Exacerbation of Chronic Illnesses
• Asthma and COPD• Diabetes Mellitus• Hypertension♦ Coronary artery disease• Peptic ulcer disease• Alcohol and substance abuse♦ Mental health
Quinary Blast Injuries
■ SIRS manifestations- Fever-Tachycardia- Hypotension
• No infectious source recognized• BAL reveals eosinophil ia• Management supportive +/- steroids
Any Questions or Comments?
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