Outline. Madrid Bombing - Injuries 10/2/2015. Clinical Manifestation of Blast Injuries

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1 Clinical Manifestation of Blast Injuries ADVANCED 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 in 99 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 1

2 Boston Marathon Bombing-April 15, deaths prior to reaching the hospital 264 injuries More than 20 with critical injuries Amputations, soft tissue injuries TM rupture ;1: n t 1 M, m M Trauma Activations at Mass General Hospital *«u- *»*ÿ> * u> USnlmi t SO Ns*c.. a<n4l li. ># * ' b < j.t» nu> SO «MVtH4 nrjlt t St WlI' Of-** x»irti *SO *W**»m> rnrjn* 10.ai a>! nt»ct.j CM j» (O IUUL **», so II. r Li) pn r*r.rds..i iql <3:1 SE." iliiii; if: s S# MW M»Q»Y A0S0O14U0 lift «MUS.n4«ntWilk'fh»l»«JJ * tuut..<««rt«lmk«pictlln»y)**«;pnof Mtrr> i*< xv nik Mm> «rvi «-*.» -<31-01 Tertiary Blast Injury Jlnjuies cbc to ttiport Wtl* arvothcr obinctl Hi L / '/ÿ// y'v. A <r Secondary Blast Injury I'ftunes die ti nuss.les beny propelled by oleÿt furÿej Primary Blast Injury Onjuies due ro the 2

3 Primary Blast Injuries Affect air-filled organs or air-fluid interfaces 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 (56-76 psi) so if the TM is intact, they are unlikely ncopyright Michael Hawke MD_ 3

4 Normal and Perforated Right Tympanic Membranes 4 The drawing of a traumatic perforation shows an irregular margin or rim with blood or a blood clot, and the draw ing of a permanent 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 A i7*j /, 4

5 w 1 'W, -i, *1 ' mi,,tt> BHlKopvnghi 2<>1-2uU H Pulmonary Injuries Onset of symptoms is commonly w ithin minutes - Controversial Body Armor Protects from secondary blast injuries Does not protect from primary blast injury -JCK ass * 552 ; 3«f'SSw -sx~ 5

6 Kevlar Helmet D f TM 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 occurred in 18 of 27 critically injured victims - 17 of these were bilateral Data from Madrid Screening 647 survivors of explosions on buses used immediate radiography of the chest to screen for pulmonary injuries from the blasts Primary injuries, in some form, were found in 193 persons: had isolated perforation of the eardrum Data from Israel 6

7 Screening 51 had other forms of primary blast injuries: - 18 with isolated pulmonary injuries - 31 with combined otic and pulmonary injuries - Two with intestinal injuries Visceral Injury Visceral injury is third most common primary blast injury Rupture of the colon and, less frequently, the small intestine may occur as an immediate result of a blast Mesenteric ischemia or infarct can cause delayed rupture of the large or the small intestine; these injuries are difficult to detect initially_ f 7

8 ' y, : vt V' - t * t.1 C / : V Visceral Injuries \ f V- I * i i The ileocecal area is the most vulnerable Accumulates gas Observed findings I lemorrhages - Edema - Perforations Lacerations Other Injuries Serous retinitis Concussion Air embolism may be seen and can present as stroke. MI. acute abdomen. blindness, deafness, spinal cord injury, or claudication 8

9 . Ruptured Globes '1 % lb Secondary Injuries Penetrating injuries from: - Primary fragments (fragments that are part of the weapon) - Secondary fragments (those that result from the explosion) j 1 1 9

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12 Tertiary Injuries Caused by trauma from falling objects or from bodies being thrown against other objects Blunt and penetrating injuries - Crush syndrome and secondary rhabdonivolvsis 1.U.jt - Open or closed head injuries Crush Syndrome Rhabdomyolysis: Myoglobinuric renal failure Hyperkalemia - : I Au Electrocardiographic Sine Wave in Hyperkalemia y -vy-."s 4.y- 1 VWÿVÿWv'V\5-'..or.v M IMiUhl ViUj-umioiu Pelvic Fractures H J it 12

13 Crush Syndrome-Earthquakes Y»bU1. StatistKi Related to Ma srcirth< uab(t Inth«Pait 18Yrt. Location and Year 0*»lh Crush Syndrom* Diatydt Sp wit.a,*rt*nia. WBl1 "17 Northern (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. PaUsun To!a' 28,000 > WfM'l n irr.bt' cfcrj\b ytcbm* 600 >17,000 6)9 2, » ? )) ,002 > > ? IS? 124 1) * Rhabdomyolysis Secondary complication of crush syndrome * Myoglobinurea and CK. elevation Quaternary Injuries Bums (chemical or thermal) Toxic inhalation of carbon monoxide or hydrogen cyanide gas * Exposure to radiation: ARS and Internal Contamination Inhalation of dust containing coal or asbestos Exacerbation of chronic illnesses 13

14 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 eosinophilia Management supportive +/- steroids Any Questions or Comments? 14