BLAST INJURIES

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries. Bombs and explosions can cause unique patterns of injury seldom seen outside combat. The 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 onehour 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.

such as Molotov cocktails or aircraft improvised as guided missiles. HE and LE cause different injury patterns The four basic mechanisms of blast injury are termed as primary, secondary, tertiary, and quaternary . Blast Wave (primary) refers to the intense over-pressurization impulse created by a detonated HE. Blast injuries are characterized by anatomical and physiological changes from the direct or reflective overpressurization force impacting the bodys surface. The HE blast wave (over-pressure component) should be distinguished from blast wind (forced super-heated air flow). The latter may be encountered with both HE and LE.

Primary

(1- characteristics, 2- body part affected, 3- type of injury) 1. Unique to HE, results from the impact of the over-pressurization wave with body surfaces. 2. Gas filled structures are most susceptible - lungs, GI tract, and middle ear. 3. Blast lung (pulmonary barotrauma) TM rupture and middle ear damage Abdominal hemorrhage and perforation - Globe (eye) ruptureConcussion (TBI without physical signs of head injury)

Secondary 1. Results from flying debris and bomb fragments. 2. Any body part may be affected. 3. Penetrating ballistic (fragmentation) or blunt injuries Eye penetration (can be occult). Tertiary 1. Results from individuals being thrown by the blast wind. 2. Any body part may be affected. 3. Fracture and traumatic

High-order explosives (HE) or Low-order explosives (LE)

HE produce a defining supersonic over-pressurization shock wave. TNT, C-4, Semtex, nitroglycerin, dynamite, and
ammonium nitrate fuel oil (ANFO).

LE create a subsonic explosion and lack HEs over-pressurization wave. pipe bombs, gunpowder, and most pure petroleumbased bombs

amputation Closed and open brain injury Quaternary

1. All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms. Includes exacerbation or complications of existing conditions. 2. Any body part may be affected. 3. 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 Lung Injury Signs usually present at time of initial evaluation, but may be delayed up to 48 hrs Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso Varies from scattered petechiae to confluent hemorrhages Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast CXR: butterfly pattern High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube Fluid management similar to pulmonary contusion; ensure tissue perfusion but avoid volume overload Endotracheal intubation for massive hemoptysis, impending airway compromise or respiratory failure Consider selective bronchial intubation for significant air leaks or massive hemoptysis

Positive pressure may risk alveolar rupture or air embolism...

Prompt decompression for clinical evidence of pneumothorax or hemothorax. Consider prophylactic chest tube before general anesthesia or air transport Air embolism can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, claudication High flow O2; prone, semileft lateral, or left lateral position Consider transfer for hyperbaric O2 therapy

Abdominal Injury Gas-filled structures most vulnerable (esp. colon) Bowel perforation, hemorrhage (small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia

Clinical signs can be initially subtle until acute abdomen or sepsis is advanced Brain Injury Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression,

anxiety, insomnia, or other constitutional symptoms. The symptoms of concussion and post traumatic stress disorder can be similar. Ear Injury Tympanic membrane most common primary blast injury Signs of ear injury usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, bleeding from external canal, otorrhea)

stress management o Debriefing

Critical Incident Stress Management (CISM an approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their jobs and that can also occur to anyone involved in a disaster Components of a management plan: Education before an incident about critical incident stress and coping strategies; Field support (ensuring that staff get adequate rest, food and fluids, and rotating work loads) during an incident; and Defusings, debriefings, demobilization, and follow-up care after the incident. The 7 core components of CISM 1. Pre-crisis preparation. This includes stress management education, stress resistance, and crisis mitigation training for both individuals and organizations. 2. Disaster or large-scale incident, as well as, school and community support programs including demobilizations, informational briefings, "town meetings" and staff advisement 3. Defusing. This is a 3-phase, structured small group discussion provided within hours of a crisis for purposes of assessment, triaging, and acute symptom mitigation.

Other Injury Traumatic amputation of any limb is a marker for multi-system injuries Concussions are common and easily overlooked Consider delayed primary closure for grossly contaminated wounds, and assess tetanus immunization status Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings Consider possibility of exposure to inhaled toxins (CO, CN, MetHgb) in both industrial and terrorist explosions Significant percentage of survivors will have serious eye injuries Disposition No definitive guidelines for observation, admission, or discharge Discharge decisions will also depend upon associated injuries Admit 2nd and 3rd trimester pregnancies for monitoring Close follow-up of wounds, head injury, eye, ear, and stressrelated complaints

4. Critical Incident Stress Debriefing

(CISD) refers to the "Mitchell model" (Mitchell and Everly, 1996) 7-phase, structured group discussion, usually provided 1 to 10 days post crisis, and designed to mitigate acute symptoms, assess the need for follow-up, and if possible provide a sense of post-crisis psychological closure. 5. One-on-one crisis intervention/counseling or psychological support throughout the full range of the crisis spectrum.

Patients with ear injury may have tinnitus or deafness; communications and instructions may need to be written Stress reactions Posttraumatic o Stress disorder critical incident

6. Family crisis intervention, as well as, organizational consultation. 7. Follow-up and referral mechanisms for assessment and treatment, if necessary Defusing is a process by which the individual receives education about recognition of stress reactions and management strategies for handling stress. Debriefing is a more complicated intervention; involves a 2- to 3- hour process during which participants are asked about their emotional reactions to the incident, whatsymptoms they may be experiencing (eg, flashbacks, difficultysleeping, intrusive thoughts), and other psychological ramifications. >>goal of the debriefing is to reduce the likelihood of post traumatic stress disorder, or other psychological problems People with ongoing stress reactions are referred tomental health specialists. PTSD = is an anxiety disorder that some people get after seeing or living through a dangerous event. When in danger, its natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. fight-or-flight response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when theyre no longer in danger.

dbridement or suturing may be performed May serve as the triage officer... exact role of a nurse in disaster management depends on the specific needs of the facility at the time, it should be clear which nurse or physician is in charge of a given patient care area and which procedures each individual nurse may or may not perform. Assistance can be obtained through the incident command center, and nonmedical personnel can provide services where possible.

> For example, family members can provide nonskilled interventions for their loved ones. Nurses should remember that nursing care in a disaster focuses on essential care from a perspective of what is best for all patients. New settings and atypical roles for nurses arise during a disaster:

may provide shelter care in a temporary housing area, or bereavement support and assistance with identification of deceased loved ones.

Individuals may require crisis intervention, or the nurse may participate in counselling other staff members and in critical incident stress management (CISM).

Nurses' Roles in Disaster and Emergency VARIES may be asked to perform outside his or her area of expertise may take on responsibilities normally held by physicians or advanced practice nurses. may intubate a patient or even insert chest tubes. Wound