Blast and crush injuries tintinalli chap 8
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Blast and Crush Injuries Tintinalli Chap. 8. Blast and Crush Injuries. Stress Waves Created by the brief acceleration of a surface Transmitted deep into the body through the fluid of the tissues

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Blast and Crush Injuries Tintinalli Chap. 8

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Blast and crush injuries tintinalli chap 8

Blastand Crush InjuriesTintinalli Chap. 8


Blast and crush injuries

Blast and Crush Injuries

  • Stress Waves

    • Created by the brief acceleration of a surface

    • Transmitted deep into the body through the fluid of the tissues

    • Damage occurs when the stress wave encounters tissues of different densities creating differential pressure forces, motion, stretching, and eventual tearing

    • Primary Blast Injury of the ears, lungs, and bowel

  • Shear Waves

    • Created by body deformation, which stretches tissues tangentially to the displaced surface

    • Blunt trauma and crush injuries


Blast injuries

Blast Injuries

  • Ignition of explosives releases large amounts of energy in the form of expanding gases

  • These gases compress and superheat the surrounding air or water creating a shock wave

    • Solid Surfaces (Bone)

      • Shatter

    • Most body surfaces

      • “spring back” to original shape


Common blast injuries

Common Blast Injuries

  • Ear

    • TM bleeding/rupture

    • Fracture/dislocation of ossicles

    • Temporary or permanent hearing loss

  • Lungs

    • Hemo-/pneumothorax

    • Tension pneumothorax

    • Parenchymal hemorrhage

    • Pulmonary Contusion

    • Pneumatocele

    • Arterial Air Embolism (AAE) with subsequent distal ischemia

  • Bowel

    • Bleeding

    • Perforation and peritonitis


  • Common blast injuries1

    Common Blast Injuries

    • Other

      • Burns

      • Toxic inhalations

      • Traumatic amputations

  • Brain (TBI)

    • Not mentioned in Tintinalli

    • Leading nonfatal injury in the wars in Iraq and Afghanistan


  • Detection and intervention

    Detection and Intervention

    • Airway Compromise

      • d/t depressed level of consciousness, facial/neck trauma, inhalation injury, or massive hemoptysis

    • Ventilatory Insufficiency

      • High-flow oxygen should be given to all victims with dyspnea, hemorrhage, or evidence of serious injury

        • CPAP

        • PPV

          • Can increase risk of AAE

    • External Hemorrhage

      • Control with direct pressure or tourniquets


    Detection and intervention1

    Detection and Intervention

    • Tension Pneumothorax

      • Immediate needle thoracostomy

      • Tube thoracostomy if no improvement

    • Shock

      • Causes

        • Hemorrhage

        • Traumatic DVT and PE

        • Crush Syndrome

        • Sepsis (delayed care)

        • AAE causing brainstem stroke, MI, or spinal cord injury


    Detection and intervention2

    Detection and Intervention

    • Arterial Air Embolism (AAE)

      • Consider if any of the following:

        • Localized ischemia of the skin/mucous membranes

        • Altered mental status

        • Focal neurologic deficits

        • Chest pain

        • Dysrrhythmia

        • Pulmonary edema

        • Abdominal pain

        • Hematuria

        • Sudden deterioration after an intervention (intubation)


    Additional evaluation

    Additional Evaluation

    • Pulmonary Primary Blast Injury

      • Dyspnea and chest pain

      • Pharyngeal petechiae or hemoptysis

      • Hemo-/pneumothorax

      • Pulmonary contusion

      • pneumatocele

  • Gastrointestinal Primary Blast Injury

    • Abdominal or testicular pain

    • N/V

    • Urge to defecate

    • Hematochezia


  • Management caveats

    Management Caveats

    • External Hemorrhage is much more likely than airway compromise

      • MARCH

    • Air Embolism from positive-pressure ventilation is the most common cause of early death among immediate survivors

    • Positioning patient on the left side slightly forward prone may lower risk of AAE

    • Avoid rapid infusion of fluids because of high risk of pulmonary contusion


    Disposition

    Disposition

    • Observe X 4 hours

      • If no chest or abdominal complaints and normal chest Xray and ABGs, may consider discharge with close follow-up

      • Admit all others


    Crush injuries

    Crush Injuries

    • Acute Traumatic Ischemia (ATI)

      • More-appropriate term

    • Causes

      • Industrial Machinery Accidents

      • Building Collapse

      • Combat Injuries

      • Drug Overdose

      • Mining Accidents

      • Torture

      • Transportation and Construction Accidents


    Pathophysiology

    Pathophysiology

    • Disruption of adequate perfusion of the affected tissues

    • 2 Categories

      • Direct Macroscopic Muscular and Vascular Trauma

      • Microvascular Trauma

    • Hemorrhage, Edema, and Hypoperfusion

      • Leads to tissue hypoxia and ischemia

      • Cellular lysis results in the release of inflammatory mediators which further increase edema and hypoperfusion

      • Capillary blood flow is compromised at pressures exceeding 20 mmHg


    Clinical approach

    Clinical Approach

    • Exam

      • Remove all clothing and jewelry

      • Palpate entire body for crepitus, swelling, or tenderness

      • Check capillary refill

      • Thorough neurologic examination

      • Re-assess frequently

    • Labs

      • CBC

      • BUN/Cr

      • Electrolytes

      • Phosphorus

      • Calcium

      • CK

      • Urinalysis

      • Urine myoglobin

      • Serial potassium, CK, and urine myoglobin


    Management

    Management

    • Oxygen

    • Blood Transfusion

    • Continuous cardiac monitoring/pulse oximetry

    • NSS 250 cc bolus every 15 minutes until urine output is 2 cc/kg/hr

    • Furosemide 40-120 mg IV

      • Causes renal vasodilation, decreased oxygen demands by kidney, and increased renal flow


    Disposition1

    Disposition

    • Admit all patients

      • IV hydration

      • Serial labs

      • Close monitoring for compartment syndrome

      • Hyperbaric oxygen therapy, if available


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