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Explosive events, burn patient management

Explosive events, burn patient management. 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.

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Explosive events, burn patient management

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  1. Explosive events, burn patient management

  2. 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

  3. 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.

  4. 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.

  5. Mechanisms of Blast Injury

  6. Overview of Explosive-Related Injuries

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. 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.

  12. Burn victim in precarious situations

  13. Selected recent burn mass casualty disasters.

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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 mass-casualty 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

  19. Magnitude of Injury • The rule of “nines” • The depth of burn • +/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs

  20. Magnitude of Injury • The rule of “nines” • The depth of burn • +/- Inhalation injury, circumferencial burns, chemical or electrical burns, children or W< 30 kgs

  21. Superficial or 1st degree Deep partial thickness or 2nd degree Full thickness or 3rd degree

  22. 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 ! ! !

  23. 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 !

  24. 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

  25. Escharotomy and / or Fasciotomy Primary Escharectomy Secondary Escharectomy

  26. 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

  27. International Co-operation • Burn Teams • Classification of Burn Care Facilities according to ISBI • 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 • Level C, existing tertiary burn centres which provide definitive care including invasive monitoring, management of inhalation injury, early wound excision, complete rehabilitation, infection control and metabolic support

  28. Rehabilitation and long-term follow-up Incorporation of occupational, physical and psychological rehabilitation of the survivors Debriefing

  29. Thank You

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