Morning Report: 7/23/13

Thanks to Dr. Berzon for today’s Morning Report!

Blast Injuries

The CPSC (Consumer Product Safety Commission), reports that in 2011, an estimated 9600 consumers were injured by firecrackers and that more than half of the injuries occurred during the 30 days surrounding Independence Day. Four fatalities were reported, one of whom was decapitated as a result of the explosion. Fireworks injuries most often resulted in burns to the hands and head, including the eyes, face, and ears.

Below, I have attached the “Essential Blast Injury Facts” from ACEP’s website that we discussed in Morning Report. While they are more applicable to Terrorist bombings such as the Boston bombings, the concepts apply to firecracker injuries as well.

Key Concepts

Bombs and explosions can cause unique patterns of injury seldom seen outside combat
Expect half of all initial casualties to seek medical care over a one-hour period
Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals
Predominant injuries involve multiple penetrating injuries and blunt trauma
Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality
Primary blast injuries in survivors are predominantly seen in confined space explosions
Repeatedly examine and assess patients exposed to a blast
All bomb events have the potential for chemical and/or radiological contamination
Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk of exposure to caregivers is small
Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers
For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current)

Blast Injuries

Primary: Injury from over-pressurization force (blast wave) impacting the body surface
- TM rupture, pulmonary damage and air embolization, hollow viscus injury
Secondary: Injury from projectiles (bomb fragments, flying debris)
- Penetrating trauma, fragmentation injuries, blunt trauma
Tertiary: Injuries from displacement of victim by the blast wind
- Blunt/penetrating trauma, fractures and traumatic amputations
Quaternary: All other injuries from the blast
- Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness

Primary Blast Injury

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, semi-left 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

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)

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 stress-related complaints
Patients with ear injury may have tinnitus or deafness; communications and instructions may need to be written

This fact sheet is part of a series of materials developed by the Centers for Disease Control and Prevention (CDC) on blast injuries. For more information on blast injuries, visit CDC on the Web at:www.emergency.cdc.gov/BlastInjuries.

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
June 2009