JCAT Counterterrorism Guide For Public Safety Personnel

RESPOND & MITIGATE

Bombings: INJURY PATTERNS AND CARE

UNIVERSAL BLAST

BLAST EVENT

SCENE SAFETY

Check in at staging area for safety briefing.
Personnel safety
PPE—Protective clothing, hard hats, eye protection, respiratory protection.
Protection of uninvolved public and volunteers.
Protection of injured.
Be aware of secondary explosive devices.
Be aware of multi-agent devices, e.g. chemical release, dirty bomb, etc.

TRIAGE CONSIDERATIONS

Unique patterns, multiple and occult injuries.
Death is often a result of combined blast, ballistic, and thermal effect injuries.
Walking wounded and noncritical patients are time intensive.
Hidden/internal injuries.
Over triage can increase critical mortality— resulting from poor patient distribution from scene and self-referrals to hospitals.
Up to 75% of victims self-refer to hospital.
Do patients require decontamination?

INITIAL TRIAGE, TRAUMA RESUSCITATION, AND TRANSPORT SHOULD FOLLOW STANDARD PROTOCOLS FOR MULTIPLE INJURED PATIENTS OR MASS CASUALTIES.

FACTORS THAT CONTRIBUTE TO BLAST INJURY SEVERITY

ENVIRONMENT

Was the bombing in an open or closed space? The effects of the blast wave are more intense in a confined space such as a building, bus or train.

AGENT

Low-order Explosive
High-order Explosive

OTHER FACTORS

Device type—large (vehicle) or small (suitcase)
Delivery method
Distance from device
Protective barriers

PRIMARY INJURIES

Unique to high-order explosives; results from the impact of the over-pressurization wave with body surfaces by the blast wave.

HEAD INJURIES

May or may not include history of loss of consciousness.
Headache, seizures, dizziness, memory problems.
Gait/balance problems, nausea/vomiting, difficulty concentrating.
Visual disturbances, tinnitus, slurred speech.
Disoriented, irritability, confusion.
Extremity weakness or numbness.

TYMPANIC MEMBRANE—
EAR INJURIES

Evaluate and resuscitate per standing protocols.
Impaired hearing may complicate triage process.
Secondary evaluation and examination to identify all blast-related injuries including perforated tympanic membranes.
Serious blast injuries can occur in the absence or presence of tympanic membrane rupture.
Stable patients without signs and symptoms of significant blast injury, may be discharged after 4 to 6 hours of observation despite the presence of TM rupture.
Patients should have urgent consultation and follow up care with ENT specialist.
Spontaneous healing occurs in 50-80% of all patients with perforations.

ABDOMINAL INJURIES

Treatment follows established protocols.
Perforations can be delayed and develop 24 to 48 hours post blast. Manifestations of peritonitis can occur hours or days after a blast.
There is the possibility of missed injury, especially in semiconscious or unconscious patients.

Treatment follows established protocols, but it is important to remember that these injuries may be easily missed.

SECONDARY, TERTIARY, AND QUATERNARY INJURIES ARE COMMON IN BLAST EVENTS, AND LARGE MAJORITY ARE NOT CRITICAL.

IT IS UNLIKELY TO EXPERIENCE PATIENTS WITH INJURIES ISOLATED TO ONE CATEGORY. A MORE LIKELY SCENARIO WOULD BE TO EXPERIENCE PATIENTS WITH A COMBINATION OF ALL THE INJURIES LISTED BELOW.

TREATMENT FOR MOST OF THESE BLAST INJURIES FOLLOWS ESTABLISHED PROTOCOLS FOR THAT SPECIFIC INJURY.

SECONDARY INJURIES

Result from flying debris and bomb fragments causing shrapnel wounds.

COMMON INJURIES

Trauma to the head, neck, chest, abdomen, and extremities in the form of penetrating and blunt trauma.
Fractures
Soft tissue injuries

TERTIARY INJURIES

Results from individuals being thrown by the blast wind.

COMMON INJURIES

Head injuries
Skull fractures
Bone fractures

QUATERNARY INJURIES

All explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms.

COMMON INJURIES

Burns
Head injuries
Exacerbation of pre-existing medical conditions

CRUSH INJURIES—Go to Crush Injury Section

COMBINED INJURIES

Avoid tunnel vision on one injury.
Monitor fluid replacement amounts when treating blast lung with another injury to avoid fluid overload which can exacerbate blast lung injury.
Airway management and oxygenation/ ventilation are critical and performed with standard techniques.

BURN/BLAST INJURY

PREHOSPITAL

Burn injury will require significant amounts of fluid resuscitation while avoiding fluid overload to prevent further pulmonary injury.
Fluid resuscitation targeted to vital signs, to avoid hypotension; judicious fluid administration to maintain perfusion without volume overload.
Transfer to a facility with specific expertise in both trauma and burn management, or at least the trauma management.

HOSPITAL

Fluid resuscitation guided by urine output. Consider monitoring central venous pressure, and systematic vascular resistance when indicated.

CRUSH INJURY

BLAST EVENT

ENTRAPPED PATIENT TREATMENT

Fluid resuscitation before extrication—1 L NS bolus, 1-1.5 L/hr infusion
Limb Stabilization
Minimize potential systemic effects of reperfusion (tourniquets)

Consider alkalinization—1 ampule Sodium Bicarbonate (50 mEq) prior to extrication, followed by 1 ampule of Sodium Bicarbonate with each liter of NS infused at 1-1.5 L/hr. Maintain a second IV w/o Sodium Bicarbonate.

Vital signs, oxygen, EKG, IV—Additional treatment and transport

FIELD AMPUTATION INDICATED?

INDICATIONS

Inability to safely extricate the patient.
Continued environmental toxins that pose a hazard to victims or rescuers.

When the extrication time would be long enough that it would endanger the patient’s life without field amputation.

FIELD AMPUTATION

Best performed by an appropriately trained physician, such as a trauma or orthopedic surgeon.

Ensure adequate analgesia and anesthesia.

IS CRUSH SYNDROME OR COMPARTMENT SYNDROME SUSPECTED?

Areas commonly affected:

Lower/Upper extremities

Pelvis

Gluteal region

Abdominal muscles

CRUSH SYNDROME

The general condition of a patient with crush injury is dictated by: (1) other injuries, (2) delay in extrication, and (3) environmental conditions.

Common presentations are:

Hypothermia or hyperthermia dehydration/shock

Clinical Concerns:

The systemic effects are due to rhabdomyolysis and reperfusion of hypoxic and damaged tissues.

Patients may appear well until extricated, and then precipitously decompensate.

Skeletal muscle damage is greatest after reperfusion.

Mental status varies from alert to comatose.

Reperfusion of body part results in the systemic effects of crush injury.

Cardiovascular instability due to massive fluid shift, electrolyte abnormalities, and direct myocardial toxicity.

COMPARTMENT SYNDROME

Pain, Pallor, Paresthesia, Paralysis, Pulselessness Progression of symptoms (the 6th P)

Clinical Concerns:

Bone fractures with extravasation of blood or edema within a closed compartment.

High velocity penetrating injury to muscles in closed compartment with extensive tissue disruption.

Can also occur in sub-acute fashion due to prolonged immobilization on hard surface.

Compartment syndrome typically occurs in major muscle groups enclosed by inelastic, fibrous sheaths.

Principal areas for compartment syndrome are upper extremities, including thenar and hypothenar eminences of hand, and lower extremities, including the foot.

Untreated compartment syndrome will produce the same effects as a crush injury.

CRUSH INJURY TREATMENT: PREHOSPITAL

CRUSH SYNDROME

Primary survey and initial stabilization (ABCs)

Fluid resuscitation before patient is extricated with severe or prolonged entrapment of limb or pelvis (more than a hand or foot).

COMPARTMENT SYNDROME

Primary survey and initial stabilization (ABCs)

Suspect compartment syndrome due to mechanisms of injury, examination, and patient complaints.

Treat other injuries

Immobilize affected part; do not use constricting bandages or MAST trousers.

CRUSH INJURY TREATMENT: HOSPITAL

CRUSH SYNDROME

Fluid resuscitation

Diagnose and treat other metabolic derangements: Hyperkalemia; Hypocalcemia

Brisk diuresis (2ml/kg/hr)

Pain control

Anxiolysis

COMPARTMENT SYNDROME

Primary survey, stabilization and resuscitation, secondary survey

Diagnose through examination and confirmation with compartment pressure measurements

Treat systematic effects of compartment syndrome similar to crush injury

If injury is open:
- Antibiotics, tetanus, jet irrigation;
- Debridement of nonviable tissues;
- Early amputation for severely injured limbs may be required to reduce sepsis

Fasciotomy

BLAST LUNG INJURY

BLAST EVENT

INITIAL TRIAGE, TRAUMA RESUSCITATION, AND TRANSPORT SHOULD FOLLOW STANDARD PROTOCOLS FOR MULTIPLE INJURED PATIENTS OR MASS CASUALTIES.

Was the bombing in an open or closed space?
There is a higher incidence of blast lung injury in enclosed spaces

SIGNS OR SYMPTOMS SUGGESTIVE OF BLI OR RESPIRATORY DISTRESS

SIGNS

Apnea, tachypnea or hypopnea, hypoxia and cyanosis, cough, wheezing, dullness to percussion, decreased breath sounds, or hemoptysis

SYMPTOMS

Dyspnea, hemoptysis, cough, and chest pain

CLINICAL CONCERNS

Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, A-V fistulas (source of air embolism), penetrating chest trauma, and blunt chest trauma. Evaluate patient for >10% BSA burns, skull fractures, and penetrating torso or head injuries

COMPROMISED VENTILATION

YES

VITAL SIGNS, OXYGEN, MONITOR IV

APPROPRIATE TREATMENT AND TRANSPORT

AIRWAY MANAGEMENT PROTOCOL

If ventilatory failure occurs or is imminent, patients should be intubated; caution should be used as positive pressure and mechanical ventilation may increase the risk of further pulmonary injury

MANAGEMENT

OXYGENATION

High flow O2 sufficient to prevent hypoxemia via nonrebreather mask, CPAP, or endotracheal intubation.
Hemothorax or Pneumothorax

CLOSE OBSERVATION

Chest decompression for clinical presentation of tension pneumothorax.
Fluid administration
Provide enough fluid to ensure tissue perfusion but avoiding volume overload.

AIR EMBOLISM*

Position in prone, semi-left lateral, or left lateral positions; transport to a facility with a hyperbaric chamber.

*Close observation for any patient suspected of BLI for the development of tension pneumothorax transported by air.

HOSPITAL DIAGNOSTIC EVALUATION

Chest radiography
Arterial blood gases, computed tomography, and doppler ultrasound can be used to help diagnose BLI and air emboli
Most lab and diagnostic testing conducted per resuscitation protocols—based upon nature of explosion (e.g. confined space, fire, etc.)

HOSPITAL DISPOSITION AND OUTCOME

No definitive guidelines for observation, admission, or discharge following emergency department evaluation for patients with possible BLI following an explosion
Patients diagnosed with BLI may require complex management and should be admitted to and intensive care unit. Patients with any complaints or findings suspicious for BLI should be observed in the hospital
Discharge decisions will also depend on associated injuries; other issues related to the event, including the patient's current social situation
In general, patients with normal chest radiographs, blood gases, and pule oximetry who have no complaints suggesting a BLI, can be considered for discharge after 4-6 hours of observation
Data on the short and long-term outcomes of patients with BLI is currently limited. However, one study conducted on survivors one year post injury, no patients had pulmonary complaints, all had normal physical examinations and chest radiographs.

INCIDENT COMMAND COMPONENTS: OPERATIONAL CONSIDERATIONS / AWARENESS AND SAFETY

The Incident Command System (ICS) structure is meant to expand and contract as the scope of the incident requires. While not all of the ICS positions need to be active in each incident, those that are will need the same safety measures. In addition, not all ICS positions may be collocated with the incident commander, but all components of the ICS should take into account the operational considerations.

INCIDENT COMMAND PROXIMITY TO EVENT
WHO IS RESPONDING TO HELP?

Identification of personnel (other jurisdictions)
Uniform variations (mutual aid)
Verifiable credentials

PROTECTION

Secure perimeter (ASAP)
Single point of entry
Control ingress/egress–vehicle, pedestrian

SECONDARY SCREENING OF AREA

EOD screening
Unattended vehicles
Bystanders

INFORMATION AND INTELLIGENCE ARE IMPORTANT ELEMENTS OF ICS

Information and intelligence can include classified material, risk assessments, medical intelligence, weather information, geospatial data, structural designs, toxic contaminant level, and utilities/public works data, and may come from a variety of sources.

Depending on the needs of an incident, the information/intelligence functions can be assigned within the Command Staff, as a unit within the Planning Section, as a branch within the Operations Section, or as a separate General Staff Section.
Initial set-up considerations:

Collect and evaluate information while responding to the incident scene
Obtain a comprehensive briefing regarding the incident
Confer with Incident Comander or Unit Chief to determine those intelligence or investigative agencies that are involved in the incident—involvement of some agencies may be required by law