Traumatic Blast Injury - Extremis



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Traumatic Blast Injury - Extremis

Laparotomy

Control significant external bleeding

Massive hemothorax or thoracic compartment syndrome

Thoracotomy

Blood in trachea?

Consider blast lung injury as primary etiology of extremis

Consider thoracotomy for unresponsive patients with massive air leak or evidence of thoracic compartment syndrome

FAST exam

Hemoperitoneum

Inclusion Criteria
  • Patient in extremis with known or suspected blast injury
Exclusion Criteria
  • Patient not in extremis
  • Patient not suspected to have blast injury

Consider other compartments as primary etiology of extremis

Needle decompression

Tension Pneumothorax?

Intubate

Follow ATLS guidelines

  • 2 large bore peripheral IV's
  • Warm IV fluids & packed RBCs
  • Bilateral chest tubes

General Guidelines

  • Pertinent history: distance from blast, enclosed space (amplifies blast effect) vs. open air, time since blast.
  • Vent settings should be lung protective by minimizing peak airway pressures.
  • Limit fluid administration as much as possible as patients are at risk for pulmonary edema.
  • All blast injury patients eventually need pan scan CT if resources and patient stability permit.
  • TM perforation does not correlate to hollow organ damage. It only identifies patients who would benefit from a period of observation. Investigate hollow organs indepedently.
  • All penetrating wounds are dirty. Start antibiotics (Augmentin or 2nd gen Cephalosporins to cover for soil), TDAP, and send to OR for I&D if necessary.

Blast Lung Injury (BLI)

  • Only 0.6% of blast injury survivors, but 80% will require intubation.
  • Signs/symptoms: tachycardia, tachypnea, dyspnea, hemoptysis
  • Clinically significant BLI will be symptomatic by arrival in ED. Mild injury may not manifest for several hourrs due to secondary inflammatory response.
  • Primary BLI often mixed with secondary (penetrating fragments) and tertiary (pulmonary contusion) injuries.
  • Chest X-ray: bilateral fluffy infiltrates in 'bat wing' pattern.
  • CT: alveolar hemorrhage, commonly around the mediastinum; lacerations, pneumatoceles and pneumothoraces
  • Vent settings: permissive hypercapnia, minimize peak pressures, use low volume/high PEEP as in ARDS except in presence of bronchopleural fistulas and pneumatoceles.

Admit to ICU




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