ICD-10-CM Y36.23* Blown All The Way Up *War Operation Involving Explosion of Improvised Explosive Device
Objectives ● Overview of Blast Injuries and Pathophysiology ● Kinematics of Blast Trauma ● Tactical Combat Casualty Care – 2015 Updates ● Care Under Fire, Tactical Field Care, Tactical Evacuation Care ● Hemorrhage Control, Airway and Ventilation, Fluid Resuscitation, Medications ● Practical Applications
Objectives ● What we won’t be discussing ● Just and unjust wars ● Tactics, techniques and procedures used by enemy and coalition forces ● Current United States foreign policy initiatives or politics influencing military and strategic decisions
Disclosures ● No conflicts of interest ● No benefits from any of the products shown in the slides ● All pictures and videos belong to the presenter unless noted ● Please Ask Questions – Learn from the others in the audience
Victim Operated Improvised Explosive Device Home Made Explosives ● HME ● Nitrate/Fuel Mixture ● Pressure Plate/Victim Operated ● Command Detonated ● Blast wave ● Primary injury ● Fragmentation ● Secondary injury ● Landing ● Secondary impact ●
1 ST PERSON VOIED VIDEO
Blast Pathophysiology ● Primary Injury – Blast wave – overpressure. A pushing force = blunt trauma ● Expanding gases moving at very high speeds – 1500 mph ● Rapid increase in pressure, 100 PSI in a matter of milliseconds ● Lower velocity = lower pressure in non-weapons grade (HME)
● Blast Pathophysiology ● Secondary Injuries – shrapnel and everything pushed by the blast wave ● Usually found as penetrating trauma ● Cutting force ● Cavitation process into body tissues – potential spaces fill with blood and debris
● Blast Pathophysiology ● Tertiary Injuries ● Blast wave moving victims into objects ● Can be a mixture of blunt and penetrating trauma
● Blast Pathophysiology ● Quarternary Injuries ● Everything else ● Burns ● Barotrauma ● Crush Injuries
IED Injuries ● Obvious ● Fractures ● Amputations ● Burns ● High index of suspicion ● Vascular injury ● Genital/Rectal trauma ● Pelvic trauma ● Abdominal trauma ● HEENT Injury
VOIED – Size Matters 5lbs – ipsilateral foot damage ● 10lbs – ipsilateral foot amputation & ● contralateral foot damage 15lbs – ipsilateral AKA & ● contralateral foot amputation 20lbs – bilateral AKA – possible ● genital/pelvic trauma, ipsilateral arm 25lbs- proximal bilateral femur, ● pelvis, bilateral arms, bowel 30lbs – quadruple amputations, ● pelvic/abdominal, thoracic, facial trauma >40lbs - death ●
How Big Was That Bomb? ● Based on Photograph and Injury Pattern ● Audience Participation Encouraged, Coerced or Extracted through threat of Force
How Big Was That Bomb? ● Ipsilateral tibia/fibula 5lbs – ispilateral foot damage ● fracture 10lbs – ipsilateral foot amputation & ● contralateral foot damage ● Contralateral foot 15lbs – ipsilateral AKA & ● laceration contralateral foot amputation 20lbs – bilateral AKA – possible ● genital/pelvic trauma, ipsilateral arm 25lbs- proximal bilateral femur, ● pelvis, bilateral arms, bowel 30lbs – quadruple amputations, ● pelvic/abdominal, thoracic, facial trauma >40lbs - death ●
How Big Was That Bomb? ● Ipsilateral foot 5lbs – ispilateral foot damage ● amputation 10lbs – ipsilateral foot amputation & ● contralateral foot damage ● Contralateral foot 15lbs – ipsilateral AKA & ● damage contralateral foot amputation 20lbs – bilateral AKA – possible ● Minor* Genital Trauma ● genital/pelvic trauma, ipsilateral arm 25lbs- proximal bilateral femur, ● pelvis, bilateral arms, bowel 30lbs – quadruple amputations, ● pelvic/abdominal, thoracic, facial trauma >40lbs - death ●
How Big Was That Bomb? ● Bilateral AKA 5lbs – ispilateral foot damage ● 10lbs – ipsilateral foot amputation & ● Left Proximal Femur ● contralateral foot damage amputation 15lbs – ipsilateral AKA & ● contralateral foot amputation ● Massive Pelvic Injuries 20lbs – bilateral AKA – possible ● ● Special Consideration genital/pelvic trauma, ipsilateral arm ● Geriatric Patient 25lbs- proximal bilateral femur, ● ● 45 Minute transport to pelvis, bilateral arms, bowel Role I aid station 30lbs – quadruple amputations, ● pelvic/abdominal, thoracic, facial trauma >40lbs - death ●
How Big Was That Bomb? ● Ipsilateral AKA 5lbs – ispilateral foot damage ● 10lbs – ipsilateral foot amputation & ● Contralateral BKA ● contralateral foot damage ● Pelvic Injuries 15lbs – ipsilateral AKA & ● contralateral foot amputation ● Bilat Upper Extremity 20lbs – bilateral AKA – possible ● Amputation genital/pelvic trauma, ipsilateral arm ● Cranial/Facial Trauma 25lbs- proximal bilateral femur, ● ● Special Consideration pelvis, bilateral arms, bowel 30lbs – quadruple amputations, ● Pediatric Patient ● pelvic/abdominal, thoracic, facial trauma ● Approx 25kg weight >40lbs - death ●
Tactical Combat Casualty Care ● Care Under Fire ● Tactical Field Care ● Tactical Evacuation Care
Tactical Combat Casualty Care ● Care Under Fire ● Overwhelming, Direct, Lethal fire to suppress and eliminate enemy threat ● Prevent further casualties ● Self Aid/Buddy Aid ● If casualty can remain engaged, return fire ● Casualty and treatment 1 ‐ 25 SBCT Archive personnel should seek cover and concealment
Tactical Combat Casualty Care ● Care Under Fire ● Defer Airway Management ● Extricate casualties from burning vehicles and buildings ● Initial Tourniquet placement: high and hasty
Tactical Combat Casualty Care ● Tactical Field Care ● HABCs ● More time to do more ● Goal should focus on preventing further injury and evacuation ● Hemorrhage ● Direct tourniquet placement ● Hemostatic Dressings ● Junctional Tourniquets
Tactical Combat Casualty Care ● Tactical Field Care ● HABCs ● Goal should focus on preventing further injury and evacuation ● Airway Management ● Jaw maneuvers ● NPA ● Recovery Position ● Surgical Airway ● Endotracheal Intubation ● Supraglottic Airway
Tactical Combat Casualty Care ● Tactical Field Care ● HABCs ● Goal should focus on preventing further injury and evacuation ● Breathing ● Chest wounds – Chest seals ● Needle Chest Decompression
Tactical Combat Casualty Care ● Tactical Field Care ● HABCs ● Goal should focus on preventing further injury and evacuation ● Bleeding/Circulation
Tactical Combat Casualty Care ● Casualty Evacuation Care ● Tactical Evacuation ● CASEVAC vs MEDEVAC ● Monitor and Reassess previous interventions ● HABCs ● GCS ● Vital Signs
Tactical Combat Casualty Care ● Evacuation Care ● More Time to Do More ● Provide additional medications ● Provide supplemental oxygen ● Coordinate care at receiving facility
Tactical Combat Casualty Care ● Casualty Evacuation Care ● CASEVAC ● Non-Standard Platform ● MEDEVAC ● Vehicle designed to provide medical care during transport
H ABC ● H – Hemorrhage Control ● Casualty can bleed to death in under three minutes with a triple amputation ● Compressible hemorrhage ● Tourniquets ● Junctional hemorrhage control ● Blood sweep for additional wounds ● Combat gauze and kerlix to occupy potential spaces
Presence Patrol ● 1 Platoon US, 1 Company Afghan National Army ● Movement to contact through Pro-Taliban village along dried canal – wadi ● Valon low metal frequency mine detector carried by 2 Soldiers at front of 30 man column
Helmet Camera
IED strike treatment ● Stay calm HABCs - Tourniquets, tourniquets, tourniquets ● ● Combat gauze, kerlix ● Casualty will be covered in dirt and may have to have his mouth and eyes washed out - Airway ● Stump dressing ● Expose for additional wounds ● IV/IO access ● High index of suspicion for other life threatening injuries
IED strike treatment ● Assessment Level of Consiousness ● ● Responsiveness ● Talking ● Shock ● Radial pulse ~ 80-90mmHg systolic ● Visible Wounds ● Expose for additional wounds ● High index of suspicion for other life threatening injuries
Tourniquets CAT – Combat Application SOF-TT – SOF Tactical Tourniquet Tourniquet
Junctional Hemorrhage AAT – Abdominal Aorta CRoC – Combat Ready Clamp Tourniquet
H A BC ● A – Airway ● Casualty may have dirt and debris in every orifice – rinse out mouth and nose ● Position of comfort – casualty will work to protect their own airway – anatomic position usually is not the best ● Early definitive airway – if you think they need a tube, then they need a tube ● Cricothyroidotomy vs Oropharyngeal airway
Definitive Airway ● Open the airway as your first option ● Adjunct Airway Devices ● OPA, NPA, Bite Block – Rinse out airway ● Suppraglottic airway - KING LT ● Endotracheal Intubation ● Surgical Airway ● Once you have the tube, you are committing manpower to ventilate
Cricothyroidotomy
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