ICD-10-CM Y36.23* Blown All The Way Up *War Operation Involving - - PowerPoint PPT Presentation

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ICD-10-CM Y36.23* Blown All The Way Up *War Operation Involving - - PowerPoint PPT Presentation

Dec 07, 2022 25 likes •570 views

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

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SLIDE 1

ICD-10-CM Y36.23* Blown All The Way Up

*War Operation Involving Explosion of Improvised Explosive Device

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SLIDE 2

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
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SLIDE 3

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
  • r politics influencing military and strategic

decisions

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SLIDE 4

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

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SLIDE 5

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
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SLIDE 6

1ST PERSON VOIED VIDEO

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SLIDE 7

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)

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SLIDE 8
  • 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

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SLIDE 9
  • Blast Pathophysiology
  • Tertiary Injuries
  • Blast wave moving victims

into objects

  • Can be a mixture of blunt

and penetrating trauma

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SLIDE 10
  • Blast Pathophysiology
  • Quarternary Injuries
  • Everything else
  • Burns
  • Barotrauma
  • Crush Injuries
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SLIDE 11

IED Injuries

  • Obvious
  • Fractures
  • Amputations
  • Burns
  • High index of suspicion
  • Vascular injury
  • Genital/Rectal trauma
  • Pelvic trauma
  • Abdominal trauma
  • HEENT Injury
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SLIDE 12

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
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SLIDE 13

How Big Was That Bomb?

  • Based on Photograph and Injury Pattern
  • Audience Participation Encouraged, Coerced or

Extracted through threat of Force

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SLIDE 14
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SLIDE 15

How Big Was That Bomb?

  • Ipsilateral tibia/fibula

fracture

  • Contralateral foot

laceration

  • 5lbs – ispilateral 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
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SLIDE 16
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SLIDE 17

How Big Was That Bomb?

  • Ipsilateral foot

amputation

  • Contralateral foot

damage

  • Minor* Genital Trauma
  • 5lbs – ispilateral 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
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SLIDE 18
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SLIDE 19

How Big Was That Bomb?

  • Bilateral AKA
  • Left Proximal Femur

amputation

  • Massive Pelvic Injuries
  • Special Consideration
  • Geriatric Patient
  • 45 Minute transport to

Role I aid station

  • 5lbs – ispilateral 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
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SLIDE 20
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SLIDE 21

How Big Was That Bomb?

  • Ipsilateral AKA
  • Contralateral BKA
  • Pelvic Injuries
  • Bilat Upper Extremity

Amputation

  • Cranial/Facial Trauma
  • Special Consideration
  • Pediatric Patient
  • Approx 25kg weight
  • 5lbs – ispilateral 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
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SLIDE 22

Tactical Combat Casualty Care

  • Care Under Fire
  • Tactical Field Care
  • Tactical Evacuation Care
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SLIDE 23

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

personnel should seek cover and concealment

1‐25 SBCT Archive

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SLIDE 24

Tactical Combat Casualty Care

  • Care Under Fire
  • Defer Airway Management
  • Extricate casualties from

burning vehicles and buildings

  • Initial Tourniquet

placement: high and hasty

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SLIDE 25

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
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SLIDE 26

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
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SLIDE 27

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

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SLIDE 28

Tactical Combat Casualty Care

  • Tactical Field Care
  • HABCs
  • Goal should focus on

preventing further injury and evacuation

  • Bleeding/Circulation
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SLIDE 29

Tactical Combat Casualty Care

  • Casualty Evacuation

Care

  • Tactical Evacuation
  • CASEVAC vs MEDEVAC
  • Monitor and Reassess

previous interventions

  • HABCs
  • GCS
  • Vital Signs
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SLIDE 30

Tactical Combat Casualty Care

  • Evacuation Care
  • More Time to Do More
  • Provide additional

medications

  • Provide supplemental
  • xygen
  • Coordinate care at

receiving facility

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SLIDE 31

Tactical Combat Casualty Care

  • Casualty Evacuation

Care

  • CASEVAC
  • Non-Standard Platform
  • MEDEVAC
  • Vehicle designed to

provide medical care during transport

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SLIDE 32

HABC

  • 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

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SLIDE 33

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

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SLIDE 34

Helmet Camera

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SLIDE 35

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

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SLIDE 36

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

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SLIDE 37

Tourniquets

CAT – Combat Application Tourniquet SOF-TT – SOF Tactical Tourniquet

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SLIDE 38

Junctional Hemorrhage

CRoC – Combat Ready Clamp AAT – Abdominal Aorta Tourniquet

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SLIDE 39

HABC

  • A – Airway
  • Casualty may have dirt and debris in every
  • rifice – 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
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SLIDE 40

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

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SLIDE 41

Cricothyroidotomy

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SLIDE 42

HABC

  • B – Breathing
  • Most combat casualties

do not require supplemental Oxygen

  • Airway compromise
  • Burn/Inhalation injuries
  • TBI/Altered

consciousness

  • High altitude environment
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SLIDE 43

HABC

  • Concern for tension

pneumothorax

  • Penetrating trauma to

shoulder, neck, chest, back, abdomen

  • Needle Chest

Decompression

  • Use largest needle you

have

  • 14 GA, 3.25in

needle/catheter

  • Second intercostal space
  • Midclavicular line
  • Alternate site(s)
  • 4th or 5th intercostal space

anterior axillary line

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SLIDE 44

HABC

  • B – Breathing
  • Chest Thoracostomy

Tube for long transport times or need for repeat NCD treatments

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SLIDE 45

HABC

  • Fluid Resuscitation
  • IV/IO Access
  • Blood Products
  • Tranexemic Acid
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SLIDE 46

HABC

  • C – Circulation/Bleeding
  • Tourniquets – limb and junctional
  • Frequent reassessment – goal is less than 6 hours
  • f total tourniquet time
  • May convert tourniquets to pressure dressings

– Not in shock – No amputation – Easy monitoring of wound

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SLIDE 47

HABC

  • Fluid Resuscitation
  • Indicated for shock,

mental status change or lack of radial pulse

  • IV/IO Access
  • IV 18 GA or large

preferred

  • IO – tibial, humeral head,

sternum

  • Fluids of Choice
  • Whole Blood
  • Plasma, RBC, Platelets in

1:1:1 ratio

  • Blood products alone
  • Hetastarch Colloid
  • Crystalloid
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SLIDE 48

HABC

  • Tranexamic Acid
  • Antifibrinolytic Agent
  • Binds to Plasmin and

Plasminogen

  • Stops clot lysis
  • More clots prevent more

blood loss

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SLIDE 49

HABC

  • Tranexamic Acid
  • Must be given within 3

hours of injury

  • 1 gram IV in 100cc of LR
  • r NS
  • May administer 2nd gram

after administration of colloid or crystalloid infusion

  • Should be administered

to casualties with large transfusion requirement

  • Shock
  • Limb amputation
  • Penetrating torso/neck

trauma

  • Severe bleeding
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SLIDE 50

TCCC Additional Considerations

  • Blast Injuries in closed spaces
  • House Borne IED
  • Increased suspicion for baro-trauma
  • Viscous injuries, pulmonary injuries,
  • HEENT – globe trauma to eyes ruptured

tympanic membranes

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SLIDE 51

TCCC Additional Considerations

  • Prevention of

hypothermia

  • Heated blankets
  • Warmed fluids
  • Dry clothing
  • Sleeping bag, poncho

liners

  • Eye/globe Trauma
  • Rapid visual acuity
  • Rigid shield
  • Secure foreign bodies in

place

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SLIDE 52

Pharmacology

  • Analgesia
  • Acetaminophen – 1gram PO

every 8 hours

  • Meloxicam – 15mg PO daily
  • Transmucosal fentanyl – 800ug
  • Ketamine – 50mg IM, 20mg

IV/IO

  • Disarm your casualty if using

narcotics – frequent monitoring required

  • Naloxone needed if using

narcotics 0.4-2mg IV/IM

  • Antiemetics
  • Ondansetron 4-8mg

IV/IM/ODT every 8 hours

  • Antibiotics
  • Moxifloxacin 400mg PO

daily

  • Ertapenem 1gram IV/IM
  • nce daily
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SLIDE 53

Blast Injury

  • Practical Applications
  • IEDs are becoming an effective weapon used in

domestic terrorist and mass casualty events

  • Massive poly-trauma protocols can be useful in

high speed collision, penetrating trauma and industrial/workplace explosions

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SLIDE 54

Questions? Comments?