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NousDefionsDoc
04-28-2004, 15:05
Let's talk about the effects of blasts on the human form.

NousDefionsDoc
04-28-2004, 15:10
Pathophysiology: Blast injuries traditionally are divided into 4 categories: primary, secondary, tertiary, and miscellaneous injuries. A patient may be injured by more than one of these mechanisms.

A primary blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures such as the lung, ear, and gastrointestinal (GI) tract.

A secondary blast injury is caused by flying objects that strike people.

A tertiary blast injury is a feature of high-energy explosions. This type of injury occurs when people fly through the air and strike other objects.

Miscellaneous blast-related injuries encompass all other injuries caused by explosions. For example, the collision of two jet airplanes into the World Trade Center created a relatively low-order pressure wave, but the resulting fire and building collapse killed thousands.

Roguish Lawyer
04-28-2004, 15:14
You want to credit that, right?

http://www.emedicine.com/emerg/topic63.htm

Here's some more:

Mortality/Morbidity:

Mortality rates vary widely. Injury is caused both by direct blast overpressure (primary blast injury) and by a variety of associated factors.

Mortality is increased when explosions occur in closed or confined spaces (eg, terrorist bus bombings) or under water. Land mine injuries are associated with a high risk of below- and above-the-knee amputations. Fireworks-related injuries prompt an estimated 10,000-12,000 ED visits in the United States annually, with 20-25% involving either the eye or hand.

Presence of tympanic membrane (TM) rupture indicates that a high-pressure wave (at least 40 kilopascal [kPa], 6 psi) was present and may correlate with more dangerous organ injury. Theoretically, at an overpressure of 100 kPa (15 psi), the threshold for lung injury, TM routinely ruptures; however, a recent Israeli case series of 640 civilian victims of terrorist bombings contradicts traditional beliefs about a clear correlation between the presence of TM injury and coincidence organ damage. Of 137 patients initially diagnosed as having isolated eardrum perforation who were well enough to be discharged, none later developed manifestations of pulmonary or intestinal blast injury. Furthermore, 18 patients with pulmonary blast injuries had no eardrum perforation.

NousDefionsDoc
04-28-2004, 15:19
I wasn't finished, but thanks.

Roguish Lawyer
04-28-2004, 15:22
Originally posted by NousDefionsDoc
I wasn't finished, but thanks.

Yeah, sorry. Just had to show that my google sometimes is strong. LOL

lrd
04-28-2004, 15:38
I'm not sure if I'm asking this correctly, but which effects are temporary and which are permanent?

NousDefionsDoc
04-28-2004, 15:40
NP

SOAP?

Surgicalcric
04-28-2004, 15:40
Originally posted by lrd
I'm not sure if I'm asking this correctly, but which effects are temporary and which are permanent?

The affects of the blast are all injury dependent.


NDD:

Did you have a specific blast pattern or scenario in mind or just generalities?

What do you need the SOAP for? You scrubbing in? :D

NousDefionsDoc
04-28-2004, 15:56
Well, since the toy of choice for terrorists in the current theaters appears to be roadside IEDs, let's go with that.

Grasshopper, you will very shortly need to overcome your fear of SOAP.

So what is our SOAP for a blast from a roadside IED 5 klicks outside of Bagdad going to look like?

BTW, nice of you to volunteer.

Sacamuelas
04-28-2004, 16:14
The level of structural damage and injury caused by blast is dependent on the peak pressure(pressure decreases as you increase distance from origin), impulse length (a function of time and pressure), the overall shape of the pressure–time curve, and the elastic–plastic strength and natural period of oscillation of the structure or body.

In the human body, the shock wave/blast interacts with many types of tissues (eg, skin, fat, muscle and bone) that differ in density, elasticity and strength. Each tissue type, when interacting with a blast wave, is compressed, stretched, sheared or disintegrated by overload according to its properties.

Internal organs that contain air (sinuses, ears, lungs and intestines) are particularly vulnerable to blast.

These injuries are very difficult to diagnose. Will be interesting to hear how medics are trained to diagnose the internal injures. :munchin

Roguish Lawyer
04-28-2004, 16:14
Hey Crip:

Don't drop the SOAP.

NousDefionsDoc
04-28-2004, 16:16
Nice graphic

Crip, if you haven't saved your avatar, you might want to do so in the next 30 seconds.

Sacamuelas
04-28-2004, 16:20
LOL......

Hey RL... since your in the medical forum AGAIN cracking jokes, you might want to be careful too. ONE good post doesn't give you a free pass for very long in here. Remember ME from your brain MRI thread??? LOL hahha

Just kidding.. Alright, lets get back to the thread's topic. This is a very serious topic for current and future medics/soldiers.

Surgicalcric
04-28-2004, 16:21
For me to come up with a SOAP report for a patient I am going to need more patient/blast specific information.

Avatar has been saved for some time JIC.

NousDefionsDoc
04-28-2004, 16:23
More information like what?

26y/o WM...oh wait, you're supposed to be doing it!

:munchin

Surgicalcric
04-28-2004, 16:30
Was soldier riding or walking patrol? Proximity to blast device and position of body at time of blast in relation to blast (back, front, side), etc. I have never been very good with abstract patient assessment.

NousDefionsDoc
04-28-2004, 16:36
Riding in an unarmored HUMMV truck thing. Passenger side front.

30 meters.

Body position? - sitting LOL

Blast was right front quarter. They set it off too early, but not much.

Surgicalcric
04-28-2004, 16:50
NDD:

I can tell you what my primary concerns would be with this scenario, but I dont know how to put that into SOAP format without specific injuries being present with specific findings and specific complaints. Not trying to be evasive...

NousDefionsDoc
04-28-2004, 16:55
Go ahead Max, bail him out.

Max Power
04-28-2004, 16:58
One of the few times I'll post, but I've had some first hand experience with this type of situation, and I've got the blessing from NDD. Background, spent 8 months in Iraq (Fallujah), 11B, line platoon. My platoon alone hit 5 IEDs, the whole Bn is probably around 50.

First IED, went off between two of our Humvees (mine and the one behind me), daisy chained 155s, only one detonated. Lots of shrapnel, but nothing hit anyone, no other injuries (concussions, etc.).

Second IED, went off right beside a Delta Co. truck, no injuries, but plenty shaken up.

Third IED, little further off (25-50m), two mild lacerations (forehead and below eye) and I believe one mild burn where a piece of shrapnel slid between a gunner's IBA and body (it happened, just can't remember which one it was).

Fifth IED, probably 5m or less away from a truck, lots of debris in the air (LOTS), but no contact injuries. Two guys were knocked around pretty good, one was close to unconcious for a few minutes and was still shaken when we got back.

The big one, IED number 4. 2 155s surrounded by 3 55gal fuel drums. Instant non-hearing status for me, and a lot of others, hearing took a few days to come back fully. Lots of shrapnel, 6 WIA, 1 KIA that day. Lots of lower extremity shrapnel wounds, 2 in my squad got peppered on the lower legs (mainly calves) (one still has a piece behind his patella, right next to a major artery), another had a piece go through the left thigh and embedded into his right (just missing cock and balls). 3 guys were extremely close to the IED, first in line was KIA, punctured IBA and chest, severe burns, second had mild burns and a compound fracture of the foot, third had a cut on his inner thigh. Two other guys had small shrapnel embedded in the rear and tricep, didn't even notice till we got back.

That should give you some idea that injuries vary from one IED to another and can run the full spectrum of what is possible. I know of one instance where the only injury was a guy that had his nose cut off (they fixed that). Another one where an IED went off right beside the passenger door (in fact much like your scenario), and because they had taken the armor doors off, a piece of shrapnel cut his throat. Believe he is doing fine now. Fractures occured on that one as well.

What it boils down to on IEDs is that what happens all depends on a few things: 1) how the IED is emplaced and what it consists of; 2) how close the vehicle is to it (which can vary depending on speed, seperation, when it was triggered, etc.); and 3) unfortunately, luck.

Hope that's fine with you NDD, if you want me to change anything, let me know.

NousDefionsDoc
04-28-2004, 17:02
Thanks Max.

Let's used IED number 4. That help SCrip?

Surgicalcric
04-28-2004, 17:42
Originally posted by Max Power
...3 guys were extremely close to the IED, first in line was KIA, punctured IBA and chest, severe burns, second had mild burns and a compound fracture of the foot, third had a cut on his inner thigh. Two other guys had small shrapnel embedded in the rear and tricep, didn't even notice till we got back....


I am going with second man.

S 26 y/o walking patrol when IED detonated. C/O pain to R foot and to face/neck/hands.

O Pt found lying on ground. ABC +, A&O, PEARL, Partial thickness burns to areas exposed(face, neck, hands). LS-clear/equal w/ good rise and fall. Airway clear of extension burns. Obvious deformity and Fx to R foot no gross hemorrhage noted. No other S/S of trauma noted.

A Open Fx R foot and partial thickness burns ~10% BSA.

P Bandage and splint R foot with wire ladder splint and elastic bandage. Moist, sterile dressings on burns. IV saline lock R AC 18ga. Phentenyl LP for pain. Transport to FSH for eval and further Tx.

Did you want one for every PT?

NousDefionsDoc
04-28-2004, 21:47
Let's finish this one first, especially since we are doing them in reverse triage order (apparently).

Are you sure about A&O? How are you going to know?

Surgicalcric
04-28-2004, 21:55
When you asked for SOAP I did not know you meant for everyone. Damn thats an MCI for me..lol In triage we dont do reports so I just started with the one with the most injuries.
___________

I guessed on the A&O. It would be questioning on Person, Place, Time, & Events leading up to accident.

NousDefionsDoc
04-28-2004, 22:00
I guessed on the A&O. It would be questioning on Person, Place, Time, & Events leading up to accident.

Instant non-hearing status for me, and a lot of others, hearing took a few days to come back fully.


You guys triage by number of wounds. not severity?

Surgicalcric
04-28-2004, 22:09
Originally posted by NousDefionsDoc
You guys triage by number of wounds. not severity?

Thats not where I would start triage, but its the one I chose to start my 8-up SOAP report on. Triage would start with the first injured person I came upon. Treatment priorities assigned and then treatment and transport. Triage is based on mental status and repiratory rate.

NousDefionsDoc
04-28-2004, 22:17
LOL - we need to get Cap's missues to give you some SOAP trauma counseling.

Ok, again, how are you going to determine mental status - they're all deaf?

There might be a difference between battlefield triage and civilian - I don't know.

Does everybody agree that triage is based on mental state and respiratory rate or does somebody have a different idea?

NousDefionsDoc
04-28-2004, 22:19
What's the leading cause of death on the battlefield when its not immediate?

Anybody says gettin' shot or blown up is gonna sit in the corner for three days.

Surgicalcric
04-28-2004, 22:31
Originally posted by NousDefionsDoc
...Ok, again, how are you going to determine mental status - they're all deaf?
Questioning: person, place, time, and events. Written on note pad like in Saving Private Ryan at the crashed glider.

What's the leading cause of death on the battlefield when its not immediate?
Internal hemorrhage?

The Reaper
04-28-2004, 22:36
Originally posted by NousDefionsDoc
What's the leading cause of death on the battlefield when its not immediate?

Anybody says gettin' shot or blown up is gonna sit in the corner for three days.

If us non-medical types are permitted to guess, I would say exsanguination for those who do not make it to clinical treatment.

TR

NousDefionsDoc
04-28-2004, 22:39
That takes too much time IMO. To me, there's not a lot I can do about altered mental state at the scene, so I focus on the things I can fix. Make sure everybody's yelling "Medic!" (Airway, breathing), then move right to "C". The burns weren't too bad, so not likely to be a priority. Shrapnel seems to have done the most damage, so I'm looking for bleeders.

Seems like it was bleeding out. I would check the guys with the thigh wound first, especially the through and through to the other leg, make sure it didn't get the femoral.

quick glance at the compount FX to make sure he wasn't going to go south on me. Then deal with him after I'm sure of the thighs.

Plus, the thigh wound stands a good chance of going into shock if I don't reassure him about his package ASAP.

Make sense? Just me.

Surgicalcric
04-28-2004, 22:42
That was not in SOAP format Sarn't.

NousDefionsDoc
04-28-2004, 22:43
Originally posted by The Reaper
If us non-medical types are permitted to guess, I would say exsanguination for those who do not make it to clinical treatment.

TR


From the Special Operations Forces Medical Handbook (2001).

Circulation: Uncontrolled hemorrhage is the leading cause of preventable battlefield deaths. Rapid identification and effective management of bleeding is perhaps the single most important aspect of the primary survey while caring for the combat casualty.


Sir, a soldier with your training is hardly guessing.

NousDefionsDoc
04-28-2004, 22:44
Originally posted by Surgicalcric
That was not in SOAP format Sarn't.

LOL - Touche Cherry. I SOAP 'em after I get 'em dirty.

Surgicalcric
04-28-2004, 22:50
Originally posted by NousDefionsDoc
From the Special Operations Forces Medical Handbook (2001).

Circulation: Uncontrolled hemorrhage is the leading cause of preventable battlefield deaths. Rapid identification and effective management of bleeding is perhaps the single most important aspect of the primary survey while caring for the combat casualty.


Seems like I have seen that somewhere before...

NousDefionsDoc
04-28-2004, 22:52
Here's a SOAP for ya:

S -VERY year-old smart ass 18Xer reports to clinic app 22:48. C/O knowing it all.

O - Pt observed floundering around worried about mental status after a large order explosion thread. Guarding and avoidance on mention of SOAP format. PERRLA. Alert, however 12 on the NDD coma scale.

A - 1. Lack of quality time with old soldiers
2. Too much time as a civie

P - 1. Refer Pt to SFAS Instructors ASAP
2. Check PRN for attitude adjustment
3. Repeat SFAS PRN

LOL - I crack myself up.:D

Just funnin' ya Crip - you know you're my favorite 18B candidate.

NousDefionsDoc
04-28-2004, 22:53
Back to the PTs at hand. Do you agree with my analysis?

We'll see what Eagle has to say when he comes in.

Max Power
04-28-2004, 23:04
Well, in the case that was chosen, there are a few more things that should be mentioned. First, we were under fire after the blast, so there's a lot of gunfire going on. Second, the most serious injury (one closest to blast, punctured IBA, etc.) was still alive for sometime after the blast. Third, we had one medic, almost everything except the three closest to the IED was addressed using buddy aid.

Surgicalcric
04-28-2004, 23:05
Originally posted by NousDefionsDoc
Here's a SOAP for ya:

S -VERY year-old smart ass 18Xer reports to clinic app 22:48. C/O knowing it all.

O - Pt observed floundering around worried about mental status after a large order explosion thread. Guarding and avoidance on mention of SOAP format. PERRLA. Alert, however 12 on the NDD coma scale.

A - 1. Lack of quality time with old soldiers
2. Too much time as a civie

P - 1. Refer Pt to SFAS Instructors ASAP
2. Check PRN for attitude adjustment
3. Repeat SFAS PRN

LOL - I crack myself up.:D

Just funnin' ya Crip - you know you're my favorite 18B candidate.

You are too funny.

S- no comment

O- no comment other than shouldn't "knowing it all" fall in 'O' lol

A1- concur but working on that daily
2- what can I say...

P1- not much longer
2- James who...we have no idea who you are talking about Sarn't. No attitude here NDD
3- hopefully not

You are not baiting me with the 18B comments. I stumbled into that firing lane last time and I am not going to make that mistake twice. I barely escaped with my life last time.

Doc T
04-28-2004, 23:07
Originally posted by NousDefionsDoc
12 on the NDD coma scale.



care to elaborate?

NousDefionsDoc
04-28-2004, 23:07
Sounds like you guys and your medic did an outstanding job.

I'm sorry you lost your teammate.

With the added information, the chest wound becomes my #1 priority, followed by the through and through thigh.

NousDefionsDoc
04-28-2004, 23:10
Originally posted by Doc T
care to elaborate?

Just messin' with Crip, ma'am. I didn't know you were here. I'll stop now.:o

Surgicalcric
04-28-2004, 23:11
I would agree.

I was under the impression from your wording Max the soldier with the chest injury was deceased. He would have become my first priority.

On that note, I find it difficult to treat patients sometimes without being able to physically see them and what occurred. This was a good learning tool though.

Doc T
04-28-2004, 23:12
Originally posted by NousDefionsDoc
Just messin' with Crip, ma'am. I didn't know you were here. I'll stop now.:o

the residents have a hard enough time remembering the glascow coma score....was hoping for something more interesting....

keep messing around.... James can take it I am sure....

doc t.

NousDefionsDoc
04-28-2004, 23:12
O- no comment other than shouldn't "knowing it all" fall in 'O' lol

Only if I actually observed you knowing something. NOW STOP! Doctor Ma'am is here - no more messin' around.

Are you still going with mental status and respiratory rate for triage?

Surgicalcric
04-28-2004, 23:17
Originally posted by NousDefionsDoc
...Are you still going with mental status and respiratory rate for triage?
Thats what I was taught as the primary triage standard for MCI's. Secondary triage is mechanism of injury and pulse rate or B/P.


Mass Casualty Incident, for those that dont know, is defined as any incident where the number of patients is greater than the resouces immediately available to treat their injuries.

NousDefionsDoc
04-28-2004, 23:24
Well, in this case, Max has told us that there were seven casualties and one medic. So the medic has to triage. Not to say everybody else wasn't helping, as Max pointed out.

Plus, you have security to worry about. Those little bastards may not be finished.

This is the kind of event that happens.

Max, what's your TO&E for medics? One per platoon? Combat Lifesavers?

Max Power
04-28-2004, 23:31
One per platoon. Ironically, he wasn't CLS qualified, whereas we had others that were. Unfortunately, most of the CLS guys were the leadership (TLs, SLs, PSG). That day took out 2 SLs, 2 TLs, and the PL. We were hurting for a while.

So basically, whoever could took care of whoever they could using the basics. Eventually (I say that because it seemed like a few minutes, but I was informed later it was possibly almost an hour or more before the QRF got there) our BN PA came on scene, but that was after we'd already gotten the worst guys over to the field hospital.

I apologize, some of the very minute details are still unclear, I was busy trying to engage any targets and having to move my Humvee all over the place when they tried to reorganize security, etc.

NousDefionsDoc
04-28-2004, 23:38
Don't worry about the details. Completely understandable.

That's one medic to every 40 or so. The event took out most of the leadership and along with it the CLS. Very Murphy's Law. And very the reason SF Teams cross train so much.

Sounds like you guys did very well, as US soldiers are known to do.

Max Power
04-28-2004, 23:41
Glad to have been of help. Anything I can do to help current/future medics. I view it as an investment in the future, never know when I may need one. Take care guys. Let me know if you want any more details on this or any of the other cases.

Surgicalcric
04-29-2004, 07:54
Thank you Max Power. From the sounds of things you guys did great.

Is one medic per platoon standard army wide? I ask because it sounds like the Medics are spread way too thin at least in combat. Sounds like maybe Mother Army needs to follow suit with Ranger Regiment and have an EMT-B+ per squad.

Thanks again Max.