Blast Injuries
http://www.100md.com
《新英格兰医药杂志》
To the Editor: DePalma et al. (March 31 issue)1 review four patterns of injuries from explosions and offer protocol for evaluating blast injuries that is based on the presence or absence of ruptured tympanic membranes. However, as suggested in the article, tympanic-membrane perforations are found in only 60 percent of patients with clinically significant injuries, and clinically significant injuries are present in less than 30 percent of patients with tympanic-membrane perforations.2,3
We summarize our findings from our experience with more than 30 mass-casualty incidents caused by terrorist bombing. First, most persons with clinically significant blast-associated lung injury have respiratory failure within minutes after the explosion. Among those few who have delayed respiratory failure, additional features are manifested in the primary evaluation, such as dyspnea and hemoptysis. Relying on tympanic-membrane perforation and a screening chest radiograph is unnecessary. Second, patients in stable condition — with or without tympanic-membrane perforation — who do not have hemoptysis or tachypnea and in whom the primary evaluation reveals no evidence of other clinically significant injuries may be discharged if vital signs are stable after four to six hours of observation. Finally, multiple penetrating wounds from metallic fragments are common, creating diagnostic and treatment difficulties, especially in persons in unstable condition. If blood is present in the trachea, we consider blast-associated lung injury to be the primary cause of instability and treat the condition accordingly. However, if the patient has no response to treatment or if blood is not present in the trachea, penetrating trauma should be considered as the cause of instability.
Itamar Ashkenazi, M.D.
Hillel Yaffe Medical Center
Hadera 38100, Israel
i_ashkenazi@yahoo.com
Oded Olsha, M.B., B.S.
Shaare Zedek Medical Center
Jerusalem 91031, Israel
Ricardo Alfici, M.D.
Hillel Yaffe Medical Center
Hadera 38100, Israel
References
DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med 2005;352:1335-1342.
Katz E, Ofek B, Adler J, Abramowitz HB, Krausz MM. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg 1989;209:484-488.
Gutierrez de Ceballos JP, Turegano Fuentes F, Perez Diaz D, Sanz Sanchez M, Martin Llorente C, Guerrero Sanz JE. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33:Suppl:S107-S112.
To the Editor: Current explosive devices are particularly challenging in that they are often loaded with metallic objects to inflict penetrating injuries in crowded civilian settings. The Israel National Center for Trauma and Emergency Medicine Research manages the Israeli National Trauma Registry and has accumulated data in the past four years on the nature and consequences of these new injuries and the challenges they present for caregivers. The registry has data on 976 people who have been injured by explosions. Explosives detonated by suicide bombers frequently included nails, bolts, and other metal parts, often referred to as shrapnel. Detonation in crowded and confined spaces increased the effects of the explosions. Nearly 30 percent of hospitalized patients had injuries that were categorized as severe to critical (injury-severity score, 16). Triage has changed, since shrapnel, nails, and bolts contained in the bombs penetrate the body with great force and may result in tiny holes that are easily hidden by hair or clothes. Among casualties of explosive devices set off by suicide bombers, 37 percent of patients underwent computed tomographic scanning and 26 percent underwent ultrasonographic scanning in the emergency department; others underwent total-body fluoroscopy in the operating room. From the emergency department, 28 percent of the patients went directly to the operating room, 10 percent to the intensive care unit, and only 58 percent directly to the ward (approximately 3 percent were unaccounted for). The injuries were mainly internal injuries, open wounds, and burns, with an excess of injuries to nerves and to blood vessels as compared with other trauma situations. Some patients had multiple complex injuries that called for contradictory treatment protocols. These findings have implications for triage, diagnosis, treatment, hospital organization, and the definition of surge capacity.
Kobi Peleg, Ph.D., M.P.H.
Limor Aharonson-Daniel, Ph.D.
Israel National Center for Trauma and Emergency Medicine Research
Tel Hashomer 52621, Israel
kobip@gertner.health.gov.il
To the Editor: The Kleihauer–Betke assay does not test for maternal hemorrhage, as stated in the article by DePalma et al. on blast injuries. Instead, it is a test for the presence of fetal red cells in the maternal circulation.1 Although small numbers of fetal cells can be detected in the maternal circulation throughout gestation, large numbers of fetal red cells in the maternal circulation are diagnostic of fetal–maternal hemorrhage, as with placental abruption. Pregnant women who have sustained abdominal trauma from any cause and who have a positive Kleihauer–Betke test should receive Rh immune globulin to prevent Rh isoimmunization if they are Rh-negative and unsensitized.
Mack Barham, M.D.
Monroe Surgical Hospital
Monroe, LA 71203
armadilo@bayou.com
References
Kleihauer E, Braun H, Betke K. Demonstration von Fetalem Haemoglobin in den Erythrozyten eines Blutausstriches. Klin Wochenschr 1957;35:637-637.
The authors reply: We thank Dr. Barham for his clarification regarding the Kleihauer–Betke assay.
The clinical experience of our Israeli colleagues and the importance of the Israeli National Trauma Registry in documenting the nature, severity, and outcomes of injuries from terrorist bomb explosions cannot be overemphasized. The schema of tympanic-membrane evaluation was offered as a tool for a limited subgroup of persons involved in mass-casualty situations who have been spared fragment injuries but might have sustained a blast injury. We agree that patients who incur pulmonary injuries from a blast, particularly in a confined space, will have immediate symptoms.
Ralph G. DePalma, M.D.
Veterans Health Administration
Washington, DC 20420
rgdepalma@mail.va.gov
David G. Burris, M.S.
Howard R. Champion, F.R.C.S.
Uniformed Services University of the Health Sciences
Bethesda, MD 20814
We summarize our findings from our experience with more than 30 mass-casualty incidents caused by terrorist bombing. First, most persons with clinically significant blast-associated lung injury have respiratory failure within minutes after the explosion. Among those few who have delayed respiratory failure, additional features are manifested in the primary evaluation, such as dyspnea and hemoptysis. Relying on tympanic-membrane perforation and a screening chest radiograph is unnecessary. Second, patients in stable condition — with or without tympanic-membrane perforation — who do not have hemoptysis or tachypnea and in whom the primary evaluation reveals no evidence of other clinically significant injuries may be discharged if vital signs are stable after four to six hours of observation. Finally, multiple penetrating wounds from metallic fragments are common, creating diagnostic and treatment difficulties, especially in persons in unstable condition. If blood is present in the trachea, we consider blast-associated lung injury to be the primary cause of instability and treat the condition accordingly. However, if the patient has no response to treatment or if blood is not present in the trachea, penetrating trauma should be considered as the cause of instability.
Itamar Ashkenazi, M.D.
Hillel Yaffe Medical Center
Hadera 38100, Israel
i_ashkenazi@yahoo.com
Oded Olsha, M.B., B.S.
Shaare Zedek Medical Center
Jerusalem 91031, Israel
Ricardo Alfici, M.D.
Hillel Yaffe Medical Center
Hadera 38100, Israel
References
DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med 2005;352:1335-1342.
Katz E, Ofek B, Adler J, Abramowitz HB, Krausz MM. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg 1989;209:484-488.
Gutierrez de Ceballos JP, Turegano Fuentes F, Perez Diaz D, Sanz Sanchez M, Martin Llorente C, Guerrero Sanz JE. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33:Suppl:S107-S112.
To the Editor: Current explosive devices are particularly challenging in that they are often loaded with metallic objects to inflict penetrating injuries in crowded civilian settings. The Israel National Center for Trauma and Emergency Medicine Research manages the Israeli National Trauma Registry and has accumulated data in the past four years on the nature and consequences of these new injuries and the challenges they present for caregivers. The registry has data on 976 people who have been injured by explosions. Explosives detonated by suicide bombers frequently included nails, bolts, and other metal parts, often referred to as shrapnel. Detonation in crowded and confined spaces increased the effects of the explosions. Nearly 30 percent of hospitalized patients had injuries that were categorized as severe to critical (injury-severity score, 16). Triage has changed, since shrapnel, nails, and bolts contained in the bombs penetrate the body with great force and may result in tiny holes that are easily hidden by hair or clothes. Among casualties of explosive devices set off by suicide bombers, 37 percent of patients underwent computed tomographic scanning and 26 percent underwent ultrasonographic scanning in the emergency department; others underwent total-body fluoroscopy in the operating room. From the emergency department, 28 percent of the patients went directly to the operating room, 10 percent to the intensive care unit, and only 58 percent directly to the ward (approximately 3 percent were unaccounted for). The injuries were mainly internal injuries, open wounds, and burns, with an excess of injuries to nerves and to blood vessels as compared with other trauma situations. Some patients had multiple complex injuries that called for contradictory treatment protocols. These findings have implications for triage, diagnosis, treatment, hospital organization, and the definition of surge capacity.
Kobi Peleg, Ph.D., M.P.H.
Limor Aharonson-Daniel, Ph.D.
Israel National Center for Trauma and Emergency Medicine Research
Tel Hashomer 52621, Israel
kobip@gertner.health.gov.il
To the Editor: The Kleihauer–Betke assay does not test for maternal hemorrhage, as stated in the article by DePalma et al. on blast injuries. Instead, it is a test for the presence of fetal red cells in the maternal circulation.1 Although small numbers of fetal cells can be detected in the maternal circulation throughout gestation, large numbers of fetal red cells in the maternal circulation are diagnostic of fetal–maternal hemorrhage, as with placental abruption. Pregnant women who have sustained abdominal trauma from any cause and who have a positive Kleihauer–Betke test should receive Rh immune globulin to prevent Rh isoimmunization if they are Rh-negative and unsensitized.
Mack Barham, M.D.
Monroe Surgical Hospital
Monroe, LA 71203
armadilo@bayou.com
References
Kleihauer E, Braun H, Betke K. Demonstration von Fetalem Haemoglobin in den Erythrozyten eines Blutausstriches. Klin Wochenschr 1957;35:637-637.
The authors reply: We thank Dr. Barham for his clarification regarding the Kleihauer–Betke assay.
The clinical experience of our Israeli colleagues and the importance of the Israeli National Trauma Registry in documenting the nature, severity, and outcomes of injuries from terrorist bomb explosions cannot be overemphasized. The schema of tympanic-membrane evaluation was offered as a tool for a limited subgroup of persons involved in mass-casualty situations who have been spared fragment injuries but might have sustained a blast injury. We agree that patients who incur pulmonary injuries from a blast, particularly in a confined space, will have immediate symptoms.
Ralph G. DePalma, M.D.
Veterans Health Administration
Washington, DC 20420
rgdepalma@mail.va.gov
David G. Burris, M.S.
Howard R. Champion, F.R.C.S.
Uniformed Services University of the Health Sciences
Bethesda, MD 20814