Emergency Medical Services-MD15
CASE OF THE MONTH — November/December 2020
EMS responds to an explosion at an industrial site. A 44-year-old male was performing maintenance work when a pressurized gas tank in the next room exploded. The patient was thrown 15 feet, striking an adjacent wall. Co-workers called 911 following the blast. The patient is extricated from the blast site within minutes.
This patient has sustained multi-system trauma and should be treated in accordance with TP-1244, Traumatic Injury. Blast injuries can result in traumatic injury by multiple mechanisms.
Primary blast injury results from the pressure changes associated with the blast wave of the explosion moving through the body. Injury manifestations include tympanic membrane rupture, injury to lung tissue, bowel perforation and globe rupture.
Secondary blast injury results from the projectile debris from the blast striking the patient, leading to penetrating trauma.
Tertiary blast injury is due to blunt force trauma from the patient striking another object due to being thrown by the explosive blast.
Quaternary blast injury is the result of the sequelae of the blast including burns, fume inhalation, and chemical exposures.
This patient will require a full trauma assessment. After assessing for and controlling any major hemorrhage, one should proceed to managing the airway, assessing for adequate breathing, circulation and disability. Once extricated, the patient will need to be exposed to assess for major injuries and then transported to the appropriate receiving facility, based on the injuries identified.
A primary survey is completed. The patient’s airway is intact. Equal breath sounds are noted with normal tidal volume. He has a contusion to his right flank, deformity to his right distal forearm, and diffuse abdominal tenderness to palpation. There are wounds to his face including multiple superficial penetrating debris wounds. There are no penetrating injuries to the torso or extremities. The patient is fully alert and oriented. However, he has difficulty hearing. Vitals signs are BP 120/74, HR 120, RR 20, O2Sat 98%.
This patient will require systematic management of his traumatic injuries. He is hemodynamically stable and does not require intravenous fluids at this time. One should follow guidelines for permissive hypotension in the setting of trauma, only administering fluids for SBP < 90 when signs of poor perfusion are present. The patient will need to be exposed so that a secondary survey can be completed to determine the extent of his traumatic injury. Pain should be addressed. Spinal motion restriction should be maintained given his mechanism.
Secondary trauma survey reveals the following:
- Decreased hearing, possibly due to a tympanic membrane rupture
- Superficial projectile debris embedded in the face
- Blurry vision and pain to the right eye with a visible foreign body and irregularly shaped pupil Penetrating Globe
- Diffuse abdominal tenderness
- Right flank contusion
- Closed right forearm deformity
Paramedics administer Fentanyl 50mcg IV for pain control. Repeat vital signs are BP 122/88, HR 115, RR 16, O2Sat 98%.
Spinal motion restriction should be maintained in accordance with MCG 1360 – Spinal Motion Restriction. His right arm should be splinted in a position of comfort after confirming normal pulses and perfusion to the extremity. The patient likely has an intraabdominal injury which may be due to a solid organ injury (e.g. liver or spleen rupture) from blunt force trauma that could lead to significant blood loss, or bowel perforation from the blast. Often with blast injury the external signs of injury may be less than the internal injuries so assume the patient is seriously injured regardless of physical findings. The patient should be reassessed frequently to look for signs for hemorrhagic shock. The eye should be shielded which means protected but not patched placing no additional pressure on the eye.
Eye Injuries are treated in accordance with TP-1228 – Eye Problem. A globe rupture should be suspected for any penetrating eye injury. Signs of globe rupture include vision loss, “deflated” appearing globe as compared to the other side, irregularly shaped pupil, or visible prolapse of intraocular contents. The priority in management is to prevent further damage to the eye. One must avoid applying any pressure to the affected eye and place an eye shield to protect the eye from further injury. If a commercial eye shield is not available, sunglasses or a foam cup can be substituted.
Do not patch the eye as this will apply pressure to the globe and further damage the eye. Ocular injuries are usually associated with nausea and vomiting. Further, vomiting should be prevented, because the increase in pressure generated can further damage a ruptured globe. Treat nausea with Ondansetron 4mg ODT/IV/IM. Impaled foreign bodies should be left in place.
The patient remains hemodynamically stable at the scene and his injuries are addressed. After placing a splint for his forearm fracture and sunglasses to shield the eye, ondansetron is given for nausea. The patient meets trauma criteria due to his diffuse abdominal pain. He is transported to the nearest Trauma Center. In the Emergency Department, free air is noted in his abdomen on CT Scan and a bowel perforation is repaired in the operation room. Specialists address his fractures and globe rupture.
- Blast injuries result from 4 primary mechanisms related to pressure waves, penetrating injury, blunt force injury, and injury from environmental sequelae from the blast.
- All trauma patients should be evaluated and treated systematically in accordance with a primary survey including addressing airway, breathing, circulation, disability and exposure.
- Stable trauma patients should have a complete secondary survey performed prior to transport to identify injuries.
- For a suspected globe rupture, the injured eye must be shielded. Avoid pressure to the eye and treat nausea with ondansetron.
Author: Dr. Denise Whitfield, MD