- Part I: Physiology and pathophysiology of shock
- Part II: Triage, treatment, and the rapid trauma assessment
- Part III: Treatment philosophy and things to think about in SHTF/WROL
Today we’ll look at what types of trauma injuries would be most likely in a SHTF/WROL scenario where Bolshevik flying monkeys have nuked your metro area and are putting the squeeze on the outlying areas in an attempt to impose a flying monkey worker’s paradise in your town.
Let’s do some cursory exploration of wound types in our wars in Afghanistan and Iraq:
The United States forces in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) are primarily engaged in counterinsurgency operations within an irregular war. The US combat medical experience has reported new injury patterns secondary to the enemy’s reliance on explosive mechanisms, particularly improvised explosive devices (IEDs), and the widespread use of individual and vehicular body armor. Musculoskeletal extremity injuries have been reported to comprise approximately 50% of all combat wounds for OIF/OEF. Utilization of individual body armor has dramatically reduced thoracic injuries and has decreased the lethality of gunshot wounds, as measured by the percent killed in action, which in conflicts prior to OIF/OEF was estimated at 33% but is now 4.6%. Explosive mechanisms of injury, with IEDs being the most common, account for over 75% of all combat casualties. The lethality of IEDs coupled with the protection of the thorax and abdomen provided by individual body armor has resulted in increasingly severe orthopaedic injuries. Collection and careful examination of orthopaedic combat casualties will allow for improved military personnel protective measures and treatment of injured soldiers. (Journal of Surgical Orthopaedic Advances 19(1):2–7, 2010)Source: LTC Philip J. Belmont, Jr., MD, MAJ Andrew J. Schoenfeld, MD, and CPT Gens Goodman, DO, Epidemiology of Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom: Orthopaedic Burden of Disease, Journal of Surgical Orthopaedic Advances, Copyright 2010 by the Southern Orthopaedic Association
The distribution of wounds in soldiers WIA [wounded in action] is reflected by the different mechanisms of injury. Gunshot wounds most commonly involve single body regions (e.g., head/neck, thorax, abdomen, or extremities) and characteristically have a single entrance and exit wound. In contrast, explosive injuries tend to simultaneously affect multiple body regions….Owens et al. (11) also reported that explosions were responsible for 75% of orthopaedic injuries, while gunshot wounds accounted for 16%. Fifty-three percent of wounds were penetrating injuries to the soft tissues and a further 26% were fractures (11). Eighty-two percent of all fractures were found to have been open injuries (11). Fractures and soft tissue injuries were evenly distributed between the upper and lower extremities, with hand fractures being the most common fracture type in the upper limbs and tibia–fibula fractures most common in the lower limbs (11)…Over the course of the 20th century, a generalized trend has occurred whereby the number of casualties due to explosives has increased relative to those caused by gunshot. In World War I, 65% of all recorded combat casualties resulted from gunshots (21). This decreased to 35% during Vietnam (22) and has been reported to be between 16% and 23% in recent studies of OIF/OEF (9, 11). An analysis of the epidemiology of injuries in OIF/OEF documented that 81% of all injuries were due to explosions (19). The 16%–23% casualty figure for ballistic trauma during OIF/OEF represents the lowest proportion of military wounds from gunshots in history (9, 11, 19)
Blast injuries from explosions have three phases:
- Primary injuries: The overpressure or pressure wave from an explosion. This hits the fastest, and will cause damage to the inner ears, lungs, and every hollow organ in your body (intestines, stomach, etc.) if you are close enough to the blast.
- Secondary injuries: This is the fragmentation wave that sends shrapnel everywhere and causes massive soft tissue damage from penetrating and puncture wounds. Amputations happen here.
- Tertiary injuries: This is the “blast wind” that will throw people around and into things. Depending on the force of the explosion, this can be an extremely deadly phase.
As indicated by the article above, a person who is subject to an explosion is going to have multiple traumatic injuries at once, including traumatic brain injuries. When you add burns and burn damage to the airway from a blast, you understand why these weapons are so deadly, and why they are the choice weapon for insurgents fighting a conventional military force.
Key to treating these injuries is to remember your rapid trauma assessment and fixing the immediate life threats as you find them. The mental state of your patient is going to be very important on these, as the more debilitated he is, the more severe the injury may be to his brain. Always be suspicious of cervical spine injury with these. Take c-spine precautions immediately and work in a field neuro exam to test for injury along the spine. Infection is a huge concern because of open fractures, amputations, penetrating wounds, and the mixture of dirt, fuel, explosives, other people’s body parts / blood mixing in with your patient’s wounds. Once stabilized, massive doses of antibiotics and debridement of burned and heavily damaged flesh is critical. Definitive treatment at a specialty center is absolutely required. These injuries will test all of your skills and your mettle. You will need to work fast and always keep the triage priority in mind.
These are injuries that compromise the patient’s ability to get air into his lungs to breathe. With explosions and burns, you need to look around the patient’s nose and mouth for soot and/or swelling indicating he inhaled hot gases. Your concern here is that his airway may swell shut and it’s game over. It’s critical to get an advanced airway that isolates the trachea in place BEFORE the swelling gets bad in these patients. Supraglottic airways like Cobras, Kings, and LMAs aren’t effective because they sit in the esophagus and are of no use if the trachea swells shut. If the patient is conscious, has a gag reflex, and is still breathing on his own, you may be able to insert a nasotracheal tube, or use rapid sequence induction if you have the training and the drugs to do it. If the patient is unconscious with no gag reflex, a regular endotracheal tube is what you need.
In a patient has seriously altered mental status and is at risk of aspirating blood, vomit, or anything else into his lungs, you’ll need an advanced airway.
Severe facial trauma is scary, and something you’ll see in an environment where explosions are happening and bullets are flying. Nasotracheal (NT) tubes are a no-no in this case, as the patient may have a basilar skull fracture, and your insertion of the NT tube into his nose may end up in his brain, and that’s bad. In the rare cases where someone we’ve encountered has been less than successful with a gun-under-chin suicide and blown his lower jaw off, we have the saying “aim for the bubbles” when it comes to getting the airway. This is also the scenario where the surgical cricothyrotomy may be indicated. This is a procedure – bluntly stated – where you cut a hole in your in a space in your patient’s Adam’s apple and insert an endotracheal tube directly into the trachea. If you are having to do this, your patient’s day and your day sucks.
Advanced airways are, in my mind, part of the cool-guy gear contingency. This is good and bad. If I can easily ventilate a patient with a bag valve mask and keep him perfused adequately until disposition to definitive care, I am staying with that. If I have a patient who is still breathing on his own but has an airway that is in danger of being compromised, I would choose a nasotracheal tube (NT) as my first course of action before performing rapid sequence induction (RSI), where you sedate your patient, completely paralyze him, including his ability to breathe on his own, with paralytic drugs, insert an endotracheal tube using a laryngoscope, and assist him with ventilations for as long as he is your care. An unconscious patient that isn’t breathing is getting an ET tube, no drugs needed unless we resuscitate him and he needs sedation to keep from pulling the tube out. I make very sure that my decisions on airway are based on getting the right physiological outcome and minimizing risks to the patient. Taking away a guy’s ability to breathe on his own is a hell of a responsibility and should be done with proper consideration.Treat that patient as you would your wife, kids, or relatives in this situation, and don’t be cavalier about what you use to keep their airway open.
Keeping the SHTF/WROL scenario in context, if you are in the middle of nowhere with minimal access to rapid transport and specialty centers, the prognosis for your patient needing an advanced airway is poor.
The 13 years of war and the use of IEDs by the man-jammie crowd has created a high incidence of traumatic brain injuries (TBIs) in our wounded guys. I’m going to cover three injuries very briefly. The treatment for all of them is essentially the same. Put the patient in full spinal immobilization and get them out of the fray. The reality is, a mild TBI like a concussion can have the same initial presentation as an epidural bleed, which can kill you pretty dead, pretty fast. If you are able to differentiate what kind of TBI your patient has in the field, it’s probably because he’s dying in front of you. These injuries require rapid transport to emergency care where a CT scan can be done on the head to help diagnose the injury and give the patient definitive care.
Concussion: Your patient gets knocked out for a short period and wakes up confused. This state of confusion can last anywhere from under 30 minutes to over 24 hours. He may be dizzy, sleepy, and nauseous after the injury. If those symptoms continue or get worse, he may have something a lot more serious. Remember your rapid trauma assessment and focus on the AVPU portion. Also make sure you are looking for dilated pupils bilaterally or on one side. They may indicate the next type of TBI. If your patient only has a concussion, he will require physical and mental rest for a while. The level really depends on the severity of the concussion.
Epidural bleed or hematoma: Without going too much into the anatomy and physiology on this one, this can present very similarly to a concussion at the outset. The difference is that an artery has been damaged and is bleeding away in the space between the brain and the skull. Your patient will be knocked out for a short period, and may wake back up into a brief lucid period. Shortly thereafter, the effects of the bleed will take effect; extreme headache, dizziness, blurred vision, nausea, vomiting, weakness, seizures, and dilated pupils in one or both eyes. What’s happening is blood filling up space in the skull, pushing on the brain, and forcing it to herniate out of the opening in the back of the skull called the foramen magnum, where the spine and spinal cord connect to the brain. Without immediate treatment of getting the excess fluid out of the skull and stopping the bleed, this is a fatal condition.
Subdural hematoma: This is a venous (not arterial) bleed in between membranes that surround the brain called the meninges. A subdural hematoma is often caused by a rapid acceleration / deceleration event that causes injury to bridging veins within the meninges. Since it is a venous injury, the bleed is much slower than the arterial bleed epidural hematoma and the onset of symptoms is much slower. Like it’s arterial cousin, the subdural hematoma starts to fill the skull cavity with extra blood, causing increased pressure on the brain and inside the skull. Ultimately, the patient will have symptoms of headache, dizziness, nausea, vomiting, weakness, seizures, disorientation, and dilated pupils. There is high risk for brain herniation, and like the epidural hematoma, definitive care is rapid transport to an OR for surgery to stop the bleed and relieve the pressure. Without that, the prognosis is fatal.
Other things to watch out for with TBIs are the presence of cerebral spinal fluid (CSF) in the ears or nose. This indicates that something has broken the blood / brain barrier, and the shock-absorbing fluid that the brain floats in is leaking out of a fracture or penetration of some kind. Sean Parnell, the walking badass Ranger captain that wrote the book Outlaw Platoon chronicles how he got a TBI in a firefight in Afghanistan but continued to lead his men for weeks with CSF leaking out of his ears. He ended up being medically discharged in the end because of the extensive damage neurological damage done, but he lives today to talk about it. Crazy? Brave? Lucky? Probably plenty of each. In any case, don’t screw around if you see CSF, even if your patient is OK. Get them off the field and into care as soon as practicable.
Continued assessment of EVERYONE that you suspect of having a TBI is critical to their survival. Keep up on their mental status and treat with an over abundance of caution. Check a blood glucose level of a suspected TBI patient if you have the equipment because injuries to the central nervous system can cause it to gobble up massive amounts of glucose. An abnormally low BGL reading in a suspected TBI patient with no history of hypoglycemia can help you narrow your differential diagnoses.
As shown in the metrics above, these are the most likely injuries you will encounter if things are hot and the lead is flying. In blast injuries, be ready to deal with MULTIPLE extremity injuries on one patient. Refer to the rapid trauma assessment piece for procedures to stop bleeding and deal with open and closed fractures.
Here you will see punctures, tears (or avulsions), fractures of all kinds, amputations, burns of all kinds.
Key with these is preservation of motor and sensory function of the extremities as much as you can. If you can avoid cutting off circulation to a limb entirely with a tourniquet and stop bleeding with other measures, there will be a better prognosis for the patient. If you are dealing with an arterial bleed and the patient is fading fast, don’t screw around. Get that CAT-T on it and get on with it.
Bullet wounds will have cavitation damaging tissues in a much great area than the diameter of the bullet holes. The faster the projectile is going, the worse the damage will be.
As mentioned before, infection is going to be a top-level worry. Getting the wounds cleaned and dressed is a top priority. Broad spectrum IV antibiotics may be needed. Minor extremity wounds can be treated in the field with attention to hygiene and regular reassessments of the patient and the wound.
Since we’re dealing with squads of imperfect people who may have different levels of physical ability running around doing things with heavy packs on their backs, be ready for strains and strains of ankles and wrists from people losing their footing and flopping onto the ground. Practice your splinting techniques when you get together with your team and see how well you move around with a guy limping along with a gimp leg. Have fun carrying his gear, too.
Thoracic and abdominal wounds
From the study above, we see that the use of body armor has helped reduce the number of wounds to the thorax (chest) and abdomen. Here are a couple of great illustrations I stole from AR15.com that show proper placement of rifle plates to cover the most vital areas of the thorax.
As you can see, a good SAPI plate can prevent a lot of bad things from happening, but there are still enough vital areas exposed that can be of concern. In Part I of this series, we talked about hemorrhages, and in Part II, areas of the body that we need to be especially concerned about should somebody receive a penetrating wound, like in the pelvis, since there is a very high probability of massive blood loss. Rifle plates do a great job of covering the mediastinum, which in gross terms is the center of your chest containing the heart and the great vessels – the aorta and vena cavae. However, once you get outside of the SAPI plate, with great concern about the abdomen, you still have things like the descending aorta, the iliac arteries, the inferior vena cava, and of course, the spine. For any patient that’s been shot in the abdomen below the SAPI plate, be on the lookout for massive internal bleeding and shock. Penetrating abdominal wounds are nasty, because in addition to tissue damage, whatever is in the small and large intestines is going to spill into the abdominal cavity if they are damaged. This is yet another cause for nasty infections. If your patient’s spine has been hit, he’ll complain about leg pain, weakness, numbness, or just plain not feeling anything below the wound site. Check for pulse, motor, and sensory function below the site of the injury. If you can get this guy into full spinal immobilization ASAP, that’s a good thing. These patients need to be transported out to definitive care as well.
If your patient is hit above the SAPI plate in the clavicles, be suspicious of damage to the subclavian artery and vein that run underneath the clavicle. Damage to the patient’s trachea and neck are very serious and need to be dealt with immediately with special concern being the compromised airway. Be suspicious of a pneumothorax as well, since there is still enough lung poking around the side of the plate to cause trouble. Check and recheck your patient’s breathing rate, capillary refill, and AVPU routinely to ensure he is getting perfused.
There is still plenty of opportunity for a patient to experience extreme blunt force trauma to the chest and abdomen even with soft armor and plates in place. The armor helps mitigate it, but if the force is big enough, you can still wind up with a patient with serious internal injuries. Look for massive bruising developing wherever the blunt impact took place. If over the chest, be suspicious of pneumothorax, hemothorax, and pulmonary contusion – which is a bruise to the lung tissue itself. The pneumo and the hemo are air and/or blood filling up the thoracic cavity outside of the lung and compressing the lung. The pulmonary contusion is the vessels and capillaries in the lungs bleeding themselves. With this, you get blood in the lungs disrupting gas exchange at the alveoli. Be on the lookout for this after a blast as well. Be prepared to assist ventilations with a bag valve mask. In bad cases, deep suctioning may be needed to help get fluid out of the lungs.
Look for bruising in the abdomen after any blunt trauma and always be suspicious of liver lacerations, spleen lacerations, and damage to the great veins. If the patient’s abdomen becomes distended and he is presenting with signs of shock, this is an ominous sign of an internal bleed.
If nothing else, the wound potential to these areas should be motivation for you to get in enough shape to drop to prone and minimize your profile or be able to run fast enough to find cover should flying monkeys be hurling kinetic weapons at you.
Burns will always be a concern when angry people and Bolshevik flying monkeys are in conflict with each other. The Ukrainian resistance definitely lived up to their Kievan Rus heritage with the employ of the molotov cocktail.
As mentioned in the Blast Injury section, you FIRST concern with a burn patient is going to be his airway. Look for soot, redness, swelling, and blistering around the nose and mouth. If present, you need to secure an airway ASAP because this patient may have gotten a lungful of scorching hot gases and his airway is going to swell shut. If your patient is already complaining of having trouble breathing, trust him and know that his airway may be closing up. You need an airway that isolates the trachea, and this means either a nasotracheal or endotracheal tube, both of which are advanced airways.
Below is a very perfunctory breakdown of burn types.
A first degree, or superficial burn is on the epidermis only. Sunburn? Touch a radiator? Redness and a little swelling? Pain? That’s what it looks and feels like.
A second degree, or partial thickness burn goes deeper into the dermis from the epidermis. These can present with blisters, deep, dark redness to whiteness. These burns are very painful, because the dermis is thick with sensory (or afferent) nerve endings that like to tell the brain how much pain they are in.
A third degree, or full thickness burn goes through epidermis, dermis, and subcutaneous layer. These tend to be dark brown in color and leathery in appearance. Essentially, the proteins in the skin have been denatured, which is the same thing that happens to an egg when it goes from liquid to solid when you fry it. These burns tend not to hurt because the nerve endings that tell the brain that there is pain have been destroyed. However, you don’t see a third degree burn without a big old ring of second degree burn wrapping around it, so these patients will still be in pain.
There is a tool we use to determine the total body surface area (TBSA) of the burn called the Rule of Nines, that helps drive treatment priority and planning. Below is a graphic showing how you apply the rules to body areas (Source:http://armymedical.tpub.com/MD0576/MD05760056.htm):
Once you calculate the percent of body area burned, here is a suggested treatment priority:
“GCS” stands for Glasgow Coma Scale, which is a more detailed AVPU diagnostic tool that you should definitely check out.
Any patients that are yellow or red priorities are going to be in immense pain (so can a green, but we’re talking life threats here). As a paramedic, we are limited to how much morphine we can give a patient based on protocols and what’s on the truck. With MD approval, we can give more. It is not uncommon for an MD to load you up with lots of extra morphine when you are transporting a severe burn patient to a burn center. Be prepared to deal with a patient who is screaming out for help.
Other things to be on the lookout for with burn patients is what we call a “fluid shift” where the body moves fluid from the rest of the body to the burned areas as part of the inflammation response mechanism. It is important to begin fluid resuscitation immediately with burn patients, as this shift can cause hypovolemic shock. Use the Parkland Burn Formula to calculate how much fluid you give to your patient.
4cc fluid x patient’s weight in kg x %TBSA
Key detail, when using %TBSA, DO NOT move the decimal point over two places to the left. If your patient weighs 150kg and is burned on 10% of his BSA, then the calculation is:
4cc x 150kg x 10 = 6000cc
As you can see, this is a lot of fluid. You want to give your patient 3000cc of fluid in the first eight hours of treatment, and 3000cc more of fluid over the second 16 hours of treatment, so it’s 6000cc over 24 hours.
Lactated Ringer’s is the preferred fluid because it can help with the activation of white blood cells called neutrophils, which help in fighting infection. It is also turned into an alkaline buffer by the liver, which helps with metabolic acidosis that may be occurring from the burn injury. There are other things it can do which are a little more advanced for this discussion, so let’s just keep it at “preferred.” Normal saline is fine, too, just remember is pH and temperature when treating a patient that is at risk for shock.
Paradoxically, you need to watch for hypothermia with burn patients and cover them with clean, dry dressings / sheets. It’s that shock thing again.
Ultimately, what will help a severe burn patient is debridement (removal) of the dead tissue and new skin. There are hug risks for infection with severe burn patients, so broad spectrum antibiotics are probably something that will be used.
This is another injury type that when things are primitive or near-primitive in terms of medical care, the prognoses aren’t too good.
The best thing I can recommend is that an ounce of prevention is worth a pound of cure. Stay away from fire, people throwing fire, people shooting fire, and things that like to catch on fire. To that end, hydrocarbons like to burn. Octane, which helps make up gasoline, has a chemical formula of C8H18. Methane, the simplest hydrocarbon, has a chemical formula of CH4. That kick-ass polypropylene underlayer you’re wearing has a chemical formula of C3H6. Notice some similarities? That warm layer is woven gasoline, and it can’t wait to catch on fire, stick to you, and melt your skin off. Polyester in your wicking shirts for warm weather have some carbon and hydrogen in them too, and tend to like to burn, so keep that in mind.
Be sure to shop around for Nomex gear and other fire-resistant fabrics. Cotton and wool work well too, and there are some sites out there that have how-to’s on making your cotton a little more fire resistant using Borax and whatnot. Use your own search engine and find what you need. Remember, I’m just a guy on the Internet, and if you follow my advice and burn yourself to death, that’s on you.
From a perspective of a Bolshevik flying monkey takeover and breakdown in rule of law, supply chains, and other things that keep civilization civil, this was again designed to scratch the surface and get you thinking about what kind of injuries one might see when people start hurling kinetic and thermal weapons at each other. If you have a crew you train with, I hope this helps facilitate some discussion to help you expand your medical training and increase your medical knowledge.
Part V is going to hit some gear ideas.