爆炸傷害的診斷和處置

Primary Blast Injury from Sun YaiCheng

Primary blast injury: Update on diagnosis and treatment

Crit Care Med 2008; 36:[Suppl.]:S311–S317


Injuries from explosions are traditionally classified into:

1. Primary blast injuries: injuries due solely to the blast wave
2. Secondary blast or explosive injury: primarily ballistic trauma resulting from fragmentation wounds from the explosive device or the environment
3. Tertiary blast or explosive injury: result of displacement of the victim or environmental structures, is largely blunt traumatic injuries
4. Quaternary explosive injuries: burns, toxins, and radiologic contamination

Ocular Injury

• Ophthalmology consultation should be obtained for suspected globe injuries, corneal foreign bodies or abrasions, orbital fractures, retinal detachments, hyphema, intraocular foreign bodies, corneal or eyelid burns, lid lacerations, subconjunctival hemorrhage, or head injuries that involve the orbit or may compromise vision

Aural Injury

• Tympanic membrane rupture is the most common primary blast injury
• Clinicians should make otoscopic examination a routine part of the initial evaluation of explosion injured patients

Pulmonary Injury

• Blast lung injury is the most common fatal injury among initial survivors of explosions
• Clinical diagnosis of blast lung injury is based on the presence of respiratory distress, hypoxia, and “butterfly” or batwing infiltrates.

CVS Injury

• Triad of immediate bradycardia, hypotension, and apnea.

GI Injury

• Mesenteric or mural hematoma in hemodynamically stable patients without peritoneal signs may be managed with NPO, NG tube decompression, and resuscitation.
• Massive hemorrhage or obvious hollow viscus perforation should be treated with laparotomy for hemostasis and control of spillage of enteric contents.

Traumatic Amputations

• Early tourniquet use

Brain Injury

• PE should include a thorough NE to include checking for positive Romberg's sign as well as funduscopy to look for evidence of air emboli.
• CT scan should be used to search for evidence of blunt head injury and ICH.

Patient Risk Stratification

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【重點摘要】

1. 初級爆炸傷害：直接由爆炸波導致的傷害
2. 次級爆炸傷害：因爆炸物或環境的碎片導致的傷害
3. 三級爆炸傷害：因傷患或環境的位移導致的傷害，主要是鈍挫傷
4. 四級爆炸傷害：燒燙傷、毒物或輻射污染

耳道傷害

• 鼓膜破裂 是最常見的原發性爆炸傷害
• 臨床醫生對於所有爆炸受傷的病人，常規性的耳鏡檢查，應列為初步評估的一部分

肺傷害

• 爆炸性肺損傷 是爆炸倖存者早期最常見的致命傷害
• 臨床診斷：呼吸窘迫，缺氧，X光會有“蝴蝶 butterfly” 或 “蝙蝠 batwing” 浸潤