01Approach to the Critical Patient/attcp77

Immediate stabilization

›Airway priorities

›Early intubation triggers

›Facial burns with anticipated edema

›Stridor or hoarseness

›Burns >=20% TBSA with resuscitation edema expected

›GCS <8 or inability to protect airway

›Cervical spine precautions if concurrent blast or fall mechanism

›Inline stabilization during intubation

›Video laryngoscopy preferred with edematous airway

›100% O2 via non-rebreather mask immediately

›All blast-exposed patients pending CO assessment

›Treats concurrent CO poisoning

›Breathing and ventilation

›Lung-protective ventilation if intubated

›Tidal volume 6 mL/kg ideal body weight

›Avoid high peak inspiratory pressures if concurrent blast lung

›Air embolism risk with barotrauma in blast lung

›Continuous pulse oximetry unreliable in CO poisoning

›SpO2 may appear falsely normal

›ABG with co-oximetry required for COHb measurement

›Circulation

›Aggressive IV fluid resuscitation for burns

›Parkland formula: 4 mL/kg/% TBSA over 24 hours

›Half in first 8 hours, half in next 16 hours

›Crush syndrome resuscitation

›Isotonic saline >=1 L/hr ideally before extrication

›Target urine output 200-300 mL/hr

›Two large-bore IV access minimum

›Avoid burned or crushed extremities for IV sites

›Intraosseous access if IV unobtainable

Threat identification

›Quaternary injury categories requiring simultaneous assessment

›Burns: estimate %TBSA, depth, circumferential involvement

›Rule of nines or Lund-Browder chart

›Circumferential burns require escharotomy planning

›Inhalation injury: upper airway thermal vs lower airway chemical

›Carbonaceous sputum, singed nasal hairs, facial burns

›Bronchoscopy gold standard for grading

›CO and cyanide co-poisoning

›Enclosed space + fire = high suspicion for both

›Lactate >10 mmol/L strongly suggests cyanide

›Crush syndrome with rhabdomyolysis

›Dark urine, rising CK, oliguria, hyperkalemia

›McMahon Score for AKI risk stratification

›Psychological trauma

›Two-thirds of blast survivors develop PTSD symptoms

›Acute stress reaction may be primary presentation

Monitoring and escalation

›Monitoring bundle

›Continuous cardiac monitoring

›Hyperkalemia ECG changes in crush syndrome

›CO-related arrhythmia and ST changes

›Urinary catheter for crush syndrome or major burns

›Hourly urine output measurement

›Urine color assessment for myoglobinuria

›Serial laboratory monitoring

›CK every 6-8 hours in crush injury

›COHb trend in CO poisoning

›Escalation triggers

›Burns >=20% TBSA or inhalation injury: burn center

›ICU level care required

›Early burn surgery consultation

›COHb >25% or neurologic symptoms: HBO2 consultation

›Crush syndrome with AKI or hyperkalemia: nephrology consult

›Compartment pressure >30 mmHg or within 30 mmHg of diastolic: orthopedic surgery

Immediate consults

›Consultation triggers

›Burn surgery

›Burns >=20% TBSA

›Full-thickness burns >=10% TBSA

›Burns to face, hands, feet, genitalia, joints

›Toxicology

›CO or cyanide poisoning confirmed or suspected

›CBRN agent exposure concern

›Nephrology

›Crush syndrome with rising creatinine or hyperkalemia

›Rhabdomyolysis not responding to IV fluids

›Psychiatry or mental health

›Acute stress reaction with functional impairment

›Suicidal ideation in blast survivor

02History/hx67

Blast exposure details

›Scene characteristics

›Enclosed vs open space

›Enclosed space amplifies all quaternary injury types

›Fire or smoke present in enclosed environment

›Proximity to detonation

›Thermal flash exposure distance

›Toxic fume concentration higher at closer range

›Duration of exposure or entrapment

›Crush injury risk increases with prolonged compression

›Prolonged smoke inhalation worsens CO burden

›Device type

›Incendiary or fuel-laden devices increase burn burden

›Vehicle-borne IEDs associated with higher burn rates

Symptom characterization

›Pulmonary symptoms

›Cough, dyspnea, hemoptysis, stridor, wheezing

›Soot in sputum suggests inhalation injury

›Progressive dyspnea may indicate ARDS development

›Airway symptoms

›Hoarseness or voice change

›Difficulty swallowing from edema

›Neurologic symptoms

›Headache, confusion, syncope, seizures

›CO poisoning can mimic viral illness

›Visual changes in CO or cyanide poisoning

›Loss of consciousness at scene

›Duration and recovery trajectory

03Physical Exam/exam50

Primary survey

›Airway exam

›Facial burns, singed eyebrows and nasal hairs

›Carbonaceous sputum

›Oropharyngeal edema or erythema

›Stridor, hoarseness, voice change

›Signs of impending airway compromise

›Nasolaryngoscopy to quantify upper airway edema

›Breathing assessment

›Auscultation: wheezing, crackles, decreased breath sounds

›Work of breathing: accessory muscle use

›Respiratory rate trend

›Subcutaneous emphysema

›Expanding emphysema suggests pneumothorax or blast lung

›Circulation assessment

›Capillary refill, perfusion

›Hypovolemic shock from burns or third-spacing

›Hyperkalemia signs: peaked T waves, arrhythmia

Burns assessment

›%TBSA estimation

›Lund-Browder chart (most accurate)

›Rule of nines for rapid field estimate

›Palmar method (1% per palm) for small areas

›Burn depth assessment

›Superficial: erythema, pain, no blisters

›Partial thickness: blisters, moist, painful

›Full thickness: dry, leathery, insensate

›Circumferential burns

04Differential Diagnosis/ddx49

Within quaternary injury category

›Inhalation injury types

›Upper airway thermal injury

›Supra-glottic: edema, erythema, airway compromise

›ICD-10 T27.0

›Lower airway chemical and particulate injury

›Bronchospasm, mucus plugging, ARDS

›ICD-10 T27.3

›Distinguishing feature: thermal mainly supra-glottic, chemical reaches lower airways

›Toxic gas poisoning

›Carbon monoxide poisoning

›ICD-10 T58.0

›Pulse oximetry falsely normal; co-oximetry required

›COHb level correlates with symptom severity

›Cyanide poisoning

›ICD-10 T65.0

›Lactate >10 mmol/L disproportionate to clinical picture

›Concomitant CO plus cyanide poisoning common in fires

›Distinguishing feature: lactate disproportionately elevated in cyanide

›Crush injury spectrum

›Simple crush injury without systemic effects

›Local tissue injury only

›ICD-10 T14.0 series

›Crush syndrome with rhabdomyolysis

›CK >5x upper limit of normal

›Systemic complications: AKI, hyperkalemia, DIC

›ICD-10 T79.5

›Compartment syndrome

05Laboratory Tests/lt54

Core labs

›ABG with co-oximetry

›Essential in all blast-exposed patients with fire or smoke

›Directly measures COHb (standard pulse ox does not)

›PaO2/FiO2 ratio for severity of respiratory failure

›pH and lactate for tissue perfusion

›Interpretation

›COHb >25%: severe poisoning, HBO2 indication

›Lactate >10 mmol/L: strongly suggests cyanide toxicity

›Lactate

›Elevated in both CO and cyanide poisoning

›Disproportionate elevation relative to hemodynamics suggests cyanide

›Serial lactate trend for treatment response

›Threshold significance

›Lactate >10 mmol/L: cyanide poisoning strongly suspected

Crush and rhabdomyolysis labs

›Creatine kinase

›>1000 U/L suggests crush injury

›>5x upper limit of normal diagnostic of rhabdomyolysis

›Serial CK every 6-8 hours to track trajectory

›Urine myoglobin

›Dipstick positive for blood without RBCs on microscopy

›Tea-colored urine visual indicator

›Comprehensive metabolic panel

›Potassium: hyperkalemia in crush syndrome

›ECG correlation required with potassium result

›Life-threatening when >6.0 mmol/L with ECG changes

›Creatinine and BUN for AKI assessment

06Diagnostic Tests/dt113

Scoring Systems

›Rhabdomyolysis risk stratification

›McMahon Score for AKI prediction in rhabdomyolysis

›Age, CK, phosphate, bicarbonate, albumin, calcium inputs

›Score >6 identifies high risk for renal replacement therapy

›Guides nephrology consultation threshold

›CK threshold thresholds

›CK >5000 U/L: significant rhabdomyolysis

›CK >15000 U/L: high AKI risk requiring aggressive hydration

›Burn severity scoring

›%TBSA and burn depth combined assessment

›Burns >=20% TBSA: burn center transfer criteria

›Full-thickness >=10% TBSA: burn center transfer criteria

›Baux Score (age + %TBSA): mortality prediction in burns

›Lund-Browder chart

›More accurate than rule of nines in all age groups

›Accounts for age-related body proportion differences

›CO poisoning severity

›COHb classification

›COHb 10-20%: mild, headache and nausea

›COHb 20-40%: moderate, confusion, chest pain

›COHb >40%: severe, coma, arrhythmia

›Threshold for HBO2: COHb >25%, GCS <15, pregnancy, cardiac ischemia

›Blast Lung Injury Severity Score

›PaO2/FiO2 ratio, CXR findings, bronchopleural fistula

›Guides ventilator management strategy

›Distinguishes inhalation from primary blast lung

MRI

›MRI head indications

›Blast-related TBI evaluation

›Superior to CT for diffuse axonal injury

›White matter changes from blast wave transmission

›ICD-10 S09.90 blast-related TBI

›Limitations in acute setting

›Time-consuming in unstable polytrauma patient

›CT head first for acute hemorrhage exclusion

›Timing

›Subacute phase when patient stabilized

›MRI at 24-72 hours if TBI concern persists

›MRI extremity

›Crush injury muscle viability assessment

›Distinguishes reversible edema from necrosis

›Guides surgical debridement planning

›Compartment syndrome evaluation adjunct

›Not first-line: clinical diagnosis with pressure measurement preferred

›MRI if diagnosis uncertain after stabilization

›MRI contraindications

›Metallic foreign bodies from blast (shrapnel)

›Plain radiographs first to exclude ferromagnetic fragments

›Absolute contraindication if ferromagnetic shrapnel near vital structures

›Hemodynamic instability

›CT preferred in unstable patient

CT

›CT chest

›Indications in blast injury

›Pulmonary contusion assessment

›Vascular injury evaluation with IV contrast

›Pneumothorax quantification

›Foreign body localization

›Findings in quaternary injury

›Bilateral ground-glass opacities: inhalation or ARDS

›Airspace consolidation: aspiration or contusion

›Pleural effusion or hemothorax

›ACR Appropriateness Criteria support CT chest for penetrating and blast thoracic trauma

›CT abdomen and pelvis with IV contrast

›Gold standard for comprehensive trauma evaluation in stable patients

›Superior for solid organ injury identification

›Vascular injury assessment

›Required in polytrauma with unclear mechanism

›Hemodynamically stable patient requirement

›FAST exam preferred for unstable patients

›CT head

›Indications

›Altered mental status to exclude hemorrhagic TBI

›GCS <13

›Focal neurologic deficit

›Loss of consciousness at scene

›Limitations

›Less sensitive than MRI for diffuse axonal injury

›Normal CT does not exclude blast-related brain injury

›CT extremity

›Fracture assessment

›Foreign body localization

›Subcutaneous gas indicating compartment concern

›Vascular injury in traumatic amputation

Ultrasound

›FAST exam

›Hemodynamically unstable blast casualty

›Pericardial effusion or tamponade

›Free intraperitoneal fluid

›Pneumothorax on extended FAST

›Time to result advantage

›Performed during primary survey

›ACEP Level B recommendation for FAST in trauma

›Lung ultrasound

›ARDS and pulmonary edema monitoring

›B-lines indicating interstitial edema

›Consolidation pattern

›Pleural effusion quantification

›Pneumothorax detection

›Absent lung sliding with A-lines

›Lung point sign for confirmation

›Sensitivity superior to supine CXR

›Vascular ultrasound

›Crush injury DVT risk assessment

›Extremity swelling and immobility

›Compressibility and Doppler assessment

›IV access guidance

›Central venous access when peripheral unavailable

›Avoid burned extremities

›POCUS cardiac

›CO poisoning cardiac effect monitoring

›Wall motion abnormality

›LV function assessment

›Hypovolemia assessment

›IVC collapsibility

›Integrate with clinical exam and urine output

07Disposition/dispo54

ICU admission criteria

›Burns requiring ICU

›Burns >=20% TBSA

›Inhalation injury with any burn

›Circumferential burns requiring escharotomy

›50% ICU admission rate for terrorism burn patients

›Polytrauma with >=2 body regions injured: 71% ICU admission

›Toxic inhalation requiring ICU

›COHb >25% or neurologic symptoms

›Cardiac ischemia from CO poisoning

›Cyanide poisoning with hemodynamic compromise

›Respiratory failure: intubation or escalating O2 requirement

›Crush syndrome requiring ICU

›AKI with rising creatinine despite fluids

›Hyperkalemia with ECG changes

›Hemodynamic instability

›DIC or severe rhabdomyolysis (CK >15000 U/L)

›Polytrauma with concurrent blast injury categories

›Primary plus quaternary injury combinations

›Blast lung plus burns: very high mortality

›Early surgical planning

Ward or observation admission

›Moderate burns without inhalation injury

›10-20% TBSA partial thickness

›Adequate fluid resuscitation ongoing

›Wound care management

›Rhabdomyolysis with CK >5000 but stable renal function

›IV fluid therapy and serial CK monitoring

08Treatment/t141

Airway management

›Inhalation injury airway

›Early intubation for impending compromise

›Facial edema, stridor, progressive hoarseness

›Oral burns with anticipated swelling from resuscitation

›Inhalation Injury Severity Score to guide timing

›Video laryngoscopy preferred

›Edematous airway visualization

›Surgical airway backup prepared

›Post-intubation ventilation

›Tidal volume 6 mL/kg ideal body weight

›PEEP 5-8 cmH2O initially

›FiO2 titrated to SpO2 92-96% (not applicable to CO monitoring)

Carbon monoxide treatment

›Normobaric oxygen therapy

›100% O2 via tight-fitting non-rebreather mask

›Minimum 6 hours duration

›Reduces CO half-life from 5 hours to 60-90 minutes

›Class I recommendation per AHA 2023 toxicology guidelines

›Intubated patients: FiO2 1.0 initially

›Wean based on COHb clearance and SpO2 after co-oximetry confirms clearance

›Hyperbaric oxygen therapy

›Indications for HBO2 consultation

›COHb >25%

›GCS <15 or loss of consciousness

›Cardiac ischemia or arrhythmia

›Pregnancy (any CO exposure)

›Persistent neurologic symptoms after normobaric O2

›Contraindications relative

›Active wheezing or significant airway debris

›Concurrent blast lung injury (air embolism risk)

›Hemodynamic instability requiring intervention

›CO half-life reduction

›Room air: ~5 hours

›100% normobaric O2: ~60-90 minutes

›HBO2 at 2.5 atm: ~20-30 minutes

Cyanide treatment

›Hydroxocobalamin (first-line)

›Adults: hydroxocobalamin 5g IV over 15 minutes

›Preferred over sodium nitrite when concurrent CO suspected

›Sodium nitrite worsens methemoglobinemia in combined CO/CN

›AHA 2023 and AHA 2025 resuscitation guidelines support

›Pediatric dosing

›70 mg/kg IV, maximum 5g

›Neonates: 35 mg/kg

›Mechanism

›Binds cyanide forming cyanocobalamin

›Does not reduce oxygen-carrying capacity

›Sodium thiosulfate adjunct

›12.5g IV (50 mL of 25% solution)

›May be added after hydroxocobalamin

›Enhances conversion to thiocyanate

›Slower onset than hydroxocobalamin

Burn fluid resuscitation

›Parkland formula

›Total volume: 4 mL x kg x % TBSA

›Half delivered in first 8 hours from time of burn

›Remaining half over next 16 hours

›Lactated Ringer's solution preferred

›Titration targets

›Urine output 0.5-1 mL/kg/hr in adults

›1 mL/kg/hr in children

›Adjust formula based on response

›Avoid excess crystalloid

›Abdominal compartment syndrome risk

›Pulmonary edema risk with concurrent blast lung

›Colloid consideration

›Fresh frozen plasma or 5% albumin after first 8 hours

›Reduces total crystalloid volume

›Burn center practice variation

Crush syndrome and rhabdomyolysis treatment

›Aggressive IV fluid resuscitation

›Isotonic saline: start before extrication when possible

›Rate: 1-1.5 L/hr initially, titrate to UOP 200-300 mL/hr

›Avoid potassium-containing fluids (Lactated Ringer's)

›Total volume may reach 10-20 L in first 24 hours

›Avoid excessive fluid in concurrent blast lung

›Pulmonary edema risk

›Balance urine output targets with respiratory status

›Urine alkalinization

›Sodium bicarbonate 50 mEq per alternate liter of IV fluid

›Target urine pH >6.5

›Reduces myoglobin precipitation in tubules

›Continue until CK trending down and urine clears

›Monitoring

›Serum pH: avoid systemic alkalosis >7.5

›Serum calcium: alkalosis worsens hypocalcemia

›Mannitol

›1-2 g/kg/day as adjunct osmotic diuresis

›Only if adequate urine flow established (not oliguric)

›Maximum 200 g/day

›Monitor serum osmolality: stop if osmolar gap >55

›Hyperkalemia management

›Calcium gluconate 10 mL of 10% IV over 2-5 minutes

›Membrane stabilization, not potassium removal

›Repeat every 5 minutes if ECG changes persist

›Insulin plus dextrose

›Insulin 10 units regular IV with 50 mL of 50% dextrose

›Shifts potassium intracellularly

›Onset 15-30 minutes, duration 4-6 hours

›Sodium bicarbonate IV for acidosis-driven hyperkalemia

›50 mEq IV over 5-10 minutes

›Renal replacement therapy

›Refractory hyperkalemia or AKI not responding to fluids

›McMahon Score >6 predicts need

Burn wound management

›Topical wound care

›Silver sulfadiazine or mafenide acetate

›Antimicrobial coverage for partial and full thickness burns

›Non-adherent dressings

›Tetanus prophylaxis

›All burn patients require tetanus immunization assessment

›Booster if >5 years since last dose

›Avoid prophylactic systemic antibiotics

›Increases resistance risk

›No mortality benefit shown

›Escharotomy

›Circumferential full-thickness burns to extremities

›Compartment pressure elevation

›Impaired distal perfusion

›Chest escharotomy

›Circumferential chest burns reducing ventilation

›Rising peak airway pressures in intubated patient

Bronchospasm and inhalation treatment

›Nebulized bronchodilators

›Salbutamol 2.5-5 mg nebulized every 4 hours PRN

›For irritant-induced bronchospasm

›Titrate to response

›N-acetylcysteine nebulized

›20% solution 3 mL every 4 hours

›Reduces mucus cast formation in inhalation injury

›Bronchoscopy

›Gold standard for inhalation injury grading

›Also therapeutic for cast removal

›Baux-Abbreviated Injury Scale for inhalation severity

›Timing

›Early bronchoscopy within 24 hours of inhalation injury

›Repeat for cast removal if needed

Psychological first aid

›Acute psychological support

›Psychological first aid principles

›Safety, calm, connectedness, self-efficacy, hope

›Screen all blast survivors at presentation

›Short-term anxiolytics for severe acute stress

›Lorazepam 1-2 mg IV or PO for acute agitation

›Avoid benzodiazepine dependence with prolonged use

›Early mental health consultation

›Suicidal ideation screening

›PTSD screening tools: PCL-5 at follow-up

09Special Populations/sp91

Pregnancy

›Physiologic considerations

›CO crosses placenta with fetal accumulation

›Fetal hemoglobin binds CO 2.5-3x stronger than maternal

›Fetal COHb lags behind maternal but is higher at steady state

›Fetal hypoxia risk exceeds maternal risk from same CO exposure

›Delayed gastric emptying increases aspiration risk

›Cricoid pressure during intubation

›Rapid sequence intubation preferred

›Treatment modifications

›HBO2 more strongly indicated in pregnancy

›Any CO exposure in pregnancy warrants HBO2 consultation

›Lower threshold than non-pregnant patients

›Duration typically 90-120 minutes at 2.0-2.5 atm

›Hydroxocobalamin safe in pregnancy for cyanide

›Class C drug but life-threatening indication overrides

›Sodium nitrite relatively contraindicated (methemoglobin reduces fetal O2 delivery)

›Burn resuscitation goals

›Maintain urine output 0.5-1 mL/kg/hr

›Avoid excessive fluid causing uteroplacental hypoperfusion

›Maternal SpO2 target >=95% for fetal oxygenation

›Fetal monitoring

›Continuous fetal heart rate monitoring for viable gestation

›Fetal distress may precede maternal deterioration

›Obstetrics consultation for viable gestation (>=24 weeks)

›Rh factor and Kleihauer-Betke test if abdominal trauma

›Fetomaternal hemorrhage risk

›Rho(D) immunoglobulin if Rh-negative

Geriatric

›Physiologic vulnerabilities

›Reduced physiologic reserve

›Burns >=10% TBSA may be life-threatening in elderly

›Baux Score >100 (age + %TBSA) associated with very high mortality

›Reduced cardiac output limits resuscitation tolerance

›CO poisoning vulnerability

›Cardiovascular disease lowers ischemia threshold

›Atherosclerosis impairs compensatory response

›Higher risk of myocardial ischemia from CO

›Rhabdomyolysis in elderly

›Pre-existing CKD lowers AKI threshold

›Baseline creatinine must inform AKI diagnosis

›More aggressive nephrology consultation threshold

›Reduced muscle mass may mask CK elevation

›CK may be relatively lower despite significant injury

›Medication considerations

›Beta-blockers blunt tachycardia response to burns

›May mask early hemorrhagic shock signs

›Do not withhold antihypertensives reflexively

›Anticoagulant and antiplatelet use

›Reversal considerations in concurrent hemorrhage

›Increased bleeding risk with escharotomy

›Disposition bias

›Lower threshold for ICU admission

›Reduced physiologic reserve limits monitoring at home

›Social support and ability to perform wound care

›Goals-of-care discussion early in severe burns

›Mortality prediction tools guide prognosis discussions

Pediatrics

›Physiologic differences

›Greater surface area to body mass ratio

›Higher fluid losses per %TBSA burned

›Hypothermia risk more pronounced

›Larger tidal volumes relative to minute ventilation

›More susceptible to blast lung and inhalation injury

›Airway more easily obstructed by edema

›Burn resuscitation in children

›Parkland formula modified for children

›3-4 mL/kg/% TBSA + maintenance fluids

›Maintenance: 4 mL/kg/hr for first 10 kg, 2 mL/kg/hr next 10 kg, 1 mL/kg/hr beyond 20 kg

›Urine output target 1 mL/kg/hr

›Lund-Browder chart essential in children

›Body proportions differ significantly from adults

›Rule of nines inaccurate in children <15 years

›CO poisoning in children

›COHb thresholds for HBO2 similar to adults

›Any neurologic symptom or syncope

›COHb >25%

›Hydroxocobalamin for cyanide

›70 mg/kg IV, maximum 5g per dose

›Safe in pediatric age group

›Crush syndrome in children

›Weight-based fluid resuscitation

›Isotonic saline 20 mL/kg bolus initially

›Titrate to urine output 1 mL/kg/hr

›Sodium bicarbonate: 1-2 mEq/kg per alternate liter

›McMahon Score not validated in children

›Clinical judgment and serial CK primary guides

›Psychological impact in children

›Acute stress reactions more overt in children

›Regression, separation anxiety, nightmares

›Pediatric PTSD screening tools: UCLA PTSD-RI

›Parent or caregiver involvement critical

›Family-centered psychological first aid

›Child life specialist consultation

10Background/b100

Epidemiology

›Blast injury burden

›Burns present in up to 27% of blast-injured patients

›Associated with immediate mortality and high coexisting blast lung rates

›Terrorism-related burns: 87% have associated injuries vs 10% non-terrorism

›ICU admission rates

›50% ICU admission in terrorism burn patients

›71% ICU admission in polytrauma with >=2 body regions injured

›12% ICU admission in non-terrorism burns for comparison

›Crush syndrome prevalence

›2-15% of victims after major structural collapse events

›Earthquake crush syndrome series: Bartels and VanRooyen, Lancet 2012

›Crush syndrome is leading cause of preventable death after structural collapse

›AKI from rhabdomyolysis mortality

›20-50% mortality if dialysis required

›Early aggressive fluid resuscitation reduces AKI risk

›CO and cyanide co-poisoning

›Common in enclosed-space fires and explosions

›Cyanide frequently underdiagnosed at initial presentation

›Lobo-Antuna 2026: cyanide co-poisoning in smoke inhalation victims

›CO mortality contribution underestimated

›Standard SpO2 monitoring misses poisoning

›Psychological morbidity

›Two-thirds of blast survivors develop PTSD symptoms

›Blast exposure severity is independent psychiatric risk factor

›Beyond TBI and traditional PTSD risk factors

›Epshtein 2025: chronic psychiatric disability in military blast survivors

Pathophysiology

›Burns pathophysiology

›Thermal injury mechanism

›Protein denaturation and cell death proportional to temperature and duration

›Zone of coagulation (central), stasis (surrounding), hyperemia (peripheral)

›Zone of stasis salvageable with adequate perfusion

›Systemic inflammatory response

›Cytokine release: IL-1, IL-6, TNF-alpha

›Increased vascular permeability causing third-spacing

›Burn shock from fluid loss and vasoplegia

›Inhalation injury mechanism

›Thermal injury primarily supra-glottic

›Chemical injury from aldehydes, acids, carbon particles reaches lower airways

›Surfactant destruction, mucus cast formation, ciliary dysfunction

›CO and cyanide pathophysiology

›CO mechanism

›Binds hemoglobin with 250x affinity vs oxygen

›Shifts oxyhemoglobin dissociation curve left

›Binds cytochrome c oxidase: mitochondrial poisoning

›Cyanide mechanism

›Inhibits cytochrome c oxidase complex IV

›Blocks oxidative phosphorylation

›Cells shift to anaerobic metabolism: lactic acidosis

›Combined poisoning synergy

›Both inhibit mitochondrial respiration

›Explains disproportionate lactate in fire victims

›Crush syndrome pathophysiology

›Compression phase

›Ischemia-reperfusion injury on release

›Muscle cell necrosis releasing myoglobin, CK, potassium, phosphate

›Reperfusion injury

›Free radical generation on restoration of blood flow

›Third-spacing into injured muscle

›Myoglobin precipitation in renal tubules at acidic pH

›Systemic complications

›AKI from tubular obstruction and direct myoglobin toxicity

›Hyperkalemia from cell lysis

›DIC from tissue factor release

›Compartment syndrome from edema

Therapeutic Considerations

›Evidence base for key treatments

›CO treatment evidence

›Normobaric O2 for 6 hours: standard of care, Class I

›HBO2: AHA 2023 and 2025 guidelines support use in severe CO

›No RCT definitively proves HBO2 reduces delayed neurologic sequelae

›Cyanide antidote evidence

›Hydroxocobalamin preferred over dicobalt edetate in most guidelines

›Sodium nitrite contraindicated when concurrent CO (methemoglobin worsens O2 delivery)

›AHA 2025 resuscitation guidelines support hydroxocobalamin

›Crush syndrome fluid evidence

›Sever 2006 NEJM review: early aggressive IV fluids reduce AKI mortality

›Optimal fluid composition and rate not definitively established by RCT

›Bicarbonate alkalinization: observational support, not proven by RCT

›Pitfalls in management

›CO poisoning missed due to normal pulse oximetry

›All blast-exposed patients from fire require co-oximetry

›High index of suspicion in enclosed space + altered mental status

›Cyanide underdiagnosed

›Treat empirically with hydroxocobalamin in severe fire casualties

›Do not wait for confirmed cyanide level (delayed result)

›Excessive crystalloid in burns with concurrent blast lung

›Pulmonary edema can worsen rapidly

›Monitor respiratory status closely during resuscitation

›Potassium-containing fluids in crush syndrome

›Lactated Ringer's contains 4 mEq/L potassium

›Normal saline preferred in hyperkalemic rhabdomyolysis

›Multidisciplinary care requirements

›Early burn surgery involvement

›Escharotomy and grafting planning

›Wound infection surveillance

›Nephrology for crush syndrome

›RRT timing and modality selection

›Continuous RRT preferred in hemodynamically unstable

›Psychiatry for psychological trauma

›PTSD prevention strategies: cognitive behavioral first aid

›Long-term follow-up at 2-4 weeks and 3 months

11Patient Discharge Instructions/pdi59

copy discharge instructions

›Blast injury home care instructions

›Burns wound care at home

›Clean burns gently with mild soap and water daily

›Apply prescribed topical antibiotic cream and non-stick dressing

›Keep wound covered and protected from sun

›Do not pop blisters

›Carbon monoxide exposure follow-up

›Headaches, memory problems, personality changes can appear days to weeks after exposure

›Return to ER if these symptoms develop even if you felt fine initially

›Crush injury or dark urine

›Continue prescribed fluids if instructed

›Renal function follow-up at 24-48 hours

›Avoid NSAIDs, ibuprofen, naproxen

›Warning signs requiring immediate return to ER

›Airway and breathing emergencies

›Difficulty breathing or worsening shortness of breath

›Stridor or noisy breathing

›Coughing blood

›Signs of infection in burns

›Increasing redness, swelling, warmth, or pus around wound

›Fever above 38.5 C

›Increasing pain in the burn area

›Limb emergency signs

›Increasing pain, tightness, numbness, or tingling in arms or legs

›Inability to move fingers or toes

›Leg or arm color turning white, blue, or very pale

›Urine changes

12References/r38

Guidelines and key sources

›Blast injury core references

›Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast Injuries. Lancet. 2009. PMID 19631372

›Comprehensive classification and management review

›Quaternary injury category definition

›DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. NEJM. 2005

›Mechanism and clinical management overview

›Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. High Risk and Low Prevalence Diseases: Blast Injuries. Am J Emerg Med. 2023. PMID 37207597

›Emergency medicine focused review

Toxicology guidelines

›CO and cyanide treatment references

›Lavonas EJ et al. 2023 AHA Focused Update: Management of Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning. Circulation. 2023

›Hydroxocobalamin as first-line cyanide antidote

›HBO2 indications for CO poisoning

›Cao D et al. Part 10: Adult and Pediatric Special Circumstances of Resuscitation. 2025 AHA Guidelines. Circulation. 2025

›Updated cyanide and CO management recommendations

›Culnan DM et al. CO and Cyanide Poisoning in the Burned Pregnant Patient. Ann Plast Surg. 2018. PMID 29461288

›HBO2 in pregnancy: indications and rationale

Crush syndrome and rhabdomyolysis

›Rhabdomyolysis and AKI references

›Sever MS, Vanholder R, Lameire N. Management of Crush-Related Injuries after Disasters. NEJM. 2006

›Fluid resuscitation protocol and AKI prevention

›Long B, Koyfman A, Gottlieb M. Emergency Department Evaluation and Management of Rhabdomyolysis. Am J Emerg Med. 2019. PMID 30630682

›McMahon Score and risk stratification

›Richert Q et al. Updates on Rhabdomyolysis: A Clinically Oriented Narrative Review. Chest. 2026. PMID 41619932

›Current evidence on fluid targets and bicarbonate alkalinization

Burns and inhalation

›Burns management references

Evidence & Review