01Approach to the Critical Patient/attcp64

Immediate priorities

›Hemorrhage control

›Active external bleeding from fragment wounds

›Tourniquet application for compressible extremity hemorrhage

›Wound packing with hemostatic gauze for junctional or truncal wounds

›Hemorrhagic shock recognition

›Tachycardia with hypotension from major vessel laceration

›Deceptively small entry wounds may hide severe vascular injury

›Massive transfusion protocol activation

›1:1:1 ratio packed red cells to fresh frozen plasma to platelets

›Tranexamic acid within 3 hours of injury

›Airway and penetrating neck injury

›Airway compromise from fragment injury to face, neck, or larynx

›Early definitive airway before edema progresses

›Surgical airway if orotracheal access is not feasible

›Concurrent primary blast lung

›Dyspnea, hemoptysis, hypoxemia after blast exposure

›SpO2 target 94% to 98%

›Tension pneumothorax from penetrating thoracic fragments

›Needle decompression followed by chest tube

›Bilateral decompression if unstable with bilateral wounds

›Exposure and full-body sweep

›Log roll with complete skin inspection

›Hair-bearing areas, axillae, perineum, and interdigital spaces

›Small puncture wounds easily missed

›Count and map all wounds before dressings applied

›Trajectory estimation for organ involvement

›Paired entry and exit wound documentation

02History/hx61

Blast event details

›Mechanism and device

›Type of device: IED, military ordnance, industrial explosion, improvised device

›Intentionally fragmented devices embed ball bearings, nails, screws

›Fragment density increases injury burden

›Enclosed versus open space

›Enclosed space amplifies overpressure and fragment density

›Structural collapse risk in confined settings

›Distance from blast epicenter

›Secondary injuries occur hundreds to thousands of meters from explosion

›Proximity correlates with fragment velocity and tissue penetration

›Prehospital course

›Time of injury and time to presentation

›Delay increases infection risk and missed hemorrhage risk

›Field interventions: tourniquet time, hemostatic agents used

›Body position relative to blast

›Shielding by body armor or cover reduces injury

›Ballistic eyewear absence increases ocular injury rate

›Number of casualties

›Mass casualty context affects triage and resource allocation

›Bystander accounts of patient position and entrapment duration

Symptom review

›Injury-related complaints

›Pain location and severity

›All painful regions mapped for wound identification

›Pain out of proportion to visible wound suggests compartment syndrome

›Hemorrhage history

›Estimated blood loss at scene

03Physical Exam/exam69

Primary survey

›Airway

›Patency and protective reflexes

›Stridor or gurgling from oropharyngeal blood or debris

›Facial or laryngeal fragment injury

›GCS and mental status

›GCS less than 13 prompts immediate airway control

›Agitation from hypoxemia or pain versus TBI

›Breathing and circulation

›Respiratory rate and effort

›Rate 30 or greater as severity marker

›Absent or asymmetric breath sounds indicating pneumothorax or hemothorax

›Vital signs

›Tachycardia above 120 beats per minute as hemorrhagic shock marker

›Systolic blood pressure below 90 mmHg indicating class III or IV shock

›Active hemorrhage sites

›Direct pressure or tourniquet adequacy assessment

›Junctional wound packing reassessment

Wound survey

›Systematic head-to-toe skin inspection

›Scalp and hair-bearing regions

›Fragment wounds concealed by hair

›Crepitus indicating skull involvement

›Face and neck

›Wound proximity to major vessels

›Zone classification for penetrating neck wounds

›Axillae and perineum

›High-miss regions requiring deliberate inspection

04Differential Diagnosis/ddx66

Life-threatening injuries from fragments

›Vascular laceration

›Peripheral artery transaction causing hemorrhagic shock

›ICD-10 S45 to S85 injury of blood vessel at limb level

›Entry wound may appear minor despite major vessel involvement

›Aortic or great vessel injury from thoracic fragments

›ICD-10 S25 injury of blood vessels of thorax

›CT angiography diagnosis

›Mesenteric vessel injury with abdominal hemorrhage

›ICD-10 S35 injury of blood vessels of abdomen

›Peritoneal signs evolve over minutes to hours

›Penetrating thoracic injury

›Pneumothorax ICD-10 S27.0

›Simple versus tension on clinical assessment

›Tension pneumothorax causes tracheal deviation and hemodynamic collapse

›Hemothorax ICD-10 S27.1

›Massive hemothorax over 1.5 litres requires operative intervention

›Draining less than 200 mL per hour after chest tube does not exclude injury

›Cardiac tamponade from pericardial fragment injury

›Beck triad: hypotension, muffled heart sounds, JVD

›FAST demonstrates pericardial effusion

›Penetrating abdominal injury

›Hollow viscus perforation ICD-10 S36

›Small bowel most commonly injured

›Peritonitis may be delayed several hours after injury

›Solid organ laceration

›Liver ICD-10 S36.1, spleen ICD-10 S36.0

›Hemorrhagic shock with abdominal pain

05Laboratory Tests/lt47

Hemorrhage and resuscitation

›Type and screen or crossmatch

›Immediate crossmatch for 4 to 6 units in hemorrhagic shock

›Uncrossmatched O-negative blood if no time for crossmatch

›Activate massive transfusion protocol early

›Complete blood count

›Initial hemoglobin may not reflect acute blood loss until hemodilution

›Serial CBC every 4 to 6 hours or after transfusion

›Coagulation panel

›PT, INR, and PTT for trauma-induced coagulopathy

›Fibrinogen below 1.5 g/L indicates hypofibrinogenemia requiring cryoprecipitate

›Lactate and metabolic

›Lactate as tissue perfusion marker

›Above 4 mmol/L indicates severe shock

›Serial measurements guide resuscitation endpoint

›Basic metabolic panel

›Electrolytes and renal function baseline

›Hyperkalemia with crush injury or massive transfusion risk

›Creatine kinase

›Elevated in crush injury or prolonged entrapment

›Rhabdomyolysis threshold above 5000 U/L warrants aggressive hydration

Infection risk assessment

›Wound contamination markers

›White blood cell count as baseline before antibiotic initiation

›Elevated WBC not specific in acute trauma phase

›Serial trending useful for infection diagnosis

›C-reactive protein

›Limited utility acutely but baseline for trending

06Diagnostic Tests/dt95

Scoring Systems

›Trauma severity tools

›Injury Severity Score

›Sum of squares of three highest AIS scores by body region

›Score above 15 defines major trauma

›Predicts mortality and intensive care need

›Revised Trauma Score

›Combines respiratory rate, systolic blood pressure, GCS

›Lower score correlates with higher mortality

›Used in mass casualty triage protocols

›Glasgow Coma Scale

›Eye, verbal, and motor component scoring

›GCS below 13 indicates significant TBI

›Serial GCS most informative for trajectory

›Shock classification

›ATLS hemorrhagic shock classes I through IV

›Class I less than 750 mL blood loss, heart rate below 100

›Class II 750 to 1500 mL, tachycardia 100 to 120

›Class III 1500 to 2000 mL, tachycardia above 120 with hypotension

›Class IV above 2000 mL, severe hypotension, altered mental status

›Limitations in blast polytrauma

›Multiple injury sites complicate class estimation

›Compensatory mechanisms may mask severity initially

MRI

›Indications and limitations in blast fragment injury

›MRI is contraindicated when retained ferromagnetic shrapnel is present or cannot be excluded

›Ferromagnetic fragments may migrate causing further injury

›Fragment composition unknown in most acute blast cases

›Plain radiography or CT to exclude metallic fragments before MRI consideration

›All body regions with wound proximity require imaging first

›Non-ferromagnetic materials may be MRI-compatible after individual assessment

›Delayed MRI role when ferromagnetic fragments excluded

›Subacute TBI characterization

›Spinal cord injury assessment without bony injury

›Soft-tissue injury mapping for reconstruction planning

CT

›CT head without contrast

›Indications for penetrating brain injury

›Scalp wound over calvarium with any neurologic symptom

›GCS below 13 after blast exposure

›Suspected retained intracranial fragment

›Findings

›Fragment trajectory and intracranial location

›Hemorrhagic contusion, epidural or subdural hematoma

›Pneumocephalus indicating dural disruption

›CT thorax with IV contrast

›Indications

›Penetrating thoracic wound with hemodynamic stability

›Chest radiograph equivocal for pneumothorax or hemothorax

›Suspected aortic or great vessel injury

›Performance

›Chest radiograph sensitivity 43% for pneumothorax in blast-exposed patients

›CT far superior for identifying trajectory, organ injury, and vascular damage

›CT angiography for suspected thoracic vascular injury

›Sensitivity and specificity approach 100% for aortic injury

›ACEP Level B recommendation for CT angiography in suspected aortic trauma

›CT abdomen and pelvis with IV contrast

›Indications

›Penetrating abdominal fragment wound

›Peritoneal signs or free fluid on FAST

›Fragment trajectory suggesting abdominal violation

›Findings

›Free intraperitoneal air indicating hollow viscus perforation

›Solid organ laceration grading

›Mesenteric hematoma and vascular blush

›Limitations

›Small bowel perforation may be occult on initial CT

›Serial clinical examination mandatory despite negative CT

›CT extremity and soft tissue

›Fragment localization for operative planning

›Three-dimensional reconstruction aids trajectory assessment

›Proximity to neurovascular structures determines urgency

›In the Boston Marathon bombing

›CT imaging identified 189 shrapnel fragments in 32 of 43 patients

›Most fragments in lower extremities: ball bearings, nails, metal pieces

Ultrasound

›FAST examination

›Focused assessment for free fluid

›Hepatorenal, splenorenal, pelvic, and pericardial windows

›Positive FAST with hemodynamic instability indicates operative intervention

›Negative FAST does not exclude injury in hemodynamically stable patients

›E-FAST extended to include thorax

›Anterior bilateral pleural sliding for pneumothorax detection

›Sensitivity superior to chest radiograph for pneumothorax

›Operator-dependent limitation acknowledged

›Vascular Doppler ultrasound

›Extremity arterial assessment after fragment injury

›Ankle-brachial index below 0.9 warrants CT angiography

›Absent Doppler signal mandates emergent vascular assessment

›Neck vascular assessment when CT angiography not immediately available

›Carotid and vertebral artery Doppler flow assessment

›Limited by operator experience and body habitus

›Ocular ultrasound

›Open globe assessment when slit lamp not available

›High-frequency probe with gel over closed lid

›Vitreous hemorrhage, retinal detachment, lens dislocation

›Avoid direct pressure on globe during examination

›Low-pressure technique mandatory

›Ophthalmology consultation prior to manipulation

07Disposition/dispo57

Operative and resuscitation disposition

›Immediate operative indications

›Hemodynamic instability with penetrating abdominal or thoracic injury

›Damage control laparotomy or thoracotomy

›Abbreviated procedure followed by ICU resuscitation

›Expanding hematoma or pulsatile bleeding from major vessel injury

›Operative or endovascular repair

›Vascular surgery or interventional radiology

›Tension pneumothorax not responding to needle decompression

›Thoracotomy in resuscitation bay

›Bilateral procedures if bilateral wounds

›Resuscitation bay continued care

›Hemodynamically unstable with ongoing resuscitation

›Massive transfusion protocol active

›Damage control resuscitation principles

›Multiple simultaneous injuries requiring sequential operative planning

›Life-threatening injuries prioritized in order

›Contaminated wounds temporized pending definitive surgery

ICU admission indications

›Criteria for intensive care

›Post-operative damage control

›Planned return to theatre after resuscitation

›Temporary abdominal closure monitoring

›Mechanical ventilation requirement

›Penetrating lung or airway injury

›Concurrent blast lung with refractory hypoxemia

›Multiregion injury with monitoring need

›Penetrating brain injury with ICP monitoring

08Treatment/t113

Hemorrhage control and resuscitation

›Tourniquet and wound packing

›Commercial tourniquet for compressible extremity hemorrhage

›Apply 5 to 8 cm proximal to wound

›Tighten until bleeding stops and record time of application

›Do not remove in emergency department pending operative assessment

›Hemostatic gauze packing for junctional wounds

›Combat gauze or kaolin-impregnated gauze into wound cavity

›Direct pressure for 3 to 5 minutes minimum

›Wound packing maintained until operative intervention

›Tranexamic acid

›Administer within 3 hours of injury for hemorrhagic shock

›Loading dose 1 g IV over 10 minutes

›Maintenance dose 1 g IV over 8 hours

›Class I recommendation based on CRASH-2 trial data

›Contraindicated beyond 3 hours due to increased thromboembolic risk

›Not indicated in isolated non-hemorrhagic injury

›Massive transfusion protocol

›1:1:1 ratio of packed red blood cells to fresh frozen plasma to platelets

›Balanced resuscitation reduces coagulopathy

›Minimize crystalloid use

›Cryoprecipitate for fibrinogen below 1.5 g/L

›10 units cryoprecipitate IV

›Repeat fibrinogen after each administration

›Calcium replacement with massive transfusion

›Calcium chloride 1 g IV or calcium gluconate 3 g IV per 4 units packed red cells

›Hypocalcemia impairs myocardial function and coagulation

Antibiotic therapy

›Open soft-tissue wound prophylaxis

›Cefazolin first-line for open contaminated wounds

›2 g IV every 8 hours for wounds less than 10 cm

›3 g IV every 8 hours for larger wounds or obesity

›Clindamycin if penicillin-allergic

›600 mg IV every 8 hours

›Monitor for C. difficile with prolonged use

›Duration: 24 hours for most soft-tissue wounds without visceral injury

›Extended courses not supported for simple penetrating wounds

›Class IIa recommendation from trauma surgery guidelines

›Penetrating abdominal injury

›Cefoxitin 2 g IV every 6 hours for bowel contamination

›Single preoperative dose acceptable in some protocols

›Anaerobic coverage integral to cefoxitin spectrum

›Alternative: metronidazole 500 mg IV every 8 hours plus ceftriaxone 2 g IV daily

›Continue for 24 hours after operative control achieved

›Longer courses if gross contamination or established peritonitis

›Open fracture antibiotic therapy

›Administer as soon as possible after injury

›Cefazolin 2 g IV for Gustilo grade I and II fractures

›Add gentamicin 5 mg/kg IV daily for grade III fractures

›Duration limited to 24 hours from time of definitive wound closure

›Prolonged courses beyond 24 to 72 hours not supported by evidence

›EAST guideline Class IIa recommendation

›Penetrating brain injury

›Broad-spectrum antibiotics with anaerobic coverage for up to 5 days in high-risk patients

›Meropenem 2 g IV every 8 hours or equivalent

›Consider rifampicin addition for CSF penetration

›Metronidazole 500 mg IV every 8 hours for anaerobic coverage

›Penetrating cranial injuries with gross contamination

›Coordinate with neurosurgery for duration decisions

›Ocular penetrating injury

›Systemic antibiotics to reduce endophthalmitis risk

›Moxifloxacin 400 mg PO daily for 7 to 10 days

›Levofloxacin 500 mg IV daily in field or hospital settings

›Topical antibiotics under ophthalmology guidance only

›Do not instill drops if open globe confirmed

›Rigid eye shield placement maintained

Tetanus prophylaxis

›Tetanus prophylaxis protocol

›Tetanus-prone wound criteria

›Wound older than 6 hours

›Puncture wound, wound with devitalized tissue, contaminated wound

›All blast fragment wounds presumed tetanus-prone

›Fully immunized within 5 years: no additional vaccine required

›Tetanus toxoid if last booster more than 5 years ago

›Unknown or incomplete immunization history

›Tetanus toxoid 0.5 mL IM and tetanus immunoglobulin 250 units IM at separate site

›Complete primary series arrangement as outpatient

Analgesia and procedural sedation

›Analgesia for fragment wounds

›Ketamine for procedural sedation in polytrauma

›1 to 2 mg/kg IV for procedural sedation

›0.1 to 0.3 mg/kg IV as subanesthetic analgesic dose

›Preferred over opioids when concurrent TBI suspected

›Regional nerve blocks when feasible

›Femoral nerve block or fascia iliaca block for femur fracture

›Reduces systemic opioid requirement

›Ultrasound-guided technique preferred

›Avoid excessive opioids in polytrauma with potential TBI

›Respiratory depression masks neurologic deterioration

›Nausea risk increases aspiration risk

Wound management

›Fragment wound care principles

›Debridement of devitalized tissue

›Remove visible surface contamination

›Operative debridement for deep contaminated wounds

›Copious irrigation

›Normal saline irrigation under pressure

›Reduces bacterial load and contamination

›Delayed primary closure

›Do not close contaminated blast wounds primarily

›Closure at 48 to 72 hours after reassessment

›Retained fragment management

›Not all fragments require removal

›Indications for removal: neurovascular proximity, joint involvement, infection

›Subspecialty decision for deep or critical location fragments

Compartment syndrome management

›Monitoring and threshold

›Compartment pressure measurement if clinical suspicion

›Pressure above 30 mmHg or within 30 mmHg of diastolic blood pressure

›Absolute threshold 30 mmHg widely used

›Clinical diagnosis sufficient in high-suspicion cases

›Do not delay fasciotomy for pressure measurement in obvious cases

›Fasciotomy

›Four-compartment fasciotomy for leg compartment syndrome

›Medial and lateral incisions releasing all four compartments

›Wound left open with negative pressure wound therapy

›Forearm fasciotomy for volar and dorsal compartments

›Two-incision technique for complete release

›Carpal tunnel release when hand involved

09Special Populations/sp78

Pregnancy

›Physiologic considerations

›Altered hemodynamics in pregnancy

›Physiologic tachycardia and lower blood pressure at baseline

›Aortocaval compression in supine position reduces venous return

›Lateral tilt or manual uterine displacement during resuscitation

›Placental abruption risk after blast or penetrating trauma

›Abdominopelvic fragments pose direct risk to uterus and placenta

›Abruption may present with minimal external injury

›Perimortem cesarean section

›If maternal cardiac arrest, delivery within 4 minutes improves maternal and fetal outcome

›Viable fetus at 24 weeks gestation or beyond

›Imaging and medication

›CT imaging when clinically indicated despite ionizing radiation

›Life-threatening injury takes precedence over radiation risk

›Shield uterus when feasible without compromising diagnostic value

›Antibiotic selection in pregnancy

›Cefazolin and penicillin-based regimens preferred: FDA category B

›Avoid aminoglycosides (ototoxicity), tetracyclines (fetal tooth and bone effects)

›Metronidazole generally considered safe in second and third trimester

›Tranexamic acid in pregnancy

›Limited safety data but life-threatening hemorrhage warrants use

›Crosses placenta; theoretical risk not quantified

›Fetal monitoring

›Continuous fetal heart rate monitoring for viable gestation above 24 weeks

›Minimum 4 hours monitoring after significant trauma

›Obstetrics consultation for all pregnant trauma patients

Geriatric

›Physiologic reserve and presentation

›Attenuated tachycardia response to hemorrhagic shock

›Heart rate may not rise despite significant blood loss

›Beta-blocker use masks compensatory tachycardia

›Medication complexity

›Anticoagulant or antiplatelet use increases hemorrhagic risk

›Reversal agent planning: vitamin K, PCC, idarucizumab, andexanet alpha

›Higher mortality at equivalent injury severity scores

›Age over 55 is independent predictor of mortality in blast trauma

›Lower physiologic tolerance for permissive hypotension

›Special management considerations

›Aggressive early resuscitation with earlier blood product use

›Older patients tolerate crystalloid poorly

›Pulmonary edema risk with fluid overload

›Antibiotic dosing adjustment

›Renal function assessment mandatory before aminoglycoside use

›Reduced clearance prolongs drug half-life

›Wound healing impairment

›Delayed primary closure timeline may need extension

›Nutritional assessment and supplementation

›Cognitive effects of sedation and analgesia

›Opioid-induced delirium risk higher in elderly

›Ketamine may cause emergence agitation but preferred for hemodynamic stability

Pediatrics

›Anatomical and physiologic differences

›Higher injury rate per unit body surface area from fragments

›Smaller body size means fragments traverse more critical structures

›Lower mass means greater kinetic energy transfer per kilogram

›Compensatory reserve maintained longer before decompensation

›Heart rate and blood pressure age-adjusted thresholds

›Tachycardia above 160 in infant or above 140 in toddler as shock marker

›Head disproportionately large increases TBI frequency in blast events

›Penetrating brain injury proportion higher in children than adults

›GCS interpretation age-adjusted

›Weight-based drug dosing

›Tranexamic acid in pediatric hemorrhagic shock

›15 mg/kg IV loading dose maximum 1 g

›2 mg/kg/hour maintenance maximum 1 g over 8 hours

›Cefazolin for wound prophylaxis

›25 to 50 mg/kg IV every 8 hours maximum 2 g per dose

›Clindamycin 10 mg/kg IV every 8 hours if penicillin-allergic

›Ketamine for procedural sedation

›1 to 2 mg/kg IV or 4 mg/kg IM

›Atropine 0.02 mg/kg IV to reduce secretions if needed

›Special pediatric considerations

›Child protection assessment when blast context involves neglect or intentional harm

›Documentation of circumstances and referral when appropriate

›Parental presence and communication

›Separate family from resuscitation bay if necessary

›Designated family liaison nurse

›Long-term outcomes

›Fragment retention in growing bones may require staged removal

›Orthopedic follow-up for growth plate involvement

10Background/b81

Epidemiology

›Prevalence and context

›Secondary blast injury is the most common type of blast injury overall

›Fragments injure at distances of hundreds to thousands of meters from epicenter

›Far exceeds range of primary blast overpressure effects

›Terrorist IEDs intentionally loaded with fragmenting materials

›Ball bearings, nails, screws, and scrap metal to maximize casualties

›Multiple simultaneous casualties common in urban attacks

›Boston Marathon bombing 2013 as illustrative event

›189 shrapnel fragments identified in 32 of 43 patients

›Lower extremity injuries predominant from ground-level device placement

›Mortality and morbidity patterns

›Fragment wounds contribute to majority of preventable battlefield deaths

›Extremity hemorrhage from fragments is most common preventable cause of death

›Tourniquet and hemostatic agent training reduces mortality

›Multiregion injury pattern in survivors reaching hospital

›Average 4 to 7 wounds per patient in high-density fragmentation attacks

›Polytrauma management principles required

›Long-term morbidity

›Retained fragment-associated infections may present years later

›Lead toxicity from retained lead fragments is a recognized complication

›Psychiatric morbidity including PTSD in 30 to 40% of blast survivors

Pathophysiology

›Fragment injury mechanism

›Kinetic energy transfer from high-velocity projectiles

›Energy transfer proportional to mass times velocity squared

›Fragment tumbling and deformation increase wound cavity

›Penetrating trajectory injuries

›Stab wound and gunshot wound analogy

›Temporary and permanent wound cavities depending on fragment velocity

›Blunt component from low-velocity secondary fragments

›Displaced structural debris from explosion

›Blunt force trauma and crush injury pattern

›Concurrent injury mechanisms in blast events

›Primary blast lung from pressure wave

›Air-filled organ barotrauma independent of fragments

›Alveolar hemorrhage and pulmonary edema

›Tertiary injury from body displacement

›Blast wind throws victim against structures

›Closed head injury and long-bone fractures

›Systemic physiologic effects of blast

›Sympathetic surge initially then parasympathetic rebound

›Coagulopathy from polytrauma and hypothermia

›Wound infection pathogenesis

›Devitalized tissue and contamination create ideal infection environment

›Clostridial species and anaerobes in heavily contaminated wounds

›Delayed presentation increases bacterial load

›Open fracture infection risk correlated with Gustilo grade

›Grade I less than 2% infection rate

›Grade IIIB and IIIC up to 50% infection rate without prophylaxis

›Retained fragments as nidus for chronic infection

›Biofilm formation on fragment surface

›Antibiotic penetration limited

Therapeutic Considerations

›Damage control principles

›Damage control resuscitation

›Balanced blood product ratio rather than crystalloid

›Permissive hypotension until surgical hemorrhage control

›Correction of coagulopathy, acidosis, and hypothermia

›Damage control surgery

›Abbreviated initial operative procedure

›Temporary closure and ICU resuscitation before definitive repair

›Re-exploration at 24 to 48 hours when physiology corrected

›Lethal triad prevention

›Hypothermia: warming blankets, warmed IV fluids, heated ventilator circuits

›Acidosis: resuscitation with blood products, bicarbonate if pH below 7.1

›Coagulopathy: early fresh frozen plasma, cryoprecipitate, and platelets

›Antibiotic stewardship in fragment wounds

›Short-course prophylaxis supported over extended courses

›Prolonged antibiotics increase resistance and C. difficile risk

›Duration guided by wound closure and absence of infection signs

›Culture-directed therapy when infection established

›Gram stain and culture from wound prior to antibiotic initiation when possible

›De-escalate based on culture results

›Fragment removal decision-making

›Most fragments do not require removal

›Removal indicated for neurovascular compromise, joint involvement, or infection

›Retained fragments monitored with serial imaging

›Lead fragment toxicity monitoring

›Blood lead level at 6 weeks and at 3 months post-injury

›Level above 10 microg/dL warrants chelation consideration

›Multidisciplinary planning for complex fragment locations

›Spinal cord proximity requires neurosurgery input

›Vascular proximity requires vascular surgery input

11Patient Discharge Instructions/pdi50

copy discharge instructions

›Wound care instructions

›Keep all wounds clean and dry for 48 hours

›Gently clean with soap and water after 48 hours

›Change dressings daily or when soaked through

›Do not remove wound packing yourself

›Return to clinic or ED for packing removal as instructed

›Sutures or staples removed at follow-up appointment

›Elevate injured extremity above heart level when resting

›Reduces swelling and pain

›Especially important for hand and foot wounds

›Activity and diet

›Rest injured region and avoid heavy lifting until cleared by surgeon

›Gradually increase activity as pain allows

›Use crutches or sling if prescribed

›Regular meals and hydration to support healing

›Protein-rich diet aids wound healing

›Avoid alcohol while taking antibiotics

›Medications

›Complete full antibiotic course as prescribed

›Do not stop early even if wound looks better

›Take with food to reduce stomach upset

›Pain relief options as prescribed

›Acetaminophen scheduled rather than opioid-first approach

›Ibuprofen if no contraindication and no active bleeding concern

›Tetanus vaccination follow-up if primary series started

›Arrange remaining doses with family doctor

›Warning signs to return to emergency department immediately

12References/r29

Guidelines and key sources

›Trauma and military medicine guidelines

›ATLS Advanced Trauma Life Support 10th edition, American College of Surgeons

›Primary and secondary survey framework

›Hemorrhagic shock classification and management

›Tactical Combat Casualty Care guidelines, Committee on Tactical Combat Casualty Care

›Hemorrhage control and tourniquet recommendations

›Prehospital antibiotic and TXA protocols

›EAST Practice Management Guidelines for penetrating abdominal trauma

›Antibiotic prophylaxis duration evidence

›Operative decision-making for abdominal fragment injury

›Key trials and evidence

›CRASH-2 trial: tranexamic acid in traumatic hemorrhage

›Lancet 2010; 376: 23 to 32

›Class I evidence for TXA within 3 hours of injury

›Boston Marathon bombing analysis

›Annals of Surgery 2014 review of fragment injury patterns

›189 fragments in 32 of 43 patients; lower extremity predominance

›Blast injury review literature

›Clemedson CJ: Blast injury, Physiological Reviews 1956 foundational text

›DePalma RG et al: Blast injuries, NEJM 2005; 352: 1335 to 1342

›Coding standards

›ICD-10 codes for blast-related fragment injuries

›S09.2 traumatic rupture of ear drum

›S27.0 traumatic pneumothorax, S27.1 traumatic hemothorax

›S36 injury of intraabdominal organs

›T14.0 open wound of unspecified body region for undifferentiated fragment wounds

›SNOMED CT blast injury concepts

Evidence & Review