Approach to the Critical Patient

Immediate priorities

Hemorrhage control

Airway and penetrating neck injury

Exposure and full-body sweep

Monitoring and targets

Hemodynamic monitoring

Escalation triggers

Immediate consults

Trauma team activation

Subspecialty triggers

History

Blast event details

Mechanism and device

Prehospital course

Symptom review

Injury-related complaints

Concurrent primary blast injury symptoms

Risk factors and past history

Injury severity modifiers

Tetanus and allergy history

Relevant comorbidities

Physical Exam

Primary survey

Airway

Breathing and circulation

Wound survey

Systematic head-to-toe skin inspection

Extremity assessment

Targeted organ exams

Ocular exam

Ear exam

Abdominal exam

PITFALLS

Missed wounds

Imaging underestimation

Differential Diagnosis

Life-threatening injuries from fragments

Vascular laceration

Penetrating thoracic injury

Penetrating abdominal injury

Concurrent blast injury types

Primary blast injury

Tertiary blast injury

Quaternary blast injury mimics

Delayed presentations

Delayed vascular injury

Compartment syndrome

Missed hollow viscus injury

Laboratory Tests

Hemorrhage and resuscitation

Type and screen or crossmatch

Lactate and metabolic

Infection risk assessment

Wound contamination markers

Urinalysis and renal function

Gas exchange

Arterial blood gas

Diagnostic Tests

Scoring Systems

Trauma severity tools

Shock classification

MRI

Indications and limitations in blast fragment injury

CT

CT head without contrast

CT thorax with IV contrast

CT abdomen and pelvis with IV contrast

CT extremity and soft tissue

Ultrasound

FAST examination

Vascular Doppler ultrasound

Ocular ultrasound

Disposition

Operative and resuscitation disposition

Immediate operative indications

Resuscitation bay continued care

ICU admission indications

Criteria for intensive care

Ward and step-down criteria

Stable ward admission

Transfer indications

Discharge criteria

Outpatient management eligibility

Treatment

Hemorrhage control and resuscitation

Tourniquet and wound packing

Tranexamic acid

Massive transfusion protocol

Antibiotic therapy

Open soft-tissue wound prophylaxis

Penetrating abdominal injury

Open fracture antibiotic therapy

Penetrating brain injury

Ocular penetrating injury

Tetanus prophylaxis

Tetanus prophylaxis protocol

Analgesia and procedural sedation

Analgesia for fragment wounds

Wound management

Fragment wound care principles

Compartment syndrome management

Monitoring and threshold

Fasciotomy

Special Populations

Pregnancy

Physiologic considerations

Imaging and medication

Geriatric

Physiologic reserve and presentation

Special management considerations

Pediatrics

Anatomical and physiologic differences

Weight-based drug dosing

Special pediatric considerations

Background

Epidemiology

Prevalence and context

Mortality and morbidity patterns

Pathophysiology

Fragment injury mechanism

Concurrent injury mechanisms in blast events

Wound infection pathogenesis

Therapeutic Considerations

Damage control principles

Antibiotic stewardship in fragment wounds

Fragment removal decision-making

Patient Discharge Instructions

copy discharge instructions

Wound care instructions

Activity and diet

Medications

Warning signs to return to emergency department immediately

Follow-up schedule

References

Guidelines and key sources

Trauma and military medicine guidelines

Key trials and evidence

Coding standards