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Blast Injury (Tertiary)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Blast Injury (Tertiary)
POCUS
Procedures
Calculators
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ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Hemorrhage control and CABC priorities
Catastrophic hemorrhage — first priority before airway
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Tourniquet application for life-threatening extremity hemorrhage
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Apply proximal to wound, record time
Do not remove until surgical capability available
90% of blast amputation survivors had tourniquets vs 24% of deceased (combat data)
Pelvic binder for suspected unstable pelvic fracture
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Single application; do not repeatedly test stability
Direct pressure for compressible hemorrhage sites
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Junctional wounds require wound packing with hemostatic gauze
Airway and breathing
Airway status
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GCS < 8 or inability to protect airway — definitive airway required
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Rapid sequence intubation; anticipate facial trauma
Surgical airway if oral/nasal route compromised by blast trauma
Suspected tension pneumothorax
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Needle decompression followed by tube thoracostomy
Asymmetric breath sounds, tracheal deviation, hemodynamic instability
Concurrent blast lung (primary injury)
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Avoid high peak inspiratory pressures if blast lung suspected
Lung-protective ventilation strategy from outset
Circulation and resuscitation targets
Damage-control resuscitation principles
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Permissive hypotension target SBP 80–90 mmHg until hemorrhage control
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Exception: TBI patients require SBP > 100 mmHg to maintain CPP
Class I recommendation for damage-control resuscitation
Balanced blood product transfusion 1:1:1 ratio pRBC:FFP:platelets
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Activate massive transfusion protocol early
Avoid crystalloid-predominant resuscitation in hemorrhagic shock
Tranexamic acid (TXA) within 3 hours of injury
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1 g IV over 10 minutes loading dose, then 1 g IV over 8 hours
Class I recommendation; mortality benefit diminishes after 3 hours
Neurological stabilization
Severe TBI management priorities
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Avoid hypotension (SBP < 90 mmHg worsens outcome)
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Avoid hypoxia (SpO2 < 90 mmHg worsens outcome)
Dual secondary injury prevention is primary early goal
ICP management targets
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Target CPP 60–70 mmHg
ICP monitoring for GCS ≤ 8 with intracranial pathology
Immediate team activation
Consultation and activation triggers
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Trauma surgery for all significant tertiary blast injuries
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Activate trauma team on arrival for any hemodynamic instability
Damage-control surgery for unstable patients
Neurosurgery for intracranial pathology or depressed skull fracture
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Vascular surgery for limb ischemia or blunt cerebrovascular injury
Orthopedics for fractures and compartment syndrome concern
History
Mechanism and exposure
Blast event circumstances
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Type of device: IED, industrial explosion, gas detonation
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Distance from blast center
Enclosed vs. open space (enclosed significantly worsens all blast categories)
Physical displacement mechanism
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Thrown against fixed object (wall, vehicle, ground)
Struck by structural collapse or debris
Estimated distance thrown
Entrapment details
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Duration of entrapment (>1 hour raises crush syndrome risk)
Surface trapped under (structural vs. soft material)
Symptom onset and progression
Neurological symptoms
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Loss of consciousness: duration and quality of recovery
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Post-traumatic amnesia: duration
Confusion, disorientation, GCS trajectory
Headache, visual changes, unequal pupils
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Seizure activity
Focal neurological deficits
Systemic symptoms
▶
Dyspnea, chest pain, hemoptysis (screen for concurrent blast lung)
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Abdominal pain, nausea, vomiting, hematemesis
Extremity pain, deformity, inability to bear weight
Musculoskeletal and vascular
Extremity and compartment concerns
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Pain out of proportion to apparent injury
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Paresthesias or numbness in extremity
Timing: compartment syndrome irreversible within 6 hours
Dark or tea-colored urine (myoglobinuria)
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Decreased urine output
Risk stratifiers
High-risk features
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Enclosed space detonation
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Proximity < 5 meters from epicenter
Structural collapse with entrapment
Extremes of age: children and elderly more vulnerable to blunt trauma
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Anticoagulant or antiplatelet use (increased intracranial hemorrhage risk)
Pre-existing osteoporosis (elevated fracture risk)
Lack of protective equipment (body armor, helmet)
Past medical history
Comorbidities relevant to blast care
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Prior TBI (cumulative effects; worse outcomes with repeat injury)
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Bleeding disorders or anticoagulant/antiplatelet use
Chronic kidney disease (lower threshold for AKI with rhabdomyolysis)
Cardiac disease (tolerance of resuscitation, myocardial contusion risk)
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Prior abdominal surgery (adhesions complicate operative management)
Mental health history (baseline for PTSD assessment)
Collateral history
Pre-hospital information
▶
Witness or first responder account of mechanism
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Pre-hospital vitals and GCS trajectory
Interventions performed (tourniquet time, airway maneuvers)
Time from injury to ED presentation
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Time tourniquet applied (ischemia duration)
Physical Exam
Primary survey
CABC primary survey
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Catastrophic hemorrhage sites: active bleeding, tourniquet placement check
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Airway patency and protection
Bilateral breath sounds, chest wall symmetry
Circulation: skin color, capillary refill, peripheral pulses
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Disability: GCS, pupil size and reactivity
Exposure: full body examination, log-roll for posterior injuries
Vital signs and hemodynamics
Hemodynamic assessment
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Tachycardia and hypotension: hemorrhagic shock pattern
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SBP < 90 mmHg: immediate resuscitation trigger
Tachypnea: thoracic injury or metabolic acidosis
Pulse oximetry baseline
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Concurrent blast lung may present with deceptively normal SpO2 initially
Head and neurological
Cranial and neurological examination
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GCS components: eye, verbal, motor
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Pupil size, reactivity, symmetry
Scalp lacerations, step-off deformities
Basilar skull fracture signs
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Battle sign (mastoid ecchymosis)
Raccoon eyes (periorbital ecchymosis)
Otorrhea or rhinorrhea (CSF leak)
Focal neurological deficits
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Motor strength by limb
Cranial nerve assessment
Neck and thorax
Cervical spine
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Midline tenderness on palpation
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Step-off deformity
Maintain immobilization until cleared clinically or radiographically
Chest wall assessment
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Asymmetric breath sounds
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Subcutaneous emphysema (crepitus)
Flail segment: paradoxical chest wall movement
Percussion: dullness (hemothorax) vs. hyperresonance (pneumothorax)
Abdomen and pelvis
Abdominal examination
▶
Tenderness, guarding, rigidity
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Distension
Contusion pattern (seatbelt-equivalent injury)
Pelvis stability
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Single compression test only — do not repeat
Instability: apply binder immediately
Extremities and compartment syndrome
Extremity assessment
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Deformity: open vs. closed fracture classification
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Neurovascular status distal to injury
Skin: degloving, avulsion, tourniquet sites
Compartment syndrome examination
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Firmness of compartments on palpation
Pain with passive stretch of muscles in compartment
Diminished two-point discrimination
Differential Diagnosis
Life-threatening injuries — must not miss
Traumatic brain injury spectrum
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Epidural hematoma: ICD-10 S06.4
▶
Subdural hematoma: ICD-10 S06.5
Diffuse axonal injury: ICD-10 S06.2
Lucid interval followed by rapid deterioration (classic epidural pattern)
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Most common cause of death in blast survivors
Vascular and thoracic emergencies
Thoracic injuries
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Tension pneumothorax
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Hemothorax
Traumatic aortic injury (deceleration mechanism)
Cardiac contusion
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Blunt cardiac rupture (rare, high mortality)
Hemopericardium/tamponade
Abdominal emergencies
Solid and hollow organ injuries
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Splenic laceration: most commonly injured solid organ in blunt trauma
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Hepatic laceration with active hemorrhage
Hollow viscus perforation (delayed peritonitis)
Mesenteric injury with bowel ischemia
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Pancreatic injury: ICD-10 S36.2
Renal pedicle injury
Musculoskeletal and soft tissue
Fractures and compartment emergencies
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Unstable pelvic fracture with retroperitoneal hemorrhage
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Femur fracture: 1–2 L blood loss per fracture
Traumatic amputation: ICD-10 S98 (foot/ankle), S88 (leg)
Compartment syndrome: ICD-10 M79.A
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Crush syndrome/rhabdomyolysis: ICD-10 T79.5
Concurrent blast injury categories
Primary blast injury overlap
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Blast lung (pulmonary barotrauma): may be silent initially
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Bowel perforation from pressure wave
Tympanic membrane rupture (ICD-10 S09.2)
Secondary blast injury overlap
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Retained shrapnel with occult penetrating injury
Combined mechanism injuries common in IED explosions
Crush and metabolic complications
Crush syndrome
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Rhabdomyolysis with AKI: ICD-10 M62.82 + N17.9
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Hyperkalemia causing fatal arrhythmia
Disseminated intravascular coagulation (DIC): ICD-10 D65
Laboratory Tests
Hemorrhage and coagulation
Type and screen/crossmatch
▶
Crossmatch 6 units pRBC if massive transfusion anticipated
▶
Massive transfusion protocol activation criteria
Assessment of Blood Consumption (ABC) score ≥ 2 triggers MTP
Coagulation studies
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PT/INR and aPTT: baseline coagulopathy from dilution or TBI
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Fibrinogen: target > 1.5 g/L; low fibrinogen predicts transfusion need
TEG/ROTEM if available for viscoelastic-guided resuscitation
CBC with differential
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Hemoglobin/hematocrit: baseline and serial (q4–6h in active hemorrhage)
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Platelet count: target > 50 x10^9/L in active bleeding
Leukocytosis may indicate stress response or early infection
Metabolic and organ function
Lactate and base deficit
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Lactate > 4 mmol/L: high mortality correlation in trauma
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Base deficit > -6 mEq/L: surrogate for shock severity
Serial lactate clearance guides resuscitation adequacy
Arterial blood gas
▶
PaO2/FiO2 ratio: ARDS diagnosis threshold < 200 mmHg
PaCO2: ventilation adequacy, avoidance of hypocapnia in TBI
Basic metabolic panel (BMP)
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Potassium: hyperkalemia from crush injury causes fatal arrhythmias
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Check q4–6h initially in crush syndrome
K+ > 6.5 mmol/L: emergent management required
Creatinine and BUN: baseline and serial renal function monitoring
▶
Sodium: hyponatremia may develop with aggressive crystalloid
Rhabdomyolysis panel
Creatine kinase (CK)
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CK > 1000 U/L: rhabdomyolysis screening threshold
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CK > 5000 U/L: high risk for acute kidney injury
Serial CK q6h; peak CK predicts AKI risk
Urinalysis
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Dipstick positive for blood without RBCs on microscopy: myoglobinuria
Target urine output > 200–300 mL/hr during aggressive hydration
Urine pH target > 6.5 with bicarbonate alkalinization
Organ-specific markers
Troponin
▶
Myocardial contusion screening in thoracic trauma
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Elevated troponin with normal ECG: serial monitoring 6h
Arrhythmia risk correlates with troponin elevation
Liver enzymes and lipase
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AST/ALT > 200 U/L: hepatic injury screening threshold
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Lipase for pancreatic injury
Both may be elevated from muscle injury (CK confirmation required)
Adjunct studies
Ethanol level and urine drug screen
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If altered mental status with unclear mechanism
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Intoxication confounds GCS interpretation
Concurrent TBI and intoxication have additive effect on outcome
Diagnostic Tests
Scoring Systems
Injury Severity Score (ISS)
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ISS ≥ 16: major trauma designation; ICU-level care
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ISS ≥ 25: highest mortality tier
Calculated from Abbreviated Injury Scale (AIS) across six body regions
Glasgow Coma Scale
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GCS 13–15: mild TBI
GCS 9–12: moderate TBI
GCS ≤ 8: severe TBI; intubation and ICP monitoring threshold
Revised Trauma Score (RTS)
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Combines GCS, SBP, and respiratory rate
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Low RTS correlates with high mortality
Used for field triage in mass casualty events
Assessment of Blood Consumption (ABC) Score
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SBP ≤ 90 mmHg: 1 point
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HR ≥ 120 bpm: 1 point
Penetrating mechanism: 1 point
Positive FAST: 1 point
Score ≥ 2: activate massive transfusion protocol (sensitivity 75%, specificity 86%)
Compartment Syndrome Pressure Thresholds
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Absolute compartment pressure > 30 mmHg: fasciotomy indicated
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Delta pressure (diastolic BP minus compartment pressure) < 30 mmHg: fasciotomy indicated
Clinical diagnosis remains primary; pressure thresholds are adjuncts
MRI
MRI head and spine indications
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Blast-related TBI with normal CT but persistent neurological symptoms
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Diffuse axonal injury (DAI): CT-occult but MRI-visible on DWI/susceptibility-weighted imaging
Gradient echo/SWI: sensitive for microhemorrhages from blast TBI
Spinal cord injury without radiographic abnormality (SCIWORA)
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MRI within 72 hours for suspected spinal cord injury with normal CT
Contraindicated if retained ferromagnetic fragments (screen with plain films first)
MRI limitations in acute blast injury
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Not first-line in acute polytrauma (time-prohibitive)
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CT remains standard for acute phase
Reserve MRI for subacute phase or when CT findings do not explain deficits
CT
Whole-body CT (pan-scan)
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Standard for hemodynamically stable or transiently responsive blast/blunt trauma patients
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Head through pelvis with IV contrast
Identifies clinically unsuspected injuries in up to 38% of closed head injury patients
Protocol: non-contrast head, IV contrast chest/abdomen/pelvis, CT angiography as indicated
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ACR Appropriateness Criteria: usually appropriate for major blunt trauma
Time from injury to CT completion predicts missed injury rate
CT head without contrast
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Mandatory for any alteration in consciousness, GCS < 15, or focal neurological deficit
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Sensitivity for acute intracranial hemorrhage: > 95%
Cannot exclude DAI (gradient echo or susceptibility-weighted MRI required)
CT angiography
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Blunt cerebrovascular injury (BCVI) screening
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Denver Criteria for BCVI screening: Horner syndrome, carotid bruit, focal neuro deficit not explained by CT head
Extremity vascular injury with hard signs: pulsatile bleeding, expanding hematoma, absence of distal pulse
CT aortography for high-energy deceleration mechanism
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Aortic injury sensitivity > 95% with CT angiography
Pelvic and extremity CT
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CT pelvis with contrast for unstable pelvic fracture before pelvic angioembolization
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Plain films first for extremity fractures; CT for complex periarticular injuries
CT identifies soft tissue gas suggesting open fracture or clostridial infection
Ultrasound
FAST and E-FAST examination
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Hemodynamically unstable patient: FAST before pan-scan
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Four views: hepatorenal, splenorenal, pelvic (pouch of Douglas/rectovesical), pericardial
E-FAST adds bilateral anterior lung for pneumothorax/hemothorax
FAST sensitivity for hemoperitoneum: 73–88%
▶
Specificity: 99%
Negative FAST does not exclude significant injury in unstable patient
Cardiac ultrasound
▶
Hemopericardium: pericardial effusion with tamponade physiology
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RV collapse in diastole: marker of hemodynamically significant tamponade
Pericardiocentesis as bridge to OR if tamponade confirmed
Vascular and extremity ultrasound
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Doppler for limb ischemia assessment if CTA not immediately available
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Ankle-brachial index (ABI) < 0.9: vascular injury screen positive
Compartment pressure measurement using ultrasound-guided technique
Disposition
Immediate operative disposition
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Direct to operating room (bypass CT)
▶
Hemodynamically unstable despite initial resuscitation
▶
Positive FAST with ongoing hemorrhage
Traumatic amputation requiring operative control
Massive transfusion protocol activation
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Damage-control surgery principles apply
ICU admission criteria
ICU-level indications
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GCS ≤ 13 or any intracranial pathology on CT
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Hemodynamic instability or requirement for ongoing transfusion
Mechanical ventilation requirement
Rhabdomyolysis with CK > 5000 U/L or rising trend
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Compartment syndrome requiring serial examinations q1–2h
Blast lung coexistence: minimum 8-hour ICU observation
ISS ≥ 16: polytrauma designation
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Crush syndrome with AKI requiring dialysis consideration
Surgical and specialist consultation
Mandatory consultations
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Trauma surgery: all significant tertiary blast injuries
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Neurosurgery: intracranial hemorrhage, depressed skull fracture, refractory ICP
Orthopedics: fractures, compartment syndrome
Vascular surgery: vascular injury, ischemic limb
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Nephrology: AKI from crush syndrome if RRT required
Ophthalmology: blast-related ocular injury
Step-down and floor admission
Floor-level admission criteria
▶
Hemodynamically stable without transfusion requirement
▶
GCS 15 with negative CT head or non-operative intracranial injury
Fractures not requiring operative fixation
Rhabdomyolysis with declining CK and adequate urine output on IV fluids
▶
Serial neurological checks if mild TBI
Discharge criteria
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Criteria for discharge from ED
▶
Minor contusions or abrasions only
▶
Normal imaging (CT head, plain films as indicated)
GCS 15 throughout observation
No rhabdomyolysis (CK normal or minimally elevated, trending down)
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Hemodynamically stable throughout
Reliable follow-up confirmed
Treatment
Hemorrhage control and resuscitation
Damage-control resuscitation protocol
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Balanced transfusion 1:1:1 ratio pRBC:FFP:platelets
▶
Target hemoglobin 70–90 g/L in active hemorrhage
Target platelets > 50 x10^9/L (> 100 x10^9/L if TBI)
Target fibrinogen > 1.5 g/L; cryoprecipitate if low
Tranexamic acid (TXA)
▶
1 g IV loading dose over 10 minutes
1 g IV maintenance over 8 hours
Administer within 3 hours of injury; no benefit after 3 hours
Class I recommendation (CRASH-2 trial; AAST/ACS protocol)
Airway management
Definitive airway for GCS ≤ 8 or inability to protect airway
▶
Rapid sequence intubation (RSI)
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Ketamine 1.5–2 mg/kg IV (preferred in hemodynamic instability)
Succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV
Video laryngoscopy preferred for anticipated difficult airway
Post-intubation ventilation strategy
▶
Lung-protective ventilation: tidal volume 6 mL/kg IBW
PEEP 5–8 cmH2O; adjust for oxygenation
Avoid high peak pressures if concurrent blast lung
Crush syndrome and rhabdomyolysis
Aggressive IV fluid resuscitation
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Normal saline (0.9% NaCl): 1 L/hr initially
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Total fluid target up to 12 L/day in severe crush syndrome
Avoid lactated Ringer's (potassium-containing) in crush syndrome
Avoid potassium-containing fluids throughout crush syndrome management
Urine alkalinization
▶
Sodium bicarbonate 50 mEq in 2nd and 3rd liter of IV fluid
Target urine pH > 6.5
Prevents myoglobin precipitation in renal tubules
Urine output target
▶
Target UOP > 200–300 mL/hr during IV fluid resuscitation
Mannitol 0.5–1 g/kg IV if UOP adequate but CK not clearing
Furosemide only if volume-overloaded; avoid in hypovolemic rhabdomyolysis
Hyperkalemia management in crush syndrome
Emergent hyperkalemia treatment for K+ > 6.5 mmol/L or ECG changes
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Calcium gluconate 1–2 g IV over 5–10 minutes (cardiac membrane stabilization)
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Onset 1–3 minutes, duration 30–60 minutes
Repeat if ECG changes persist
Sodium bicarbonate 50–100 mEq IV for K+ shift intracellularly
▶
Concurrent glucose-insulin: dextrose 50% 50 mL + insulin 10 units IV
Potassium-lowering effect within 30 minutes
Emergent dialysis if renal replacement required
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Indications: K+ > 6.5 mmol/L refractory, severe AKI, acidosis pH < 7.1
Compartment syndrome
Emergent fasciotomy
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Indication: compartment pressure > 30 mmHg or delta pressure < 30 mmHg
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Clinical diagnosis sufficient if pressure measurement unavailable
Irreversible muscle damage begins within 6 hours of ischemia
Four-compartment fasciotomy of the leg (most common site)
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Generous incisions releasing all compartments
Wound left open; delayed primary closure or skin grafting at 48–72 hours
Traumatic brain injury management
Prevent secondary injury
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Maintain SBP > 100 mmHg (not permissive hypotension if TBI present)
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Maintain SpO2 > 94%
Avoid hyperventilation (target PaCO2 35–40 mmHg unless herniation)
Osmotherapy for elevated ICP
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Mannitol 0.25–1 g/kg IV bolus; repeat q4–6h if serum osmolality < 320 mOsm/kg
Hypertonic saline (23.4% NaCl) 30 mL IV bolus for refractory ICP or herniation
Head of bed 30 degrees, midline position
Seizure prophylaxis
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Levetiracetam 500–1000 mg IV q12h for 7 days in severe TBI (GCS ≤ 8)
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Phenytoin as alternative: 15–20 mg/kg IV load, then 100 mg IV q8h
Prophylaxis reduces early post-traumatic seizures; no proven effect on long-term epilepsy
Class IIA recommendation (Brain Trauma Foundation guidelines)
Analgesia
Analgesic strategy
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Ketamine for hemodynamically unstable patients
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Sub-dissociative dose: 0.3–0.5 mg/kg IV
Avoids opioid-related hemodynamic depression
Opioid caution in compartment syndrome
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Avoid excessive opioids that may mask compartment syndrome pain
Regional anesthesia (nerve blocks) with caution — monitor closely for compartment syndrome development
Acetaminophen 1 g IV q6h as adjunct (opioid-sparing)
Fracture management
Damage-control orthopedics
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External fixation initially for unstable fractures in polytrauma
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Definitive fixation delayed until patient physiologically stable
Open fracture management
Open fractures: antibiotics within 1 hour
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Grade I/II: cefazolin 1–2 g IV q8h
Grade III or contaminated: add gentamicin 5 mg/kg IV q24h
Tetanus prophylaxis: update per immunization status
Wound irrigation and debridement in OR
Antibiotics and infection prevention
Antibiotic prophylaxis for open fractures
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Cefazolin 1–2 g IV q8h (Grade I/II open fractures)
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Add gentamicin 5 mg/kg IV q24h for Grade III or heavily contaminated wounds
Continue until wound closure or 72 hours maximum for prophylaxis
Military blast wounds: higher rate of multidrug-resistant organisms
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Broaden empirically in military/combat settings
Complications monitoring
Anticipated complications requiring active surveillance
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Delayed intracranial hemorrhage
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Repeat CT head at 6–24 hours if GCS declining
Anticoagulated patients: lower threshold for repeat imaging
ARDS from blast lung or massive transfusion
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PaO2/FiO2 < 200 mmHg: ARDS diagnosis
Lung-protective ventilation strategy
Fat embolism syndrome: days 1–3 post long bone fracture
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Petechiae, hypoxemia, confusion triad
VTE prophylaxis
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Mechanical prophylaxis from admission
Chemical prophylaxis when safe from hemorrhage standpoint
Special Populations
Pregnancy
Anatomical and physiological considerations
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Uterine displacement of intra-abdominal organs alters injury pattern after first trimester
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Uterus and placenta are highly vascularized; abruptio placentae risk high with blunt trauma
Placental abruption can occur with relatively minor trauma
Physiologic changes affecting resuscitation
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Physiologic anemia of pregnancy: lower baseline hemoglobin
Supine hypotension syndrome: left lateral tilt 15 degrees to displace uterus off IVC
Increased blood volume (40–50%); may tolerate greater blood loss before hemodynamic instability
Fetal monitoring and imaging
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Obstetric ultrasound for fetal heart rate and placental position
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Cardiotocography (CTG) monitoring minimum 4–6 hours after significant blunt trauma
Kleihauer-Betke test for feto-maternal hemorrhage if Rh-negative mother
CT imaging: do not withhold for fear of radiation in hemodynamically unstable mother
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Fetal radiation dose from pan-scan < 30 mGy (below teratogenic threshold)
Maternal survival takes priority
Treatment modifications
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TXA: administer if hemorrhagic shock present; fetal safety profile acceptable
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Emergency cesarean section if fetal distress with viable gestational age (> 23–24 weeks)
Rh immunoglobulin (300 mcg IM) for Rh-negative mothers
Geriatric
Physiologic vulnerability
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Reduced physiologic reserve: masked hemodynamic instability despite significant hemorrhage
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Beta-blockers mask tachycardia response; normal HR does not exclude hemorrhagic shock
Baseline systolic hypertension: "normal" BP may represent relative hypotension
Osteoporosis markedly increases fracture risk at lower force thresholds
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Increased brain atrophy: subdural hematoma risk higher from bridging vein stretch
Anticoagulant or antiplatelet use in 30–40% of elderly: increased hemorrhage risk
Resuscitation and medication modifications
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Lower threshold for massive transfusion protocol activation
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Avoid overly aggressive crystalloid (cardiac and pulmonary reserve limited)
Ketamine dose reduce 25–50% for analgesia/sedation
Renal function considerations
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Age-related decline in GFR: higher AKI risk with rhabdomyolysis
Avoid nephrotoxic antibiotics (aminoglycosides) or use with drug-level monitoring
Contrast nephropathy risk: consider pre-hydration if time permits
Outcome and disposition
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Higher ISS-adjusted mortality vs. younger patients
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Lower threshold for ICU admission
Early social work and rehabilitation planning
Pediatrics
Anatomical and physiological differences
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Relatively larger head-to-body ratio: higher incidence of TBI in pediatric blast victims
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Less calcified skull and more compliant brain: different injury biomechanics
Abdominal solid organs (liver, spleen) proportionally larger and less protected by ribcage
Physiologic reserve: children maintain BP until >25% volume loss, then decompenate rapidly
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Normal BP in children does not exclude significant hemorrhage
Tachycardia is earliest reliable indicator
Weight-based dosing
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Fluid resuscitation: 20 mL/kg IV isotonic saline bolus; reassess after each bolus
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Maximum 3 boluses (60 mL/kg) before blood products
pRBC transfusion: 10 mL/kg IV if hemodynamic instability persists
Ketamine for RSI: 1.5–2 mg/kg IV
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Succinylcholine: 2 mg/kg IV in children (higher dose per kg than adults)
TXA: 15 mg/kg IV loading dose (max 1 g), then 2 mg/kg/hr for 8 hours
Levetiracetam for seizure prophylaxis in severe pediatric TBI
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20 mg/kg IV loading dose (max 1000 mg), then 10 mg/kg IV q12h
Non-accidental trauma consideration
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Unusual blast injury in child without clear mechanism: consider safeguarding evaluation
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Social work consultation in appropriate context
Background
Epidemiology
Incidence and setting
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Blast injuries are the leading cause of combat casualty in modern warfare
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IED (improvised explosive device) responsible for majority of blast injuries in Iraq and Afghanistan conflicts
Civilian blast injuries increasing: terrorist attacks, industrial explosions, gas explosions
Tertiary blast injury prevalence
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Tertiary injuries occur in majority of blast survivors when structural collapse occurs
Structural collapse: dramatically increases mortality; entrapment > 24 hours carries very high mortality
Traumatic amputation rate in combat blast: Israel-Hamas 2023–24 data showed significant amputation burden among military personnel
Mortality and morbidity
▶
TBI is the most common cause of death in blast survivors who reach medical care
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Polytrauma patients with ISS ≥ 25 have mortality rates approaching 50% without damage-control surgery
Rhabdomyolysis-induced AKI in crush syndrome: mortality 5–20% even with modern dialysis support
Compartment syndrome, if missed, results in permanent functional loss or limb loss
Pathophysiology
Blast injury classification
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Primary blast injury: barotrauma from pressure wave (lung, bowel, ears)
▶
Secondary blast injury: penetrating injury from shrapnel/fragmentation
Tertiary blast injury: blunt trauma from physical displacement by blast wind
Quaternary blast injury: burns, chemical, toxicological exposure
Quinary blast injury: hyperinflammatory state from biological/chemical/radiological contamination
Tertiary injury mechanisms
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Blast wind creates positive pressure wave displacing victim
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Victim impacts fixed object: acceleration-deceleration injury pattern
Structural collapse: crush mechanism with weight bearing on body
TBI mechanism in blast
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Direct impact: skull fracture, contusion, hemorrhage
Acceleration-deceleration: DAI, subdural hematoma
Blast wave propagation through brain parenchyma (primary + tertiary overlap)
Crush syndrome pathophysiology
▶
Prolonged muscle compression causes ischemia and cell death
On extrication: reperfusion releases myoglobin, potassium, phosphate into circulation
Myoglobin precipitates in renal tubules — tubular obstruction and AKI
Hyperkalemia and acidosis cause cardiac arrhythmias
Therapeutic Considerations
Evidence base for blast trauma management
▶
Damage-control resuscitation: CRASH-2 trial established TXA mortality benefit
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PROPPR trial established 1:1:1 transfusion ratio benefit in trauma hemorrhage
ATLS and TCCC (Tactical Combat Casualty Care) protocols are standard of care
TBI management evidence
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Brain Trauma Foundation (BTF) guidelines: ICP monitoring, CPP targets, osmotherapy
VA/DOD mTBI CPG 2021 for management of post-acute mild TBI
Compartment syndrome
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Lancet 2015 (von Keudell): fasciotomy principles and pressure threshold evidence
Clinical diagnosis primary; pressure measurement adjunctive
Crush syndrome
▶
NEJM 2006 (Sever et al.): IV fluid and alkalinization strategy in crush injuries
Normal saline preferred; avoid potassium-containing fluids
ICD-10 coding
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Blast injury, unspecified: T70.8 (blast effects, other)
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Traumatic brain injury: S06.9 (unspecified intracranial injury)
Crush syndrome: T79.5 (traumatic anuria)
Compartment syndrome, traumatic: T79.A (traumatic compartment syndrome)
Traumatic amputation, lower limb: S98 series
Patient Discharge Instructions
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Blast injury discharge instructions
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You were evaluated after a blast or explosion that caused physical injury
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Most of your injuries are expected to heal with time and rest
Follow all instructions below carefully
Activity and wound care
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Rest for the next 24–48 hours; avoid strenuous activity
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Keep any wounds clean and dry; change dressings as instructed
Do not put weight on a splinted or injured limb unless cleared by your doctor
Keep injured extremity elevated to reduce swelling
Head injury precautions
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Do not drive, operate machinery, or make major decisions for 24 hours if you had a head injury
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Avoid alcohol and sedating medications after a head injury
Headache and mild memory difficulty may occur after a concussion and usually improve over days to weeks
Sleep with a responsible adult who can monitor for symptoms overnight
Medications
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Take all prescribed medications as directed
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Pain medication: take with food; avoid alcohol
Tetanus booster: received if needed; no special precautions required
Antibiotics (if prescribed): complete the full course even if feeling better
Hydration
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Drink plenty of fluids (at least 2–3 litres of water per day) for the next 48 hours
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Adequate hydration helps protect your kidneys if muscle injury occurred
Monitor urine colour: pale yellow is normal
Return to emergency department immediately for
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Worsening headache, repeated vomiting, confusion, seizure, or unequal pupils
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Increasing arm or leg pain, swelling, numbness, or weakness
Dark, brown, or cola-coloured urine or markedly decreased urine output
Chest pain, shortness of breath, or coughing up blood
Fever > 38.5 degrees Celsius, wound redness, pus, or increasing warmth
Any new or worsening symptom that concerns you
Follow-up appointments
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Head injury: see your family doctor in 1–2 weeks for neurocognitive assessment
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Fractures: orthopedic follow-up as scheduled (within 1–2 weeks)
Muscle injury/dark urine: repeat blood and urine tests within 48–72 hours
Mental health: blast events can cause anxiety, nightmares, or flashbacks — seek support early
References
Guidelines and key sources
Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast Injuries. Lancet. 2009
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Foundational review of all blast injury categories including tertiary mechanisms
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PMID: 19631372
DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. N Engl J Med. 2005
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Classification system and pathophysiology of blast injury types
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https://www.nejm.org/doi/full/10.1056/NEJMra042083
Singh AK, Ditkofsky NG, York JD, et al. Blast Injuries: From IED Blasts to the Boston Marathon Bombing. Radiographics. 2016
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Imaging approach to all blast injury categories
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PMID: 26761543
Ortega R, Vietor R, Arbelaez C, et al. Blast Injuries. N Engl J Med. 2024
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Contemporary review including tourniquet survival data
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https://www.nejm.org/doi/full/10.1056/NEJMvcm2408353
Rosenfeld JV, McFarlane AC, Bragge P, et al. Blast-Related Traumatic Brain Injury. Lancet Neurol. 2013
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TBI pathophysiology and management in blast survivors
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PMID: 23884075
Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. High Risk and Low Prevalence Diseases: Blast Injuries. Am J Emerg Med. 2023
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Emergency medicine perspective on blast injury management
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PMID: 37207597
von Keudell AG, Weaver MJ, Appleton PT, et al. Diagnosis and Treatment of Acute Extremity Compartment Syndrome. Lancet. 2015
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Evidence base for fasciotomy indications and pressure thresholds
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PMID: 26460664
Sever MS, Vanholder R, Lameire N. Management of Crush-Related Injuries after Disasters. N Engl J Med. 2006
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IV fluid strategy and alkalinization in crush syndrome/rhabdomyolysis
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https://www.nejm.org/doi/full/10.1056/NEJMra054329
LaGrone LN, Stein D, Cribari C, et al. AAST/ACS Clinical Protocol for Damage-Control Resuscitation. J Trauma Acute Care Surg. 2024
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TXA dosing, 1:1:1 transfusion, permissive hypotension targets
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https://doi.org/10.1097/TA.0000000000004088
Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria: Major Blunt Trauma. J Am Coll Radiol. 2020
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CT imaging appropriateness in blunt/blast trauma
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PMID via linkinghub.elsevier.com
Stengel D, Leisterer J, Ferrada P, et al. Point-of-Care Ultrasonography for Thoracoabdominal Injuries. Cochrane Database Syst Rev. 2018
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FAST exam performance characteristics in blunt trauma
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Cochrane Library: CD012669
Bosch X, Poch E, Grau JM. Rhabdomyolysis and Acute Kidney Injury. N Engl J Med. 2009
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CK thresholds and renal injury mechanisms
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https://www.nejm.org/doi/full/10.1056/NEJMra0801327
Chechik Y, Almog O, Gutterman YJ, Abuhasira S. Amputation Trends in Military Personnel During the Israel-Hamas War 2023–24. Injury. 2025
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Contemporary combat blast amputation epidemiology
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PMID: 40738012
VA/DOD mTBI Clinical Practice Guideline 2021. Management and Rehabilitation of Post-Acute Mild TBI
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Post-concussive management and return-to-duty protocols
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https://www.healthquality.va.gov/guidelines/Rehab/mtbi/VADODmTBICPGFinal508.pdf
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Blast Injury (Tertiary)