Indications: Field Amputation

The context may dictate the need for field amputation. Indications would include the inability to safely extricate the patient, continued environmental toxins that pose a hazard to victims or rescuers, and a grossly prolonged time until definitive treatment is available even after extrication.

Field amputations are best performed by trauma or orthopedic surgeons. Few EMS systems have amputation protocols. If a field amputation is performed, ensure adequate analgesia and anesthesia. Ketamine, a dissociative anesthestic that does not cause cardiorespiratory depression, decreases or only minimally increases serum potassium levels.

Key elements of terrorism

This topic provides a brief history of recent explosions and bombings used by terrorists. The types of explosives used, the characteristics of explosives, and explosive classification are also included.

The emphasis for each topic is the unique characteristics of an explosive event, such as a terrorist bombing, that results in mass casualties. This content is to cover the unique knowledge and skills required to effectively respond to a mass casualty explosive or bombing event. Includes: (1) the uniqueness of blast injury, including blast physics, (2) the most common types of blast injuries, and (3) the appropriate treatment (prehospital and initial hospital) for injures that result from blasts.

Explosive devices are a rather inexpensive and easy method for terrorists to trigger major disruptions to our everyday lives. Terrorists have used everything from a small backpack to large trucks and even commercial jet airliners to deliver the explosive agent. Injuries can vary from various forms of trauma and burns to amputations or even immediate death.

Terrorism can be defined as containing four key elements.

It is premeditated—planned in advance, rather than an impulsive act of rage.
It is political—not criminal but designed to change the existing political order.
It is aimed at civilians—not at military targets or combat ready troops.
It is carried out by sub-national groups—not by the army of a country.

Scene Safety

Describe common hazards that could be encountered in an explosive event. Recognize the personal protective equipment (PPE) appropriate for use during explosive events.

Triage

List the factors common to explosive events that may complicate effective triage. Explain the possible effect of overtriage at explosive events. Explain the issues related to patient self-referral in explosive events.

Blast Injuries

Describe the unique aspects of blast injury, including blast physics and the pattern of injuries. List the factors affecting severity (morbidity and mortality) of injuries in an explosive event. Explain the pathophysiology of blast injuries. Define the four categories of blast injuries. List the most common types of injuries in each category—primary, secondary, tertiary, and quaternary (miscellaneous).

Primary Blast Lung Injury

Describe the pathophysiology of blast lung. Describe the clinical manifestations of blast lung injury. Explain the appropriate treatment (prehospital and initial hospital) for blast lung injury. Explain why tympanic membrane rupture may or may not be an indicator for blast lung injury.

Additional Primary Blast Injuries

Describe the presentation and clinical manifestations of other primary blast injuries, including ear, abdominal, and head injuries. Explain the appropriate treatment (prehospital and initial hospital) for other primary blast injuries, including ear, abdominal, and head injuries. Explain the treatment priorities (prehospital and initial hospital) for combined injuries, including blast lung injury and burn injury; blast lung injury and crush injury.

Crush Injuries

Define crush injury, crush syndrome, and compartment syndrome. Explain the pathophysiology of crush injury. Describe the clinical presentations common with crush injury. List the potential complications for crush injury. Explain the treatment (prehospital and initial hospital) for crush injury.

Compartment Syndrome

Explain the pathophysiology of compartment syndrome. Describe the clinical presentation common with compartment syndrome. Explain the treatment (prehospital and initial hospital) for compartment syndrome. Describe the procedural skills needed for management of compartment syndrome, including measuring compartment pressures, use of ketamine, and fasciotomies. Describe the unique treatment of an entrapped patient. Describe the indications (potential need) for field amputation.

Military Experiences

Discuss current military experiences in blast injury care, such as hemorrhage control and use of tourniquets.

Special Considerations

Describe the considerations that should be addressed for special needs patients such as children, women who are pregnant, the elderly, the disabled, and those with language barriers.

Psychological Issues

Describe factors that affect mental health during an explosive event.

Types of terrorism: explosives and terrorist bombings

Nationalist terrorism

Seeks to form a separate state for their own national group. These terrorists use violence to capture national attention and to alienate those not supporting their movement.

Religious terrorism

Uses violence to further their purpose, targeting broad categories of enemies. Religious terrorists come from major faiths as well as small cults. The more extreme sects use an almost limitless amount of violence against anyone who is not part of their religious group, and they are considered some of the most dangerous terrorists. Nearly half of the 56 known international terrorist groups are religiously motivated.

State-sponsored terrorism

Use of terrorist groups or surrogate warriors by radical states as a foreign policy tool. With enhanced state funded resources at their disposal, they are often able to carry out larger and more deadly attacks, including commercial airliner bombings.

Suicide terrorism

Used throughout history, but it has become much more common in the last 20 years. Both religious and secular terrorist groups use this form of terrorism. Some feel suicide terrorists are crazy, but many experts say such terrorists are just deeply committed to their cause and see themselves as martyrs who can inspire imitation.

Types of Explosives

Improvised explosive devices

Improvised explosive devices (IEDs) are handmade or improvised bombs used by terrorists. They can be made from stolen explosives, commercial blasting supplies or fertilizer, fuel oil, and other household ingredients. Examples of IEDs:

Pipe bomb: This is the most common type of terrorist bomb and usually consists of low-velocity explosives inside a tightly capped piece of pipe. Pipe bombs are very easily made using gunpowder, iron, steel, aluminum, or copper pipes. They are sometimes wrapped with nails to cause more harm.

Molotov cocktail: This improvised weapon is used by terrorists world-wide. Molotov’s cocktails are extremely simple to make and can cause considerable damage. They are usually made from materials such as gasoline, diesel fuel, kerosene, ethyl or methyl alcohol, lighter fluid, and turpentine, all of which are easily obtained. The explosive material is placed in a glass bottle, which breaks upon impact. A piece of cotton serves as a fuse, which is ignited before the bottle is thrown at the target.

Fertilizer bomb: Fertilizer bombs consist of ammonium nitrate. Hundreds of kilograms may be required to cause major damage. The Irish Republican Army, Tamil Tigers, and some Middle Eastern groups use the ammonium nitrate bomb.

Barometric bomb: The barometric bomb is one of the more advanced weapons in the terrorist’s arsenal. The detonator of the bomb is linked to an altitude meter, causing the explosion to occur during flight.

Fuel-air explosives

Also called high-impulse thermobaric weapons (HITs) and enhanced blast explosives, fuel-air explosives use atmospheric oxygen, instead of carrying an oxidizer in their explosives. They produce more explosive energy for a given size than do other explosives.

“Dirty” bombs

The term dirty bomb is used to refer to a Radiological Dispersal Device (RDD), a radiological weapon that combines radioactive material with conventional explosives. A dirty bomb kills or injures through the initial blast of the conventional explosive and spreads airborne radiation and contamination.

Incendiary bombs

Also known as firebombs, incendiary bombs are designed to start fires or destroy sensitive equipment using materials such as napalm, thermite, chlorine trifluoride, or white phosphorus.

Military munitions

Military munitions are ammunition products and components produced for or used by the armed forces. They include explosives, pyrotechnics, riot control agents, smokes and incendiaries, bulk explosives, rockets, guided and ballistic missiles, bombs, warheads, mortar rounds, artillery ammunition, small arms ammunition, grenades, mines, torpedoes, depth charges, cluster munitions, dispensers, and demolition charges.