NUR 113: DISASTER NURSING

STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR

Session # 8

LESSON TITLE: Mass Casualty Incidents: Traumatic Materials:

injury due to Explosives and Blast Incidents
LEARNING OUTCOMES: Book, pen and notebook

Upon completion of this lesson, the nursing student can:

1. Define what traumatic injuries may happen due to References:

blast incidents and explosives Veenema, T.G. (2019) Disaster Nursing and
2. Identify the factors associated with explosives and Emergency Preparedness for Chemical,
blast incidents Biological, and Radiological Terrorism and other
3. Identify the classifications of blast injuries Hazards 4th Edition
4. Determine the appropriate nursing interventions for
patients with traumatic injury due to explosives and
blast effects
5. Understand the rationale behind the managements
for patients with traumatic injury due to explosives and
blast effects

LESSON PREVIEW/REVIEW (5 minutes)

Instruction: Identify and explain the Three-Tier system of Triaging.

1.

2.

3.

MAIN LESSON (40 minutes)

Traumatic Injury Due to Explosives and Blast Effects

Resultant bodily & structural damage following an explosion depends on:
o Type of explosive
o Medium in which the explosion occurred
o Proximity to the explosion’s epicenter
Assist the health care providers to determine what type of injuries & how many casualties to expect following an
explosion
o Total number of casualties = Number of casualties arriving in the first hour x 2

Classifications of Blast Injury

A. Primary Blast Injury
o Unique to HE
o Due to impact of over-pressurization wave with body surfaces
o Commonly involve air-filled organs & air-fluid interfaces (middle ear, lungs, GIT )
• Types of injuries
o Blast lung, TM rupture
o Abdominal hemorrhage & perforation
o Globe rupture

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 Tympanic Membrane Injury
o TM- structure most frequently injured by blast
• TM rupture
• Ossicle dislocation
• Disruption of oval or round window
o Sx: hearing loss, tinnitus, vertigo, bleeding from external canal, mucopurulent
otorrhea
B. Secondary Blast Injury
o Due to flying debris & bomb fragments
o Penetrating ballistic or blunt injuries
o Leading cause of death in military & civilian terrorist attacks except in cases of major building collapse
o Wounds can be grossly contaminated

C. Tertiary Blast Injuries

o Due to persons being thrown into fixed objects by wind of explosions
o Also due to structural collapse & fragmentation of building & vehicles; structural collapse may cause
extensive blunt trauma.
o Crushing injuries, fracture & traumatic amputation
o Closed & open brain injury

D. Quaternary Blast Injuries

o Explosion related injuries or illnesses not due to primary, secondary, or tertiary injuries
o Exacerbations of preexisting conditions (asthma, COPD, CAD, HTN, DM, etc.)
o Burns (chemical & thermal)
o Toxic inhalation
o Radiation exposure
o Asphyxiation (CO, cyanide)

General Considerations
• Confined space vs. open space: increase number of penetrating & primary blast injuries if closed space
• Blast wave reflected by solid surfaces: person next to a wall may sustain a greater primary blast injury
• Detonating a bomb underwater will produce more damage than air detonation because water is incompressible.
• Half of all initial casualties seek medical care over first hour
• Expect upside down triage
• Most severely injured arrive after less injured who bypass EMS & self-transport to closest hospitals
• Initial explosion attracts law enforcement & rescue personnel who will be injured by second explosion

• Open Space
o Potential for shrapnel to travel a large distance (>100m)
o Less primary blast injury
• Enclosed Space
o Increased mortality
o Increased blast pressure
o Complicated rescue
• Structural Collapse
o Increased mortality from primary blast wave as well as from tertiary and quaternary injuries

Management Elements of an Explosion

• Search & Rescue
• Triage
• Initial stabilization
• Definitive medical treatment
• Evacuation

ATLS Primary Survey (Advance Trauma Life Support)

SURVEY IDENTIFICATION AND MANAGEMENT
A. Airway and Cervical Spine Assess and maintain airway patency: assess for foreign bodies and fractures
Immobilization that may lead to obstruction

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 Immobilize cervical spine with an available device
B. Breathing and Ventilation Assess for bilateral chest wall movement; auscultate and visualize chest wall
and lung fields

Identify pneumothorax, flail chest, hemothorax, and open pneumothorax

C. Circulation Consider hypovolemia the cause of hypotension until proven otherwise

Assess LOC, skin color, and pulse for signs of hypovolemia and hypoxia

Identify and control external hemorrhage, identify internal hemorrhage

D. Disability and Neurologic Deficit Assess Glascow Coma Scale, pupil size and reactvity

A decreased LOC may require intubation

E. Exposure and Environmental Control Expose the patient t view all body surfaces for evidence of injury
Cover with warm blankets and use warmed intravenous fluids to maintain
temperature

ATLS Secondary Survey Physical Examination

BODY SYSTEM EXAMINATION
Neurologic Assess LOC, sensory and motor function, and pupillary response

Consult neurosurgery and obtain a head CT if head injury is suspected

Head Examine head and scalp for injury and fractures

Assess vision and pupils. Hemorrhage, penetrating injury, lens dislocation and ocular
entrapment may occur

Contacts should be removed

Maxilofacial Assess for fractures and soft-tissue injury

Place a gastric tube orally in patients with suspected or confirmed facial fractures
Cervical Spine and Neck Maintain spine precautions
Chest Auscultate breath and cardiac sounds

Obtain chest x-ray

Abdomen Unexplained hypotension may be the result of an internal hemorrhage

Peritoneal lavage, ultrasound, abdominal CT may be necessary to rule out injury

Perineum, Rectum, and Assess for contusions, hematomas, lacerations, and bleeding
Vagina
Perform a rectal exam prior to placing a Foley catheter
Musculoskeletal All extremities, pelvic ring, peripheral pulses, and thoracic and lumbar spine should be
assessed

X-rays should be obtained when the patient is stabilized, if necessary

Blast Injuries
SYSTEM INJURY OR CONDITION
Auditory TM rupture, ossicular disruption, cochlear damage, foreign body
Eye, orbit, face Perforated globe, foreign body, fractures
Respiratory Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, airway
epithelial damage
Digestive Bowel perforation, hemorrhage, ruptured liver or spleen, sepsis
Circulatory Cardiac contusion, myocardial infarction from air embolism, shock, hypotension, peripheral
vascular injury, air embolism-induced injury
CNS Injury Concussion, closed and open brain injury, stroke, spinal cord injury
Renal Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and
hypovolemia
Extremity Injury Traumatic amputation, fractures, crush injuries, compartment syndrome, burns, cuts,

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 lacerations, acute arterial occlusion, air embolism-induced injury

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 10 minutes for this activity:

Multiple Choice
1. The nurse is caring for a client with a blast injury. Which of the following nursing assessments would be most
appropriate for this client?
a. Assess for vasovagal hypotension
b. Assess the client for confusion
c. Assess for asphyxia
d. Assess for hypervolemia
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

2. The patient has a blasted lung and injury to his tympanic membrane. This classification of blast injury is:
a. Primary blast injury
b. Secondary blast injury
c. Tertiary blast injury
d. Quarternary blast injury
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

3. The patient has crushing injuries, fracture, traumatic amputation, and open brain injury This classification of blast
injury is:
a. Primary blast injury
b. Secondary blast injury
c. Tertiary blast injury
d. Quarternary blast injury
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

4. After a blast incident, the primary responsibility of the responders is to:

a. Search and rescue
b. Conduct survey
c. Raise an alarm
d. Provide medications
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

5. During initial stabilization, the nurse should keep in mind that

a. Provide first aid in a safe place
b. Alleviate the worries of patients who are panicking
c. Find the patient’s belongings for identification
d. Ask questions to the patient during first aid
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Activity: Muddiest Point:

In today’s session, what was least clear to you?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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