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爆風による単独神経障害の評価アルゴリズム(一例)

外観上、頭部外傷を認めず、頭部CTでも明らかな所見がなくても、動脈性空気塞栓が起こっている可能性があるため、注意が必要である。

一次~三次爆風損傷

一次、二次そして三次爆風損傷を図を用いて説明しています。
出典
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1: 著者提供

爆弾爆発による圧力波の推移・・・解放空間と閉鎖空間の違い

閉鎖空間では圧力波の推移が複雑になるため、解放空間での爆発に比べて重度の一次爆風損傷が来し得る。
a:解放空間での爆発による圧力波の推移
b:閉鎖空間での爆発による圧力波の推移
出典
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1: Primary blast injuries--an updated concise review.
著者: Daniel Dante Yeh, William P Schecter
雑誌名: World J Surg. 2012 May;36(5):966-72. doi: 10.1007/s00268-012-1500-9.
Abstract/Text: Blast injuries have been increasing in the civilian setting and clinicians need to understand the spectrum of injury and management strategies. Multisystem trauma associated with combined blunt and penetrating injuries is the rule. Explosions in closed spaces increase the likelihood of primary blast injury. Rupture of tympanic membranes is an inaccurate marker for severe primary blast injury. Blast lung injury manifests early and should be managed with lung-protective ventilation. Blast brain injury is more common than previously appreciated.
World J Surg. 2012 May;36(5):966-72. doi: 10.1007/s00268-012-1500-9.

爆風肺損傷

一次爆風損傷重傷後時間の胸部X線写真。両側のバタフライ サインを認める。この患者には外観上、何の所見もない。
出典
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1: Primary blast injury after a bomb explosion in a civilian bus.
著者: E Katz, B Ofek, J Adler, H B Abramowitz, M M Krausz
雑誌名: Ann Surg. 1989 Apr;209(4):484-8.
Abstract/Text: A 6-kg explosive charge detonated under a seat in the center of a crowded city bus in Jerusalem, killing three passengers immediately. Of the 55 survivors, all of whom were transferred to two major medical centers, 29 were hospitalized. Among those admitted, a high rate of primary blast injuries was found, including perforated ear drums (76%), blast lung (38%), and abdominal blast injuries (14%). Two of the latter patients suffered bowel perforations, which were diagnosed with considerable delay. Eight patients (31%) had sustained life-threatening trauma, consisting of a combination of primary, secondary, and tertiary blast injuries. The overall mortality rate was 10.3%. The large number of primary blast injuries, including the unexpected finding of bowel perforations, is explained by the high amplitude of the air pressure wave (3.8-5.2 atm) and its relatively long duration (2-3 msec) resulting from the detonation of the high-energy explosive charge in the small, enclosed space of the bus. Besides the usual wounds sustained by victims of an explosion that occurs in a confined space, the possibility of primary blast injury to the abdomen and to the lungs should be taken into account by the treating surgeon.
Ann Surg. 1989 Apr;209(4):484-8.

爆風肺損傷患者の種々の画像所見

a:① 胸部X線写真でのバタフライ サイン。②、③胸部CT写真上の肺門部から末梢へうっ血像を認める。
b:13歳 男性における爆風肺損傷の画像
① 胸部X線写真では、縦隔気腫と皮下気腫そして右肺挫傷を認める。
② 胸部CT写真では、縦隔気腫、右気胸そして両側の肺浸潤を認める。
出典
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1: Blast lung injury: clinical manifestations, treatment, and outcome.
著者: Vered Avidan, Moshe Hersch, Yaron Armon, Ram Spira, Dvora Aharoni, Petachia Reissman, William P Schecter
雑誌名: Am J Surg. 2005 Dec;190(6):927-31. doi: 10.1016/j.amjsurg.2005.08.022.
Abstract/Text: BACKGROUND: Blast lung injury (BLI) is a major cause of morbidity after terrorist bomb attacks (TBAs) and is seen with increasing frequency worldwide. Yet, many surgeons and intensivists have little experience treating BLI. Jerusalem sustained 31 TBAs since 1983, resulting in a local expertise in treating BLI.
METHODS: A retrospective study of clinical and radiologic characteristics, management, and outcome of victims of TBAs sustaining BLI who were admitted to ICU during December 1983 to February 2004. Long-term outcome was determined by a telephone interview.
RESULTS: Twenty-nine patients met inclusion criteria. Hypoxia and pulmonary infiltrates in chest x-ray were sine qua non for the diagnosis. Seventy-six percent required mechanical ventilation, all within 2 hours of admission. One patient died. Seventy-six percent had no long-term sequelae.
CONCLUSIONS: Most patients with significant BLI injury require mechanical ventilation. Late deterioration is rare. Death because of BLI in patients who survived the explosion is unusual. Timely diagnosis and correct treatment result in excellent outcome.
Am J Surg. 2005 Dec;190(6):927-31. doi: 10.1016/j.amjsurg.2005.08.022....

一次爆風損傷の肉眼所見

a:肋骨痕が認められる肺損傷
b:大腸損傷
出典
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1: Mechanisms of injury by explosive devices.
著者: Jeff Garner, Stephen J Brett
雑誌名: Anesthesiol Clin. 2007 Mar;25(1):147-60, x. doi: 10.1016/j.anclin.2006.11.002.
Abstract/Text: Explosive devices cause injury by four mechanisms, of which primary blast injury is the least familiar to most non-military clinicians. The pathophysiology of the various mechanisms of injury is described, and the implications for translating a knowledge of mechanism of injury to clinical management is discussed.
Anesthesiol Clin. 2007 Mar;25(1):147-60, x. doi: 10.1016/j.anclin.2006...

二次爆風損傷のX線写真

a:多数の金属小球を両側肺に認める。
b:上腕に釘と金属片を多数認める。
c:釘が脳内に入り込んでいることがCTで発見された。
出典
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1: Conventional terrorism and critical care.
著者: Pierre Singer, Jonathan D Cohen, Michael Stein
雑誌名: Crit Care Med. 2005 Jan;33(1 Suppl):S61-5.
Abstract/Text: Incidents of conventional weapons terror are increasingly part of the reality of the modern world, and in Israel, 19,948 incidents have been reported from September 2000 to December 2003. Most victims are injured in explosions resulting from suicide bombings. Exposure to the blast (primary mechanism of injury) may produce unique injuries affecting gas-containing organs, including perforation of the eardrums (most common injury); pulmonary blast injury, characterized by alveolar capillary disruption and bronchopleural fistulas; and bowel perforation, which is uncommon and may be delayed from 1 to 14 days after the injury. However, most injuries are the result of penetrating trauma (secondary mechanism) resulting from bomb fragments and nails, bolts, and steel pellets embedded in the bomb striking the victim, and blunt trauma (tertiary mechanism) sustained when the victim is propelled against an object by the blast wind. The severity of the injuries is increased when the blast occurs in a confined space. Victims of terror-inflicted injuries have a high Injury Severity Score (30% >16), a high requirement for intensive care unit admission (22.8% in Israel), and have a more prolonged hospital course and higher mortality than victims of any other form of trauma.
Crit Care Med. 2005 Jan;33(1 Suppl):S61-5.

二次爆風損傷による受傷部位

四肢と顔面に多いのが特徴である。
出典
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1: Terror-related injuries: a comparison of gunshot wounds versus secondary-fragments-induced injuries from explosives.
著者: Nadav Sheffy, Yoav Mintz, Avraham I Rivkind, Shmuel C Shapira
雑誌名: J Am Coll Surg. 2006 Sep;203(3):297-303. doi: 10.1016/j.jamcollsurg.2006.05.010. Epub 2006 Jun 19.
Abstract/Text: BACKGROUND: Terror-related injuries caused by secondary fragments (SF) from explosive devices show a distinctive pattern in severity, distribution, outcomes of assault, and health-system resource use as compared with terror-related penetrating injuries caused by gunshot wounds.
STUDY DESIGN: A case-comparison study conducted in a tertiary university hospital and the only Level I trauma center in the Jerusalem vicinity. During a period of 4 years, over 1,500 casualties of terror-related injuries were treated in one Level I trauma center. The study included 533 patients who were admitted for hospitalization. Excluded from the study were victims who were dead on arrival or who succumbed to their injuries within 30 minutes of arrival at the emergency department. Data were collected from trauma registry records.
RESULTS: Gunshot-wound victims were mostly men, aged 19 to 30, and SF victims were more evenly distributed between the genders and across the age spectrum. Injury Severity Score (ISS) was considerably higher in SF victims, although critical mortality rates were higher in gunshot-wound victims. More than 40% of SF victims were injured in three or more body regions, as opposed to < 10% in gunshot-wound victims. Use of imaging modalities and ICUs was considerably higher for SF victims.
CONCLUSIONS: Terror victims suffering from SF wounds have more complex, widespread, and severe injuries than victims suffering from gunshot wounds. They tend to involve multiple body regions and use more in-hospital resources. Attenuation of bus seats and protective vests can lead to a reduction in severity of these injuries.
J Am Coll Surg. 2006 Sep;203(3):297-303. doi: 10.1016/j.jamcollsurg.20...

TNT爆弾の量・爆発地からの距離と死亡・損傷の関係

聴力が最も影響を受けやすく、次に鼓膜破裂、そして爆傷肺が起こることが多い。
出典
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1: Primary blast injury: an intact tympanic membrane does not indicate the lack of a pulmonary blast injury.
著者: Peter Peters
雑誌名: Mil Med. 2011 Jan;176(1):110-4.
Abstract/Text: The tympanic membrane (TM) has long been viewed as an indicator of primary blast injury. A primary blast injury occurs due overpressure occurring as a result of the detonation of high explosives. Cadaver studies indicated pressure required for perforation of the tympanic membrane to be 137 kPa for adults. The accepted range in which other organs (lung, colon, and intestines) are damaged by the pressure wave emanating from an explosion is in the 400-kPa range. The use of the perforation of the tympanic membrane as an indicator of a primary blast injury missed a range of up to 50% of those suffering a primary blast injury to the lung. The status of the tympanic membrane following exposure to a blast does not preclude the need for further investigations for a primary blast injury and the clinician needs to evaluate the patient dependent on their particular exposure to an explosion.
Mil Med. 2011 Jan;176(1):110-4.

PSIと身体損傷の関連性

爆風により最も損傷を受けやすいのが鼓膜である。
出典
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1: 石井昇、奥寺敬、箱崎幸也:災害・健康危機管理ハンドブック、p252「用語解説2」、診断と治療社、2007年 ( ISBN-10: 4787815318 一部改変あり)

通常爆薬の種類と比較

プラスチック爆弾であるC4が最も強力であることがわかる。
出典
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1: 石井昇、奥寺敬、箱崎幸也:災害・健康危機管理ハンドブック、p252「用語解説2」、診断と治療社、2007年 ( ISBN-10: 4787815318 一部改変あり)

2008年7月1日から2010年1月15日までの間に爆発により受傷した517名の軍人の予後

戦時に爆発により受傷した軍人の7割強がレベル4医療施設での治療を要していることは、治療・後送体制の重要性を示唆している。
出典
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1: Blast injuries to the lung: epidemiology and management.
著者: Iain M J Mackenzie, Bill Tunnicliffe
雑誌名: Philos Trans R Soc Lond B Biol Sci. 2011 Jan 27;366(1562):295-9. doi: 10.1098/rstb.2010.0252.
Abstract/Text: Lung injury is frequently a component of the polytrauma sustained by military personnel surviving blast on the battlefield. This article describes a case series of the military casualties admitted to University Hospital Birmingham's critical care services (role 4 facility), during the period 1 July 2008 to 15 January 2010. Of the 135 casualties admitted, 107 (79.2%) were injured by explosive devices. Plain chest films taken soon after arrival in the role 4 facility were reviewed in 96 of the 107 patients. In 55 (57.3%) films a tracheal tube was present. One or more radiological abnormalities was present in 66 (68.75%) of the films. Five patients met the consensus criteria for the definition of adult respiratory distress syndrome (ARDS). The majority of casualties with blast-related lung injury were successfully managed with conventional ventilatory support employing a lung protective strategy; only a small minority received non-conventional support at any time in the form of high-frequency oscillatory ventilation. Of those casualties who survived to be received by the role 4 facility, none subsequently died as a consequence of lung injury.
Philos Trans R Soc Lond B Biol Sci. 2011 Jan 27;366(1562):295-9. doi: ...

二次爆風損傷

a:爆弾内に仕込まれたボールベアリングや釘が、右大腿部に認められる。
b:飛来した金属片が、左腓骨と脛骨の骨折の原因と思われる。
c:頚部の皮下に金属片を認めるが、CT検査では血管損傷は認めていない。
出典
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1: Radiologic features of injuries from the Boston Marathon bombing at three hospitals.
著者: Ajay K Singh, Eric Goralnick, George Velmahos, Paul D Biddinger, Jonathan Gates, Aaron Sodickson
雑誌名: AJR Am J Roentgenol. 2014 Aug;203(2):235-9. doi: 10.2214/AJR.14.12549.
Abstract/Text: OBJECTIVE: The aim of this study is to describe the radiologic imaging findings of primary, secondary, tertiary, and quaternary blast injuries in patients injured in the Boston Marathon bombing on April 15, 2013.
MATERIALS AND METHODS: A total of 43 patients presenting to three acute care hospitals and undergoing radiologic investigation within 7 hours of the time of the bombing on April 15, 2013, were included in this study. The radiographic and CT features of these patients were evaluated for imaging findings consistent with primary, secondary, tertiary, and quaternary blast injury.
RESULTS: There were no pulmonary or gastrointestinal manifestations of the primary blast wave on imaging. Secondary blast injuries identified on imaging included a total of 189 shrapnel fragments identified in 32 of the 43 patients. The shrapnel was identified most often in the soft tissues of the leg (36.5%), thigh (31.2%), and pelvis (13.2%). Imaging identified 125 ball bearings, 10 nails, one screw, 44 metal fragments, and nine other (gravel, glass, etc.) foreign bodies.
CONCLUSION: Injuries from the Boston Marathon bombing were predominantly from the secondary blast wave and resulted in traumatic injuries predominantly of the lower extremities. The most common shrapnel found on radiologic evaluation was the ball bearing.
AJR Am J Roentgenol. 2014 Aug;203(2):235-9. doi: 10.2214/AJR.14.12549....

テロ現場の状況による損傷の違い

出典
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1: Danyal Magnus et al. Epidemiology of civilian blast injuries inflicted by terrorist bombings from 1970-2016. Defence Technology 2018; 14 469-476.

爆弾テロ発生時の大量傷者治療アルゴリズム

明らかな外傷や10%以上の熱傷がある場合はJATECに準じたアプローチが必要となる。歩行が可能であっても、一次爆風損傷による傷害の有無を慎重にチェックする必要がある。
出典
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1: 著者提供

爆風による単独神経障害の評価アルゴリズム(一例)

外観上、頭部外傷を認めず、頭部CTでも明らかな所見がなくても、動脈性空気塞栓が起こっている可能性があるため、注意が必要である。

一次~三次爆風損傷

一次、二次そして三次爆風損傷を図を用いて説明しています。
出典
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1: 著者提供