Explosive injury represents three-quarters of woundings and over half of the deaths on today’s battlefield. While severe injuries still occur to those traveling mounted on vehicles, advancements in vehicle armor and personal protective equipment have led to a substantial improvement in the survivability of these incidents. On the other hand, the dismounted complex blast injury (DCBI) has become the signature injury pattern of the conflicts in Iraq and Afghanistan . Since 2009, these injuries dramatically increased among both dismounted coalition forces and civilian in Afghanistan due to increasing numbers of high-energy improvised explosive devices (IED) partially buried or disguised in the landscape. The uniquely devastating injury pattern that has resulted includes multiple traumatic amputations of the lower and upper extremities, as well as complex penetrating and blast-effect injuries of the pelvic and abdominal cavities, severe pelvic fractures , spine fractures, and injuries of the internal and external genitalia (Fig. 13.1). Frequently, these injuries also include varying severity of traumatic brain injury. Unfortunately, despite continuing efforts, the highly lethal DCBI cluster has a mortality rate as high as 73%.

Although IED injury has become a hallmark of modern battlefield trauma , events such as the Boston Marathon bombing and attacks in Madrid, Paris, and Brussels have also raised recent awareness of the increasing threat to civilian settings. While the devices deployed against troops and vehicles are typically high-yield explosives, IEDs can come in almost any shape, size, and explosive yield. Smaller yield devices are a particular problem among civilian populations since they can be easily hidden or attached to common objects and triggered when they are picked up—and some are even purposefully made to look like toys. Among civilian children and adults who encounter these devices, a common pattern is significant facial and neck injuries as well as one upper extremity traumatic amputation consistent with their bending over to inspect the object in the landscape when it detonates (Fig. 13.2), whereas coalition forces frequently lose the nondominant upper extremity due to its forward location in the “low-ready” weapons carry position. Table 13.1 illustrates the wide spectrum of blast injury effects.

Details of prehospital care for this type of patient have been provided in the previous chapters. The main emphasis is on hemorrhage control, with additional adjuncts of pain control, administration of antibiotics, and rapid preparation for transport to a Role 2 or 3 facility.

Upon arrival to surgically capable treatment facilities, initial management remains consistent with the “CABC” mantra. Hasty field tourniquets are assessed and replaced with more effective pneumatic tourniquets. Initial resuscitation is begun immediately following massive transfusion protocol guidelines of a 1:1:1 ratio of packed red blood cell to plasma to platelets or the use of low titer group O whole blood. Due to peripheral venous access site limitations from the extent of injury and to allow for easy use of a rapid transfusion device, large-bore central venous access above the diaphragm is rapidly obtained, usually at the subclavian site since the cervical spine should be protected in these patients; however, initial standard peripheral intravenous access may be adequate to begin resuscitation until movement to the operating room (OR). If peripheral or central venous access is difficult to obtain, intraosseous access is obtained. Since use of the commonly utilized tibial or humeral locations may be limited by injury, a sternal intraosseous line (IO) is a reliable and effective initial conduit for administration of drugs, fluids, and blood products. Care must be taken to use an appropriately sized needle to avoid passing through the sternum into the mediastinum.

As resuscitation progresses, blood product administration is guided by the patient’s hemodynamic status as well as standard coagulation parameters (PT/INR), hemoglobin/hematocrit, and arterial or venous blood gases. Measurement of base deficit upon arrival and serially throughout the resuscitation remains one of the easiest and most useful resuscitation markers.

There is now an increasing body of experience and evidence with using either thromboelastography (TEG ) or rotational thromboelastometry (ROTEM ) to assess clotting function, clot strength, and platelet contribution and to identify any evidence of significant hyperfibrinolysis. The goal of these TEG/ROTEM protocols is to rapidly identify or even prevent the development of the acute coagulopathy of traumatic shock that is seen among severely injured patients and associated with significant mortality and morbidity (Fig. 13.3). Recent evidence suggests that the early (within 3 h of injury) administration of the antifibrinolytic agent tranexamic acid (TXA ) is associated with improved morbidity and mortality in the setting of severe injury and major hemorrhage. TXA is now a part of the Joint Theater Trauma System guidelines for the treatment of life-threatening bleeding in massive transfusion situations and should be considered to all patients with large-volume bleeding or to those at risk of major bleeding. In many cases, TXA administration is now started in the prehospital setting due to TCCC guidelines.

Rapid sequence intubation must not be undertaken in a cavalier manner in the DCBI patient. Due to near exsanguination, these patients initially have little reserve and may be unable to undergo the procedure without initial resuscitation. Medication dosages should be decreased, and the team must be prepared for potential hemodynamic collapse and arrest. If able to ventilate and oxygenate the patient temporarily, you should strongly consider waiting on endotracheal intubation until after a brief period of volume expansion with blood products.

DCBI by definition includes severe multisystem trauma and requires expeditious but thorough ongoing evaluation before and during surgery. The initial sequence of evaluation and management will vary depending on your facility’s location, capabilities, and available personnel and resources, but should always follow principles of damage control (Fig. 13.4). Unstable patients should proceed directly to the operating room for exploration and control of major hemorrhage, while stable patients may tolerate further resuscitation and imaging to assist in operative planning. For the patient in extremis, take caution when making even short delays to do things like place a central line or intubate the patient—these can be done in the OR while simultaneously initiating surgical exploration. Resuscitative surgical care requires efficiency and teamwork; utilize multiple teams and surgeons working simultaneously rather than in sequence (Fig. 13.5).