Peter A. Burke, MD Chief of Trauma Services Boston Medical Center

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Peter A. Burke, MD

Chief of Trauma Services

Boston Medical Center

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Faculty/Presenter Disclosure

Faculty:

Peter A Burke MD

Relationships with commercial interests:

• Grants/Research Support: None

• Speakers Bureau/Honoraria: NA

• Consulting Fees: T2 Biosystems Inc.

• Other: Boston University School of Medicine, Boston Medical Center

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Disclosure of Commercial Support

This program has received NO financial support

This program has received NO in‐kind support

Potential for conflict(s) of interest:

• Peter A Burke has received an honorarium and travel expenses from

the CAEP to give this talk

• Peter A Burke has received NO payment/funding, etc. from

organization whose product(s) are being discussed in this program

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The Boston Marathon Bombings 4.15.2013

World’s oldest annual marathon

First started in 1897

Held on Patriots’ Day

Attracts 500,000 spectators

• Making it the most widely attended athletic event in New England

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2:50 pm: AN EXPLOSION OCCURS JUST

BEFORE THE FINSH LINE AT

MARATHON SPORTS

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THIRTEEN SECONDS LATER, A

SECOND EXPLOSION, 1500 YARDS

AWAY FURTHER UP BOYLSTON ST.

7

Note Medical

Tent proximity to

the Explosions

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Boston Medical Center receives first marathon

patient at 3:08pm

First call – colleague on scene called BMC ED “something just happened.” 2 mins later – C‐MED Radio: Bomb had gone off. Fortunate circumstances: Boston has 5 Adult Level I Trauma Centers Patriots Day Holiday ORs were open Change of shift EMS were already at the scene

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EMS SUCCESS

• Mutual Aid called immediately

• 90 patients transported in 30 minutes

• 30 of the most severely injured were transported out 18

minutes after the blasts

• 3 people dead on scene (not transported)

• 264 Injured, many Critically

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45 minutes after the blasts, all

seriously injured patients had

been transported to the 5 Adult

Level 1 Trauma Centers

• Beth Israel Deaconess Medical Center • Boston Medical Center • Brigham and Women’s Hospital • Mass General Hospital • Tufts Medical Center

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Adult Level 1 Trauma Centers in relation to Marathon

Sports

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Route from

first

explosion to

BMC

emergency

department

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Crucial to success at the scene

Timely interventions by pre‐hospital personnel and

bystanders (pressure dressings and tourniquets)

Minimal treatment at the scene

Rapid transport to trauma centers that could provide

definitive care

Equal distribution of critical patients

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Lancet 2009; 374: 405-15 Peak Overpressure

Medium



Water vs air

Distance



Exposure to peak overpressure

inversely related to the cube of

distance from explosion



If twice as far away, experience

1/8

th

_{the overpressure}

Low‐order Vs High‐order explosives

Physics of Blast Injuries

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Physics of Blast Injuries

Open vs Confined Space



Effective overpressure amplified by reflection



Open spreads circumferentially & dissipates



Confined raises the overpressure and duration of positive pressure

phase



Increases ISS, incidence of primary blast injury, overall mortality

J Trauma 1996 41: 1030-35.

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Primary



Blast overpressure



Atmospheric wave

Secondary



Physical debris that is displaced by overpressure



Penetrating injuries, fragmentation wounds

Tertiary



Physical displacement of the person



Blunt injuries



Closed head injuries, blunt abd trauma, fractures

Quaternary



Everything else



Burns, toxic substance exposure (radiation, carbon monoxide, etc)

Lancet 2009; 374: 405-15

Mechanisms of Blast Injuries

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Pool Data from all Boston Level 1 Trauma Centers who saw bombing patients

• Institutional IRBs

• Established a collaborative data collecting system ( Red Cap)

• Data open to other specialties utilizing collaborative model

After Action Review and Report:

J Trauma Acute Care Surg. 2014 Sep;77(3):501‐3.

Publication: Describing the first 6hrs:

Annals of Surgery ,Vol 260, (6) ,Dec. 2014

Hospital experience: work in progress

Potential for further research and systems issues identification and modification

• User friendly mass casualty record

• improved family access/communications

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Demographics: Total Pts. Seen 151, 127 in the first 24hrs Adults 141 (93%) Children <15 10 (6.6%) Spectators (109) 72% Runners ( 3 ) 2% Other (39) 26%

Hospital Distribution Pts. seen Pts. admitted

BIDMC 25 16 BMC 28 19 B/W 35 16 MGH 39 12 Tufts 23 15 BCH 7 3

Boston Level I Trauma Center Collaborative Data

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Boston Level I Trauma Center Collaborative Data

Patient flow into the Boston Level I Trauma Centers by ISS April 15 ,2013

Patient distribution to the Boston Level I Trauma Centers

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127 patients seen on Day 1, 151 total 75 admitted (60%) 52 discharged (40%) 31 (24%) had exsanguinating hemorrhage 26 (84%) had tourniquet applied 75 admitted; 45 to OR, 11 to ICU, 19 to Ward (9 to OR after ICU/ward) 15 amputations, 14 vascular procedures, 24 F.B. removal 12 on Day 1, 3 on Day 2 33 Discharged to Rehab 30 Discharged to Home 11 Discharged to Home w/Services 1 Discharged to Skilled Nursing Facility

Boston Level I Trauma Center Collaborative Data

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BMC Patients

28 (bomb‐related) patients, 19 admissions

Age range: 5‐70

6 males, 13 females, 1 child; Most spectators; 1‐2 runners

16 operations first 8 hours ‐11 major, 5 minor (52 total)

• _{7 amputations in 5 patients}

• _{3 major vascular injuries}

• _{1 significant penetrating abdominal evisceration}

• 2 head injuries

• 1 pulmonary blast injury

• 12/19 had acoustic trauma

• All with lower extremity fragment injuries

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Fragment removed from abdominal evisceration

patient

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OR time Average – 104.6 min Range 258-15 min Temp Average - 35.5 Range 37.1 - 31.5

pH Average – 7.25 Range 7.48 - 6.98

Lactic acid Average – 3.67 Range 7.7 - 1.0 Base deficit Average - -8.37 Range -2 to -19 INR (Post op) Average - 1.24 Range 1.03 – 1.72 EBL Average – 551cc Range 3000 - 1 cc 69% ( 11/16) patients went

to ICU

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Primary operation at BMC, N =16

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Total operations 50 in 16 patients

87% of patients required reoperation

Re ops in 14 patients Average 3.1 Range 11‐1 69% ( 11/16) patients

went to ICU

ICU/IMCU LOS Average 5.25 days Range 29‐1 days Intubated Average 1.75 days Range 10‐1 days

ISS Average 11.18 Range 1‐30

Hospital LOS Average 20 days Range 3‐37 days

Disposition 9 Rehab , 5 Home , 2 Home W/VNA Major Complication No wound complications or infections 1 deep space infection ,intra abd abscess 32

Outcomes: BMC, Boston Marathon bombing patients

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Crucial to success in the ER at BMC

• Establish /practice command and control

• Early replacement of improvised tourniquets with effective

tubing/clamp tourniquets

• Simultaneous resuscitation

• Treatment of shock early and aggressive blood transfusion (O neg

blood given in the ED)

• Expedient movement to the OR for definitive care

• Utilization of lessons learned from the military experience in Iraq

and Afghanistan

• Debridement of War Wounds • Damage Control Procedures

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Additional Considerations In the ER phase

Things to think about: Don’t count on meaningful scene triage Have senior Trauma surgeon in ED to Triage, not to operate Place Critical pts. in one large space, so they can be managed together, maximizing resources Parallel Process: Move people out of ER ,OR ,ICU, Floor Establish staff and family support area Facility security, managing the 4th_estate Expect the unexpected: Acoustic Trauma Infectious Diseases

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After Action Report J Trauma Acute Care Surg. 2014 Sep;77(3):501‐3. Fortunate Timing Early communication often incomplete and unofficial Plan for equal distribution of critical patients Minimal Triage at the scene First responders and bystander aid crucial (tourniquet and transport) Lessons Learned Be prepared and Practice Communications needs to be redundant, Senior Trauma surgeon determines performs triage in ED Abbreviated medical record/mass casualty form Feedback loop from hospitals to Field/Scene/DPH for patient tracking, resource availability and family reunification All Uniform Services Personnel to be trained and equipped with Tourniquets to be standardized and universal everywhere

Boston Level I Trauma Center Collaborative

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http://www.usaisr.

amedd.army.mil/c

linical_practice_g

uidelines.html

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