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  1. How are blast-induced injuries classified?

  2. What organ systems are typically affected in blast-induced polytrauma?

  3. Are there strategies to predict which patient might experience delayed onset of primary blast injuries?

  4. What are current management strategies for specific primary blast injuries?

  5. How are blast-induced traumatic brain injuries classified?

  6. How does blast-induced traumatic brain injury (TBI) differ from other types of traumatic brain injuries?

  7. How can secondary insults to TBIs be avoided?

  8. What are the current diagnostic and management strategies for mild, moderate, and severe TBI?

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The incidence of explosive blast injuries is on the rise. From 1996 to 2006, it is estimated that blast-related events have risen fourfold. Although there have been a number of explosive blast events worldwide, the actual number of mass casualty blast events occurring on United States soil have been relatively few. In 1995, a large explosive device composed of fuel oil and fertilizer was detonated in front of the Alfred P. Murrah Federal Building in Oklahoma, which resulted in 518 injuries and 168 deaths. More recently, the 2001 World Trade Center terrorist attack has resulted in more focus on homeland security and disaster preparation for these events. A civilian physician may have to respond to domestic terror events such as bombings in subways, trains, public gatherings, and nightclubs. The National Counterterrorism Center reported in 2007 that approximately 14,000 terrorist attacks have occurred worldwide, resulting in about 44,000 injuries and more than 22,000 deaths. This represented a 20% to 30% increase since 2006.

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Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan have greatly increased our knowledge and experience in treating blast injuries. A recent study of the Joint Theater Trauma Registry (JTTR) revealed that explosive blasts accounted for almost 80% of all combat casualties from October 2001 through January 2005. The most common explosive weapon employed in OIE/OEF is the improvised explosive device (IED), which broadly describes any makeshift incendiary device constructed to injure, incapacitate, harass, or distract. Most IEDs utilize conventional military weapons (ie, artillery shells, plastic explosives, etc.) with various detonating triggers (ie, pressure plate, cellular phone, remote control) and are employed almost anywhere (ie, roadside, suicide bomber, vehicle-borne). Typical injuries seen from an IED blast have concentrated mainly on extremity and head injuries. This is likely due to advanced body armor systems currently used that afford good protection from blast injuries in the torso region.

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The complex physics of an explosive blast can result in a myriad of injuries on multiple victims. An explosion results in sudden and near instantaneous expansion of gas that results in a shockwave also known as a blast wave. As this blast wave travels, it begins to lose its pressure and velocity with distance and time (Figure 268-1). A blast wave is made of two components: a shockwave of high pressure, followed closely by a blast wind. Blast winds can be strong enough to propel people or objects, thus resulting in secondary injury. ...

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