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484
A. Padalko et al.
Variable accessibility and timing of resources in the postburn setting may lead to signicant differences in physical
and psychosocial outcomes based on geography [24, 26].
Standardized burn treatment across regions is needed to optimize recovery and decrease long-term consequences of burn
injury. Routine burn care educational sessions may be benecial to review up-to-date treatment recommendations [27],
coordinate specialized burn care between disciplines, and
standardize burn treatment to optimize patient outcomes.
The dissemination of advanced burn care knowledge to the
burn team can be facilitated effectively using multidisciplinary burn journal clubs, with each discipline leading discussion of an article of interest [27].
High-Risk Populations andPrevention
Burns are a preventable injury. Risk of sustaining a burn
injury is heavily inuenced by environment and social determinants of health [25]. Recent literature has identied a
number of social determinants of health that are associated
with an increased risk of burn injury in Canadian children.
Children from a low family income, from families receiving
income assistance, in foster care, or born to a teen mother
were all seen to increased risk of burn injury [25]. Identifying
populations at an increased risk of burn injury enables personalization and targeting of burn prevention programs to
those that would benet most.
Active prevention methods, such as burn prevention programs, have been shown to decrease incidence of burn injury
[28, 29]. Initiating prevention programs in low-income areas
would provide the most benet.
Summary
Burns are a preventable injury with signicant sequelae. The
most common cause of burn injury depends on age groups
but is predominantly ame related, except in the younger and
older ages in whom scalds become common. The physiologic effects of burn injury are directly related to the inammatory response to injury. The physiologic response may be
evident immediately or take time to evolve. The response to
the cutaneous burn injury is compounded by the presence of
inhalation injury. Smoke inhalation can result in not only airway injury but also systemic toxicity through agents such as
carbon monoxide. The inammatory response causes capillary leakage requiring uid resuscitation. The most common
formula used is the Parkland formula. The endpoint of the
resuscitation is adequate tissue perfusion as measured by
urine output in most situations. Under-resuscitation has been
shown to worsen the inammatory response. Prophylactic
systemic antibiotics are not indicated, but topical antibiotic
dressings should be used. Early consultation with the regional
burn center is advised for any larger or deeper burns, burns
from unusual etiologies, and burns affecting specialized
body parts. Through ongoing education and dissemination of
advanced multidisciplinary burn care the mortality from
burn injuries has improved dramatically. Future work is
needed to identify optimal treatment pathways and to
improve the psychosocial outcomes from burn injury.
Key Points
• Burn injuries are complex and may benet from a
team-based approach.
• Initial management of burns can benet from the
ABCDE approach (Airway, Breathing, Circulating,
Disability, Exposure).
• Burn patients benet from a high protein/caloric
diet due to signicant hypermetabolic drive.
• Understanding social determinants of health that
may place individuals at increased risk of future
burn injury may be useful for targeted burn prevention programs.
References
1. Padalko A, Cristall N, Gawaziuk JP, Logsetty S.Social complexity
and risk for pediatric burn injury: a systematic review. J Burn Care
Res. 2019;40:478–99. https://doi.org/10.1093/jbcr/irz059.
2. Peck MD. Epidemiology of burns throughout the world. Part I:
distribution and risk factors. Burns. 2011;37:1087–100. https://doi.
org/10.1016/j.burns.2011.06.005.
3. Parachute Canada– some stats 2021. http://www.parachutecanada.
org/child- injury- prevention/item/burns- and- scalds- prevention.
Accessed 10 May 2021.
4. American Burn Association. Burn incidence fact sheet; n.d.
5. Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem
EH, Tompkins RG.Objective estimates of the probability of death
from burn injuries. N Engl J Med. 1998;338:362–6. https://doi.
org/10.1056/nejm199802053380604.
6. Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS,
Logsetty S.Burn injury. Nat Rev Dis Prim. 2020;6:11. https://doi.
org/10.1038/s41572- 020- 0145- 5.
7. Osler T, Glance LG, Hosmer DW. Simplied estimates of the
probability of death after burn injuries: extending and updating
the baux score. J Trauma. 2010;68:690–7. https://doi.org/10.1097/
TA.0b013e3181c453b3.
8. Dokter J, Meijs J, Oen IMMH, Van Baar ME, Van Der Vlies
CH, Boxma H.External validation of the revised Baux score for
the prediction of mortality in patients with acute burn injury. J
Trauma Acute Care Surg. 2014;76:840–5. https://doi.org/10.1097/
TA.0000000000000124.
9. Haigas B, Bay C, Foster K.A comparison of injury scoring systems in predicting burn mortality. Ann Burns Fire Disasters.
2018;31:89–93.
10. Roberts G, Lloyd M, Parker M, Martin R, Philp B, Shelley O, etal.
The Baux score is dead. Long live the Baux score: a 27-year retrospective cohort study of mortality at a regional burns service. J
Trauma Acute Care Surg. 2012;72:251–6. https://doi.org/10.1097/
TA.0b013e31824052bb.
55 Burns
485
11. Matsumoto N, Noda H, Nakazawa H, Traber LD,
Herndon DN, Traber DL. The sequence of injury determines the degree of lung damage in both inhalation and
thermal injuries. Shock. 1994;1:166–70. https://doi.
org/10.1097/00024382- 199403000- 00002.
12. Weaver LK, Hopkins RO, Chan KJ, Churchill S, Elliott CG,
Clemmer TP, etal. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002;347:1057–67. https://doi.
org/10.1056/NEJMoa013121.
13. Herndon DN, Traber DL, Traber LD.The effect of resuscitation on
inhalation injury. Surgery. 1986;100:248–51.
14. Choosing Wisely. Twenty things physicians and patients should
question; 2019. https://www.choosingwisely.org/wp- content/
uploads/2015/02/AAFP- 20- things- List_Updated101119.pdf.
15. American Burn Association. Advanced burn life support course.
Provider manual 2018 update; 2018.
16. Eljaiek R, Heylbroeck C, Dubois MJ. Albumin administration
for uid resuscitation in burn patients: a systematic review and
meta-analysis. Burns. 2017;43:17–24. https://doi.org/10.1016/j.
burns.2016.08.001.
17. Carta T, Gawaziuk JPP, Diaz-Abele J, Liu S, Jeschke M, Logsetty
S.Properties of an ideal burn dressing: a survey of burn survivors
and front-line burn healthcare providers. Burns. 2018;45:364.
https://doi.org/10.1016/j.burns.2018.09.021.
18. Ross JA, Allan N, Olson M, Schatz C, Nation PN, Gawaziuk JP,
etal. Comparison of the efcacy of silver-based antimicrobial burn
dressings in a porcine model of burn wounds. Burns. 2020;46:1632.
https://doi.org/10.1016/j.burns.2020.04.004.
19. Coutris N, Gawaziuk JP, Cristall N, Logsetty S. Interrupted
nutrition support in patients with burn injuries: a single-centre
observational study. Plast Surg. 2019;27:334–9. https://doi.
org/10.1177/2292550319880917.
20. Jeschke MG, Finnerty CC, Suman OE, Kulp G, Mlcak RP, Herndon
DN. The effect of oxandrolone on the endocrinologic, inammatory, and hypermetabolic responses during the acute phase
postburn. Ann Surg. 2007;246:351–60. https://doi.org/10.1097/
SLA.0b013e318146980e.
21. Stone J, Gawaziuk JP, Khan S, Chateau D, Bolton JM, Sareen J,
etal. Outcomes in adult survivors of childhood burn injuries as compared with matched controls. J Burn Care Res. 2016;37:e166–73.
https://doi.org/10.1097/BCR.0000000000000323.
22. Enns J, Gawaziuk JP, Khan S, Chateau D, Bolton JM, Sareen
J, etal. Mental and physical health outcomes in parents of children with burn injuries as compared with matched controls.
J Burn Care Res. 2016;37:e18–26. https://doi.org/10.1097/
BCR.0000000000000309.
23. Gittings PM, Grisbrook TL, Edgar DW, Wood FM, Wand BM,
O’Connell NE. Resistance training for rehabilitation after burn
injury: a systematic literature review & meta-analysis. Burns.
2018;44:731–51. https://doi.org/10.1016/j.burns.2017.08.009.
24. Padalko A. Environmental scan of mental health supports across
Canadian burn centers: a healthcare providers’ perspective. n.d.
25. Padalko AA, Gawaziuk J, Logsetty S. 754 Social determinants associated with Paediatric burn injury: a population based, case-control
study. J Burn Care Res. 2020;41:S210–1. https://doi.org/10.1093/
jbcr/iraa024.335.
26. Espinoza LF, Friedstat J, Faoro N, Chang PH, McMullen KA,
Simko LC, et al. Geographic variation in outcomes after burn
injury: a burn model system national database study. Ann Plast Surg.
2020;84:644. https://doi.org/10.1097/SAP.0000000000002287.
27. Carta T, Gawaziuk JP, Cristall N, Forbes L, Logsetty S.Evaluation
of a multidisciplinary burn care journal club: lessons learned. Burns.
2018;44:560–5. https://doi.org/10.1016/j.burns.2017.10.017.
28. Corrarino JE, Walsh PJ, Nadel E.Does teaching scald burn prevention to families of young children make a difference? A pilot
study. J Pediatr Nurs. 2001;16:256–62. https://doi.org/10.1053/
jpdn.2001.25535.
29. Cagle KM, Davis JW, Dominic W, Gonzales W.Results of a focused
scald-prevention program. J Burn Care Res. 2006;27:859–63.
https://doi.org/10.1097/01.BCR.0000245423.79531.50.
War Zones andBiological Weapons
JasonD.Heiner andWilliamHurley
56
Abbreviations
HEPA High-efciency particulate air
PPE Personal protective equipment
War Zones
Introduction toBattleeld Care
War zone trauma providers generally train in civilian and
noncombat military settings prior to engaging in battleeld
medical care and often have little or no experience in the
combat setting prior to their rst medical war zone assignment [1, 2]. When not deployed to the combat setting, urban
civilian trauma hospitals provide an important environment
for training military trauma teams due to the relatively high
volume of injured patients at these centers [1–3]. While the
dynamics of trauma team care in the war zone and non-war
settings share some similarities, notable differences to care
within the battleeld exist.
Team Members andEchelons ofBattleeld Care
On the battleeld, the individuals composing trauma teams
and the specic circumstances in which trauma care is provided can vary considerably. Trauma care occurs along a
spectrum from battleeld care at the point of injury while
under enemy re and other combat hazards and with minimal medical resources to larger mobile or xed structures
that resemble more familiar emergency care and resuscitation environments. War zone trauma care in the American
military and similar modern military systems utilizes a tiered
J. D. Heiner (*)
University of Washington, Department of EmergencyMedicine,
Seattle, WA, USA
e-mail: jheiner@uw.edu
W. Hurley
Olympia Emergency Care Physicians, WA, USA
trauma care and evacuation system to organize and deploy its
medical resources (Table56.1) [4–6]. Advancing capabilities
exist upward along the echelons of care. However, with factors including the asymmetric nature of the modern battleeld and availability of rapid casualty transport, the injured
may bypass lower echelons for regions of higher care capabilities [4].
The rst typical echelon of battleeld care is near the
point of injury with trauma care teams often consisting of
combat medics or Battalion Aid Station personnel. Care at
the second echelon takes place in settings such as the Forward
Surgical Team, Mobile Field Surgical Team, and
Expeditionary Medical Support Unit where immediate life
and limb-saving surgical interventions and stabilization may
occur. The third echelon of care occurs in settings such as the
Army Combat Hospital, Air Force Theater Hospital, or Naval
eet hospitals—combat trauma casualties may arrive to this
level of care from the rst or second echelon of care, and
from here, may be transferred out of the war zone. These
levels of care are connected by medical evacuation services
to transport patients efciently up or between these echelons
Table 56.1 Levels of common warzone patient care settings and typical trauma team member composition [4–6]
Level I/Role 1 (i.e., point of injury)
Combat medic
General physician
Physician assistant
Level II/Role II (i.e., forward surgical team)
Combat medic
Nurse
Surgeon
Anesthesiology provider
Level III/Role III (i.e., combat support hospital)
Combat Medic
Nurse
Physician assistant
Surgeon (including specialists)
Emergency physician
Anesthesiology provider
General physician
Radiologist
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_56
487
488
J. D. Heiner and W. Hurley
of care. The varying levels of care allow treatment of minimally injured patients at the lowest tier of care needed to
maximally maintain local war ghting strength, while also
providing key opportunities to stabilize more critically
injured patients prior to their transport out of the war zone.
Members of modern war zone trauma teams can include
varying numbers of surgeons and surgical specialists, emergency physicians, combat medics, anesthesiologists, nurses,
and additional ancillary providers (Table56.1) [4–6]. The
multidisciplinary physician nature of modern robust military
trauma teams provides optimal care to combat casualties and
addresses the frequently devastating penetrating, blast, and
orthopedic injuries seen on the battleeld. Radiologists may
aid in the triage of imaging studies for trauma patients and
report immediate results to trauma team leaders. Many additional providers assist in patient care at the higher echelons
to include blood bank, pharmacy, laboratory services, and
operating room personnel. In multi-casualty and masscasualty incidents, the trauma team members vary based on
number of casualties and the priority and nature of their
injuries.
Casualty Care Team Preparation
War zone casualties can include soldiers, adult civilians,
children, and enemy combatants and often arrive with little
warning, in critical condition, and in multi-casualty or masscasualty numbers. Team preparedness to ensure effective
communication, identied leadership, role clarity, situational
awareness, and action anticipation is imperative. The ability
of the individual and the trauma teams to function in a predictable manner to dynamic situations is key to care in the
combat setting. Team training prior to combat deployment,
ongoing training in the war zone, and consistent debrieng is
vital to optimizing battleeld care.
Pre-deployment simulation-based training has positively
affected trauma team performance in areas such as modern
battleeld injury care, individual performance awareness,
and team performance during mass-casualty incidents [3,
7–9]. This simulation training may employ a variable of
training tools such as high-delity mannequins, perfused
cadavers, and in situ positioning of eld care elements or
entire facilities [3, 7–9]. Importantly, pre-deployment training can identify critical areas of needed improvement in
trauma team performance such as communication lapses,
inappropriate trauma triaging, delays to lifesaving procedures, and failure to recognize hazards such as unexploded
ordnance. Often, medical specialists are assigned to differing
echelons of care in part due to the specialty expertise they
deliver; at times, their specialty background may be less
complementary to the battleeld and reveal opportunities to
provide additional team and setting training. In the war zone,
ongoing team exercises and simulation-based training can be
an effective tool to maintain and improve trauma team performance and may be particularly valuable to orient new
members to the deployed trauma team. Team exercises can
target critical events, complement debrieng tools, and can
include all aspects of patient care from initial triage through
evacuation to higher levels of care.
Care of the trauma patient can be stressful for care team
members in any setting. The consistent high acuity and devastating nature of battleeld casualties within unfamiliar
surroundings combined with a setting typically removed
from a medical provider’s usual personal and professional
support can add additional emotional burden. Medical providers in combat settings are at risk of developing syndromes such as post-traumatic stress disorder and should be
offered interventions such as critical incident debrieng.
Regular debrieng of trauma care as well as critical incident
debrieng of particularly stressful events may optimize
team and individual performance, enhance individual coping, nurture team communication, and prevent stress reactions or identify individuals in need of more mental health
resources.
Biological Weapons
Introduction toBiological Weapons
Biological warfare agents are unconventional weapons considered to be a modern threat in military and civilian settings.
Although a natural event, the recent medical, social, and economic disruption produced by the COVID-19 pandemic
demonstrates the potential immense impact of the release of
an effective infectious biological warfare agent [10]. Such
weapons are relatively inefcient on the modern battleeld
but are weapons that can be obtained with relative ease and
produced with relatively low cost and technology [11]. These
factors, coupled with their profound psychosocial impacts,
make biological weapons attractive as agents of terrorism
and crime. Several unique factors make biological weapons
problematic for the trauma team. These include challenges to
timely recognition and identication of the agent, the need
for protection of trauma team members, control of spread to
team members and the community, and recognition of the
profound physical and psychological impacts on team members caring for victims of biological weapons. Recognizing
and preparing for these unique challenges can promote optimal care of patients and enhance the performance of the
trauma team.
56 War Zones andBiological Weapons
489
Biological Warfare Historical Considerations
Historically, disease has produced greater numbers of casualties in the battleeld when compared to injury. The
exploitation of disease as a weapon dates to medieval times
and has been used with varying success by the Romans, the
United States Calvary, the Japanese, and the Soviets [12].
The use of ricin for assassination and the mailing of anthrax
spores demonstrate a recent use of biological weapons in the
United Kingdom and in the United States.
The most concerning potential biological weapons have
caused the deadliest plagues and pandemics in history. These
include anthrax, cholera, plague, smallpox, hemorrhagic
fever viruses, and now COVID-19 (SARS-COV2). Victims
exposed to biological weapons may require isolation, decontamination, and novel therapies to prevent the further spread
of these agents to communities and healthcare providers as
secondary casualties [9, 13]. Care of the trauma patient in the
setting of biological weapon exposure will be challenged by
the physiological impacts of the agent on the patient, as well
as the reduction of available resources through diversion to
the care of other victims. There will be increased workload
and stress in team members through the need to consider
their own risks of exposure and the need to work in personal
protective equipment (PPE). These challenges may be mitigated by planning, preparation, and training of the trauma
team for the care of victims of biological weapons as well as
for the care of victims of the next pandemic.
States Centers for Disease Control and Prevention has categorized biological agents into three categories, with Category
A listing the agents of highest priority and risk of use as a
weapon [14]. These bacterial, viral, and toxin agents are
found in nature and can be most efciently weaponized as an
aerosol (Table 56.2). Bacterial organisms include anthrax,
cholera, and plague. Viral agents include smallpox and viral
hemorrhagic fevers. Weaponized toxins include ricin and
botulism.
Medical Management ofBiological Weapon
Victims
The recent principles of care for patients with suspected
COVID-19 infection provide a useful framework for the care
of victims of biological weapons [15, 16]. These include:
1. Personal protection of team members while performing
initial assessment, stabilization, and management of the
patient.
2. Rapid identication of suspected infection or toxicity.
3. Maintenance of heightened personal protection until the
risk of secondary transmission can be eliminated through
appropriate decontamination or ruling-out of the suspected agent.
4. Simultaneous care of traumatic injuries as well as illness
and injury produced by the biological weapon.
Diversity ofBiological Weapons
Identication ofBioweapons
Agents used as biological weapons in warfare, terrorism, and
crime are generally infectious and often living particles or
the toxic products of living organisms [9, 11, 13]. The United
Table 56.2 Selected biological warfare agents, likely mode of delivery, and chosen physiologic effects [9, 11, 13, 14]
Biological agent Delivery mode Physiological effect
Bacterial
Anthrax (Bacillus anthracis spores) Aerosol release
Food and water contamination
Brucellosis (Brucella bacteria) Aerosol release Bone and joint, pulmonary, genitourinary
Plague (Yersinia pestis bacteria) Aerosol release Pulmonary, hematologic
Cholera (Vibrio cholerae bacteria) Aerosol release
Food and water contamination
Viral
Smallpox (variola major or minor virus) Aerosol release Skin, pulmonary, hematologic, neurologic
Viral hemorrhagic fevers (i.e., Ebola) Aerosol release Skin, hematologic, neurologic
Toxin
Clostridium Botulinum toxin Aerosol release
Food and water contamination
Ricin Aerosol release
Food and water contamination
Trichothecene Mycotoxin Aerosol release
Food and water contamination
Biological weapons may remain unnoticed for days or weeks
after exposure due to delayed onset of illness, making identi-
Pulmonary, gastrointestinal, cutaneous
Gastrointestinal
Neurologic, gastrointestinal
Pulmonary, gastrointestinal
Hematologic, neurologic, pulmonary,
Gastrointestinal
490
J. D. Heiner and W. Hurley
cation and control difcult immediately after exposure [9,
13]. The initial suspicion of exposure to a biological weapon
occurs through the recognition of a unique pattern of disease
in multiple victims [14]. To recognize such a pattern, team
members require brieng and familiarization regarding illness patterns and exposure suspicion. This is a critical time
for the team to establish and maintain situation awareness, as
well as to cross-monitor team members to ensure they maintain awareness and safety. The importance of informed pattern recognition was exemplied by care team members
recognizing the unique pattern of hemorrhagic mediastinitis
in anthrax victims and the recent recognition of a novel progressive respiratory and inammatory illness in victims of
COVID-19 [17]. Initial suspicions can then be conrmed (or
eliminated) through specic testing for the suspected agent.
Victims of biological weapons and the “worried well”
may overwhelm healthcare resources [9, 13]. In general,
healthcare facilities and their providers are thought to be
poorly prepared for these unexpected events that could
quickly deplete available protective supplies, treatments,
available hospital beds, and other resources [9]. Members of
the trauma team must be prepared and supported to treat both
contaminated and uncontaminated patients, prioritize trauma
care and medical care for biological weapon victims, and
efciently deliver care while protecting other patients, themselves, and other team members from secondary exposure.
Unique to the recent COVID-19 pandemic was an early
reduction in the use of Emergency Departments in the United
States during the pandemic [18]. This likely came from an
informed public recognizing that resources were limited by
the need to care for COVID-19 patients, as well as recognizing their personal risk of acquiring the disease through travel
and at the healthcare facility. This recent experience demonstrates a public health opportunity to control access and
match resources to needs in similar events (such as a biological weapons event) through consistent, trusted, and timely
public health messaging.
Victim Decontamination andIsolation
Individuals exposed to a biological weapon may be prevented from becoming ill through early decontamination.
Delays in symptom onset and agent identication may make
decontamination impossible. Isolation of victims may then
be required to prevent the agent from infecting other patients,
members of the community, and care team members [9, 13].
The discovery of unidentied contaminates or suspected
persistent aerosolized agents on victims (such as toxins or
anthrax spores) provides an opportunity for decontamination
[9]. For most agents, removal of clothing and washing of the
patient with soap and water to remove further biological con-
taminates is adequate [9]. Decontamination can proceed
alongside initial care if providers are appropriately protected.
Wounds can be irrigated with copious clean or sterile water
to remove the agent and assist in the removal of contaminated foreign bodies [9]. Patient decontamination should not
interfere with more immediate lifesaving treatments and
may be performed in parallel with other medical and surgical
interventions [9, 13]. Patient decontamination increases the
work burden and potentially reduces the performance of the
trauma team. Trauma team training with explicit inclusion of
decontamination scenarios is critical to preparing team members for additional communication requirements, role clarity,
and exceptional situational awareness that will be needed in
these crisis-rich events.
Personal Protective Equipment
Care of the trauma patient with exposure to a biological
weapon is complicated by the need to prevent further exposure and disease. There is limited data or consensus to rmly
guide recommendations, but if the biologic agent is identied, specic precautions should be instituted (Table56.3)
[9]. When biological weapon use is suspected but not yet
identied, personal protective equipment (PPE) with a nonencapsulated chemical-resistant suit, gloves, boots, and a
full-face organic vapor/HEPA (high-efciency particulate
air) lter cartridge mask has been recommended [9].
Personal protective equipment creates barriers to patient
care through limiting the maximum duration of work,
increasing heat stress, reducing visibility from fogging of
eyewear and face shields, and impeding ne motor and palpation skills from glove use. Several distant past studies have
been equivocal on the impact of these challenges while more
recent studies during the COVID-19 pandemic demonstrated
reduced voiced communication and increased isolation from
the patient and other team members when wearing protective
equipment [19]. These ndings underscore the importance of
training and practice for healthcare providers in the donning
and dofng of PPE, work while in PPE, and challenges to
team performance while wearing PPE.
Specic Biological Weapons
Anthrax
The spores of the bacterium Bacillus anthracis are commonly found in soil and when activated can produce cutaneous, gastrointestinal, inhalational, and injection-related
infections in humans [20]. Most severe is inhalational
anthrax, characterized by meningitis and hemorrhagic mediastinitis that occur about a week after inhalation of anthrax
56 War Zones andBiological Weapons
Table 56.3 Suggested precautions and personal protective equipment (PPE) against selected agents of biological warfare [9]
Precautions and PPE Biological agent
Universal/standard precautions
Includes gloves, masks, gown, eye protection, and frequent hand
washing
Contact precautions
Universal/standard precautions
plus Patients isolation in a standard room
Droplet precautions
Universal/standard precautions
plus Contact precautions
plus N-95 or better respirator
plus Mask worn by patient
Airborne precautions
Universal/standard precautions
plus Patient isolation in a negative pressure room
plus N-95 or better respirator
plus Mask worn by patient
Anthrax
Cholera
Clostridium Botulinum toxin
Ricin
Trichothecene mycotoxin
Brucellosis
Plague
Smallpox
Viral hemorrhagic fevers
491
spores. Treatment with antibiotics, antitoxin, and intensive
supportive care can improve the survival from inhalational
anthrax from about 15% to 55% [21]. As with most bacterial
infections, secondary spread to care team members does not
occur from inhalational anthrax, making the need for specic
personal protective equipment (PPE) unnecessary.
Hemorrhagic Fevers (Ebola andMarburg Viruses)
Exposure to a hemorrhagic fever virus produces an abrupt
viral syndrome (fever, headache, and myalgia) after an incubation period of about 6–10days. This is followed by nausea, vomiting, abdominal pain, diarrhea, profound uid
losses, chest pain, cough, and pharyngitis, then a maculopapular rash, and nally hemorrhagic manifestations (petechiae, ecchymoses, and bleeding) as the disease progresses.
Intensive supportive care, uid replacement, antiviral agents,
and antitoxins can improve survival from about 10% to over
60% [22]. As with many viral agents, secondary infection of
family members and caregivers is common and demands the
meticulous use of isolation and personal protective equipment (PPE) to avoid exposure to aerosolized viruses, infected
fomites, and infectious body uids.
Botulism Toxin
Ingestion or inhalation of botulism toxin produces a progressive descending paralysis. Cranial nerve involvement (drooping eyelids, weak jaw clench, difculty swallowing or
speaking) is followed by upper and lower body weakness
and respiratory failure from muscle paralysis. Treatment is
intensive supportive care and antitoxin administration. Key
to the management of botulism is early administration of
antitoxin that stops the progression of paralysis but does not
reverse it [23]. Once established, paralysis from botulism
toxin commonly lasts for weeks or months due to the permanent blockage of neurotramsmitter release at nerve terminals, making prolonged ventilation and intensive care
necessary. As with most toxin exposures, decontamination of
a victim of botulism toxin exposure may be needed if the
agent was aerosolized and liquid remains on the body. Soap
and water are effective for decontamination. Otherwise, care
team members are of no signicant risk of secondary exposure and no specic PPE use is recommended for their
protection.
Impact onTrauma Team Members
Easily overlooked are the psychological effects for both the
community and the providers involved in a biological weapon
attack. It has been well documented that mass population
scale attacks cause many non-injured patients to seek care at
the emergency department. Some of these patients have stress
reactions, while others have psychosomatic complaints mimicking the effects of the biological weapon. Further complicating such scenarios is the psychological toll these events
could have on the providers who must deal with unfamiliar
protocols, rare disease processes, large number of concerned
but well patients, and facing the personal risk of possible
exposure to a biologic agent during an immensely unfamiliar
and potentially tragic event [24]. Hospitals and trauma team
leaders are wise to have well-dened and practiced protocols
in place to manage large numbers of unexposed patients and
to provide rapid psychological support for trauma team members during a suspected attack with a biological weapon.
492
J. D. Heiner and W. Hurley
Conclusion
Treatment of the trauma patient in unique settings such as the
battleeld or with the addition of exceptional hazards such as
biological weapons present challenges to trauma team performance. Patient care in war zones is challenged by limited
resources, threats of combat, and variable team member
composition. Biological weapons can have a myriad of physiologic effects on the patient, and necessary medical precautions and decontamination events can impair the delivery of
typical individual and team care. Targeted trauma team and
individual preparation can optimize the delivery of patient
care in these exceptional settings.
Key Points
• The application of specic teamwork skills in assuring team member tness to work, cross-monitoring
of team members, mutual support, and regular
debrieng will be needed to ensure optimal team
performance in the unique environments of the battleeld and in caring for victims of biological
weapons.
• The COVID-19 pandemic provided a model to
demonstrate the profound impacts of an effective
biological weapon and present the opportunity to
plan, prepare, and mitigate such impacts in the
future.
• Team training and practice in identication of victims of biological weapons, decontamination, personal protective equipment use, and novel therapies
are needed to mitigate the impacts of biological
weapons on the community, care facilities, and
trauma team.
References
1. Dubose J, Rodriguez C, Martin M, Nunez T, Dorlac W, King D,
etal. Preparing the surgeon for war: present practices of US, UK,
and Canadian militaries and future directions for the US military. J
Trauma Acute Care Surg. 2012;73:S423–30.
2. Schmied Blackman V, Torres T, Stakley JA, Raiciulescu S, Garcia
E, Ross JL, Polk TM, Stotts NA.Quantifying clinical opportunities at the Navy Trauma Training Center. Mil Med. 2021;186(Suppl
1):40–8.
3. Valdiri LA, Andrews-Arce VE, Seery JM.Training forward surgical teams for deployment: the US Army Trauma Training Center.
Crit Care Nurs. 2015;35(2):e11–7.
4. Clarke JE, Davis PR. Medical evacuation and triage of combat
casualties in Helmand Province, Afghanistan: October 2010–April
2011. Mil Med. 2012;177(11):1261–6.
5. Schoenfeld AJ. The combat experience of military surgical
assets in Iraq and Afghanistan: a historical review. Am J Surg.
2012;204:377–83.
6. Beckett A, Pelletier P, Mamczak C, Beneld R, Elster
E.Multidisciplinary trauma team care in Kandahar, Afghanistan:
current injury patterns and care practices. Injury. 2012;43:2072–7.
7. Schulman CI, Garcia GD, Wyckoff MM, Duncan RC, Withum
KF, Graygo J. Mobile learning module improves knowledge
of medical shock for forward surgical team members. Mil Med.
2012;177:1316–21.
8. Kim M, Torrie I, Poisson R, Withers N, Bjarnason S, Da Luz
LT, Pannell D, Beckett A, Tien HC. The value of live tissue
training for combat casualty care: a survey of Canadian combat medics with battleeld experience in Afghanistan. Mil Med.
2017;182(9):e1834–40.
9. Multiservice tactics, techniques, and procedures for treatment of
biological warfare agent casualties. Army Techniques Publication;
2013. Report No: 4-02.84.
10. Sarkodie SA, Owusu PA. Global assessment of environment,
health and economic impact of the novel coronavirus (COVID-19).
Environ Dev Sustain. 2020;5:1–11.
11. Jansen HJ, Breeveld FJ, Stijnis C, Grobusch MP. Biological
warfare, bioterrorism, and biocrime. Clin Microbiol Infect.
2014;20(6):488–96.
12. Barras V, Greub G.History of biological warfare and bioterrorism.
Clin Microbiol Infect. 2014;20(6):497–502.
13. Eachempati SR, Flomenbaum N, Barie PS. Biological warfare: current concerns for the health care provider. J Trauma.
2002;52:179–86.
14. Bioterrorism agents/diseases. https://emergency.cdc.gov/agent/
agentlist- category.asp. Accessed 30 Dec 2020.
15. Sawhney C, Singh Y, Jain K, Sawhney R, Trikha A. Trauma
care and COVID-19 pandemic. J Anaesthesiol Clin Pharmacol.
2020;36(Suppl 1):S115–20.
16. Coimbra R, Edwards S, Kurihara H, Bass GA, Balogh ZJ, Tilsed
J, Faccincani R, Carlucci M, Martínez Casas I, Gaarder C,
Tabuenca A, Coimbra BC, Marzi I.European Society of Trauma
and Emergency Surgery (ESTES) recommendations for trauma and
emergency surgery preparation during times of COVID-19 infection. Eur J Trauma Emerg Surg. 2020;46:505.
17. Lippi G, Sanchis-Gomar F, Henry BM.COVID-19: unravelling the
clinical progression of nature’s virtually perfect biological weapon.
Ann Transl Med. 2020;8(11):693.
18. Boserup B, McKenney M, Elkbuli A.The impact of the COVID-19
pandemic on emergency department visits and patient safety in the
United States. Am J Emerg Med. 2020;38(9):1732–6.
19. Leibner ES, Stokes S, Ahmad D, Legome E.Emergency department COVID management policies: one institution’s experience
and lessons learned. Emerg Med Pract. 2020;22(5 Suppl):1.
20. Zasada AA.Injectional anthrax in human: a new face of the old
disease. Adv Clin Exp Med. 2018;27(4):553–8.
21. Anthrax information for healthcare professionals. https://www.cdc.
gov/anthrax/healthcare/index.html. Accessed 30 Dec 2020.
22. Jacob ST, Crozier I, Fischer WA 2nd, Hewlett A, Kraft CS, Vega
MA, Soka MJ, Wahl V, Grifths A, Bollinger L, Kuhn JH.Ebola
virus disease. Nat Rev Dis Primers. 2020;6(1):13.
23. Chalk CH, Benstead TJ, Pound JD, Keezer MR.Medical treatment
for botulism. Cochrane Database Syst Rev. 2019;4(4):CD008123.
24. Luan R, Pu W, Dai L, Yang R, Wang P.Comparison of psychological stress levels and associated factors among healthcare workers,
frontline workers, and the general public during the novel coronavirus pandemic. Front Psych. 2020;11:583971.
Nuclear Injuries
MansoorAliKhan andHeidiL.Frankel
57
Introduction
Trauma care can be challenging in the best of environments.
However, in certain circumstances the environment can contribute to the severity of injuries or even cause unique and
characteristic injury patterns. Herein we will discuss fallout
from nuclear disasters or nuclear weapons.
Historical Background
Survivors of the atomic bombing of Hiroshima and Nagasaki
in 1945 provide the basis for much of the available literature
on the effects of radiation. The Atomic Bomb Casualty
Commission (ABCC) was established in 1947 to study the
late effects of radiation [1]. There were more than 100,000
documented fatalities as a direct result of radiation exposure
[2] following the bombing.
The Chernobyl disaster resulted in 31 immediate fatalities
from acute radiation sickness and approximately 6000 deaths
from cancers due to radiation exposure. Almost 4000 square
kilometers of land is now uninhabited with 120 villages and
two major cities left to decay with over 100,000 losing their
homes [3].
Information on early internal radiation doses in Fukushima
after the nuclear power plant accident on March 11, 2011, is
quite limited due to initial organizational difculties, high
background radiation, and contamination of radiation measuring devices [4]. With regard to healthcare infrastructure,
the biggest lesson learned was the impact of evacuating
healthcare facilities within the emergency planning zones.
The vast majority of able-bodied populace evacuated them-
M. A. Khan · H. L. Frankel (*)
St Mary’s Hospital, Imperial College Healthcare NHS Trust,
London, UK
Keck University Hospital, University of Southern California,
Los Angeles, CA, USA
e-mail: manskhan@doctors.org.uk
selves in private or public transportation. There was no medical support provided during transportation of residents to
hospitals and care homes. This resulted in deaths directly
attributable to lack of healthcare provision during evacuation, whereas, at this point no life has been lost as a result of
radiation, although the long-term effects are still unknown as
elevated levels of radiation are still being detected 3 years
later [5].
Physics ofWeaponry
The most feared and deadly environmental hazards that exist
today are nuclear. These include both conventional ssion or
fusion devices and unconventional weapons known as “dirty
bombs.”
Fission employs high-density elements, with a heavy
unstable nucleus, that subsequently splits into two or more
lighter nuclei releasing a vast quantity of energy. The most
commonly used substances to bring about nuclear reactions
are the isotopes of Uranium and Plutonium, which undergo
ssion readily. The rst uranium-based weapons used were
“Little Boy” and “Fat Man,” used to bomb Hiroshima and
Nagasaki at the climax of the First World War.
Fusion, on the other hand, can be described as the combining of light nuclei to form a heavier nucleus-bearing
product, the same process that powers stars. It can be seen as
the reverse of ssion, but still with the production of vast
amounts of thermal energy and radiation. Practically, nuclear
power plants and weapons are the only existent environmental hazards. Nuclear reactor incidents require special consideration due to the variety of radioactive material released;
radioiodine (I
Dirty bombs, also referred to as Radiological Dispersion
Devices (RDD), are munitions that cause a purposeful dissemination of radioactive material without nuclear detonation. The purpose of the weapon is to contaminate the area
around the conventional explosion with radioactive
material.
131
) can travel over long distances.
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_57
493
494
With thermonuclear weapons, the three main methods of
injury from a nuclear explosion result from the initial blast,
thermal effects, and ionizing radiation:
• Initial blast injuries result from the shearing forces
between differing tissue planes, causing severe internal
tissue disruption. Individuals near the blast epicenter will
suffer instant vaporization, whereas the casualties on the
peripheries will suffer varying degrees of internal inju-
ries. Petechial hemorrhages within organs are difcult to
diagnose; the mainstays are CT/MRI scanning or post-
mortem ndings. The major problem arises not from
diagnosing the injury, but once diagnosed, very few thera-
peutic measures to save life can be administered. Matters
are further complicated when debris is carried in the blast
wave; the arising result will cause blunt and penetrating
injury to occur. In these situations one can only carry out
the usual life support measures.
• Thermal effects—The rapidly expanding reball that
develops into the infamous “mushroom cloud” has an ini-
tial temperature of many millions of degrees Centigrade.
As it expands at a rate of over 100 m/s, it rapidly cools to
only a few thousand degrees Centigrade. The thermal
radiation emitted can cause severe burns many kilometers
away.
• Radiation—The types of radiation are important due to
the fact that they affect cellular function in differing ways.
Alpha (ά) particles are essentially the nucleus of helium
atoms. These have a limited airborne range of a few cen-
timeters and are easily absorbed by paper. However, due
to their relatively high atomic mass, they cause the most
structural cellular damage. Beta (β) particles, ideally
described as free-oating electrons, have a range of a few
meters and are stopped by a thin sheet of aluminum.
These have an atomic mass of 1/1850 of a neutron/proton,
and therefore, are less destructive compared to alpha par-
ticles. Finally, gamma (γ) radiation is electromagnetic
waves, which can only be stopped by concrete or lead;
this allows for deeper penetration of the human body and
subsequent internal irradiation (Fig.57.1).
The scale used for quantitative measurement of radiation
is known as the Gray (Gy) scale. The cellular effects of radiation are similar for different kinds and doses of ionizing
radiation. Cell death is readily observed by light microscopy,
with nuclear and cytoplasmic deformational changes. The
type and severity of the injury is dependent on the dose of
radiation received. A useful indicator of this is the Median
Lethal Dose (LD50 2.5–5Gy), which is the dose that is lethal
to 50% of a given population.
M. A. Khan and H. L. Frankel
Fig. 57.1 Particle penetration Alpha radiation—readily stopped by a
sheet of paper Beta radiation—is stopped by an aluminum plate
Gamma radiation is eventually absorbed as it penetrates a dense material. Lead is good at absorbing gamma radiation, due to its density.
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or any later version published by the Free Software Foundation; with no
Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. A
copy of the license is included in the section entitled GNU Free
Documentation License)
Medical Management ofNuclear DeviceRelated Injuries: Scene Considerations
There are two ways in which an individual may be exposed
to radiation: external radiation hazard and internal radiation
hazard.
• External radiation hazard is received when the radioac-
tive material is external to the body. Emitted radiation
travels through space and irradiates the body; however,
the radioactive material remains external to the body.
Therefore, if one moves away from the source of radiation, the amount of radiation the body is receiving
decreases.