From the Guidelines
For a 28-year-old man with right leg pain after an explosion, immediate evaluation and management of potential blast injury, hemorrhage, and compartment syndrome are crucial to prevent morbidity and mortality. The patient should be assessed for ABCs (airway, breathing, circulation) and any hemorrhage should be controlled with direct pressure or tourniquet if severe bleeding is present 1.
- A thorough examination should be performed to identify penetrating injuries, fractures, compartment syndrome, and vascular compromise.
- Pain control should be administered with IV morphine 4-8mg or fentanyl 50-100mcg titrated to effect.
- Immediate imaging, including plain radiographs, should be obtained to identify fractures and foreign bodies, followed by a CT scan if available to assess soft tissue damage 1.
- Tetanus prophylaxis should be administered if the patient's status is unknown or outdated (Tdap 0.5mL IM).
- Broad-spectrum antibiotics, such as cefazolin 2g IV, should be initiated if open wounds are present.
- Orthopedic consultation is warranted for fracture management or compartment syndrome concerns.
- The patient should be monitored for delayed symptoms of pulmonary barotrauma, intestinal perforation, or traumatic brain injury, even if external injuries appear limited 1.
- Psychological support should also be initiated early, as blast injuries frequently cause acute stress reactions and PTSD. The presence of one or more risk factors, such as fracture, crush injury, or hypotension, should prompt repetitive investigation for compartment syndrome, including clinical signs and compartment pressure monitoring 1.
From the Research
Approach to a 28-Year-Old Man with Right Leg Pain After Explosion
- The patient's condition should be assessed promptly, and treatment should be focused on immediately life-threatening complications, such as hemorrhage, airway obstruction, or tension pneumothorax 2.
- In a mass-casualty event, the principles of "tactical abbreviated surgical care" should be applied, with the goal of saving the greatest possible number of patients 2.
- The patient's airway, breathing, and circulation (ABCs) should be assessed, and any life-threatening conditions should be treated promptly 3.
- A circulation-first approach may be considered, prioritizing restoration of circulation before endotracheal intubation (ETI) and positive pressure ventilation, especially in patients with hemorrhagic shock 3.
- The patient should be triaged according to the severity of their condition, using a targeted patient assessment and triage tools to determine the appropriate acuity category 4.
- Diagnostic tests, such as X-ray films, may be used to facilitate the triage process, but care should be taken to avoid prolonging the process 4, 5.
- The patient's medication history should be considered, as some medications may be visible on X-ray films and could be mistaken for other conditions, such as gallstones 5.