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Blast Injuries: Essential Facts

Key Concepts

  • Bombs and explosions can cause unique patterns of injury seldom seen outside combat
  • Expect half of all initial casualties to seek medical care over a one-hour period
  • Most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals
  • Predominant injuries involve multiple penetrating injuries and blunt trauma
  • Explosions in confined spaces (buildings, large vehicles, mines) and/or structural collapse are associated with greater morbidity and mortality
  • Primary blast injuries in survivors are predominantly seen in confined space explosions
  • Repeatedly examine and assess patients exposed to a blast
  • All bomb events have the potential for chemical and/or radiological contamination
  • Triage and life saving procedures should never be delayed because of the possibility of radioactive contamination of the victim; the risk of exposure to caregivers is small
  • Universal precautions effectively protect against radiological secondary contamination of first responders and first receivers
  • For those with injuries resulting in nonintact skin or mucous membrane exposure, hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine (if not current)

Blast Injuries

  • Primary: Injury from over-pressurization force (blast wave) impacting the body surface
    • TM rupture, pulmonary damage and air embolization, hollow viscus injury
  • Secondary: Injury from projectiles (bomb fragments, flying debris)
    • Penetrating trauma, fragmentation injuries, blunt trauma
  • Tertiary: Injuries from displacement of victim by the blast wind
    • Blunt/penetrating trauma, fractures and traumatic amputations
  • Quaternary: All other injuries from the blast
    • Crush injuries, burns, asphyxia, toxic exposures, exacerbations of chronic illness

Primary Blast Injury

  • Lung Injury
    • Signs usually present at time of initial evaluation, but may be delayed up to 48 hrs
    • Reported to be more common in patients with skull fractures, >10% BSA burns, and penetrating injury to the head or torso
    • Varies from scattered petechiae to confluent hemorrhages
    • Suspect in anyone with dyspnea, cough, hemoptysis, or chest pain following blast
    • CXR: “butterfly” pattern
    • High flow O2 sufficient to prevent hypoxemia via NRB mask, CPAP, or ET tube
    • Fluid management similar to pulmonary contusion; ensure tissue perfusion but avoid volume overload
    • Endotracheal intubation for massive hemoptysis, impending airway compromise or respiratory failure
      • Consider selective bronchial intubation for significant air leaks or massive hemoptysis
      • Positive pressure may risk alveolar rupture or air embolism
    • Prompt decompression for clinical evidence of pneumothorax or hemothorax
    • Consider prophylactic chest tube before general anesthesia or air transport
    • Air embolism can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, claudication
      • High flow O2; prone, semi-left lateral, or left lateral position
      • Consider transfer for hyperbaric O2 therapy
  • Abdominal Injury
    • Gas-filled structures most vulnerable (esp. colon)
    • Bowel perforation, hemorrhage (small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture
    • Suspect in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia
    • Clinical signs can be initially subtle until acute abdomen or sepsis is advanced
  • Ear Injury
    • Tympanic membrane most common primary blast injury
    • Signs of ear injury usually evident on presentation (hearing loss, tinnitus, otalgia, vertigo, bleeding from external canal, otorrhea)

Other Injury

  • Traumatic amputation of any limb is a marker for multi-system injuries
  • Concussions are common and easily overlooked
  • Consider delayed primary closure for grossly contaminated wounds, and assess tetanus immunization status
  • Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings
  • Consider possibility of exposure to inhaled toxins (CO, CN, MetHgb) in both industrial and terrorist explosions
  • Significant percentage of survivors will have serious eye injuries

Disposition

  • No definitive guidelines for observation, admission, or discharge
  • Discharge decisions will also depend upon associated injuries
  • Admit 2nd and 3rd trimester pregnancies for monitoring
  • Close follow-up of wounds, head injury, eye, ear, and stress-related complaints
  • Patients with ear injury may have tinnitus or deafness; communications and instructions may need to be written


 

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