04/05/2017

Blast Injury Management

Dr. Ahmad Muttaqin Alim, Sp.An, EMDM

Disaster

A serious disruption of the functioning of a society,

causing widespread human, material, and/or
environmental losses,
which exceed the ability of an affected society to cope
using only its own resources.

(WADEM, WHO)
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Blast Injuries: Unique Aspects

Inflict multi-
Hidden system
pattern of injuries on
injury large groups
of people

Cause many
simultaneous
life-threatening
injuries

Blast Injuries: Pathophysiology

Spalling
Caused by shock wave moving through tissues of
different densities molecular disruption
Implosion
Caused by entrapped gases in hollow organs
compressing then expanding visceral disruption
Shearing
Caused by tissues of different densities moving at
different speeds visceral tearing
Irreversible Work
Caused by forces exceeding the tensile strength of
the tissue
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Blast Injuries: Categories

Primary injury
Caused by blast wave over pressure

Secondary injury
Caused by flying debris shrapnel wounds

Tertiary injury
Caused by blast wind forceful impact

Quaternary injury
Caused by other vectors heat, radiation

Blast Injuries: Primary

Blunt trauma from over

pressure wave
Unique to high-order explosives
Results from the impact of the
over-pressurization wave with
body surfaces
Blunt force injuries
Produces barotrauma

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Blast Injuries: Primary

Most common injuries:

Blast lungpulmonary barotraumas
Traumatic brain injury (TBI),
concussion
Tympanic membrane (eardrum)
rupture
Middle ear damage
Abdominal hemorrhage
Abdominal organ perforation

Blast Injuries: Secondary

The most common cause

of death in a blast event
is secondary blast
injuries. These injuries
are caused by flying
debris generated by the
explosion. Terrorists
often add screws, nails,
and other sharp objects
to bombs to increase
injuries.

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Blast Injuries: Secondary

The most common types of

secondary blast injuries are:
Trauma to the head, neck, chest,
abdomen, and extremities in the
form of penetrating and blunt trauma
Fractures
Traumatic amputations
Soft tissue injuries

Bombings: Injury Patterns and Care

Blast Injuries: Secondary

Penetrating trauma
(shrapnel wounds)
Foreign bodies follow
unpredictable paths through
body
May have only mild external
signs
Have a low threshold for
imaging studies (plain
radiographs, computed
tomograms)
Consider all wounds
contaminated
American Journal of Roentgenology
2006; 187:609-616
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Blast Injuries: Tertiary

Tertiary injuries result from

individuals being thrown by the
blast wind.
The most common types of
tertiary blast injuries are:
Head injuries
Skull fractures
Bone fractures
Treatment for most tertiary
blast injuries follows
established protocols for that
specific injury.

Blast Injuries: Quaternary

All explosion-related injuries, Burns

illnesses, or diseases not due to Head injuries
primary, secondary, or tertiary Asthma
mechanisms are considered COPD
quaternary blast injuries. This Other breathing problems
includes exacerbation or Angina
complications of existing conditions. Hyperglycemia
Hypertension
Crush injuries
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Blast Injuries: Blast Lung

Clinical manifestations
Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability

Blast Injuries: Head

Primary blast waves can cause

concussions or mild traumatic
brain injury (MTBI) without a
direct blow to the head

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Blast Injuries: Head

Consider the proximity of the

victim to the blast particularly
when given complaints of:
Loss of consciousness
Headache
Fatigue
Poor concentration, lethargy, amnesia,
or other constitutional symptoms
Symptoms of concussion and post
traumatic stress disorder (PTSD) can
be similar

Blast Injuries: Ear & TM Rupture

Ear injuries may include not only

TM rupture, but also ossicular
disruption, cochlear damage, and
foreign bodies.

Tympanic membrane rupture

indicates exposure to an over
pressurization wave. (at least
40kPa; Lung treshold 100kPa)

NEJM, April 2005; 352: 1335-1342

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Blast Injuries: Ear

Presentation: acute hearing loss (conductive, sensorineural)

Findings: auditory canal debris, tympanic membrane rupture,
ossicular disruption, cochlear damage
Treatment: observation; 50-80% of ruptured tympanic membranes
heal; sensorineural hearing loss often permanent

Blast Injuries: Abdomen

Abdominal injuries (also called

blast abdomen) include
abdominal hemorrhage and
abdominal organ perforation

John McManus and Richard B. Schwartzhttps://aneskey.com/blast-injury/

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Blast Injuries: Abdomen

Clinical manifestations include:

Abdominal or testicular pain
Tenesmus
Rectal bleeding
Solid organ lacerations
Rebound tenderness
Guarding
Absent bowel sounds
Signs of hypovolemia
Nausea
Vomiting
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Blast Injuries: Combined Injuries

Combined injuries, especially blast and burn injury or blast and

crush injury, are common during an explosive event.

DePalma, R. G. et al. N Engl J Med 2005;352:1335-1342
Mechanisms of Blast Injury
Category Characteristics
Primary Unique to HE, results from the
impact of the over-
pressurization wave with body
surfaces.
Secondary Results from flying debris and
bomb fragments.
Tertiary Results from individuals being
thrown by the blast wind.
Quaternary All explosion-related injuries,
illnesses, or diseases not due to
primary, secondary, or tertiary
mechanisms.
Includes exacerbation or
complications of existing
conditions.
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Body Part Affected Types of Injuries
Gas filled structures are Blast lung (pulmonary
most susceptible - lungs, barotrauma)
GI tract, and middle ear. TM rupture and middle ear
damage
Abdominal hemorrhage and
perforation - Globe (eye)
rupture- Concussion (TBI
without physical signs of head
injury)
Any body part may be Penetrating ballistic
affected. (fragmentation) or blunt
injuries
Eye penetration (can be occult)
Any body part may be Fracture and traumatic
affected. amputation
Closed and open brain injury
Any body part may be Burns (flash, partial, and full
affected. thickness)
Crush injuries
Closed and open brain injury
Asthma, COPD, or other
breathing problems from dust,
smoke, or toxic fumes
Angina
Hyperglycemia, hypertension
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Mortality & Morbidity

Mortality rates vary widely between

incidents.

An analysis of 29 large bombing (1966 and

2002)
8,364 casualties,
903 immediate deaths
7,461 immediately surviving injured.

Immediate death/injury rates were higher

for bombings involving
structural collapse (25%)
confined space (8%)
open air detonations (4%).

Mortality & Morbidity

Unique patterns of injury are found in all

bombing types.

Enclosed-space explosions, including

those occurring in busses, and in-water
explosions produce more primary blast
injury.

Explosions leading to structure collapse

produce more orthopedic injuries & trend
towards high mortality (90%).

Land mine injuries are associated with a

high risk of below- and above-the-knee
amputations.
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D-I-S-A-S-T-E-R

D Detection What type of explosive and how much?

Where was victim located with respect to the blast?
I Incident Command
What did the victim do after the blast?
S Scene Security and Safety Were fire/fumes present to cause inhalational injury?
A Assess Hazards What was orientation of head and torso to the blast?
S Support
T Triage and Treatment
E Evacuation
R Recovery

Originally arranged by
National Disaster Life Support Foundation, US
(from Advanced Disaster Life Support Manual)

D-I-S-A-S-T-E-R

D Detection
I Incident Command
S Scene Security and Safety
A Assess Hazards
S Support
T Triage and Treatment
E Evacuation
R Recovery

Originally arranged by
National Disaster Life Support Foundation, US
(from Advanced Disaster Life Support Manual)
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D-I-S-A-S-T-E-R

D Detection
I Incident Command
S Scene Security and Safety
A Assess Hazards
S Support
T Triage and Treatment
E Evacuation
R Recovery

Originally arranged by
National Disaster Life Support Foundation, US
(from Advanced Disaster Life Support Manual)

D-I-S-A-S-T-E-R

D Detection Extrication and life support are the primary

I Incident Command
S Scene Security and Safety
A Assess Hazards
S Support
T Triage and Treatment
E Evacuation
R Recovery
management priorities.
Extent of blast injury cannot be reliably
assessed by typical rapid triage
examination.
Dogma: As a result, high over-triage rates
are mandated.

Originally arranged by
National Disaster Life Support Foundation, US
(from Advanced Disaster Life Support Manual)
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Hospital Management

Airway and ventilation management.

Supplemental Oxygen
PEEP/CPAP - watch for air emboli.
Positive pressure ventilation and general anesthesia has been reported to
increase mortality in blast injury.
Examination
Consider abdominal films in all patients with significant blast injury.
CT Scan Abdomen/Pelvis for patients with appropriate signs and symptoms.
Hearing in both ears should be tested at bedside.
Wound Management:
Tetanus status.
Local exploration.
Delayed primary closure.
IV followed by oral antibiotics for all but the most trivial wounds.

Special Scenarios - Homicide Bombings

Referred to as the walking smart bomb.

Device typically consists of 10 -30 lbs of
explosive.
May also contain:
Nails, bolts, ball bearings, or other secondary
blast elements.
Hazardous chemicals and pesticides.
Bombers may have HIV, HepB.
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Other Consideration: CBRN

Dirty bomb
Chemical
Biological
Radaiological - Nuclear