Blast Injuries:
Prehospital Assessment
and Management
Jeffrey P Salomone, MD, FACS
Past President,
Eastern Association for the
Surgery of Trauma
Disclosures
Editor / Associate Editor, Prehospital
Trauma Life Support 5e, 6e, 7e
– Contributor PHTLS 8e
NO financial relationships
Background
Explosive agents / Blast devices
Blast Physics
Scene Management
Injury Types
Patient Management
Blasts and Blast Injuries
Bombings / WMDs
Terrorism
– Middle East / Asia
IEDs
– GWOT: Iraq / Afghanistan
Unintentional Explosions
Gas leaks
Industry
– Fertilizer
– Petroleum
– Explosives/ fireworks
– Grain
Illicit- drug manufacturing (meth)
Deaths- unusual: only 150 in US (2004)
Worldwide Terrorism
Israel- Tel Aviv ( 2001, 2006)
Madrid (2004)- bombs on commuter trains
London (2005)- 4 bombs on trains / bus
Mumbai (2008)- 11 shooting & bombing attacks
over 4 days
US Bombings
Murrah Federal Bldg ( 1995)
168 killed
Almost 700
injured
8
Photo Courtesy of the City Of Oklahoma City
Atlanta Olympic Park Bombing
July 27, 1996 1:30 am
Olympic Park Bombing
111 victims + news reporter
– All transported to 11 area hospitals within 32
minutes by 30 EMS units
35 + reporter to Grady Memorial Hosp
– Reporter 1st to arrive, CPR in progress
– 35 with shrapnel injuries
15 admitted- 10 required surgery in 1st 12 hrs
– Ortho, vascular, thoracotomy, laparotomy, facial expl
19 treated and released
Olympic Park Bombing
61 pts to 3 downtown hospitals AMC:
– 4 operations: 2 wound closures; 2 shrapnel
removal
15 minor victims to 7 other area hospitals
September 11, 2001
Commercial aircraft
used as “bombs”
Twin towers- World
Trade Center
Pentagon
Boston Marathon Bombing
April 15, 2013
3 killed
243 injured
152 presented to ED
within 24 hrs of blast
– All survived
Blast Devices
Blast Agents
High-order explosive: HE
Nitroglycerin (NTG)
Dynamite
Plastic
Ammonium nitrate/
fuel oil (ANFO)
Trinitrotoluene (TNT)
Triacetone triperoxide
(TAPT)
Low-order explosive: LE
Petroleum products
(“Molotov cocktail”)
Gunpowder
(“black” powder)
Can become HE, if
contained (e.g., pipe
bomb)
Blast Devices
Improvised explosive devices (IEDs)
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Car and truck bombs (Oklahoma City, World Trade Center I)
Letter and parcel bombs (Idaho “Unabomber”)
Pipe bombs (Atlanta Olympics)
Backpack and satchel bombs (Israel, London)
Incendiary bombs
– Airplane bombs (World Trade Center II, Pentagon)
Rocket propelled grenades (RPGs)
Surface to air missiles (SAMs)
Blast Devices
IEDs
Improvised/“homemade” explosive devices
Made from explosives, commercial blasting
supplies, or fertilizer and household
ingredients
Designed to cause injury and death
Often packed with metal objects such as nails
or ball bearings;
Could contain toxic chemicals or radiological
materials (dirty bomb)
Blast Physics
Rapid chemical conversion of a solid or
liquid into highly pressurized gases
Gases expand rapidly and compress the
surrounding air
Blast Physics
Blast wave- causes an almost
instantaneous rise in atmospheric
pressure (barotrauma)
– Normal is 14.3 psi
– Overpressure: can exceed 4 million psi
– Underpressure
Blast wind
– Air pushed out of area, creating vacuum
– Wind speed can be hundreds of mph
Blast Physics
Importance of Injury Types vs. Distance
Emergency War Surgery, 3rd Edition
Scene Management:
SAFETY / SITUATION
Initial Staging
Safe Distance
Stage upwind / uphill
Assess with binoculars
– Liquids, contaminants, etc
– Number of victims
Need for Incident Command
Scene Safety: Hazards
Secondary devices
Shrapnel
Building collapse
Air-borne contaminants
Contaminated patients
Contaminated scene/environment
Perpetrators
Terrorist patients
Triage
Field triage
– Safe distance
– SALT / START
– Dynamic process
Unique patterns:
– Multiple injuries
– Occult / hidden / internal injuries
Triage
Walking wounded
– Many non-critical patients who require time
intensive workups
– Up to 75% of victims self-refer to hospital via
private transportation)
Crime Scene
Life saving takes precedence
Avoid disturbing or compromising
evidence (chain of custody)
Documentation of statements by victims
and witnesses
Blast Injuries
Blast Injury: Severity
Nature of device – agent, amount
Method of delivery – incendiary, explosive
Nature of environment – open, closed
Distance from device
Intervening protective barrier
Other environmental hazards
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 overpressurization wave with body surfaces
– Barotrauma: blunt force injuries
Blast Injuries: Primary
Most common injuries:
– Tympanic membrane (eardrum) rupture
Middle ear damage
– Blast lung—pulmonary barotrauma
– Abdominal organ perforation ( esp. colon)
Abdominal hemorrhage (solid organs)
– Traumatic brain injury (TBI), concussion
Blast Injuries: Blast Lung
Blast Injuries: Secondary
Most common cause of death in a blast
event is secondary blast injuries
Caused by flying debris generated by the
explosion
– Pieces of bomb / environment (glass)
– Added screws, nails, etc.
Blast Injuries: Secondary
Most common types of secondary blast
injuries are:
– Penetrating trauma to the head, neck, chest,
abdomen, and extremities
– Fractures
– Traumatic amputations
– Soft tissue injuries
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
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
– Fractures
Blast Injuries: Quaternary
Includes:
– Burns
– Biologic / radiologic / chemical contamination
– Crush injuries
– Exacerbation of chronic health conditions
Patient Assessment and
Management
Airway / Breathing
Intubate if necessary
Positive pressure ventilation in blast lung
can result in air emboli
Blast Lung
Clinical
manifestations
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Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability
Treatment
– High flow oxygen
sufficient to prevent
hypoxemia via nonrebreather mask
– CPAP
– Endotracheal
intubation
– Judicious fluid
administration
– Needle
decompression
Circulation: Hemorrhage /
Shock
Tourniquets
– Manufacture ( NOT improvised)
Topical hemostatic agents
IV therapy / fluid resuscitation
Tourniquets
Abdominal Injuries
Clinical manifestations include:
– Abdominal pain
– Rectal bleeding
– Rebound tenderness / Guarding
– Diminished / absent bowel sounds
– Signs of hypovolemia / unexplained shock
– Nausea & vomiting
Blast Injuries: Combined Injuries
Avoid tunnel vision
Treatment protocols are often
contradictory
– Blast lung vs. burn injury
– Blast lung vs. crush injury
Judicious fluid administration
Blast Injury: Combined Injuries
Typical confined space (e.g., a bus) injuries
Primary—blast lung, intestinal rupture, TM
rupture
Secondary—penetrating injury to head, eye,
chest, abdomen
Tertiary—traumatic amputation, fractures to
the face, pelvis, ribs, spine
Quaternary— crush injuries, superficial and
partial to full thickness burns
Special Considerations
Pregnancy- placental injuries
Children- pulmonary contusions
– Evidence of chest injury
Elderly- disabilities, medical conditions,
osteoporosis
Transport Destination
Trauma Centers capable of managing
injuries
Summary
Scene safety issues
Injuries can be very complex
Hemorrhage control
Support ventilation / oxygen