Management of Blast Casualties

Analysis of urban bomb blast injuries from Israel, Ireland, and the United Kingdom have identified common patterns:

1. Most victims are far enough from the explosion that they sustain only minor injuries, usually from flying debris.

2. Injuries most often affect the face, neck, and exposed extremities, indicating the protective role of ordinary clothing.

3. Injuries to the chest and abdomen are uncommon, but are associated with increased morbidity and mortality.

4. Injuries to the head are associated with the highest mortality.

5. While tympanic membrane rupture is common, primary blast injuries to other organs are unusual.

Blast injury victims should be managed in the same manner as any multiple trauma victim, except that particular attention should be directed to the respiratory system. This includes giving special attention to maintenance of a patent airway (especially when maxillofacial, cervical spine, or other head and neck injuries are present); administering supplemental oxygen; judiciously using intravenous fluids and analgesics; evacuating pneumo- and hemothoraces; and promptly implementing mechanical ventilation if signs of respiratory failure or inadequate oxygenation are present. Although positive pressure ventilation may be necessary to maintain adequate oxygenation, its use is fraught with hazard because the diffuse alveolar-capillary damage present in blast lung greatly increases the risk of causing extra-alveolar extravasation of air, including air embolism.

Systemic air embolization presents particular problems in the management of blast casualties, because the effects on the brain, heart, and viscera caused by air emboli may be indistinguishable from other types of injury. Yet, the preferred therapy for air embolism is hyperbaric oxygen treatment, which may not be readily available or may be impractical because of coexistent injuries or other logistical problems. Whenever possible, though, hyperbaric oxygen treatment should be implemented as expeditiously as possible, being given in a manner similar to the treatment of dysbaric diving casualties, because of its potential to reverse cerebral or coronary injuries if administered soon after the injury.

Tympanic membrane rupture and other otolaryngologic trauma, as well as most other types of blast injury, should be treated essentially the same as they are treated when due to other causes. Closed abdominal injuries are always of particular concern and should be treated according to the patient's signs and symptoms, with prompt surgical exploration being undertaken whenever there are signs of peritonitis or peritoneal free air. Abdominal visceral injuries should be especially looked for in victims of underwater explosion. Lacerations, fractures, amputations, and missile wounds should be treated in the usual manner, except for delayed primary closure being the generally preferred method of wound management.

Explosions in closed spaces produce greater injury and death than those occurring in the open. Primary blast injuries are especially common. Closed-space explosions also expose the victim to dust, smoke, and toxic gases, increasing the incidence of inhalation injury. Again, though, the inhalation injury is treated essentially the same as that resulting from other circumstances.

Because primary blast injuries may not always be present when the victim is first evaluated, all blast-injured patients should be closely observed for at least 6 to 12 h after the accident. This is particularly true if there is perforation of the eardrums, which is generally an indication of significant exposure to high pressure.

1 Scuba is an acronym for self-contained underwater breathing apparatus.

2In diving and hyperbaric medicine, the most commonly used units of pressure and depth are ATA and fsw.

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