Blast Injuries Follow-up

  • Author: Andre Pennardt, MD, FACEP, FAAEM, FAWM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 4, 2011
 

Further Inpatient Care

  • A high rate of ICU admission and ventilator requirement should be anticipated. In a review of 3 mass casualty incidents, approximately 50% of surgical patients with injuries resulting from blasts required each of these.[13]
  • Limited data prevent establishing the optimal duration of observation. Consider the following guidelines:
    • Persons who are exposed to open-space explosions and who have no apparent significant injury and normal vital signs and unremarkable lung and abdominal examinations generally can be discharged after 4 hours of observation. Return instructions should include shortness of breath, abdominal pain, vomiting, or other symptoms occur.
    • Persons exposed to significant closed-space explosions, in-water explosions, and those who incur tympanic membrane (TM) rupture are at higher risk of delayed complications. All these patients should have chest radiography, and selected patients should have imaging of other organs. Even if no injury is identified, these patients should receive more intensive observation over a longer period. Motivated, reliable, and completely asymptomatic patients may be sent home after 4 hours of observation.
    • Admit to the hospital all patients with significant burns, suspected air embolism, radiation or WP contamination, abnormal vital signs, abnormal lung examination findings, clinical or radiographic evidence of pulmonary contusion or pneumothorax, abdominal pain, vomiting, evidence of renal contusion/hypoxia, or penetrating injuries to the thorax, abdomen, neck, or cranial cavity.
  • Patients thought to have arterial gas embolism (AGE) or cerebral AGE
    • Positive pressure ventilation (PPV) and positive end expiratory pressures (PEEP) should be avoided whenever possible in the setting of pulmonary blast injury due to the risk of pulmonary alveolar rupture and subsequent formation of air emboli. However, mechanical ventilation often cannot be avoided. Due to the nonhomogeneous pulmonary compliance that characterizes the blast lung, localized overinflation of the more compliant lung segments occurs when high ventilatory pressures are used. Whenever possible, reduce the tidal volume to limit peak inspiratory pressure (PIP) and minimize ventilator-induced lung barotrauma injury. If necessary, consider permissive hypercapnia ventilation: reduce the tidal volume to maintain PIP less than 35-40 cm H2 O; make no attempts to control PaCO2 levels until the arterial pH falls below 7.20. When respiratory acidosis becomes too severe, increase the respiratory rate until the arterial pH rises above 7.25.
    • Patients thought to have AGE require recompression treatment. Place patients on 100% oxygen by tight-fitting face mask and, if possible, place them in the left lateral recumbent position to minimize the risk of travel of the air embolism out of the heart. Trendelenburg (head down) position is no longer recommended. If the side of the lung responsible for the AGE can be identified, unilateral lung ventilation may prevent further introduction of air into the vascular system during positive pressure ventilation.
    • In the setting of acute mental status, cerebral AGE should be considered as well as other causes of symptoms (eg, traumatic CNS injury).
    • Hyperbaric oxygen (HBO) treatment is the definitive procedure for AGE and cerebral AGE. Transfer of the patient to a facility with HBO therapy may be required.
    • Research suggests that aspirin is helpful in AGE. Aspirin may reduce inflammation-mediated injury in pulmonary barotrauma as well. However, it may be unwise to give an antiplatelet agent to a patient with acute trauma.
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Further Outpatient Care

  • As symptoms of pulmonary contusion and intestinal hematoma may take 12-48 hours to develop, instruct all discharged patients to return for reevaluation if they develop breathing problems, increasing abdominal pain, or vomiting.
  • Outpatient treatments for blast-related lacerations, burns, contusions, fractures, and other injuries are the same as for these injuries from other causes.
  • Tympanic membrane rupture
    • Tympanic membrane (TM) rupture by itself does not require specific treatment or hospitalization. Patients should be instructed not to put anything in the affected ear and should be referred to ENT for follow-up care. Remember that neomycin (a component of otic solutions and suspensions) is ototoxic and theoretically contraindicated in cases of TM perforation.
    • Most cases of TM perforation heal spontaneously; however, complications such as ossicle disruption, cholesteatoma formation, and development of perilymphatic fistulae are possible. About one third of patients with TM perforation have permanent hearing loss.
  • Exposure to blasts may induce vestibular disorders that progress over time. Referral to neurology and ENT should be considered for follow-up care.[14] Physical therapy referral may be required for vestibular rehabilitation.[15]
  • Exposure to blasts may result in mild traumatic brain injury (mTBI) and predispose to posttraumatic stress disorder (PTSD).[16] Patients with residual symptoms should be referred to neurologists and mental health specialists as required. Although insufficient data exist to make a definitive recommendation, hyperbaric oxygen (HBO) may be of some benefit in the treatment of blast-related postconcussive symptoms.[17]
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Transfer

  • Patients with significant burns should be transferred to a burn center if the initial receiving hospital does not have adequate facilities.
  • Consider transfer to a Level 1 trauma center for severely injured patients.
  • Consider transfer to a facility with hyperbaric chamber for patients who develop suspected AGE secondary to PBI of the lung.
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Deterrence/Prevention

  • Garments designed to protect against both primary blast injuries (PBIs) and secondary blast injuries (SBIs) have proven very effective in the military setting. However, except for use by bomb squad technicians and tactical law enforcement personnel, these garments have little applicability in the civilian setting.
  • Prehospital personnel should be cognizant of the possibility of a secondary device designed to target rescuers when responding to the scene of a suspected intentional bombing. Hospitals similarly may be attractive targets to terrorists and should ensure heightened security for the facility in the event of a bombing.
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Complications

  • Various sequelae of traumatic injuries may occur.
  • Crush syndrome and acute renal failure may occur in the setting of patients rescued from collapsed structures.
  • Increasing extremity pain after an explosion should raise the suspicion of developing compartment syndrome.
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Prognosis

  • The prognosis varies based on the injury.
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Contributor Information and Disclosures
Author

Andre Pennardt, MD, FACEP, FAAEM, FAWM  Clinical Associate Professor of Emergency Medicine, Medical College of Georgia; Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences; Consulting Staff, Departments of Emergency Medicine, Aviation Medicine and Dive Medicine, Womack Army Medical Center

Andre Pennardt, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US, International Society for Mountain Medicine, National Association of EMS Physicians, Special Operations Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Eric J Lavonas, MD, FACEP  Associate Director, Rocky Mountain Poison and Drug Center; Assistant Professor, University of Colorado School of Medicine

Eric J Lavonas, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Colorado Medical Society, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dan Danzl, MD  Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David B Levy, DO, FACEP, FAAEM  Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Blast injuries. Idealized graph of a blast pressure wave over time. Courtesy of Bowen TE and Bellamy RF, eds, Emergency War Surgery. Washington, DC: United States Government Printing Office, 1988.
Blast injuries. Estimated human tolerances for single, sharp, rising blast waves. Courtesy of Bowen TE and Bellamy RF, eds, Emergency War Surgery. Washington, DC: United States Government Printing Office, 1988.
 
 
 
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