Blast Injuries 

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

Background

Explosions have the capability to cause multisystem, life-threatening injuries in single or multiple victims simultaneously. These types of events present complex triage, diagnostic, and management challenges for the health care provider. Explosions can produce classic injury patterns from blunt and penetrating mechanisms to several organ systems, but they can also result in unique injury patterns to specific organs including the lungs and the central nervous system. Understanding these crucial differences is critical to managing these situations.

The extent and pattern of injuries produced by an explosion are a direct result of several factors including the amount and composition of the explosive material (eg, the presence of shrapnel or loose material that can be propelled, radiological or biological contamination), the surrounding environment (eg, the presence of intervening protective barriers), the distance between the victim and the blast, the delivery method if a bomb is involved, and any other environmental hazards. No two events are identical, and the spectrum and extent of injuries produced varies widely.

Between 1991 and 2000, 93 terrorist attacks worldwide produced more than 30 casualties, with 885 of these incidents involving explosions. The 2005 London subway bombings, the 1995 bombing of the Murrah Federal Building in Oklahoma City, and the catastrophic explosions of aircraft into 3 buildings on September 11, 2001 in New York City and Washington DC reminded health care workers of the magnitude of injuries and death that can result from a blast mechanism. Internationally, explosive devices directed against both civilian and military targets are frequently used in war or acts of terrorism. Approximately 25,000 US and coalition forces and 100,000 Iraqis were estimated to have been injured or killed by explosions in the Global War on Terrorism as of early 2009.[1] Although the United States has been spared the majority of these events, the potential exists for use of explosive weapons in the United States in the future.

As the risk of terrorist bombings in the United States increases, emergency physicians and Emergency Medical Services (EMS) personnel should be especially concerned about radiation and/or chemical contamination of explosion victims. Careful observation for signs and symptoms of exposure to poisonous chemicals, screening for radiation contamination, and decontamination of patients as needed are important steps in the management of victims of nonaccidental explosions. In addition to deliberately set explosions, incidents also occur as a result of industrial accidents (eg, factory and mining operations, fuel transportation and storage, grain elevator explosions).

In many parts of the world, undetonated military incendiary devices such as land mines and hand grenades contaminate the sites of abandoned battlefields. Such devices cause significant numbers of civilian casualties years and even decades after local hostilities cease. During wartime, injuries arising from explosions frequently outnumber those from gunshots with many innocent civilians becoming victims.

Much of the challenge facing the care providers is the potential for the sudden creation of large numbers of patients who require extensive medical resources. This scenario can overwhelm local EMS and hospital resources. Emergency physicians must remain attentive to the possibility and consequences of blast injuries.

Once notified of a possible bombing or explosion, hospital-based physicians should consider immediately activating hospital disaster and contingency plans, including preparations to care for anywhere from a handful to hundreds of victims.

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Pathophysiology

Blast injuries traditionally are divided into 4 categories: primary, secondary, tertiary, and quaternary (or miscellaneous) injuries. A patient may be injured by more than one of these mechanisms.[1, 2]

  • A primary blast injury is caused solely by the direct effect of blast overpressure on tissue. Air is easily compressible, unlike water. As a result, a primary blast injury almost always affects air-filled structures such as the lung, ear, and gastrointestinal (GI) tract.
  • A secondary blast injury is caused by flying objects that strike people.
  • A tertiary blast injury is a feature of high-energy explosions. This type of injury occurs when people fly through the air and strike other objects.
  • Miscellaneous or quaternary blast injuries encompass all other injuries caused by explosions, such as burns, crush injuries, and toxic inhalations. For example, the crash of two jet airplanes into the World Trade Center only created a relatively low-order pressure wave, but the resulting fire and building collapse killed thousands. Blast injuries. Estimated human tolerances for sinBlast 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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Epidemiology

Frequency

United States

Incidence is sporadic and infrequent. Cases tend to be grouped several (up to hundreds) at a time and have the ability to temporarily overwhelm a local health care system.

International

Incidence is sporadic. Frequency depends on the political (terrorism, war) and economic (occupational health and safety priorities) stability of the region.

Mortality/Morbidity

Mortality rates vary widely between incidents. An analysis of 29 large terrorist bombing events between 1966 and 2002 showed 8,364 casualties, including 903 immediate deaths and 7,461 immediately surviving injured.[3] Immediate death/injury rates were higher for bombings involving structural collapse (25%) than for confined space (8%) and open air detonations (4%).

Unique patterns of injury are found in all bombing types. Injury is caused both by direct blast overpressure (primary blast injury) and by a variety of associated factors. Enclosed-space explosions, including those occurring in buses, and in-water explosions produce more primary blast injury. Blasts in ultra-confined spaces such as buses have the highest associated mortality.[4] Explosions leading to structure collapse produce more orthopedic injuries. Land mine injuries are associated with a high risk of below- and above-the-knee amputations. Fireworks-related injuries prompt an estimated 10,000-12,000 ED visits in the United States annually, with 20-25% involving either the eye or hand.

Presence of tympanic membrane (TM) rupture indicates that a high-pressure wave (at least 40 kilopascal [kPa], 6 psi) was present and may correlate with more dangerous organ injury. Between 2% and 32% of patients injured by a blast will have TM rupture.[2] Theoretically, at an overpressure of 100 kPa (15 psi), the threshold for lung injury, the TM routinely ruptures; however, a recent Israeli case series of 640 civilian victims of terrorist bombings contradicts traditional beliefs about a clear correlation between the presence of TM injury and coincidence organ damage. Of 137 patients initially diagnosed as having isolated eardrum perforation who were well enough to be discharged, none later developed manifestations of pulmonary or intestinal blast injury. Furthermore, 18 patients with pulmonary blast injuries had no eardrum perforation.

Similarly, in a review of 167 patients who sustained blast exposure in Iraq, TM perforation was noted to be poorly sensitive as a biomarker for more serious primary blast injury. Only 50% of patients with serious PBI demonstrated TM rupture in this review.[5]

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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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