Blast Injuries Treatment & Management
- Author: Andre Pennardt, MD, FACEP, FAAEM, FAWM; Chief Editor: Trevor John Mills, MD, MPH more...
EMS personnel should attempt to determine and report any information regarding the nature and size of the explosion; the time of occurrence; the proximity of the victim to the epicenter of the blast; victim displacement by the blast wind if any; the presence of secondary fires, smoke, dust, or chemical or radioactive contamination; and history of entrapment in collapsed structures. EMS personnel are responsible for activating appropriate disaster and/or hazardous material responses as early as possible.
Analysis of blast incidents indicates that "upside-down" triage is common; less injured patients typically arrive at the hospital, via ambulance or private vehicle, before the most severely injured victims.
Screening for radioactive contamination with a hand-held Geiger counter is a prudent precaution for any explosion that may involve radioactive material, including any explosion that may have been deliberately set. If radioactive material is detected, decontamination of personnel and equipment as well as notification of the receiving hospital is required. The Radiation Emergency Action Center and Training Site (REAC/TS) provides advice and assistance; their 24-hour emergency telephone number is +1 (865) 576-1005undefined.
Significant extremity trauma and associated death from exsanguination is a major cause of preventable death. EMS personnel should rapidly identify patients with life-threatening external hemorrhage and control bleeding. Early use of tourniquets may be life-saving, especially in the setting of multiple seriously injured casualties.
High-flow oxygen should be administered to all patients with respiratory distress, abnormal findings on auscultation, and evidence of significant thoracic trauma.
EMS personnel should avoid administration of large quantities of intravenous fluid in patients with a high suspicion of ongoing internal hemorrhage. Judicious fluid boluses may be required if patients exhibit signs and symptoms of inadequate perfusion, such as deteriorating mental status, in this setting. Recent experiences on the battlefield suggest that Hextend is the preferred resuscitation fluid for the prehospital setting.
EMS personnel should initiate measures to reduce heat loss and prevent hypothermia in the trauma patient since this condition is associated with increased mortality.
In cases of life-threatening extremity trauma secondary to blast injuries, early use of tourniquets may prove lifesaving. In a study comparing combat application tourniquet (CAT) to the newer emergency and military tourniquet (EMT) pneumatic tourniquet, the CAT tourniquet proved ineffective in controlling arterial blood flow when applied at mid-thigh level while EMT was successful in a significantly larger number of patients. 
The FDA has approved an expandable, multi-sponge, temporary wound dressing (XSTAT) to control bleeding from certain types of wounds received in battle. The dressing, which can be used for up to four hours, consists of 3 syringe-style applicators with 92 compressed cellulose sponges that have an absorbent coating. These sponges expand and swell to fill the wound cavity, creating a temporary physical barrier to blood flow. Each tablet-shaped sponge measures 9.8 millimeters in diameter and 4 to 5 millimeters in height, and can absorb 3 milliliters of blood or body fluid. This dressing is currently approved for military use only.
Emergency Department Care
Examine the lungs, abdomen, and TMs of all patients exposed to a significant explosion.
Penetrating wounds (secondary blast injury), blunt trauma (tertiary/secondary blast injury), and burns receive standard treatment.
Shrapnel wounds (secondary blast injury) are treated as low-velocity gunshot wounds.
Hemodynamically unstable patients with significant trauma may benefit from early use of packed red blood cells (PRBC) and fresh frozen plasma (FFP) in a 1:1 ratio, as well as platelets. Recent battlefield experience suggests a benefit to the early use of fresh whole blood if available. Additionally, cryoprecipitate and recombinant factor VIIa should be considered in the severe trauma patient, especially in the setting of massive transfusion requirements. One review of 3 mass casualty incidents following explosive events in Iraq suggested that this resuscitation strategy resulted in the transfusion of an average 3.5 units of PRBC and 3.8 units of plasma, as well as a mortality rate of 8%.
The prevention of hypoxia and hypotension are critical in patients with traumatic brain injury to prevent significant increases in mortality.
Because pulmonary contusion tends to evolve over several hours, a period of observation and repeat radiography may be necessary if indicated. Definitive airway management and ventilatory support may be required.
If abdominal pain persists or vomiting develops, consider admitting the patient for observation. Intestinal hematoma may be difficult to detect in the ED.
White phosphorus (WP) burns require unique management. Initial management of WP-contaminated burns consists of copious lavage of the area, removing identifiable particles (which should be placed in water to prevent further combustion), and covering the area with saline-soaked gauze to prevent further combustion. Use of a Wood lamp in a darkened resuscitation suite or operating room may help identify WP particles in the wound.
Definitive treatment consists of a rinse using 1% copper sulfate (CuSO4) solution and removing the WP particles. Copper sulfate combines with phosphorous particles to create a blue-black cupric phosphide coating. This impedes further WP combustion and makes particles easier to find. Rinse the contaminated burn with copper sulfate solution, remove WP particles, and then use copious saline lavage to rinse off the copper sulfate. Never apply copper sulfate as a dressing. Excess copper sulfate absorption can cause intravascular hemolysis and renal failure.
WP injury can lead to hypokalemia and hyperphosphatemia with ECG changes, cardiac arrhythmias, and death. Place the patient on a cardiac monitor and closely track serum calcium levels. Intravenous (IV) calcium may be required. Moistened face masks and good ventilation help protect patients and medical personnel from the pulmonary effects of phosphorous pentoxide gas. Naturally, avoid the use of flammable anesthetic agents and excessive oxygen around WP.
Consult a trauma surgeon, otolaryngologist, pulmonary medicine specialist, critical care specialist, orthopedic surgeon, plastic surgeon, urologist, and toxicologist, as required.
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