Laboratory Studies

Judicious use of the laboratory is essential for accurate diagnosis in the mass-casualty situation. Do not overwhelm the laboratory with screening or protocol laboratory tests of little clinical benefit.

Most patients injured by significant explosions should have a screening urinalysis.

If the explosion occurred in an enclosed space or was accompanied by fire, test carboxyhemoglobin (HbCO) and electrolytes to assess acid/base status.

Pulse oximetry readings may be misleading in cases of CO poisoning. When in doubt, apply 100% oxygen by tight-fitting face mask until CO levels can be measured.

Exposure to cyanide (CN), a product of incomplete combustion of plastics, is difficult to measure directly. CN exposure often accompanies CO poisoning. Consider CN poisoning in patients exposed to combustion in an enclosed space who have an anion gap metabolic acidosis (see the Anion Gap calculator). Treatment for CN poisoning should be started for significantly ill patients while awaiting confirmatory test results. Sodium thiosulfate or hydroxocobalamin are safe and appropriate empiric therapies.

Victims of major trauma should have baseline hemoglobin determinations, crossmatching for potential blood transfusion, and screening for DIC. If significant crush injury, compartment syndrome, or severe burns have occurred, emergency physicians should be attentive to the possibility of rhabdomyolysis with resulting hyperkalemia and myoglobinuric renal failure. Useful tests for DIC include the following:

Protime
Activated partial thromboplastin time (aPTT)
Thrombin time
Fibrinogen
Fibrin split products
D-dimer levels
Serial CBC determinations, to include platelet counts

Patients with burns from military white phosphorous (WP) munitions are at risk for hypocalcemia and hyperphosphatemia; follow serial levels of these ions. WP is a metal that ignites on contact with air, creating intense heat and releasing phosphorous pentoxide, a severe pulmonary irritant. WP is a widely used component of military munitions, including hand grenades.

Imaging Studies

Perform chest radiography in patients who have been exposed to high overpressure and are therefore at high risk for primary blast injury. This group of patients may include all patients with TM rupture from blast injury. Chest radiographs should be performed on all patients who exhibit respiratory symptoms, have abnormal findings on auscultation, or have visible external signs of thoracic trauma.

If significant abdominal pain is present, consider an immediate abdominal radiographic series (flat and upright films) or abdominal CT to detect pneumoperitoneum from enteric rupture. The focused abdominal sonography for trauma (FAST) examination is a potentially useful tool for rapidly screening patients, especially in the setting of multiple seriously injured victims. A positive FAST examination in an unstable patient is an indication for surgical exploration of the abdomen in the operating room. In stable patients, a positive FAST examination can facilitate prioritization for CT imaging. A negative FAST examination is unreliable in the setting of penetrating trauma to the abdomen, flank, buttocks, or back, and it should be followed up with CT examination of the abdomen and pelvis. Ultrasonography can rapidly rule out the presence of pericardial tamponade.

No practical, sensitive test exists for intestinal hematoma. The diagnosis is often missed even when performing the best available test — abdominal CT. Because intestinal hematoma can take 12-36 hours to develop, symptoms such as increased pain or vomiting should determine decisions about testing.

Other Tests

If there is any question of radiation or chemical contamination, arrange to test and decontaminate patients and equipment. Most fire departments' hazardous materials teams have the training and equipment to perform this task. Notify the hospital's radiation safety officer (often the chief technician for the radiology department's nuclear medicine section) for assistance screening victims for radiation contamination. Contact hospital public relations to work with the press.

Treatment & Management

Jorolemon MR, Lopez RA, Krywko DM. Blast Injuries. 2021 Jan. [QxMD MEDLINE Link]. [Full Text].
Er S, Tahtabasi M. Thoracoabdominal injuries after a bomb explosion: blast injuries and their clinical effects. Eur J Trauma Emerg Surg. 2020 Nov 11. [QxMD MEDLINE Link].
Hoz SS, Al-Sharshahi ZF, Dolachee AA, et al. Blast-Induced Traumatic Brain Injuries: Experience from the Deadliest Double Suicide Bombing Attack in Iraq. World Neurosurg. 2021 Jan. 145:e192-e201. [QxMD MEDLINE Link].
Shuker ST. Emergency Treatment of Blast, Shell Fragment and Bullet Injuries to the Central Midface Complex. J Maxillofac Oral Surg. 2019 Mar. 18 (1):124-130. [QxMD MEDLINE Link].
Rankin IA, Webster CE, Gibb I, Clasper JC, Masouros SD. Pelvic injury patterns in blast: Morbidity and mortality. J Trauma Acute Care Surg. 2020 Jun. 88 (6):832-838. [QxMD MEDLINE Link].
Smith JE, Garner J. Pathophysiology of primary blast injury. J R Army Med Corps. 2019 Feb. 165 (1):57-62. [QxMD MEDLINE Link].
US Department of Defense: Blast Injury Research Coordinating Office. Blast Injury 101. Available at https://blastinjuryresearch.amedd.army.mil/index.cfm/blast_injury_101. June 18, 2019; Accessed: May 2, 2021.
Nunziato CA, Riley CJ, Johnson AE. How Common Are Civilian Blast Injuries in the National Trauma Databank, and What Are the Most Common Mechanisms and Characteristics of Associated Injuries?. Clin Orthop Relat Res. 2021 Apr 1. 479 (4):683-691. [QxMD MEDLINE Link].
Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma. 2009 May. 66(5):1468-77; discussion 1477. [QxMD MEDLINE Link].
Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. Lancet. 2009 Aug 1. 374(9687):405-15. [QxMD MEDLINE Link].
Arnold JL, Halpern P, Tsai MC, Smithline H. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med. 2004 Feb. 43(2):263-73. [QxMD MEDLINE Link].
Kashuk JL, Halperin P, Caspi G, Colwell C, Moore EE. Bomb explosions in acts of terrorism: evil creativity challenges our trauma systems. J Am Coll Surg. 2009 Jul. 209(1):134-40. [QxMD MEDLINE Link].
Moore JX, McGwin G Jr, Griffin RL. The epidemiology of firework-related injuries in the United States: 2000-2010. Injury. 2014 Nov. 45 (11):1704-9. [QxMD MEDLINE Link].
Canner JK, Haider AH, Selvarajah S, Hui X, Wang H, Efron DT, et al. US emergency department visits for fireworks injuries, 2006-2010. J Surg Res. 2014 Jul. 190 (1):305-11. [QxMD MEDLINE Link].
Harrison CD, Bebarta VS, Grant GA. Tympanic membrane perforation after combat blast exposure in Iraq: a poor biomarker of primary blast injury. J Trauma. 2009 Jul. 67(1):210-1. [QxMD MEDLINE Link].
Ashkenazi I, Olsha O, Turegano-Fuéntes F, Alfici R. Tympanic membrane perforation impact on severity of injury and resource use in victims of explosion. Eur J Trauma Emerg Surg. 2015 Dec 9. [QxMD MEDLINE Link].
Mendez MF, Owens EM, Reza Berenji G, Peppers DC, Liang LJ, Licht EA. Mild traumatic brain injury from primary blast vs. blunt forces: Post-concussion consequences and functional neuroimaging. NeuroRehabilitation. 2013 Jan 1. 32(2):397-407. [QxMD MEDLINE Link].
Keene DD, Penn-Barwell JG, Wood PR, Hunt N, Delaney R, Clasper J, et al. Died of wounds: a mortality review. J R Army Med Corps. 2015 Oct 14. [QxMD MEDLINE Link].
Bala M, Rivkind AI, Zamir G, Hadar T, Gertsenshtein I, Mintz Y, et al. Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury. Ann Surg. 2008 Aug. 248(2):303-9. [QxMD MEDLINE Link].
Hiss J, Kahana T. Suicide bombers in Israel. Am J Forensic Med Pathol. 1998 Mar. 19(1):63-6. [QxMD MEDLINE Link].
Ozer O, Sari I, Davutoglu V, Yildirim C. Pericardial tamponade consequent to a dynamite explosion: blast overpressure injury without penetrating trauma. Tex Heart Inst J. 2009. 36(3):259-60. [QxMD MEDLINE Link].
DeWitt DS, Prough DS. Blast-induced brain injury and posttraumatic hypotension and hypoxemia. J Neurotrauma. 2009 Jun. 26(6):877-87. [QxMD MEDLINE Link].
Mallonee S, Shariat S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996 Aug 7. 276(5):382-7. [QxMD MEDLINE Link].
Glenshaw MT, Vernick JS, Li G, Sorock GS, Brown S, Mallonee S. Factors associated with injury severity in Oklahoma City bombing survivors. J Trauma. 2009 Feb. 66(2):508-15. [QxMD MEDLINE Link].
Quintana DA, Parker JR, Jordan FB. The spectrum of pediatric injuries after a bomb blast. J Pediatr Surg. 1997 Feb. 32(2):307-10; discussion 310-1. [QxMD MEDLINE Link].
Badii F, Maghelli S, Costa N, Borreggine D, Zoccali G, Durì D. Acute methemoglobinemia after nitroglycerine transcutaneous absorption after bomb explosion: a case report. J Trauma. 2009 Mar. 66(3):936-7. [QxMD MEDLINE Link].
Taylor DM, Vater GM, Parker PJ. An evaluation of two tourniquet systems for the control of prehospital lower limb hemorrhage. J Trauma. 2011 Sep. 71(3):591-5. [QxMD MEDLINE Link].
FDA news release. FDA allows marketing for first-of-kind dressing to control bleeding from certain battlefield wounds. US Food and Drug Administration. Available at https://wayback.archive-it.org/7993/20170112222728/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391755.htm. Accessed: May 2, 2021.
Propper BW, Rasmussen TE, Davidson SB, Vandenberg SL, Clouse WD, Burkhardt GE. Surgical response to multiple casualty incidents following single explosive events. Ann Surg. 2009 Aug. 250(2):311-5. [QxMD MEDLINE Link].
Hoffer ME, Balaban C, Gottshall K, Balough BJ, Maddox MR, Penta JR. Blast exposure: vestibular consequences and associated characteristics. Otol Neurotol. 2010 Feb. 31(2):232-6. [QxMD MEDLINE Link].
Scherer MR, Schubert MC. Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys Ther. 2009 Sep. 89(9):980-92. [QxMD MEDLINE Link].
Elder GA, Cristian A. Blast-related mild traumatic brain injury: mechanisms of injury and impact on clinical care. Mt Sinai J Med. 2009 Mar 20. 76(2):111-118. [QxMD MEDLINE Link].
Wright JK, Zant E, Groom K, Schlegel RE, Gilliland K. Case report: Treatment of mild traumatic brain injury with hyperbaric oxygen. Undersea Hyperb Med. 2009 Nov-Dec. 36(6):391-9. [QxMD MEDLINE Link].
Mathews ZR, Koyfman A. Blast Injuries. J Emerg Med. 2015 Oct. 49 (4):573-87. [QxMD MEDLINE Link].
Almogy G, Luria T, Richter E, Pizov R, Bdolah-Abram T, Mintz Y. Can external signs of trauma guide management?: Lessons learned from suicide bombing attacks in Israel. Arch Surg. 2005 Apr. 140(4):390-3. [QxMD MEDLINE Link].
Almogy G, Mintz Y, Zamir G, Bdolah-Abram T, Elazary R, Dotan L. Suicide bombing attacks: Can external signs predict internal injuries?. Ann Surg. 2006 Apr. 243(4):541-6. [QxMD MEDLINE Link].
Almogy G, Rivkind AI. Surgical lessons learned from suicide bombing attacks. J Am Coll Surg. 2006 Feb. 202(2):313-9. [QxMD MEDLINE Link].
Argyros GJ. Management of primary blast injury. Toxicology. 1997 Jul 25. 121(1):105-15. [QxMD MEDLINE Link].
Armstrong KL, Cooper MF, Williams MT, Elsayed NM. Vitamin E and lipoic acid, but not vitamin C improve blood oxygenation after high-energy IMPULSE noise (BLAST) exposure. Biochem Biophys Res Commun. 1998 Dec 9. 253(1):114-8. [QxMD MEDLINE Link].
Bass CR, Rafaels KA, Salzar RS. Pulmonary injury risk assessment for short-duration blasts. J Trauma. 2008 Sep. 65(3):604-15. [QxMD MEDLINE Link].
Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin North Am. 2007 Feb. 87(1):157-84, vii. [QxMD MEDLINE Link].
Belanger HG, Kretzmer T, Yoash-Gantz R, Pickett T, Tupler LA. Cognitive sequelae of blast-related versus other mechanisms of brain trauma. J Int Neuropsychol Soc. 2009 Jan. 15(1):1-8. [QxMD MEDLINE Link].
Bowen TE, Bellamy RF. Emergency war surgery. Second United States revision of Emergency War Surgery NATO Handbook. Washington, DC: US Government Printing Office; 1988.
Brooks M. Soldiers Face Long-Term, Not Just Acute, Harm From Blasts: IOM Report. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/820609. February 13, 2014; Accessed: May 2, 2021.
CDC. Homemade chemical bomb events and resulting injuries--selected states, January 1996-March 2003. MMWR Morb Mortal Wkly Rep. 2003 Jul 18. 52(28):662-4. [QxMD MEDLINE Link].
Cernak I, Savic J, Ignjatovic D, Jevtik M. Blast injury from explosive munitions. J Trauma. 1999 Jul. 47(1):96-103; discussion 103-4. [QxMD MEDLINE Link].
Committee on Gulf War and Health: Long-Term Effects of Blast Exposures; Board on the Health of Select Populations; Institute of Medicine. Gulf War and Health, Volume 9: Long-Term Effects of Blast Exposures. The National Academies Press. Available at http://www.nap.edu/catalog.php?record_id=18253. Accessed: February 19, 2014.
Crabtree J. Terrorist homicide bombings: a primer for preparation. J Burn Care Res. 2006 Sep-Oct. 27(5):576-88. [QxMD MEDLINE Link].
Cripps NP, Cooper GJ. Risk of late perforation in intestinal contusions caused by explosive blast. Br J Surg. 1997 Sep. 84(9):1298-303. [QxMD MEDLINE Link].
Cripps NP, Cooper GJ. The influence of personal blast protection on the distribution and severity of primary blast gut injury. J Trauma. 1996 Mar. 40(3 Suppl):S206-11. [QxMD MEDLINE Link].
Davis TE, Lee CY. An introduction to asymmetric war (terrorism) and the epidemiology of blast trauma [Greater New York Hospital Association Emergency Preparedness Resource Center Web site]. October 17, 2005. [Full Text].
DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med. 2005 Mar 31. 352(13):1335-42. [QxMD MEDLINE Link].
Eastridge BJ, Blackbourne L, Wade CE, Holcomb JB. Radiologic diagnosis of explosion casualties. Am J Disaster Med. 2008 Sep-Oct. 3(5):301-5. [QxMD MEDLINE Link].
Elsayed NM, Gorbunov NV, Kagan VE. A proposed biochemical mechanism involving hemoglobin for blast overpressure-induced injury. Toxicology. 1997 Jul 25. 121(1):81-90. [QxMD MEDLINE Link].
Centers for Disease Control and Prevention (U.S.). Explosions and blast injuries: a primer for clinicians. Last reviewed May 26, 2005. CDC.gov. Available at https://www.cdc.gov/masstrauma/preparedness/primer.pdf. March 18, 2003; Accessed: May 2, 2021.
Garth RJ. Blast injury of the ear: an overview and guide to management. Injury. 1995 Jul. 26(6):363-6. [QxMD MEDLINE Link].
Gorbunov NV, McFaul SJ, Van Albert S, et al. Assessment of inflammatory response and sequestration of blood iron transferrin complexes in a rat model of lung injury resulting from exposure to low-frequency shock waves. Crit Care Med. 2004 Apr. 32(4):1028-34. [QxMD MEDLINE Link].
Guy RJ, Kirkman E, Watkins PE, Cooper GJ. Physiologic responses to primary blast. J Trauma. 1998 Dec. 45(6):983-7. [QxMD MEDLINE Link].
Guzzi LM, Argyros G. The management of blast injury. Eur J Emerg Med. 1996 Dec. 3(4):252-5. [QxMD MEDLINE Link].
Irwin RJ, Lerner MR, Bealer JF, et al. Cardiopulmonary physiology of primary blast injury. J Trauma. 1997 Oct. 43(4):650-5. [QxMD MEDLINE Link].
Irwin RJ, Lerner MR, Bealer JF, et al. Shock after blast wave injury is caused by a vagally mediated reflex. J Trauma. 1999 Jul. 47(1):105-10. [QxMD MEDLINE Link].
Katz E, Ofek B, Adler J, et al. Primary blast injury after a bomb explosion in a civilian bus. Ann Surg. 1989 Apr. 209(4):484-8. [QxMD MEDLINE Link].
Langworthy MJ, Sabra J, Gould M. Terrorism and blast phenomena: lessons learned from the attack on the USS Cole (DDG67). Clin Orthop Relat Res. 2004 May. 82-7. [QxMD MEDLINE Link].
Leibovici D, Gofrit ON, Shapira SC. Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury?. Ann Emerg Med. 1999 Aug. 34(2):168-72. [QxMD MEDLINE Link].
Leibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996 Dec. 41(6):1030-5. [QxMD MEDLINE Link].
Mayorga MA. The pathology of primary blast overpressure injury. Toxicology. 1997 Jul 25. 121(1):17-28. [QxMD MEDLINE Link].
Moochhala SM, Md S, Lu J, et al. Neuroprotective role of aminoguanidine in behavioral changes after blast injury. J Trauma. 2004 Feb. 56(2):393-403. [QxMD MEDLINE Link].
Multi-agency presenters. Domestic Preparedness (for) Defense Against Weapons of Mass Destruction CBD Command Course. Indianapolis, IN; February 10, 1998.
Mundie TG, Dodd KT, Lagutchik MS, et al. Effects of blast exposure on exercise performance in sheep. J Trauma. 2000 Jun. 48(6):1115-21. [QxMD MEDLINE Link].
Nelson TJ, Clark T, Stedje-Larsen ET, Lewis CT, Grueskin JM, Echols EL, et al. Close proximity blast injury patterns from improvised explosive devices in Iraq: a report of 18 cases. J Trauma. 2008 Jul. 65(1):212-7. [QxMD MEDLINE Link].
Nelson TJ, Wall DB, Stedje-Larsen ET, Clark RT, Chambers LW, Bohman HR. Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom. J Am Coll Surg. 2006 Mar. 202(3):418-22. [QxMD MEDLINE Link].
Peleg K, Liran A, Tessone A, Givon A, Orenstein A, Haik J. Do burns increase the severity of terror injuries?. J Burn Care Res. 2008 Nov-Dec. 29(6):887-92. [QxMD MEDLINE Link].
Ramasamy A, Harrisson SE, Clasper JC, Stewart MP. Injuries from roadside improvised explosive devices. J Trauma. 2008 Oct. 65(4):910-4. [QxMD MEDLINE Link].
Ritenour AE, Baskin TW. Primary blast injury: update on diagnosis and treatment. Crit Care Med. 2008 Jul. 36(7 Suppl):S311-7. [QxMD MEDLINE Link].
Ritenour AE, Wickley A, Ritenour JS, Kriete BR, Blackbourne LH, Holcomb JB. Tympanic membrane perforation and hearing loss from blast overpressure in Operation Enduring Freedom and Operation Iraqi Freedom wounded. J Trauma. 2008 Feb. 64(2 Suppl):S174-8; discussion S178. [QxMD MEDLINE Link].
Shamir MY, Rivkind A, Weissman C, Sprung CL, Weiss YG. Conventional terrorist bomb incidents and the intensive care unit. Curr Opin Crit Care. 2005 Dec. 11(6):580-4. [QxMD MEDLINE Link].
Stuhmiller JH, Phillips YY, Richmond DR. The physics and mechanisms of primary blast injury. In: Bellamy AFR, Zajtchuk R, eds. Conventional Warfare: Ballistic, Blast, and Burn. 1991:247-70.
Tuggle DW. Blast injury. J Okla State Med Assoc. 2003 Sep. 96(9):419-21. [QxMD MEDLINE Link].
Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med. 2001 Jun. 37(6):664-78. [QxMD MEDLINE Link].

Media Gallery

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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Author

Andre Pennardt, MD, FACEP, FAAEM, FAWM Professor and Vice Chairman for Operational Medicine, Department of Emergency Medicine and Hospitalist Services, Georgia Regents University

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

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

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Wilderness Medical Society

Disclosure: Nothing to disclose.