Case Review

Steven Buhrer, RN, EMT-P, and Peter Tilney, DO, EMT-P

Blast Lung Injury in a 20-Year-Old Man after a Home Explosion

A large family home exploded after a propane leak ignited. Initial reports from the scene noted that 11 people were injured, with many sustaining critical injuries. Immediately, multiple helicopter emergency medical services aircraft were dispatched to respond to the scene, and ground emergency medical services (EMS) providers were en route. Of the five aircraft requested, only two were available to respond; one aircraft was out for maintenance, and two others were committed to other missions.

After initial review and triage by ground EMS providers, three people were confirmed dead on scene, and eight patients had critical burn and traumatic blast-related injuries requiring emergent evaluation. The Fire and EMS Incident Commander immediately notified the local hospital of the evolving situation. Disaster plans at this hospital and the regional trauma center, located approximately 20 minutes away by air, were enacted to prepare for the potential influx of injured patients. The nearest burn center was approximately 70 minutes by air. The available hospital-based flight team and a state police aircraft were dispatched directly to the scene for the most severely injured patients. As the scene triage continued, two of the three critically injured patients were transported by aircraft; the other critically ill patient was transported by ground to the trauma center, despite efforts to obtain a third aircraft. The other patients who were deemed less critically injured were taken to a local hospital for stabilization before transfer to the regional trauma center. The first patient flown from the scene was a 2-month-old infant with significant burns and traumatic injuries. Given her hemodynamic instability, she was flown directly to the regional pediatric trauma center for treatment and evaluation. The decision was made on scene to transport her to the local trauma center for initial stabilization and to the burn center later. Unfortunately, her traumatic injuries were too severe, and she died before transfer to the burn center. The second patient was initially talking on the scene after being found approximately 200 yards from the remains of the house. At first, based on his traumatic injuries and severe burns, the decision was made to transfer him directly to the regional burn and trauma center approximately 130 miles away. However, after the primary assessment and transport decision was made, he experienced a several-minute episode of seizure activity, vomited, and then became unresponsive. He was intubated with rapid sequence intubation and moved to the aircraft. During the flight, he went into cardiac arrest, and the aircraft was diverted to the regional trauma center as the closet facility. The patient was appropriately resuscitated with fluids
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and advanced cardiac life support medications, including atropine and epinephrine. Before additional interventions were initiated, his spontaneous circulation returned. During the remainder of the flight, he continued to have tachycardia and labile blood pressures. When the patient arrived at the local trauma center, staff from the emergency department (ED) and trauma services were waiting. Initial assessment revealed an intubated adult man in his mid 20s who was noted to be tachycardic and mildly hypotensive. He had no evidence of external trauma but was noted to have sustained extensive partial-thickness burns covering an estimated 45% of his total body surface area across his face, neck, chest, back, upper extremities, and foot. His weight was estimated at 80 kg. Using the Parkland formula, resuscitation requirements were calculated to be approximately 14.4 L of lactated Ringers over 24 hours, with 7.2 L being given over the first 8 hours. Given his poor hemodynamic status, he immediately received a fluid bolus in the ED, resolving his hypotension. Interestingly, he then became hypertensive, which was hypothesized to be from a lack of sedation and pain control. He was immediately medicated with versed and fentanyl, and his vital signs normalized. Once he was stabilized, additional imaging was ordered to determine whether there were injuries other than extensive burns. A computed tomography (CT) scan of the head revealed mild diffuse cerebral edema, without intracranial hemorrhage or skull fracture; CT scan of the cervical spine was negative for injury. However, the CT of the chest, abdomen, and pelvis had multiple findings, including blast lung injury (BLI) pattern; a large, unstable, step-off deformity at L1; and injuries to the bowel most likely related to hypoperfusion. Laboratory test results were unremarkable, with the exception of the international normalized ratio (INR) noted to be 2.1. He was subsequently given 4 units of fresh frozen plasma and vitamin K. In addition to correcting the INR emergently, the patient was given dilantin for seizure prophylaxis in the setting of his noted cerebral edema. Neurosurgery evaluated the patient to
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determine whether intracranial monitoring was warranted. However, given his significant burns and lung and spine injuries, the decision was made to defer additional interventions until he was stabilized at the burn center. The hospital-based flight crew then transferred the patient to the regional burn center. Given his neurologic condition, the patient was placed on propofol for sedation. According to the burn formula, lactated Ringers was continued at the appropriate rate. The patient continued to have hemodynamic instability throughout the flight that was stabilized with judicious fluid boluses. Body temperature was also preserved with dry sterile dressings and a Mylar wrap. Despite the multitude of interventions and aggressive treatment that he received, the patient died of his wounds several days later. Ultimately, three other patients with both burns and traumatic injuries were transported to the regional burn center for further care after stabilization at the regional trauma center. A total of six people ultimately perished as a result of this explosion.

Discussion
Until the past decade, primary blast injuries have not routinely been encountered in the civilian realm. Traditionally, these injury patterns have been confined to regions where military conflicts are present. In noncombat situations, blast injuries occur typically as a result of industrial accidents, including explosions in coal mines, shipyards, construction sites, chemical plants, refineries, factories, grain elevators, and areas in which hazardous materials are produced or transported. Other sources of blast-related trauma are fireworks and ignition of combustibles in the home.1 Recent terrorism activities have also increased the incidence of primary blast injuries in the civilian population. When large-scale explosions occur, blast patterns are characterized into multiple phases based on the effects on the patient and the surrounding environment. Given the pattern of gases, combustibles, and detritus affected, each phase can be identified after the blast occurs.6 Each phase of blast results in different injury patterns. The primary explosion results in a blast wave of increased pressure that impacts the body surface. Air-filled structures that are less dense than the surrounding body tissues are primarily affected.2 Tympanic membrane (TM) rupture and hollow viscous injury (shock bowel) are clear examples of a primary blast injury. Thin membranes of bowel and the tympanum are sensitive to abrupt changes in pressure, and given the wide fluctuations that occur and the potential energy that is transferred, these body systems are at risk of being injured in a primary blast explosion. However, despite the clear specificity as a marker of blast injury (pathognomonic), TM ruptures are estimated to occur in approximately 50% of patients.3 As outlined in the case just discussed, the respiratory system is also affected by the primary blast wave, resulting in pulmonary damage (BLI) and air embolization from decreased tissue density and physiologic intolerance to pressure variations.
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Secondary injuries in large-scale explosions occur as a result of projectiles (including bomb fragments and flying debris from the surrounding environment). These flying objects act as missiles and can lead to significant blunt and penetrating trauma. Additional tertiary injuries also can occur as a result of the patient being thrown and becoming a projectile as well. In these situations, the location of the victim relative to the blast site can be an indicator of the amount of energy in the blast. Finally, other less critical injuries, including toxic exposures, asphyxia, or other sequelae, can occur as a result of the explosion. The full effects of these illnesses and injuries may not be felt or identified for many years after the event. This last category has only been identified as a complication of blast injuries in the past 30 years, and these effects are continuously being addressed and managed. The effects of primary blast injuries are the most severe. The pressure wave that passes through the body initially can affect most critical body systems. Because of the large airfilled spaces, the respiratory system, and specifically the lung, is the most frequently injured organ in fatally wounded victims exposed to a bomb explosion. Blast lung injury is a major cause of morbidity and mortality, both at the scene and among initial blast survivors. Mortality rates vary greatly; one analysis of 29 large terrorist bombings between 1966 and 2002 showed 8,364 casualties, including 903 immediate deaths and 7,461 immediately surviving injured.4 Pulmonary blast injury occurs from the fact that the delicate pulmonary vasculature is prone to pressure-related injuries. Blast lung injuries are manifested in a variety of ways, ranging from minor shortness of breath to extreme lung injury with bronchopleural fistula, hemoptysis, and difficulties in ventilation and oxygenation.5 Signs and symptoms of BLI (Table 1) are similar to those that occur as a result of a pulmonary contusion. In both injuries, gas exchange at the alveolar level is impaired. The degree of respiratory insufficiency is directly related to the degree of hemorrhage into the lung. The clinical signs of BLI include all those exhibited during an episode of respiratory distress. Dyspnea, cough, tachypnea, hypoxia, cyanosis, wheezing, hemoptysis, diminished breath sounds, pneumothorax, and hemothorax can be indicative. Left untreated, acute respiratory failure and massive intrapulmonary hemorrhage can result. Despite the surge in explosive-related injuries and deaths worldwide in recent years, an absence of extensive studies on treatment and therapies to maximize patient response leave medical providers to rely on others experience and their knowledge and assessment skills. However, as these incidents continue to occur, treatment protocols in both the prehospital and inpatient realm continue to be developed. Initial management strategies of BLIs require rapid identification of pulmonary injuries and concurrent causes of hemodynamic instability. In many cases, the patient will have multiple insults that require a variety of emergent therapies. By completing an initial aggressive resuscitation with airway, respiratory, and circulatory control, adequate ventilation and oxygenation will occur simultaneously.
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Table 1. Signs and Symptoms of Blast Lung Injury Signs Variations in respiratory rate, including tachypnea, bradypnea, apnea Hypoxia Cyanosis Chest wall trauma, including flailed segments Hemoptysis Pneumothoraces Decreased lung sounds and dullness to percussion Cough and bronchospasm Penetrating chest wall trauma

Symptoms Dyspnea Chest pain Dyspnea on exertion

As with many patients who present with blunt chest trauma, those with BLI will require extensive pulmonary evaluation. Initial therapies follow standard trauma algorithms to ensure tissue oxygenation. High-flow oxygen is used in patients with spontaneous respirations. Patients who are apneic or in respiratory failure should have definitive airway interventions completed early in the resuscitation to ensure airway protection and appropriate mechanical ventilation. Patients with BLI may present with pneumothoraces and hemothoraces that require emergent needle decompression or tube thoracostomy insertion. Additionally, those who present with frank hemoptysis should be evaluated for suspected airway disruption or lower airway damage. Because of the large surface area of the lungs and the vasculature nature of the organ, alveolar disruption from the pressure change inflicted on the capillary beds results in rupture and subsequent bleeding of the distal airways. Diffuse alveolar hemorrhage can be present in BLI and can be a challenge to those who are managing the mechanical ventilation. Patients with BLI also can experience air gas embolism, with air entering directly into the circulatory system. These patients are acutely unstable and require transfer and evaluation that is capable of providing hyperbaric oxygen therapy.7 Ventilatory strategies with patients with BLI are similar to those for patients with blunt chest trauma and pulmonary contusions. The overall goal is to provide adequate tissue oxygenation without instilling high pulmonary pressures. Permissive hypercapnea with alveolar hypoventilation may limit additional lung injury in intubated patients. Additionally, unilateral lung ventilation may be of benefit in those with bronchopleural fistulae. Continued reassessment of the patients pulmonary status is necessary because BLIs continue to evolve acutely in the first 24 to 48 hours.8 Cardiovascular support is directed at preserving end organ perfusion. Fluid and blood resuscitation must be focused on oxygen delivery and adequate tissue oxygenation. However, care must be taken to minimize fluid overload, which would further exacerbate the existing ventilation and perfusion mismatch and worsen pulmonary status. The overall picture of the blast victim should not be overlooked. The proximity to the blast site will determine the severity of the injuries and the body systems involved. This information may not be available to the transport team or
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receiving trauma team. This can be a complex resuscitation because of the high probability of severe traumatic injuries in conjunction with severe surface and inhalation burns. Treatment of traumatic injuries trumps the burn injuries, and as such these patients should be taken to a regional trauma center for the initial resuscitation and then transferred to a regional burn center. Fluid resuscitation should be judicious and follow established protocols, such as the Parkland Formula, and use urinary output as a guide to direct fluid resuscitation. Blast injuries are complex, multifaceted, traumatic injuries that will test any experienced provider. Coupled with the fact these types of injuries are typically not a single-patient event, blast injuries can easily overwhelm any trauma system. Each provider must prepare and be ready to recognize these devastating injuries to ensure optimal survival.

References
1. Salomone JP. PHTLS: Prehospital Trauma Life Support, 6th edition. St. Louis, MO: Mosby Elsevier; 2007. 2. Pennardt A, Lavones EJ, Kulkarni R. Blast Injuires. Emedicine May 28, 2010. Available at http://emedicine.medscape.com/article/822587-overview. Accessed September 23, 2011. 3. 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;67:210-1. 4. Arnold JL, Halpern P, Tsia MC, Smithline H. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med 2004;43:263-73. 5. Segal E, Pizov R. Pulmonary complications of blast injury. Pulmonary Critical Care and Sleep Update Vol 21. Tel Aviv, Israel: American College of Chest Physicians; 2007. 6. 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;209:134-40. 7. Lavery GG, Lowry KG. Management of blast injuries and shock lung. Curr Opin Anaesthesiol 2004;17:151-7. 8. Sasser SM, Sattin RW, Hunt RC, Krohmer J. Blast lung injury. Prehosp Emerg Care 2006;10:165-72.

Steven Buhrer RN, EMT-P, is a medical base supervisor for LifeNet of New York in Harris, NY. He can be reached at sbuhrer@airmethods.com. Peter Tilney, DO, EMT-P, is an attending physician in the department of emergency medicine at the Albany Medical Center in Albany, NY, and medical director of LifeNet of New York. He can be reached at tilneyp@mail.amc.edu.
1067-991X/$36.00 Copyright 2012 Air Medical Journal Associates doi:10.1016/j.amj.2011.10.005 Air Medical Journal 31:1