Blast Injuries

Amy Kaji, MD, MPH November 16, 2005 Acute Care College Medical Student Seminar

Iraq: Car Bombings Current Events

Historically in US
Few US bombings have caused mass casualties
First World Trade Center Attack, February 1993 Oklahoma City Bombing April 19, 1995 Fuel and fertilizer used to create a bomb 518 injuries and 168 deaths Atlanta Olympic Park Bombing, July 27, 1996 World Trade Center and Pentagon September 11th, 2001 Explosive Device Attacks at Abortion Clinics

Oklahoma City April 19, 1995

New York City September 11, 2001

Classification of Explosives
High Order (HE) Explosive
Low Order (LE) Explosive Manufactured Explosive
Produce a high pressure shock wave Examples include TNT, C-4, Semtex, dynamite Produce a subsonic explosion Examples include pipe bombs, molotov cocktails Standard military-issued quality-tested weapon

Improvised Explosive Device (IED)

Use a device outside its intended purpose Commercial jet as a guided missile Loaded with metallic objects to inflict penetrating injury

Atlanta, Georgia July 27, 1996

Bag with Bomb

Types of Blast Injuries

Primary
Secondary
Due to direct effect of pressure Due to effect of projectiles from explosion Due to structural collapse and from persons being thrown from the blast wind

Tertiary

Quaternary

Burns, inhalation injury, exacerbations of chronic disease

Primary Blast Injury

Unique to high explosives Due to impact of over-pressurization wave with body surfaces Most commonly involve air-filled organs and air-fluid interfaces
Middle ear Lungs Gastrointestinal tract

Types of injuries

Blast lung Tympanic Membrane (TM) rupture Abdominal hemorrhage and perforation Globe rupture Traumatic brain injury (TBI) without physical signs of head injury

TM Injury
TM - structure most frequently injured by blast Symptoms may include hearing loss, tinnitus,

vertigo, bleeding from external canal, mucopurulent otorrhea Otologic exam and audiometry for all TM rupture is sensitive marker, but absence does not exclude other organ injury
TM rupture Ossicle dislocation Disruption of oval or round window

TM Rupture

Blast Lung
Lung 2nd most susceptible organ to blast injury Most common fatal primary blast injury among

initial survivors Pulmonary barotrauma includes

Pulmonary contusions Systemic air embolism Free radical associated injuries Thrombosis Lipoxygenation Disseminated Intravascular Coagulation (DIC)

Blast Lung
Clinical triad of apnea, bradycardia, and hypotension Signs usually at initial presentation but may manifest as

late as 48 hours after explosion Should be suspected if dyspnea, cough, hemoptysis, or chest pain Radiographic findings
Bihilar butterfly pattern Pneumothorax or hemothorax Pneumomediastinum and subcutaneous emphysema

Prophylactic chest tube before general anesthesia and air

transport if blast lung suspected

Blast Lung

Blast Abdominal Injury

Colon visceral organ most frequently affected Mesenteric ischemia from gas embolism may cause delayed

rupture of large or small intestine Intestinal barotrauma more common with underwater air blast Solid organ injury less likely Signs and symptoms
Abdominal pain, nausea, vomiting, hematemesis Rectal pain and tenesmus Testicular pain Unexplained hypovolemia

Blast Abdominal Injury

Other Primary Blast Injuries

Eye
Globe rupture, serous retinitis, hyphema, lid laceration, traumatic cataracts, injury to optic nerve Signs and symptoms include eye pain, foreign body sensation, blurred vision, decreased vision, drainage

Brain
TBI due to barotrauma of gas embolism Signs and symptoms include headache, fatigue, poor concentration, lethargy, anxiety, and insomnia

Globe Rupture

Secondary Blast Injury

Due to flying debris and bomb fragments Penetrating ballistic or blunt injuries
Leading cause of death in military and civilian terrorist attacks except in cases of major building collapse Wounds can be grossly contaminated Consider delayed primary closure and tetanus
vaccinations

Tertiary Blast Injuries

Due to persons being thrown into fixed objects by wind of

explosions Also due to structural collapse and fragmentation of building and vehicles Structural collapse may cause extensive blunt trauma
Crush syndrome

Damage to muscles and subsequent release of myoglobin, urates,

potassium, and phosphates Oliguric renal failure

Compartment syndrome

Edematous muscle in an inelastic sheath promotes local ischemia,

further swelling, increased compartment pressures, decreased tissue perfusion, and further ischemia

Crush and Compartment Syndrome

Potential Intra-operative and Postresuscitation Complications

Surgeons, Anesthesiologists, and Critical
Care Specialists will need to be aware of potential intraoperative and postresuscitation complications
Occult pneumothorax Occult compartment syndrome Hyperkalemia Crush syndrome Rhabdomyolysis

Quaternary Blast Injuries

Explosion related injuries or illnesses not due to
primary, secondary, or tertiary injuries
Exacerbations of preexisting conditions, such as asthma, COPD, CAD, HTN, DM, etc. Burns (chemical and thermal) White Phosphorous (WP) from munitions causes extensive
burns, hypocalcemia and hyperphosphatemia

Toxic inhalation Radiation exposure Asphyxiation (carbon monoxide and cyanide)

Madrid, Spain March 11, 2004

General Considerations
Information about distance from and type of
explosion predict injury severity and type
Confined space vs. open space Increased number of penetrating and primary blast injuries if
closed space

Intensity of explosion pressure wave declines with cubed root of distance away from explosive Standing at 3m has 9x greater pressure than if at 6m Blast wave reflected by solid surfaces Person next to a wall may sustain a greater primary blast
injury

General Considerations
Half of all initial casualties seek medical care over

first hour Expect upside down triage

Most severely injured arrive after less injured who bypass EMS and self-transport to closest hospitals

Secondary devices
Initial explosion attracts law enforcement and rescue personnel who will be injured by second explosion

London, England July 7, 2005

General Management
Focus on two exams Otoscopic exam
If ruptured TM, chest radiography and eight hour observation recommended Primary blast injury notorious for delayed presentation If nonruptured TM and no other symptoms, may conditionally exclude other serious primary blast injuries Decreased oxygen saturation signals early blast lung even before symptoms

Pulse oximetry

Treatment of Blast Lung

High inspiratory pressures increase risk of
air embolism and pneumothorax
Ventilation should use limited inspiratory pressures Permissive hypercapnia High frequency ventilation may be of value

Pneumothorax

Treatment of TM rupture
Generally expectant management
Most resolve spontaneously Avoid irrigating or probing the auditory canal Avoid swimming Refer to ENT if no healing or complications occur Complications include ossicle disruption, cholesteatoma,
perilymphatic fistula, and permanent hearing loss (1/3)

Steroids may be helpful in sensorineural hearing

loss

Treatment for Acute Gas Embolism (AGE)

Recompression with 100% oxygen Left lateral recumbent position Hyperbaric oxygen (HBO) is definitive
Transfer may be necessary

Aspirin may be helpful in AGE

May reduce inflammation-mediated injury in pulmonary barotrauma Weigh bleeding risk in acute trauma setting

AGE

Treatment of Eye Injuries

28% of blast survivors sustain eye injuries Objects penetrating eye (or any other body part)
should not be removed in an emergency setting
Cover affected eye with a paper cup that will not exert pressure on the globe Remove object in operating room under controlled conditions Refer patient to ophthalmology for definitive treatment

Treatment of Burns
Cover burns to minimize heat and fluid loss WP burns require special management
Copious lavage and removal or particles and debris Rinse with 1% copper sulfate solution

Combines with phosphorous particles and impedes further

combustion

Cardiac monitor

Hypokalemia and hyperphsophatemia common

Use moistened face masks to protect from phosphorous pentoxide gas exposure Avoid use of flammable anesthetic agents and excessive oxygen

WP Smoke Hand Grenade

WP Burn Victim

Special Populations
Pediatric trauma due to terrorism vs. pediatric trauma due
to non-terrorism related events
Increased use of Intensive Care Unit (ICU) resources Higher injury severity scores (ISS) Longer hospital stays

Pregnancy
Direct injury to fetus is uncommon Fetus protected by amniotic fluid Fetal attachment to placenta is tenuous

Risk for placental abruption

If blast in second or third trimester admit to labor and delivery for fetal monitoring

Guidelines for Disposition

Limited data prevent establishing optimal duration of

observation Low risk and may be discharged with strict precautions after four hours of observation:
Persons exposed to open-space explosions with no apparent significant injury, normal vital signs and unremarkable lung and abdominal examination

Moderate risk and should be observed for longer periods

of time for delayed complications:
Persons exposed to closed-space explosion or in-water explosions Persons with TM rupture

Guidelines for Admission

High risk patients who require admission
Significant burns Suspected air embolism Radiation WP contamination Abnormal vital signs Abnormal lung examination findings Clinical or radiographic evidence of pulmonary contusion or pneumothorax Abdominal pain or vomiting Penetrating injuries to the thorax, abdomen, neck, or cranial cavity

Selected References
Arnold JL, Halperin P, Tsai MC, Smithline H. Mass casualty terrorist

bombings: a comparison of outcomes by bombing type. Ann Emerg Med 2004;43:263-73. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. N Engl J Med 2005; 352:1335-42. Hogan DE, Waeckerle JF, Dire DJ, Lillebridge ST. Emergency department impact of the Oklahoma City terrorist bombing. Ann Emerg Med 1999; 34:160-7. Karmy-Jones R, Kissinger D, et. al. Bombing related injuries. Mil Med 1994;159:536-9. Lavanos E. Blast Injuries. (Accessed September 21, 2005, at http://www.emedicine.com/emerg/topic63.htm.). Wightman JM, Gladish SL. Explosions and blast injuries: a primer for clinicians. Atlanta: Centers for Disease Control and Prevention. (Accessed September 21, 2005, at http://www.cdc.gov/masstrauma/preparedness/primer.pdf.)