Blast Injury

Steven A. Santanello, DO
Grant Medical Center
Trauma Medical Director
Explosions

• Single or multiple victims

• Multi-system injury
• Blunt, penetrating, unique blast injury
patterns
• Present complex triage, diagnostic,
management challenges
Explosions

Injury Patterns
• Amount and composition of explosive
material / delivery method
• Presence of shrapnel, radiologic or biologic
material
• Surrounding environment
• Distance victim to blast
 Explosions

• High order explosives (HE)

• Detonation (instantaneous
transformation)
• Results in extremely high over
-pressurization wave
(4 million PSI)
• Blast wave front
– TNT, Ammonium Nitrate Fuel
Oil, Dynamite, C4
Explosions

• Low order explosions

(LE)
• Deflagration (gradual
transformation)
• Subsonic over-
pressurization wave
– Gun powder, molotov
cocktails, pyrotehnics, pipe
bombs
• Injuries are characterized
by ballistics
 Explosions

• Improvised Explosive Devices (IEDs)

– Composed of HE, LE, or both
– Different injury patterns
Blast Injury
• Primary blast injury
• Secondary blast injury
• Tertiary blast injury
• Quaternary (miscellaneous) blast injury
Primary Blast Injury

• Injury caused solely by blast wave (HE)

• Blast wind (superheated airflow)
– White phosphorous
• Direct or reflective over-pressurization force
• Positive over-pressurization/negative under
pressurization
• Gas filled organs most susceptible
 Primary Blast Injury

Pulmonary Barotrauma
• Present initially or within 48
hours
• Apnea / bradycardia /
hypotension
• Scattered petechaie or confluent
hemorrhage
• S & S dyspnea / cough /
hemoptysis
• Butterfly
• Consider prophylactic CT
Primary Blast Injury

GI Barotrauma
• Gas containing organs
most vulnerable
• Mesenteric shear
injury
• Solid organ laceration
• Abdominal pain,
nausea, vomiting
hematemesis
Primary Blast Injury

Acoustic Barotrauma
• Tympanic membrane rupture (6 PSI)
• Hemotympanum / Ossicle Fracture

CNS
• Blast wave produce concussion
– mild to moderate brain injury
• Spalling effect
Secondary Blast Injury

• Caused by flying debris

• HE, LE
• Occur at distance
Tertiary Blast Injury

• Individual propelled
through the air striking
other objects
• Most common in HE
with close proximity
Quaternary Blast Injury

• Burns (chemical or
thermal)
• Toxic dust/gas/radiation
exposure
• Crush injury
Mass Casualty Terrorist Bombings, A
comparison of outcomes by bombing
type:
Terrorist Bombing Events
• 1966 – 2002 29 events
• 8364 casualties
– 903 immediate deaths
– 7461 immediate surviving injured
• Immediate death rate
– Structural collapse (25%)
– Confined space (8%)
– Open Air (4%)
Annuals of Emergency Medicine, February 2004
Pre-hospital

• “Upside Down” triage

• Half of all initial casualties seek medical
care over one hour period. (walk ins-closest
hospital)
• Initial triage standard protocol for multiple
injured patients
Management Concepts

• Be aware of primary blast injuries

• Auditory, occular, CNS injuries may be
overlooked
• Air embolism may present as stroke / acute
abdomen, SCI
Management Concepts

• Crush injury can result in compartment

syndrome / rhabdomyolysis
• Consider exposure to inhaled toxins
• TM rupture not marker of morbidity
• Traumatic amputation marker for multi-
system injury