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Blast Injuries

Blast Lung Injury


Blast lung injury
Blast lung injury (BLI) presents unique triage,
diagnostic, and management challenges and is a
direct effect of the blast wave from high
explosive energy upon the body with a major
cause of morbidity and mortality for the victims
and among initial survivors.
The explosive impact upon the lung is tearing,
hemorrhagic, contusive and edematous in nature
resultanting in ventilation-perfusion mismatch.
BLI is a clinical diagnosis characterized by
respiratory difficulty and hypoxia, which may
occur without obvious external injury,eg. chest.
Diagnostic Evaluation
Chest radiography is necessary for anyone
who is exposed to a blast with a
characteristic “butterfly” pattern.
Arterial blood gases, computerized
tomography, and doppler technology.
Most laboratory and diagnostic testing can
be conducted per resuscitation
protocols and further directed based upon
the nature of the explosion
(e.g. confined space, fire, prolonged
entrapment or extrication, suspected
chemical or biologic event.
Chest-x ray
Clinical Presentation
Symptoms : dyspnea, hemoptysis, cough,
and chest pain.
Signs: tachypnea, hypoxia, cyanosis,
apnea, wheezing, decreased breath
sounds, and hemodynamic instability.
Associated pathology: bronchopleural
fistula, air emboli, and hemothoraces or
pneumothoraces.
Other injuries may be present.
Management
Initial triage, trauma resuscitation, treatment, and transfer
should follow standard protocols; however some diagnostic
or therapeutic options may be limited in a disaster or mass
casualty situation.
In general, managing BLI is similar to caring for pulmonary
contusion, which requires judicious fluid use and
administration ensuring tissue perfusion without volume
overload.
Clinical interventions
All patients with suspected or confirmed BLI should receive
supplemental high flow oxygen sufficient to prevent
hypoxemia (delivery may include non-rebreather masks,
continuous positive airway pressure, or endotracheal
intubation).
Blast Injuries: Essential Facts

Key Concepts
Bombs and explosions can cause unique patterns of injury seldom seen outside
combat
Expect half of all initial casualties to seek medical care over a one-hour period
Most severely injured arrive after the less injured, who bypass EMS triage and go
directly to the closest hospitals
Predominant injuries involve multiple penetrating injuries and blunt trauma
Explosions in confined spaces (buildings, large vehicles, mines) and/or structural
collapse are associated with greater morbidity and mortality
Primary blast injuries in survivors are predominantly seen in confined space
explosions
Repeatedly examine and assess patients exposed to a blast
All bomb events have the potential for chemical and/or radiological contamination
Triage and life saving procedures should never be delayed because of the possibility
of radioactive contamination of the victim; the risk of exposure to caregivers is small
Universal precautions effectively protect against radiological secondary contamination
of first responders and first receivers
For those with injuries resulting in nonintact skin or mucous membrane exposure,
hepatitis B immunization (within 7 days) and age-appropriate tetanus toxoid vaccine
(if not current)
Blast Injuries
Primary: Injury from over-pressurization force (blast wave)
impacting the body surface
– TM rupture, pulmonary damage and air embolization, hollow
viscus injury
Secondary: Injury from projectiles (bomb fragments, flying
debris)
– Penetrating trauma, fragmentation injuries, blunt trauma
Tertiary: Injuries from displacement of victim by the blast
wind
– Blunt/penetrating trauma, fractures and traumatic amputations
Quaternary: All other injuries from the blast
– Crush injuries, burns, asphyxia, toxic exposures, exacerbations
of chronic illness
Primary Blast Injury
Lung Injury
Signs usually present at time of initial
evaluation, but may be delayed up to 48 hrs
Reported to be more common in patients
with skull fractures, >10% BSA burns, and
penetrating injury to the head or torso
Varies from scattered petechiae to confluent
hemorrhages
Suspect in anyone with dyspnea, cough,
hemoptysis, or chest pain following blast
CXR: “butterfly” pattern
High flow O2 sufficient to prevent hypoxemia via NRB
mask, CPAP, or ET tube
Fluid management similar to pulmonary contusion; ensure
tissue perfusion but avoid volume overload
Endotracheal intubation for massive hemoptysis, impending
airway compromise or respiratory failure
– Consider selective bronchial intubation for significant air leaks
or massive hemoptysis
– Positive pressure may risk alveolar rupture or air embolism
Prompt decompression for clinical evidence of
pneumothorax or hemothorax
Consider prophylactic chest tube before general anesthesia
or air transport
Air embolism can present as stroke, MI, acute abdomen,
blindness, deafness, spinal cord injury, claudication
– High flow O2; prone, semi-left lateral, or left lateral position
– Consider transfer for hyperbaric O2 therapy
Abdominal Injury
Gas-filled structures most vulnerable (esp. colon)
Bowel perforation, hemorrhage (small petechiae to
large hematomas), mesenteric shear injuries, solid
organ lacerations, and testicular rupture
Suspect in anyone with abdominal pain, nausea,
vomiting, hematemesis, rectal pain, tenesmus,
testicular pain, unexplained hypovolemia
Clinical signs can be initially subtle until acute
abdomen or sepsis is advanced
Ear Injury
Tympanic membrane most common primary
blast injury
Signs of ear injury usually evident on
presentation (hearing loss, tinnitus, otalgia,
vertigo, bleeding from external canal,
otorrhea)
Other Injury
Traumatic amputation of any limb is a marker for multi-
system injuries
Concussions are common and easily overlooked
Consider delayed primary closure for grossly contaminated
wounds, and assess tetanus immunization status
Compartment syndrome, rhabdomyolysis, and acute renal
failure are associated with structural collapse, prolonged
extrication, severe burns, and some poisonings
Consider possibility of exposure to inhaled toxins (CO, CN,
MetHgb) in both industrial and terrorist explosions
Significant percentage of survivors will have serious eye
injuries
Disposition
No definitive guidelines for observation,
admission, or discharge
Discharge decisions will also depend upon
associated injuries
Admit 2nd and 3rd trimester pregnancies for
monitoring
Close follow-up of wounds, head injury, eye, ear,
and stress-related complaints
Patients with ear injury may have tinnitus or
deafness; communications and instructions may
need to be written
Impending airway compromise, secondary edema, injury,
or massive hemoptysis requires immediate intervention to
secure the airway. Patients with massive hemoptysis or
significant air leaks may benefit from selective bronchus
intubation.
Clinical evidence of or suspicion for a hemothorax or
pneumothorax warrants prompt decompression.
If ventilatory failure is imminent or occurs, patients should
be intubated; however, caution should be used in the
decision to intubate patients, as mechanical ventilation and
positive end pressure may increase the risk of alveolar
rupture and air embolism.
High flow oxygen should be administered if air embolism is
suspected, and the patient should be placed in prone, semi-
left lateral, or left lateral positions. Patients treated for air
emboli should be transferred to a hyperbaric chamber.
Disposition and Outcome
There are no definitive guidelines for
observation, admission, or discharge
following emergency department
evaluation for patients with possible BLI
following an explosion.
Patients diagnosed with BLI may require
complex management and should be
admitted to an intensive care unit.
Patients with any complaints or findings
suspicious for BLI should be observed in
the hospital.
Discharge decisions will also depend upon associated
injuries, and other issues related to the event, including the
patient’s current social situation.
In general, patients with normal chest radiographs and
ABGs, who have no complaints that would suggest BLI, can
be considered for discharge after 4-6 hours of observation.
Data on the short and long-term outcomes of patients with
BLI is currently limited. However, in one study conducted
on survivors one year post injury, no patients had
pulmonary complaints, all had normal physical
examinations and chest radiographs, and most had normal
lung function tests.