Published on August 31, 2009
Key Concepts : Key Concepts Bombs and explosions can cause unique patterns of injury seldom seen outside combat. The predominant post explosion injuries among survivors involve standard penetrating and blunt trauma. Blast lung is the most common fatal injury among initial survivors. Explosions in confined spaces (mines, buildings, or large vehicles) and/or structural collapse are associated with greater morbidity and mortality. Key Concepts (Cont.) : Key Concepts (Cont.) Half of all initial casualties will seek medical care over a one-hour period. This can be useful to predict demand for care and resource needs. Expect an “upside-down” triage - the most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals. Background : Background Explosions can produce unique patterns of injury seldom seen outside combat. When they do occur, they have the potential to inflict multi-system life-threatening injuries on many persons simultaneously. Background (cont.) : Background (cont.) The injury patterns following such events are a product of the composition and amount of the materials involved, the surrounding environment, delivery method (if a bomb), the distance between the victim and the blast, and any intervening protective barriers or environmental hazards. Because explosions are relatively infrequent, blast-related injuries can present unique triage, diagnostic, and management challenges to providers of emergency care. Background (Cont.) : Background (Cont.) Few U.S. health professionals have experience with explosive-related injuries. Vietnam era physicians are retiring, other armed conflicts have been short-lived, and until this past decade, the U.S. was largely spared of the scourge of mega-terrorist attacks. Classification of Explosives : Classification of Explosives Explosives are categorized as: high-order explosives (HE) OR low-order explosives (LE). Classification of Explosives (HE) : Classification of Explosives (HE) HE produce a defining supersonic over-pressurization shock wave. Examples of HE include: TNT C-4 Semtex (1988 bombing of Pan Am Flight 103 over Lockerbie, Scotland) Nitroglycerin Dynamite Ammonium nitrate fuel oil (ANFO) (Bombing of Murrah Building in OK City) Classification of Explosives (LE) : Classification of Explosives (LE) LE create a subsonic explosion and lack HE’s over-pressurization wave. Examples of LE include: Pipe bombs Gunpowder Most pure petroleum-based bombs such as Molotov cocktails or aircraft improvised as guided missiles. HE and LE cause different injury patterns. Classification of Explosives : Classification of Explosives Explosive and incendiary (fire) bombs are further characterized based on their source. “Manufactured” implies standard military-issued, mass produced, and quality-tested weapons. Manufactured (military) explosive weapons are exclusively HE-based. Classification of Explosives (cont) : Classification of Explosives (cont) “Improvised” describes weapons produced in small quantities, or use of a device outside its intended purpose, such as converting a commercial aircraft into a guided missile. Terrorists will use whatever is available – illegally obtained manufactured weapons or improvised explosive devices (also known as “IEDs”) that may be composed of HE, LE, or both. Manufactured and improvised bombs cause markedly different injuries. Blast Physics : Blast Physics Explosive materials are those that undergo a rapid, exothermic reaction involving a phase change from solid or liquid into a gas (1,2,3). The speed and intensity of this conversion divides explosives into two catergories: high order explosives (HE) low order explosives (LE) While the relatively slow reactions of LE’s can be characterized as rapid burning, HE’s, such as TNT, C-4, or ammonium nitrate fuel oil (ANFO), detonate so rapidly that their fundamental physics are quite distinct. Blast Physics (cont.) : Blast Physics (cont.) The isovolemic phase-change of HE’s into gas produce heat and energy resulting in an intense pressure wave that radiates outward from the site of detonation. This supersonic, superheated wave, known as “overpressure” comprises the blast front (5,6). Overpressure can rise to hundreds of thousands times atmospheric pressure and this force is directly related to the severity of what is known as primary blast injury (4). Overpressure typically lasts for less than one tenth of a second, and lessens in speed and intensity as it travels until it finally degenerates into acoustic vibrations (6,7). Physics (cont.) : Physics (cont.) This shock wave can reach pressures of tens of thousands of atmospheres, travel at many miles per second and unlike the heat from detonation can wrap around buildings and obstacles. Equally powerful is the relative vacuum called underpressure that follows the blast front and produces what is known as a blast wind which can reach speeds of over 800 miles per hour (4). The environment surrounding detonation of HE’s greatly influences the physics and therefore the potential injurious effects of the blast wave. Physics (cont.) : Physics (cont.) The overpressure wave is reflected and sustained by walls and ceilings, magnifying the effects on those near the blast. This is reflected by the much higher mortality rates for explosions within enclosed spaces as opposed to open-air blasts (8). In addition, the medium of propagation is vital to determining the potential of a given explosive to cause damage. Water, as an incompressible medium, leads to higher rates of wave propagation and greater conservation of energy over distance, and the lethal blast radius for a given explosion can be three times greater in water than in air at atmospheric pressure (5,7) Blast Injuries : Blast Injuries The four basic mechanisms of blast injury are termed as: Primary Secondary Tertiary Quaternary (Table 1) Table 1 (Mechanisms of Injury) : Table 1 (Mechanisms of Injury) Blast Wave (HE) : Blast Wave (HE) “Blast Wave” (primary) refers to the intense over-pressurization impulse created by a detonated HE. Blast Injuries (HE cont.) : Blast Injuries (HE cont.) Blast injuries are characterized by anatomical and physiological changes from the direct or reflective over-pressurization force impacting the body’s surface. The HE “blast wave” (over-pressure component) should be distinguished from “blast wind” (forced super-heated air flow). The latter may be encountered with both HE and LE. Blast Injuries (LE) : Blast Injuries (LE) LE are classified differently because they lack the self-defining HE over-pressurization wave. LE’s mechanisms of injuries are characterized as due from ballistics (fragmentation), blast wind (not blast wave), and thermal. There is some overlap between LE descriptive mechanisms and HE’s Secondary, Tertiary, and Quaternary mechanisms. Table 2 (Injuries) : Table 2 (Injuries) Blast Injuries: : Blast Injuries: Note: Up to 10% of all blast survivors have significant eye injuries. These injuries involve perforations from high-velocity projectiles, can occur with minimal initial discomfort, and present for care days, weeks, or months after the event. Symptoms include: eye pain or irritation, foreign body sensation, altered vision, periorbital swelling or contusions. Findings can include: decreased visual acuity, hyphema, globe perforation, subconjunctival hemorrhage, foreign body, or lid lacerations. Liberal referral for ophthalmologic screening is encouraged. Lung Injury “Blast Lung” : Lung Injury “Blast Lung” “Blast lung” is a direct consequence of the HE over-pressurization wave. It is the most common fatal primary blast injury among initial survivors. Signs of blast lung are usually present at the time of initial evaluation but they have been reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical triad of: Apnea Bradycardia Hypotension Lung Injury “Blast Lung” (cont.) : Lung Injury “Blast Lung” (cont.) Pulmonary injuries vary from scattered petechae to confluent hemorrhages. Blast lung should be suspected for anyone with Dyspnea Cough Hemoptysis or chest pain following blast exposure. Blast lung produces a characteristic “butterfly” pattern on chest X-ray. A chest X-ray is recommended for all exposed persons and a prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport if blast lung is suspected. Ear Injury : Ear Injury Primary blast injuries of the auditory system cause significant morbidity, but are easily overlooked. Injury is dependent on the orientation of the ear to the blast. TM perforation is the most common injury to the middle ear. Ear Injury (Signs) : Ear Injury (Signs) Signs of ear injury are usually present at time of initial evaluation and should be suspected for anyone presenting with: hearing loss, tinnitus, otalgia, vertigo, bleeding from the external canal, TM rupture, or mucopurulent otorhea. All patients exposed to blast should have an otologic assessment and audiometry. Abdominal Injury : Abdominal Injury Gas-containing sections of the GI tract are most vulnerable to primary blast effect. This can cause immediate bowel perforation, hemorrhage (ranging from small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture. Abdominal Injury (signs) : Abdominal Injury (signs) Blast abdominal injury should be suspected in anyone exposed to an explosion who presents with: abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia, or any findings suggestive of an acute abdomen. Clinical findings may be absent until the onset of complications. Brain Injury : Brain Injury Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms. The symptoms of concussion and post traumatic stress disorder can be similar. Emergency Management Options : Emergency Management Options Follow your hospital’s and regional disaster system’s plan. Expect an “upside-down” triage - the most severely injured arrive after the less injured, who by-pass EMS triage and go directly to the closest hospitals. Double the first hour’s casualties for a rough prediction of total “first wave” of casualties. (See Mass Casualties Predictor.) Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty location from police, fire, EMS, ICS Commander, regional EMA, health department, and reliable news sources. If structural collapse occurs, expect increased severity and delayed arrival of casualties. Medical Management Options : Medical Management Options Blast injuries are not confined to the battlefield. They should be considered for any victim exposed to an explosive force. Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute abdomen or sepsis are advanced. Standard penetrating and blunt trauma to any body surface is the most common injury seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. “Blast Lung” is the most common fatal injury among initial survivors. “Blast lung” presents soon after exposure. It can be confirmed by finding a “butterfly” pattern on chest X-ray. Prophylactic chest tubes (thoracostomy) are recommended prior to general anesthesia and/or air transport. Medical Management Options : Medical Management Options Auditory system injuries and concussions are easily overlooked. The symptoms of mild TBI and post traumatic stress disorder can be identical. Isolated TM rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries. Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases. Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and some poisonings. Medical Management Options : Medical Management Options Consider the possibility of exposure to inhaled toxins and poisonings (e.g., CO, CN, MetHgb) in both industrial and criminal explosions. Wounds can be grossly contaminated. Consider delayed primary closure and assess tetanus status. Ensure close follow-up of wounds, head injuries, eye, ear, and stress-related complaints. Communications and instructions may need to be written because of tinnitus and sudden temporary or permanent deafness. References: : References: (1) Cooper G, Maynard R, Cross N, et al. Casualties from terrorist bombings. J Trauma. 1983;23: 955-967.(2) Adler J, Golan E, Golan J, et al. Terrorist bombing experience during 1975-79 : casualties admitted to the sharre zedek medical center. Israel J Med Sci. 1983;19: 189-93.(3) Horrocks C. Blast injuries: biophysics, pathophysiology and management priciples. J R Army Med Corps. 2001;147:28-40.(4) Mellor S. the relationship between blast loading to death and injury from explosion. World J Surg. 1992;16: 893-98.(5) Wightman J, Gladish S. Explosions and blast injuries. Ann Emerg Med. 2001;37: 664-78.(6) Guy R, Glover M, Cripps N. The pathophysiology of primary blast injury and it’s implications for treatment. Part I: the thorax. J Roy Nav Med Serv. 1998;84.2: 79-86.(7) Philips, Y. Primary Blast Injuries. Ann emerg Med. 1986. 15:12;1446-1450.(8) Leibovici D, Gofrit O, Stein M, et al. Blast injuries: bus versus open-air bombings - a cooperative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41: 1030-35.