1. Blast Injuries: Prehospital Assessment and Management
Jeffrey P Salomone, MD, FACS
Past President,
Eastern Association for the Surgery of Trauma

2. Disclosures
Editor / Associate Editor, Prehospital Trauma Life Support 5e, 6e, 7e
Contributor PHTLS 8e
NO financial relationships

3. Background
Explosive agents / Blast devices
Blast Physics
Scene Management
Injury Types
Patient Management

4. Blasts and Blast Injuries
Bombings / WMDs
Terrorism
Middle East / Asia
IEDs
GWOT: Iraq / Afghanistan

5. Unintentional Explosions
Gas leaks
Industry
Fertilizer
Petroleum
Explosives/ fireworks
Grain
Illicit- drug manufacturing (meth)
Deaths- unusual: only 150 in US (2004)

6. Worldwide Terrorism Israel- Tel Aviv ( 2001, 2006)
Madrid (2004)- bombs on commuter trains
London (2005)- 4 bombs on trains / bus
Mumbai (2008)- 11 shooting & bombing attacks over 4 days

7. US Bombings

8. Murrah Federal Bldg ( 1995) 168 killed Almost 700 injured
Photo Courtesy of the City Of Oklahoma City

9. Atlanta Olympic Park Bombing July 27, 1996 1:30 am

10. Olympic Park Bombing 111 victims + news reporter
All transported to 11 area hospitals within 32 minutes by 30 EMS units
35 + reporter to Grady Memorial Hosp
Reporter 1st to arrive, CPR in progress
35 with shrapnel injuries
15 admitted- 10 required surgery in 1st 12 hrs
Ortho, vascular, thoracotomy, laparotomy, facial expl
19 treated and released

11. Olympic Park Bombing 61 pts to 3 downtown hospitals AMC:
4 operations: 2 wound closures; 2 shrapnel removal
15 minor victims to 7 other area hospitals

12. September 11, 2001 Commercial aircraft used as “bombs”
Twin towers- World Trade Center
Pentagon

13. Boston Marathon Bombing
April 15, 2013
3 killed
243 injured
152 presented to ED within 24 hrs of blast
All survived

14. Blast Devices

15. Blast Agents High-order explosive: HE Nitroglycerin (NTG) Dynamite
Plastic
Ammonium nitrate/ fuel oil (ANFO)
Trinitrotoluene (TNT)
Triacetone triperoxide (TAPT)
Low-order explosive: LE
Petroleum products
(“Molotov cocktail”)
Gunpowder
(“black” powder)
Can become HE, if contained (e.g., pipe bomb)

16. Blast Devices Improvised explosive devices (IEDs) Incendiary bombs
Car and truck bombs (Oklahoma City, World Trade Center I)
Letter and parcel bombs (Idaho “Unabomber”)
Pipe bombs (Atlanta Olympics)
Backpack and satchel bombs (Israel, London)
Incendiary bombs
Airplane bombs (World Trade Center II, Pentagon)
Rocket propelled grenades (RPGs)
Surface to air missiles (SAMs)

17. Blast Devices IEDs Improvised/“homemade” explosive devices
Made from explosives, commercial blasting supplies, or fertilizer and household ingredients
Designed to cause injury and death
Often packed with metal objects such as nails or ball bearings;
Could contain toxic chemicals or radiological materials (dirty bomb)

18. Blast Physics
Rapid chemical conversion of a solid or liquid into highly pressurized gases
Gases expand rapidly and compress the surrounding air

19. Blast Physics
Blast wave- causes an almost instantaneous rise in atmospheric pressure (barotrauma)
Normal is 14.3 psi
Overpressure: can exceed 4 million psi
Underpressure
Blast wind
Air pushed out of area, creating vacuum
Wind speed can be hundreds of mph

20. Blast Physics Importance of Injury Types vs. Distance
Emergency War Surgery, 3rd Edition

21. Scene Management: SAFETY / SITUATION

22. Initial Staging Safe Distance Stage upwind / uphill
Assess with binoculars
Liquids, contaminants, etc
Number of victims
Need for Incident Command

24. Scene Safety: Hazards Secondary devices Shrapnel Building collapse
Air-borne contaminants
Contaminated patients
Contaminated scene/environment
Perpetrators
Terrorist patients

27. Triage Field triage Unique patterns: Safe distance SALT / START
Dynamic process
Unique patterns:
Multiple injuries
Occult / hidden / internal injuries

28. Triage Walking wounded
Many non-critical patients who require time intensive workups
Up to 75% of victims self-refer to hospital via private transportation)

29. Crime Scene Life saving takes precedence
Avoid disturbing or compromising evidence (chain of custody)
Documentation of statements by victims and witnesses

30. Blast Injuries

31. Blast Injury: Severity
Nature of device – agent, amount
Method of delivery – incendiary, explosive
Nature of environment – open, closed
Distance from device
Intervening protective barrier
Other environmental hazards

32. Blast Injuries: Categories
Primary injury
Caused by blast wave → over pressure
Secondary injury
Caused by flying debris → shrapnel wounds
Tertiary injury
Caused by blast wind → forceful impact
Quaternary injury
Caused by other vectors → heat, radiation

34. Blast Injuries: Primary
Blunt trauma from over pressure wave
Unique to high-order explosives
Results from the impact of the over-pressurization wave with body surfaces
Barotrauma: blunt force injuries

35. Blast Injuries: Primary
Most common injuries:
Tympanic membrane (eardrum) rupture
Middle ear damage
Blast lung—pulmonary barotrauma
Abdominal organ perforation ( esp. colon)
Abdominal hemorrhage (solid organs)
Traumatic brain injury (TBI), concussion

36. Blast Injuries: Blast Lung

37. Blast Injuries: Secondary
Most common cause of death in a blast event is secondary blast injuries
Caused by flying debris generated by the explosion
Pieces of bomb / environment (glass)
Added screws, nails, etc.

38. Blast Injuries: Secondary
Most common types of secondary blast injuries are:
Penetrating trauma to the head, neck, chest, abdomen, and extremities
Fractures
Traumatic amputations
Soft tissue injuries

40. Blast Injuries: Secondary
Penetrating trauma (shrapnel wounds)
Foreign bodies follow unpredictable paths through body
May have only mild external signs
Have a low threshold for imaging studies (plain radiographs, computed tomograms)
Consider all wounds contaminated

43. Blast Injuries: Tertiary
Tertiary injuries result from individuals being thrown by the blast wind.
The most common types of tertiary blast injuries are:
Head injuries
Skull fractures
Fractures

44. Blast Injuries: Quaternary
Includes:
Burns
Biologic / radiologic / chemical contamination
Crush injuries
Exacerbation of chronic health conditions

45. Patient Assessment and Management

46. Airway / Breathing Intubate if necessary
Positive pressure ventilation in blast lung can result in air emboli

47. Blast Lung Clinical manifestations Treatment
Tachypnea
Hypoxia
Cyanosis
Apnea
Wheezing
Decreased breath sounds
Hemoptysis
Cough
Chest pain
Dyspnea
Hemodynamic instability
Treatment
High flow oxygen sufficient to prevent hypoxemia via non-rebreather mask
CPAP
Endotracheal intubation
Judicious fluid administration
Needle decompression

48. Circulation: Hemorrhage / Shock
Tourniquets
Manufacture ( NOT improvised)
Topical hemostatic agents
IV therapy / fluid resuscitation

49. Tourniquets

50. Abdominal Injuries Clinical manifestations include: Abdominal pain
Rectal bleeding
Rebound tenderness / Guarding
Diminished / absent bowel sounds
Signs of hypovolemia / unexplained shock
Nausea & vomiting

51. Blast Injuries: Combined Injuries
Avoid tunnel vision
Treatment protocols are often contradictory
Blast lung vs. burn injury
Blast lung vs. crush injury
Judicious fluid administration

52. Blast Injury: Combined Injuries
Typical confined space (e.g., a bus) injuries
Primary—blast lung, intestinal rupture, TM rupture
Secondary—penetrating injury to head, eye, chest, abdomen
Tertiary—traumatic amputation, fractures to the face, pelvis, ribs, spine
Quaternary— crush injuries, superficial and partial to full thickness burns

53. Special Considerations
Pregnancy- placental injuries
Children- pulmonary contusions
Evidence of chest injury
Elderly- disabilities, medical conditions, osteoporosis

54. Transport Destination
Trauma Centers capable of managing injuries

55. Summary Scene safety issues Injuries can be very complex
Hemorrhage control
Support ventilation / oxygen