Blast injury: Difference between revisions
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===Spalling Effect=== | ===Spalling Effect=== | ||
Due to blast pressure forces, | ''Due to blast pressure forces, injuries are to organs with air-fluid interfaces (spalling effect)'' | ||
*TMs | *TMs | ||
*Alveoli | *Alveoli | ||
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! scope="col" | '''Example''' | ! scope="col" | '''Example''' | ||
|- | |- | ||
| Primary||Direct effect from shockwave||Sheer and stress forces||TM rupture, Ocular Injury, concussion, blast lung | | Primary||Direct effect from shockwave||Sheer and stress forces||[[TM rupture]], Ocular Injury, [[concussion]], blast lung | ||
|- | |- | ||
| Secondary||Impact of fragments|Penetrating trauma, amps, lacs|| | | Secondary||Impact of fragments||Penetrating trauma, amps, lacs|| | ||
|- | |- | ||
| Tertiary ||Blast propels body or large object into body||Crush and blunt trauma||Similar to MVC | | Tertiary ||Blast propels body or large object into body||[[Crush injury]] and blunt trauma||Similar to MVC: Fractures, [[Pneumothorax]], Hemopneumothorax | ||
|- | |- | ||
| Quaternary ||Environmental||Burns, Toxins, Weather|| | | Quaternary ||Environmental||Burns, Toxins, Weather|| | ||
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==Clinical Features== | ==Clinical Features== | ||
===Pulmonary=== | ===Pulmonary=== | ||
*Blast lung is the most common fatal PBI | *Blast lung is the most common fatal primary blast injury (PBI) | ||
*Pulmonary | *[[Pulmonary contusion]] | ||
*Pneumomediastinum due to alveolar rupture - | *[[Pneumomediastinum]] due to alveolar rupture - [[pneumothorax]], subcutaneous emphysema, [[pneumopericardium]], pneumoretroperitoneum, pneumoperitoneum, [[air embolus]] | ||
*Thrombosis, DIC, ARDS | *Thrombosis, [[DIC]], [[ARDS]] | ||
=== | ===HEENT=== | ||
*TM rupture most common - not a marker of PBI severity or prognosis | *[[TM rupture]] most common - not a marker of PBI severity or prognosis | ||
*Hemotympanum | *Hemotympanum | ||
*Ossicle injury | *Ossicle injury | ||
*Direct ophthalmic injury, | *Direct [[ocular Trauma|ophthalmic injury]], [[foreign bodies]], or ophthalmic artery [[air embolus]] | ||
===Thoracic=== | ===Thoracic=== | ||
* | *[[shock|Cardiovascular collapse]] (within seconds) | ||
* | *[[Hypotension]] due to impaired reflex that increases SVR | ||
===Infectious Disease=== | ===Infectious Disease=== | ||
*Transmission of disease due to penetrating trauma is rare but possible with HIV, HCV, HBV | *Transmission of disease due to penetrating trauma is rare but possible with HIV, HCV, HBV | ||
===Musculoskeletal=== | ===Musculoskeletal=== | ||
* | *[[Amputation]]s | ||
*Burns | *[[Burns]] | ||
===Markers of severe blast injury=== | ===Markers of severe blast injury=== | ||
*> 10% TBSA burn | *> 10% [[TBSA]] burn | ||
*Skull, facial | *Skull, facial fracture | ||
*Penetrating injury to head or thorax | *Penetrating injury to head or thorax | ||
*Traumatic amputations | *Traumatic amputations | ||
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{{MCI types}} | {{MCI types}} | ||
== | ==Evaluation== | ||
*CXR, CT chest | *[[CXR]] - butterfly distribution, bilateral patchy infiltrates | ||
*FAST, comprehensive CT | *CT chest | ||
*[[FAST]], comprehensive CT | |||
*Repeat clinical abdominal exams looking for peritonitis - X-rays, US, CT insensitive except in perforation | *Repeat clinical abdominal exams looking for peritonitis - X-rays, US, CT insensitive except in perforation | ||
*Initial CT head may not be enough - may require MRI for DAI | *Initial [[CT head]] may not be enough - may require [[MRI]] for DAI | ||
*Labs | *Labs | ||
**Consider | **Consider carboxyhemoglobin and electrolytes | ||
**Screening UA for significant explosions | **Screening [[UA]] for significant explosions | ||
**Burn labs (rhabdomyolysis, compartment syndrome, severe burns) | **[[Burn]] labs ([[rhabdomyolysis]], [[compartment syndrome]], severe [[burns]]) | ||
**DIC labs (PT, aPTT, CBC, D-dimer, thrombin time, fibrinogen) | **[[DIC]] labs (PT, aPTT, CBC, D-dimer, thrombin time, fibrinogen) | ||
**White | **[[White phosphorus]] labs ([[hypocalcemia]], [[hyperphosphatemia]], LFTs) | ||
== | ==Management== | ||
*pRBCs and FFP in 1:1 ratio with platelets for hemodynamically unstable | *[[pRBCs]] and [[FFP]] in 1:1 ratio with platelets for hemodynamically unstable patients | ||
*[[TM rupture]] - initial | *[[TM rupture]] - initial treatment supportive and enough for 75% with spontaneous healing; operative repair may be necessary for others | ||
*Operative exploration for peritonitis | *Operative exploration for [[peritonitis]] | ||
*[[Air embolus]] (rare) - isolate air in apex of LV by placing | *[[Air embolus]] (rare) - isolate air in apex of LV by placing patient in left decubitus, head down, feet up position | ||
==Disposition== | ==Disposition== | ||
*Ambulatory | *Ambulatory patient with normal TM evaluation at low risk for occult blast injury - discharge with precautions | ||
*All others require admission | |||
==See Also== | ==See Also== | ||
*[[Explosions]] | *[[Explosions]] | ||
*[[Wound ballistics]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
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{{#widget:YouTube|id=4Q208UposjQ}} | {{#widget:YouTube|id=4Q208UposjQ}} | ||
[[Category:EMS]] | |||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 23:35, 22 February 2021
Background
- Primary blast wave increased in closed space - detonation in corner has potential to increase blast yield to 8x
- Recent enhanced-blast weapons (EBW) disperses gas before explosion - larger blast wave with lower pressure amplitude that diffuses around corners
Spalling Effect
Due to blast pressure forces, injuries are to organs with air-fluid interfaces (spalling effect)
- TMs
- Alveoli
- GI tract
Situational Examples
- Military - young healthy soldiers with body armor reducing thoracic/abdominal injuries but significant groin and lower extremity injuries
- Civilian - children to elderly, higher rates of penetrating thoracic/abdominal injury
Injury Classifications
| Blast Type | Injury Cause | Injuries | Example |
|---|---|---|---|
| Primary | Direct effect from shockwave | Sheer and stress forces | TM rupture, Ocular Injury, concussion, blast lung |
| Secondary | Impact of fragments | Penetrating trauma, amps, lacs | |
| Tertiary | Blast propels body or large object into body | Crush injury and blunt trauma | Similar to MVC: Fractures, Pneumothorax, Hemopneumothorax |
| Quaternary | Environmental | Burns, Toxins, Weather | |
| Quinary | Bodily absorption of contaminates | Hypermetabolic state |
Effects based on blast pressure[1]
| Potential Injury | Pressure (PSI) | Structural Effects |
| Loss of balance/temporary ear damage | 0.5-3 psi | Glass shatters; facade fails |
| Slight chance of eardrum rupture | 5-6 psi | Cinderblock shatters; steel structures fail; containers collapse; utility poles fail |
| 50% chance of eardrum rupture | 15 psi | Structural failure of typical construction |
| Lung collapse/damage | 30 psi | Reinforced construction failure |
| Fatal injuries | 100 + psi* | Structural failure |
Clinical Features
Pulmonary
- Blast lung is the most common fatal primary blast injury (PBI)
- Pulmonary contusion
- Pneumomediastinum due to alveolar rupture - pneumothorax, subcutaneous emphysema, pneumopericardium, pneumoretroperitoneum, pneumoperitoneum, air embolus
- Thrombosis, DIC, ARDS
HEENT
- TM rupture most common - not a marker of PBI severity or prognosis
- Hemotympanum
- Ossicle injury
- Direct ophthalmic injury, foreign bodies, or ophthalmic artery air embolus
Thoracic
- Cardiovascular collapse (within seconds)
- Hypotension due to impaired reflex that increases SVR
Infectious Disease
- Transmission of disease due to penetrating trauma is rare but possible with HIV, HCV, HBV
Musculoskeletal
Markers of severe blast injury
- > 10% TBSA burn
- Skull, facial fracture
- Penetrating injury to head or thorax
- Traumatic amputations
Differential Diagnosis
Mass casualty incident
- Radiation exposure (disaster)
- Dirty bomb
- Bioterrorism
- Chemical weapons
- Mass shooting
- Natural Disaster (e.g. Hurricane, Earthquake, Tornado, Tsunami, etc)
- Unintentional large-scale incident (e.g. building collapse, train derailment, etc)
- Major pandemic
- Explosions
Evaluation
- CXR - butterfly distribution, bilateral patchy infiltrates
- CT chest
- FAST, comprehensive CT
- Repeat clinical abdominal exams looking for peritonitis - X-rays, US, CT insensitive except in perforation
- Initial CT head may not be enough - may require MRI for DAI
- Labs
- Consider carboxyhemoglobin and electrolytes
- Screening UA for significant explosions
- Burn labs (rhabdomyolysis, compartment syndrome, severe burns)
- DIC labs (PT, aPTT, CBC, D-dimer, thrombin time, fibrinogen)
- White phosphorus labs (hypocalcemia, hyperphosphatemia, LFTs)
Management
- pRBCs and FFP in 1:1 ratio with platelets for hemodynamically unstable patients
- TM rupture - initial treatment supportive and enough for 75% with spontaneous healing; operative repair may be necessary for others
- Operative exploration for peritonitis
- Air embolus (rare) - isolate air in apex of LV by placing patient in left decubitus, head down, feet up position
Disposition
- Ambulatory patient with normal TM evaluation at low risk for occult blast injury - discharge with precautions
- All others require admission
See Also
References
- ↑ Terrorism Handbook for Operational Responders by Armando Bevalacqua and Richard Stilp (1998) and the Department of the Navy EODB 60 A-1-1-4 (2001) “Table A-1 http://www.fema.gov/pdf/plan/prevent/rms/428/fema428_ch4.pdf
Video
{{#widget:YouTube|id=4Q208UposjQ}}