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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Blast Injury

Blast injuries result from the complex pressure wave generated by an explosion. Air-filled organs (e.g. ear, lung, and gastrointestinal tract) and organs surrounded by fluid-filled cavities (e.g. brain and spinal cord) are particularly susceptible to primary blast injury. The pressure wave dissipates quickly, causing the greatest risk of injury to those closest to the explosion. Injuries can also occur by other mechanisms due to a blast, e.g. impact from blast debris, being physically thrown, burns and inhalation of gases.

Although terrorism is an ever increasing concern, most blast injuries are caused by accidents such as gas explosions. The management will often involve implementation of the local major incident plan. Blast injuries are divided into 4 categories:

  • A primary blast injury is caused by the direct effect of blast overpressure on tissue. The injury almost always affects air-filled structures such as the lung, ear, and gastrointestinal tract.1
  • A secondary blast injury is caused by people being hit by flying objects.
  • A tertiary blast injury is caused by high-energy explosions and occurs when people fly through the air and strike other objects.
  • Miscellaneous blast-related injuries include all other injuries caused by explosions, e.g. due to fire or collapse of buildings.
Epidemiology

Frequency depends on both the political stability of the region, e.g. terrorism, and local factors such as occupational health and safety priorities.

Presentation
  • Lungs may show evidence of pulmonary trauma and pneumothorax. Wheezing may be due to pulmonary contusion, inhalation of irritant gasses or dusts, pulmonary oedema or adult respiratory distress syndrome (ARDS).
  • Rupture of tympanic membrane may but not always indicate additional more serious injury.2
  • Abdominal injuries from explosions may not be immediately obvious and serial examinations are often required. Intestinal haematoma can take 12-36 hours to develop.
Investigations

All investigations will be carried out by the within the emergency department but the following is a basic guide:

Management

See also Trauma Assessment and Resuscitation.

  • If there is any question of radiation or chemical contamination, decontamination of patients and equipment will be required.
  • There will inevitably be huge emotional as well as physical stress. Psychological help will be required from the outset and a calm, organised, supportive and caring approach to management of people involved in the accident is essential.

Drugs

  • Life support, including intravenous fluids and blood transfusions may well be required at the site of the accident.
  • Specific treatments may also need to be considered.
  • Cyanide poisoning:
    • Consider cyanide poisoning in patients exposed to combustion in an enclosed space.
    • Cyanide is produced by incomplete combustion of plastics.
    • Treatment for cyanide poisoning should be started for significantly ill patients while awaiting confirmatory test results.
    • Sodium thiosulfate and hydroxocobalamin are safe and appropriate empirical therapy.
Prognosis
  • Mortality rates vary widely.
  • Mortality is increased when explosions occur in closed or confined spaces.3
  • Tympanic membrane rupture indicates that a high-pressure wave was present and may be associated with more severe organ injury.


Document references
  1. Argyros GJ; Management of primary blast injury.; Toxicology. 1997 Jul 25;121(1):105-15. [abstract]
  2. Leibovici D, Gofrit ON, Shapira SC; Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury?; Ann Emerg Med. 1999 Aug;34(2):168-72. [abstract]
  3. Leibovici D, Gofrit ON, Stein M, et al; Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions.; J Trauma. 1996 Dec;41(6):1030-5. [abstract]

Internet and further reading Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
DocID: 1871
Document Version: 22
DocRef: bgp1881
Last Updated: 30 Jan 2009
Review Date: 30 Jan 2011

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest.

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