1. Blast/Explosion Event
Introduction to:
Blast/Explosion Event
The University of South Alabama
Center for Strategic Health Innovation
© University of South Alabama Center For Strategic Health Innovation. All Rights Reserved.
These slides are a part of the ARRTC program and cannot be reproduced for commercial purposes.

2. Objectives
Develop a basic understanding of explosions and blast injuries to include:
Types of explosives
Mechanism of blast injuries
Overview of types of injuries
Patterns of patient flow to health care facilities
overview of injury assessment and treatment concepts
I changed the order of objectives and the lead sentence

3. Blast and Bombing Events
United States
April 19, 1995
Oklahoma City Bombing-
Murrah Building
Madrid, Spain- March 1, 2004
Other recent major attacks: India, Pakistan, United Kingdom
Most common type of terrorist attack globally.
168 Killed (including 19 children,
> 680 Injured
191 Killed, 1800 Injured

4. Classification of Explosives by Type
High-order explosives (HE)
Produce a supersonic over- pressurization shock wave
(examples: TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil
Low-order explosives (LE)
Create a subsonic explosion and over pressurization wave.
(examples include: pipe bombs, gunpowder, most pure petroleum-based bombs (Molotov cocktails) or aircraft improvised guided missiles
From:
Explosive and incendiary (fire) bombs are further characterized based on their source.
“Manufactured” implies standard military-issued, mass produced, and quality-tested
weapons. “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.
Manufactured (military) explosive weapons are exclusively HE-based. 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

5. Bomb and Explosion Injury Patterns
More serious injuries than usual MVA trauma
Higher Injury Severity Score-(ISS)
Lower Glasgow Coma Scale- (GCS)
Greater ICU need-longer stay
Higher hospital mortality
Longer rehabilitation

6. Explosion Injury Profiles
Terror Casualties
RTA Casualties
Penetrating
61%
1.75%
Penetrating & Blunt
12%
Penetrating, Blunt, Burn 4%
Blunt
18%
97.4%
Blunt & Burn 2%
0.1%
RTA= road taffic associated casualties—Info from article by Peleg—comparing Israeli terrorist attack casualties and RTA’s over 5 year period

7. Explosion Injuries: Body Regions and Severity
Explosions
RTA
Trauma %
ISS 16 + 1 43
9.4% ** 53 6% 2 26
24 % **
15% 3 15
49% **
12.5
35% 4
8.6
5.3
5 +
4.6
2.8
For patients with 1, 2 or 3 body regions injured the % of ISS 16 or greater is much higher than RTA patients with same number of body regions involved
Above 3 regions injured the % of ISS 16 or greater is more nearly equal

8. Patterns of Patient Flow to Hospitals
Half of all initial casualties will seek medical care over a one hour period
These will usually bypass EMS and transport selves to hospital
More severely injured will arrive after less severely injured
These may require prolonged extrication
Will usually be transported via emergency response personnel
Took out the patterns of injury statement– it needs a ppt of its own

9. Blast Injury Mechanisms
Primary
Secondary
Tertiary
Quarternary
Unique to HE, results from the impact of the over pressurization
wave with body surfaces. Gas filled structures
are most susceptible:
lungs, GI tract and
middle ear
Blast lung (pulmonary
barotrauma)
TM rupture and middle
ear damage
Abdominal hemorrhage
and perforation
- Globe (eye) rupture
Concussion (TBI without
physical signs of head
injury)
Results from flying debris and bomb fragments. Any body part may be
affected:
Penetrating ballistic
(fragmentation) or blunt
injuries
-Eye penetration (can be
occult)
Results from individuals
being thrown by the blast
wind. Any body part may be affected:
Fracture and traumatic
amputation
Closed and open brain
injury
All explosion-related
injuries, illnesses, or
diseases not due to
primary, secondary, or
tertiary mechanisms.
- Includes exacerbation or complications of existing conditions.
Any body part may be
Affected
Burns (flash, partial,
and full thickness)
- Crush injuries
Asthma, COPD, or
other breathing
problems from
dust, smoke, or toxic
fumes
- Angina
Hyperglycemia,
hypertension

10. Basic Assessment Focus for Blast Injuries
Important: Full impact and scope of injuries may not be immediately visible and may be delayed in onset
Key types of injuries and issues to monitor for with blast events:
-Trauma related to projectiles, blunt force or impact
Potential for fractures
Foreign body impalement (glass, shrapnel, nails, etc)
Tympanic membrane rupture
Can be a ‘red flag’ to monitor for CNS injuries
Blast lung/Abdomen
Airway obstruction/ compromise
Delayed onset of acute abdomen
Projectiles of all types and sizes---TM rupture is most common blast injury, but absence does not preclude blast injury in another region– TM rupture may reduce hearing and make patient appear confused on un responsive in the absence of head injury—
Blast injury to lung or abdomen may evolve slowly requiring frequent reassessment
Air way must be secured early if any sign of respiratory difficulty—air embolism may occur suddenly
Industrial and terrorist explosions may be accompanied with exposure to toxic material inhalation

11. Overview of Explosive-related Injuries
System
Injury or Condition
Auditory
TM rupture, ossicular disruption, cochlear damage, foreign
body
Eye, Orbit, Face
Perforated globe, foreign body, air embolism, fractures
Respiratory
Blast lung, hemothorax, pneumothorax, pulmonary contusion
and hemorrhage, A-V fistulas (source of air embolism), airway
epithelial damage, aspiration pneumonitis, sepsis
Digestive
Bowel perforation, hemorrhage, ruptured liver or spleen,
sepsis, mesenteric ischemia from air embolism
Circulatory
Cardiac contusion, myocardial infarction from air embolism,
shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury
CNS injury
Concussion, closed and open brain injury, stroke, spinal cord
injury, air embolism-induced injury
Renal Injury
Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, and hypovolemia
Extremity injury
Traumatic amputation, fractures, crush injuries, compartment
syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism-induced injury

12. Basic Overview of Treatment Concepts for Blast Injuries
Perform Trauma Assessment
Focus on Airway, Breathing and Circulation
Airway, oxygen, CPR as indicated; control bleeding and hemorrhage; maintain hemodynamic status with fluid replacement as appropriate**
Monitor for trauma- occult injury
Stabilize injuries, control bleeding
Early imaging– CT scan— head, chest, abdomen
Early interventions with appropriate MD specialists
( i.e. Trauma Surgeons)
** Caution: Fluid replacement can be a fine balance between therapeutic and overload depending on injury
IV therapy for hemorrhage with hypotension may be complicated by blast injury to lungs--- ventilation of patient may worsen lung injury if high pressures are used

13. Explosion and Blast Casualties
Explosions create instant MCE’s-rapid surge demand at scene and hospital
Complex multi-system injuries rarely seen outside of military operations
Unique and difficult patient care demands
Blasts in closed environments produce increased injury severity*****
Importance of history –inside or outside blast
Surge requirement for EMS, ED, ICU, Radiology, Trauma Surgery
Risk of secondary explosions at hospital in terrorist settings

14. In Conclusion:
Explosions and blast events can be high energy or low energy events
Critical patients will arrive to hospitals AFTER the ‘walking well’
Health effects and injuries from blast/explosions may have delayed onset
Injuries will be rated as trauma
Trauma assessment and interventions is best treatment concepts to implement!

15. Blasts and Explosions

16. QUESTIONS?