Blast Injuries: From Triage to Critical Care

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Mechanism of injury

Blast injuries are multicausal and multilayered. There are four layers or types of injury (Table 1): primary injuries (blast wave), secondary injuries (soft tissue trauma), tertiary injuries (displacement leading to blunt trauma), and quaternary injuries (exposure to biological, chemical, or radiological agents, in addition to burns, crush injuries, and psychological sequelae). The complexity of care for blast victims is that they may have all four layers of injury, with the most serious

Identification of victims at increased risk for primary blast injury

During the initial assessment of blast victims, a series of questions may be useful in identifying victims at increased risk for a primary blast injury (Box 1). The most important factors are distance from the blast, size of the explosion, location, and medium (air versus water). A victim's proximity to an explosion is the most important indicator of the likelihood of having a primary blast injury. The magnitude of the overpressure is inversely related to the cubed root of the distance from the

Triage of blast casualties

Effective triage, which is an ongoing and repeated process, is essential to ensure that the correct level of care is provided to all casualties. In mass casualty events, more than 50% of the casualties arrive at a medical facility without having received any medical care or triage. In Istanbul, 184 victims of two simultaneous suicide bombings arrived within 1 hour at a trauma center, 52% arriving by nonmedical transport. Of the 184 casualties, 171 had lacerations (93%) and 7 (4%) had

Initial emergency department management

In a mass casualty event, the general principle is the brisk, forward movement of casualties into the medical system (ie, from ED to operating room [OR] or ICU or discharged—never back to the ED) [28]. During the initial stages of a mass casualty event, casualties receive “minimal acceptable care” [29]. It is important for critical care nurses to understand what care is and is not provided initially during a mass casualty event, as the casualties arrive in the ICU after undergoing relatively

Primary blast lung injuries

BLIs are the most common cause of immediate death after an explosion [8]. In a study of 828 servicemen in Northern Ireland who were killed or injured by explosions, pulmonary injury was the only finding in 17% of the fatalities [22]. In another study of military deaths from explosions, 45% of the fatalities had a pulmonary injury [30]. The underlying pathology of BLI consists of alveolar overdistention and rupture and multifocal subpleural, intra-alveolar, and perivascular hemorrhages. Larger

Suicide bombing

Although the mechanisms of injury caused by a suicide bombings or acts of terrorism are similar to other blast injuries, the severity of the injuries is worse and the injuries more complex [101], [102]. In addition, the casualty patterns and distribution of injuries are different [103]. In contrast to other trauma, victims of terrorist acts (bombings and gunshot wounds) are younger. In a study of terrorist bombing incidents in Israel, 61% of the victims were between ages 15 and 29, compared

Summary

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries.

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    The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Air Force, the Department of Defense, or the United States Government.

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