Blast Lung Injury (BLI)

• Only 0.6% of blast injury survivors, but 80% will require intubation.
• Signs/symptoms: tachycardia, tachypnea, dyspnea, hemoptysis
• Clinically significant BLI will be symptomatic by arrival in ED. Mild injury may not manifest for several hourrs due to secondary inflammatory response.
• Primary BLI often mixed with secondary (penetrating fragments) and tertiary (pulmonary contusion) injuries.
• Chest X-ray: bilateral fluffy infiltrates in 'bat wing' pattern.
• CT: alveolar hemorrhage, commonly around the mediastinum; lacerations, pneumatoceles and pneumothoraces
• Vent settings: permissive hypercapnia, minimize peak pressures, use low volume/high PEEP as in ARDS except in presence of bronchopleural fistulas and pneumatoceles.

Assessing for Other Primary Blast Injuries

GI: diagnosis based on repeat clinical exam; radiologic studies including abdominal films, ultrasound, and CT scans are insensitive in the absence of intestinal perforation.

Brain: headache, tinnitus, hypersensitivity to noise, amnesia (retrograde and anterograde), symptoms commonly associated with PTSD

MSK: radiographs important not only to detect fractures but to detect radio-opaque foreign material and articular involvement.

Penetrating Injury

• Determine trajectory of fragments. Perform local wound exploration, except in case of many wounds.

Head: maintain cerebral perfusion & oxygenation. Seizure prophylaxis. Monitor and control ICP. If evidence of increased ICP, consult Neurosurgery for possible decompressive craniectomy.

Chest: Consider angiography, bronchoscopy, or esophagoscopy.

Abdomen: FOBT, UA & micro.

Extremities: Assess neurovascular function. Monitor for compartment syndrome.

General Guidelines

• Severe blast injury markers: >10% BSA burns, skull & facial fractures, penetrating head and torso injury.
• Pertinent history: distance from blast, enclosed space (amplifies blast effect) vs. open air, time since blast.
• Limit fluid administration as much as possible as patients are at risk for pulmonary edema.
• All patients with blast injuries need pan scan CT if resources and patient stability permit.
• TM perforation does not correlate to hollow organ damage. It only identifies patients who would benefit from a period of observation. Investigate hollow organs independently.
• All penetrating wounds are dirty. Start antibiotics (Augmentin or 2nd gen Cephalosporins to cover for soil), TDAP, and send to OR for I&D if necessary.