Traumatic Blast Injury

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Traumatic Blast Injury

Pneumo/hemothorax: chest tube

CT, depending on findings:

  • Hospitalize for observation or exploratory surgery
  • Prophylactic antibiotics

Inclusion Criteria
  • Patient in extremis with known or suspected blast injury
Exclusion Criteria
  • No blast injury suspected
  • Blast injury, stable or in extremis

Hemoptysis, dyspnea, or tachypnea?

Evidence of penetrating injury?

Pneumo/hemothorax: chest tube

Preform secondary survey

X-Ray Chest (2 view)

Evidence of penetrating injury?

X-Ray Chest (2 view)

Follow ATLS guidelines

Observe 4-6 hrs. If no deterioration, consider discharge.

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.

  • CT pan scan to r/o other injuries, hospitalize for SaO2 monitoring
  • Consider calculating BLI Severity Score to anticipate likelihood of ARDS.

  • Consider blast lung injury (BLI)
  • Administer O2
  • Insert peripheral IV
  • Labs: ABG, CBC, CMP, type & screen, hCG

Perform 2º survey

  • Insert peripheral IV
  • Labs: CBC, CMP, type & screen, hCG

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.

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