The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–15, 2015
Copyright Ó 2015 Elsevier Inc.
Printed in the USA. All rights reserved
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http://dx.doi.org/10.1016/j.jemermed.2015.03.013

Clinical
Review

BLAST INJURIES

Zara R. Mathews, MD* and Alex Koyfman, MD†

*Department of Emergency Medicine, Mount Sinai Medical Center, New York, New York and †Division of Emergency Medicine,
University of Texas Southwestern Medical Center/Parkland Memorial Hospital, Dallas, Texas
Reprint Address: Zara R. Mathews, MD, Department of Emergency Medicine, Mount Sinai Medical Center,
One Gustave L. Levy Place, New York, New York 10029

, Abstract—Background: Blast injuries in the United causing >20 dead at the scene are secondary to explosions
States and worldwide are not uncommon. Partially due to and fires from a variety of causes, and a 20-year retro-
the increasing frequency of both domestic and international spective analysis of bombing events by Kapur et al. iden-
terrorist bombing attacks, it is prudent for all emergency phy- tified 36,110 bombing incidents, 5931 bomb-related
sicians to be knowledgeable about blasts and the spectrum of
injuries, and 699 bomb-related deaths in the United States
associated injuries. Objective: Our aim was to describe blast
during the study period between 1983 and 2002 (1–4).
physiology, types of blast injuries associated with each body
system, and manifestations and management of each injury. In addition, the increasing frequency of both domestic
Discussion: Blast injuries are generally categorized as pri- and international terrorist bombing attacks in the last few
mary to quaternary injuries. Primary injuries result from decades has led to blast injuries formerly only experi-
the effect of transmitted blast waves on gas-containing struc- enced in the context of war (5). Conservative estimates
tures, secondary injuries result from the impact of airborne from the RANDÒ Memorial Institute for the Prevention
debris, tertiary injury results from transposition of the entire of Terrorism suggest that terrorist explosive events have
body due to blast wind or structural collapse, and quaternary risen worldwide fourfold from 1999 to 2006, and injuries
injuries include almost everything else. Different body sys- related to these acts have increased eightfold during the
tems are affected and managed differently. Despite previous same period of time (6). Compared to military explo-
dogma, multiple studies now show that tympanic membrane
sions, civilian blasts impact a wide range of humanity
perforation is a poor predictor of other blast injury. Conclu-
whose medical comorbidities can only be expected to
sions: Blast events can produce a myriad of injuries affecting
any and every body system. All emergency physicians should impede their ability to withstand and recover from these
be familiar with the presentation and management of these events (7). These victims frequently suffer from multidi-
injuries. This knowledge may also be incorporated into triage mensional injuries involving primary blast injuries,
and discharge protocols guiding management of mass casu- burns, and both blunt and penetrating wounds (8,9).
alty events. Ó 2015 Elsevier Inc. Penetrating wounds are seen more frequently in
terrorist civilian bombing attacks than military
, Keywords—blast; bombing; terrorism; disaster; mass explosions, largely because of the lack of body armor
casualty (7). A recent review of >3000 terrorist blasts victims re-
INTRODUCTION vealed a mortality rate of 13% on scene, and 30% of those
that survive require admission (10). Notable recent blast
Perhaps contrary to common perception, blast injuries in events include the World Trade Center (New York City,
the United States are not rare. Seventy percent of disasters 1993); Argentine-Israel Mutual Association (Buenos

RECEIVED: 22 August 2014; FINAL SUBMISSION RECEIVED: 4 January 2015;

ACCEPTED: 14 March 2015

1
2 Z. R. Mathews and A. Koyfman

Aires, Argentina, 1994); Murrah Federal Building (Okla- Types of Explosives

homa City, 1995); Olympic Park (Atlanta, GA, 1996); the
U.S. embassies (Tanzania and Kenya, 1998); Omagh Explosives are either high-order explosives that create su-
bombing (Northern Ireland, 1998); the September 11 at- personic blasts or low-order explosives that create sub-
tacks (New York City, Washington, DC, and Shanksville, sonic blasts with less sheer velocity (12). High-order
PA, 2001); Bali (2001 and 2005); Istanbul (2003); Madrid explosives include C-4, Semtex, trinitrotoluene (TNT),
commuter train bombings (2004); Jakarta (2003, 2004, gelignite, dynamite, nitroglycerin, and ammonium nitrate
2009); London Underground bombings (2005), Bangkok fuel oil; and low-order explosives include gunpowder,
(2007), the Boston Marathon (2013), as well as ongoing pipe bombs, as well as Molotov cocktails and most other
incidents in the Middle East (Iraq, Afghanistan, Jordan, petroleum-based bombs (11,12,19). Low-order explo-
Saudi Arabia, and Israel) (1,11,12). sives are generally utilized as propellants and pyrotech-
Particularly because of the ever-present risk of nics. Propellants are devised to produce a controlled
terrorism in today’s society, it is crucial for prehospital release of energy, and pyrotechnics are devised to create
providers and emergency physicians to familiarize them- light, smoke, heat, and sound (20). While homemade
selves with the myriad of injuries caused by blasts (12). bombs are often low-order explosives, this is not always
Blast events can bring about chaos and panic and often the case, as rogue states and large-scale networks that
overwhelm the capacity of medical facilities, who are sponsor terrorism can provide militants with the neces-
generally unaccustomed to caring for multiple trauma pa- sary supplies for the creation of high-order explosives;
tients simultaneously (9). Despite this, victims need to be additionally, ammonium nitrate, which is used in the cre-
directed to the appropriate level of care, and life- ation of some high-order explosives, can be easily
threatening injuries need to be promptly diagnosed and amassed in the form of crop fertilizers (12).
treated, as early recognition of blast injuries may improve The damage caused by explosives can be compounded
outcomes (13). by the addition of hazardous shrapnel (such as nails,
screws, or ball bearings) or infectious agents, such as hep-
atitis B or C from blood debris (21,22). Additionally,
DISCUSSION
evolving technology has allowed improvised explosive
Blast Physiology devices (IEDs) to be triggered remotely via cell phones
and with complex timing for the initiation of multiple
Blasts are created by the instantaneous transformation of blasts (23).
solid or liquid matter to its gaseous form, which produces ‘‘Dirty bombs’’ can exponentially increase blast-
energy in the form of light, sound, heat, and pressure related destruction through the addition of nuclear mate-
(5,14). When a high-order explosive detonates (defined rials or chemical agents that are dispersed when the bomb
in section on Types of Explosives), a ‘‘blast wave,’’ or sig- goes off (12,24). Newer thermobaric (or enhanced-blast)
nificant air pressure elevation is created. The blast wave weapons emit gas before exploding, which leads to a
can travel at a rate as fast as 8000 m/s, and can reach larger pressure wave that has the ability to extend around
pressures up to 30,000 times atmospheric pressure corners and cause a much greater path of destruction than
(11,15–17). The energy of the blast wave dissipates and with conventional explosives (7).
its pressure decreases as the wave travels. Blast wind,
which follows the blast wave, consists of powerful, fast-
CLASSIFICATION OF BLAST INJURIES
moving, superheated air that can lift bodies and destroy
structures, which can result in both blunt and penetrating Primary Blast Injury
injuries (6,7,11).
The blast wave leads to injury through spalling, implo- Blast injury is typically classified as primary to quater-
sion, and inertia. Spalling is ‘‘displacement and fragmenta- nary, occasionally as primary to quinternary/quinary.
tion of the denser into the less dense medium.’’ Alveolar Blast waves themselves cause primary blast injuries
hemorrhage is an example effect of spalling in the lung. (PBIs) and generally affect gas-containing organs, most
Implosion is ‘‘displacement of the less dense into the denser commonly the eardrums and lungs and, to a lesser extent,
medium.’’ Air emboli traveling into the pulmonary circula- bowel (25). As mentioned already, PBI develops when a
tion is an example effect of implosion in the lung (7,18). blast wave accelerates and decelerates while traveling
The definition of inertia is ‘‘shear stress created by the through tissues of varying density (11).
blast wave traveling through tissues of different densities Unlike other forms of blast injury, body armor
at different velocities.’’ In the abdomen, for instance, this cannot protect against PBI (11,26). Examples of PBIs
can cause tissue tearing secondary to disparate movement include blast lung, ‘‘hemothorax, pneumothorax,
of the abdominal wall and viscera (11,16,18). tension pneumothorax, acute arterial gas embolism,
Blast Injuries 3

gastrointestinal (GI) perforation, blast-induced neuro- thought to be caused by chemicals involved in the blast
trauma, eye rupture, and tympanic membrane perfora- (22,34) (Table 1). One source reports a potential descrip-
tion’’ (11). tion as ‘‘a unique hyper-inflammatory state manifesting
Blast lung is most frequently responsible for death in as hyperpyrexia, sweating, and low central venous pressure
victims of PBI (11). Of all victims who are killed secondary despite adequate fluid input’’ (22,35).
to blast injuries, 17% to 47% are thought to have signs of
blast lung (6,11). The pathophysiology includes capillary QUALITIES THAT AFFECT SEVERITY OF
rupture within the alveoli, which leads to hemorrhage and BLAST INJURIES
pulmonary edema. This ultimately reduces gas exchange,
causing both hypoxia and hypercarbia (1,11,27,28). Blast injury severity is determined by numerous factors,
including explosive agent, explosion location, amount
Secondary Blast Injury of explosives used, the victim’s prior health, as well as
the victim’s location and proximity to the blast (9,12,29).
Secondary blast injuries result from the direct impact of
airborne debris because of blast wind (11,29). During Location of Explosion
an explosion, blast-energized environmental fragments
or pieces of the explosive device become projectiles Blast location in either open or closed space significantly
and frequently cause penetrating injury (29). The frag- affects both the quality and degree of blast injury (13,36).
ments that cause secondary injury can be classified as pri- In confined spaces, the blast wave reflects off the building
mary, those that originate from the bomb itself, or structure, slowing the dissipation of the blast wave and
secondary, those that originate from the surrounding envi- consequently amplifying its capacity for destruction
ronment (11,30). Unlike PBI, body armor can protect (29,37). Confined-space explosions also contribute to
from secondary blast injury (11). greater damage by generating more structural and envi-
ronmental fragments, which often result in more pene-
Tertiary Blast Injury trating blast injury (5,29). Leibovici et al. showed that
casualties of closed-vs. open-space explosions have a
Tertiary injury results from transposition of the entire body significantly higher mortality rate (15.8% vs. 2.8%),
due to blast wind or structural collapse and can result in greater Injury Severity Score (ISS) in those that survive
blunt or crush injuries, depending on the situation (11 vs. 6.8), and both increased PBIs and notable burns
(29,31). Tertiary blast injuries include head trauma, (36).
fractures, blunt trauma, and traumatic amputations (11). Additionally, blast waves are also transmitted faster
Traumatic amputations are thought to occur in 1% to through water than air, leading to greater destruction in
7% of blast victims, but there is some discrepancy within the event of an underwater blast (6).
the literature as to its categorization. Multiple sources
classify traumatic amputations as tertiary, and others Amount of Explosives Used
consider them PBIs (1,6,11,32). Horrocks and Harrison
et al. suggest a combined primary and tertiary Blast force increases as the amount of explosive material
mechanism where bones are fractured by blast wave is increased, and this range of force results in a wide range
while surrounding soft tissue is torn by blast wind, of clinical consequences (9). The auditory system can be
resulting in near- or total-limb avulsion (11,14,33). injured in victims exposed to pressures as low as 2 psi and
tympanic membrane (TM) perforation occurs in half of
Quaternary Blast Injury those exposed to 15 to 50 psi. Lung injury develops in
half of those subjected to 70 psi, while perforation of
Quaternary blast injuries include most other blast effects the GI tract is generally seen only with higher pressure
not categorized by primary to tertiary injury. These (9,38). Pressures >80psi are fatal for >50% of victims (9).
include burns, radiation exposure, inhalational injury,
asphyxia, crush injuries, angina, hypertension, psycho- Proximity and Position of Victim in Relation to the Blast
logical consequences, and others (11,29,31).
The closer a victim is to the center of a blast, the greater
Quinternary/Quinary Blast Injury the consequences the blast wave will have (6). It has been
found that a distance of >16 m is protective from signif-
The majority of literature does not include this category of icant PBI for explosions resulting from up to 25 kg of
blast injury, but it is occasionally mentioned and described TNT (9,25). The victim’s orientation respective to the
as a delayed hyper-inflammatory response possibly blast, including the angle and height of the victim in
 4 Z. R. Mathews and A. Koyfman

device, secondary fragments come from

relation to the center of the explosion, is also important in

Quaternary classification is a diagnosis of

Unlike all other forms of blast injury, body

Majority of literature does not include this

Some argue that traumatic amputations
determining the extent of injury (12).

Primary fragments originate from bomb

the environment (wood, debris, etc.)

are due to a combined primary and

tertiary blast mechanism (11,14,33)
BLAST VICTIMS VS. NONBLAST TRAUMA
VICTIMS
Key points

category of blast injury

armor is not protective

Blast victims in comparison to victims of traditional

trauma tend to have worse injuries, more often require
intensive care, and generally necessitate longer hospital
stays and recovery periods (7,36,39). Israeli studies
exclusion evaluating blast injury victims have determined that the
number of seriously injured (ISS $ 16) by blasts is
three times higher than those seriously injured in
traditional trauma scenarios, and four times higher for
Burns, radiation exposure, inhalational injury,
hemothorax, pneumothorax, acute arterial
gas embolism, GI perforation, concussion

victims with a Glasgow Coma Scale (GCS) score # 5

without signs of external head injury, eye

One potential description: ‘‘hyperpyrexia,

sweating, low central venous pressure

(12,34,40,41).
Perforated TM, pulmonary barotrauma,

despite adequate fluid input’’ (32,33)

Head injuries, blunt trauma, fractures,

asphyxia, crush injuries, angina,

CLINICAL CONSEQUENCES OF PRIMARY

Blunt trauma, penetrating injury
Example injuries

hypertension, psychological

BLAST INJURY
Ears
traumatic amputations

consequences, etc.

The auditory apparatus is particularly prone to blast

injury and is the most frequently damaged organ during
blast events, as a relatively low pressure is sufficient to
rupture

cause damage to the TM (38,42). Although the TM can

perforate at a pressure < 0.5 atmospheres, a pressure 8
to 10 times greater is required to directly injure
nonauditory organs (43). Many factors contribute to
Gas-containing organs

risk of TM rupture, including the pressure amplitude of

commonly bowel)
Areas affected

the blast, position of the head and ear in relation to the ex-
(TM, lungs, less

plosion, the presence of internal cerumen or external pro-

Any body part

Any body part

Any body part

Any body part

tective equipment, and history of ear infection or injury

(7). Patients with TM perforation can experience otalgia,
tinnitus, hearing loss, and dizziness. Otoscopy is
adequate to confirm diagnosis (7,44).
Traditionally, TM perforation is thought to be an indi-
Injury due to direct effect of blast wave

thought to be caused by chemicals

Injury due to direct impact of airborne

Delayed hyperinflammatory response

Injuries not categorized by primary to
Injury caused by displacement of the
entire body, either from blast wind

cation of blast exposure that should prompt pursuit of

other common, yet less recognizable blast injuries (9).
debris because of blast wind

For this reason, blast victims with TM rupture are

Table 1. Primary to Quinternary/Quinary Injury

frequently observed overnight because of concern for de-

involved in blast (31,32)

GI = gastrointestinal; TM = tympanic membrane.

Definition

or structural collapse

layed respiratory decompensation secondary to occult

pulmonary damage (9). The necessity of this practice
has not been proven by current data or literature, but con-
tertiary injury

tinues to guide management protocols in numerous insti-

tutions (45). However, a landmark study was performed
by Harrison et al. in 2009 in Iraq that evaluated 167 pa-
tients with blast injuries at a U.S. military hospital. Of
these victims, 16% (26 of 167) had TM perforation.
(Quinternary/quinary
Type of blast injury

Seven percent (12 of 167) had PBI, but only half of those
Quaternary injury
Secondary injury

with PBI (6 of 12) also had TM rupture (22,43). PBI for

Primary injury

Tertiary injury

the purposes of this study was defined as PBI aside

from TM rupture, such as ‘‘pneumothorax,
injury)

pneumomediastinum, pulmonary contusion, facial sinus

injury, or bowel perforation’’ (43). This study, the results
Blast Injuries 5

of which have been reproduced by others, shows that delayed for 24 to 48 h after exposure (54). This impression
despite traditional belief, TM perforation is a poor marker was questioned by Leibovici et al. and Pizov et al. in 1999
for PBI (22,43). As a result, some now recommend that (45,55). Pizov et al. studied 15 victims with blast-related
blast victims with isolated TM perforation be injury to the lung. Intubation was necessary for each of
discharged after a period of observation to free critical these victims either on scene or upon presentation to the
hospital resources in the event of a mass casualty emergency department; notably, none of the patients
scenario (45). without mechanical ventilation for 6 h after the initial
Conservative care is the primary management for TM event subsequently developed blast lung (54,55).
rupture; although some eventually require operative Similarly, none of the patients with pulmonary blast
repair, the important principle for most is simply prevent- injuries in the report by Leibovici et al. had damage to
ing additional damage, and no antibiotic or other medica- the lung that manifested over time, all had a fulminant
tions are advised (7). The majority of those with TM clinical course that was apparent not long after
rupture have good prognosis and experience healing presentation (45). Current thinking is that evidence of
without any intervention, however, up to 30% develop acute lung injury after 48 h post-explosive event is most
permanent hearing loss (7). likely related to systemic inflammatory response syn-
drome or sepsis rather than PBI, and standard management
Lungs algorithms should be followed for these patients (54).

Aside from the auditory apparatus, the lungs are thought GI Tract
to be the organ most vulnerable to PBI (44). PBI of the
lungs develops due to blast wave transmission across Primary blast injuries of the GI tract are uncommon and
the chest wall and airway structures and is found in occur in only 0.3% to 0.6% of survivors (56). Blast in-
0.6% to 8.4% of those exposed to blasts (46–49). Lung juries of the GI tract are generally less common than
PBI is frequently evident in blast victims killed on TM or lung injuries, but their rate of occurrence is actu-
scene, but is present in a much smaller percentage of ally similar to that of lung injuries in open-air blast set-
survivors (7,46,50). Common PBIs to the lung are tings free of obstacles (11,16,44,57). Like other forms
contusions and barotrauma, which can include of PBI, GI injuries are seen more often in blasts that
pneumothorax, pneumomediastinum, and interstitial or occur in confined spaces (7). These injuries are also
subcutaneous emphysema (44). The definition of blast more likely in underwater explosions, as blast waves
lung is PBI of the respiratory system (44). It may also travel more easily in water than air (7,25).
be referred to as pulmonary blast lung injury, and diffuse Hollow abdominal organs are more commonly
lung contusions are its hallmark (51). Those with pulmo- damaged by PBI than solid organs. Gas-containing or-
nary blast injuries can have dyspnea, cyanosis, cough, he- gans can develop edema, hemorrhage, intestinal contu-
moptysis, and chest pain; they often present with sions, intramural hematomas, and frank hollow organ
hypovolemic shock, respiratory distress, or both rupture (9,44). Case studies have shown that even
(44,45). In general, explosions in closed spaces cause delayed bowel perforation can occur in these patients
bilateral pulmonary injuries, and open-air blasts cause from evolving mucosal damage (diagnosed at
greater injury ipsilateral to the event (52). laparotomy) (58). Solid organs like the liver, spleen,
Primary blast injury of the lung is associated with a and kidney are rarely affected by PBI, but when they
mortality rate of 11% (10). For those that survive, imme- are, subcapsular hematomas often develop (44,59).
diate diagnosis and prompt resuscitative efforts are Patients with blast injury to the GI tract can have ‘‘clin-
imperative, but long-term prognosis appears to be good ical signs of absent bowel sounds, bright red blood per
(7,45). Hirshberg et al. conducted a study of 11 patients rectum, guarding, and rebound tenderness, and symptoms
with lung injuries secondary to a bus bombing in Israel of abdominal pain, nausea, vomiting, diarrhea, and
(53). Notably, none of these patients endorsed pulmonary tenesmus’’ (44).
complaints after 1 year, and all had normal lung examina-
tions, normal lung function testing, and resolution of im- Eyes
aging abnormalities at this time. As a result, the study
deduced that surviving blast victims with pulmonary in- Blast injuries to the eyes mainly fall into two categories.
juries generally experience resolution of lung damage Primary injuries result from shear forces and manifest as
within 1 year (12,53). hemorrhages, detachments, or even globe rupture. Blast-
Much of the conventional thinking that those with TM induced projectile fragments cause secondary injuries
perforation should be hospitalized for observation comes and are generally more common than primary ocular in-
from the idea that the development of blast lung may be juries (60,61).
6 Z. R. Mathews and A. Koyfman

The incidence of ocular trauma after an explosion is blunt trauma; there are many resultant contusions and
surprisingly high, given the relatively small surface area microscopic injuries, which can predispose to
of the eye (approximately 0.1% of total body surface dysrhythmia (70). Animal studies in particular have
area) (1). Up to 10% of all surviving blast victims are demonstrated vagally mediated bradycardia and hypoten-
thought to have notable ocular injuries (12). Those seen sion as a result of blasts (22,56). The belief is that blast
most frequently are intraocular foreign bodies, corneal casualties might be in profound shock without signs of
abrasions, lacerations of the lid or periorbital region, hemorrhage or other common causes for hypotension,
retinal detachment, orbital fractures, and globe rupture and their low blood pressure is frequently refractory to
(1,61–63). resuscitative efforts (64). Shock in these patients is
thought to be a direct effect of the blast wave: there is a
Brain decrease in cardiac index without a compensatory in-
crease in systemic vasoconstriction. In addition, PBI to
Blast-induced brain injury may be more common than the lung is also likely to cause alveolar-capillary derange-
previously believed (7). Dougherty et al. conducted a ment, which can lead to pulmonary hypertension and
retrospective cohort study in 2011 of 2254 blast-injured resultant cor pulmonale (64). It is important to note that
American personnel in Iraq and concluded that 37% blast-related hemorrhage can contribute to hypotension
had sustained some amount of blast-induced neurotrauma in blast victims with cardiovascular injury; medical
(11,26). Furthermore, a recent review of 3000 victims of providers should be aware that a patient can have blast-
terrorist bombings found that head injury is a major related hemorrhage but might lack compensatory tachy-
reason for both early and delayed blast mortality (7). In cardia because of blast-induced bradycardia and other
general, the high mortality rate of secondary penetrating direct blast effects on the cardiovascular system (71).
injury to the head makes this injury less likely to be seen Another cardiovascular complication of blasts, though
in victims who survive to seek medical treatment (64). rare, is air embolism of the systemic or coronary vascula-
Blast-related brain injuries can vary from minor to ture (7). Coronary air emboli manifest with coronary
fatal. More significant injuries include subarachnoid ischemia (electrocardiogram changes and dysrhythmias),
hemorrhage, subdural hemorrhage, and hyperemia of and cerebral air emboli can manifest as motor weakness
the brain and meninges (28,65). Symptoms of blast- to seizures, loss of consciousness, or coma (1). The great-
related brain injury include headache, tinnitus, hypersen- est risk of air emboli is within the first 24 h after injury, un-
sitivity to noise, retrograde and anterograde amnesia, and less casualties are receiving positive pressure ventilation
findings of post-traumatic stress disorder (7). This (PPV), in which case this risk increases (72). The combi-
constellation of symptoms has been labeled with various nation of hypotension, notable air leak, and decreased
terms previously, such as shell shock, shell concussion, end-tidal CO2 are diagnostic signs of air embolism (51).
and combat fatigue; its clinical presentation can range Another rare cardiovascular complication of blast
from subtle dysfunction to complete unresponsiveness, injury is thoracic compartment syndrome (51). It is char-
but most of these patients present with a normal GCS acterized by a significant decline in blood pressure every
(1,66). time PPV is applied; in essence, edematous tissue or he-
It is not fully understood how exactly blast leads to matomas within the mediastinum cause constriction of
traumatic brain injury (TBI) (17,67), but it may be due the heart and prevent its normal function (51). Thoracot-
to rupture of cortical vessels leading to diffuse axonal omy is the advised management for thoracic compart-
shearing and intracerebral, epidural, and subdural ment syndrome (51).
hemorrhage formation (1). It is suggested that mild TBI
might be due to free radical release and neuronal cell Musculoskeletal System
death (68).
Musculoskeletal injury is exceedingly common in vic-
Cardiovascular System tims of blast events and accounts for >80% of all surgical
procedures in those that survive (10). These soft tissue
Cardiovascular dysfunction can manifest in a small sub- and bony injuries can result by any of the four blast mech-
set of patients after close proximity blast exposure (64). anisms, but secondary musculoskeletal injury is believed
Literature on this subject is sparse, but a study by Irwin to be more common than primary (7).
et al. in 1997 conducted on rats reported a bimodal car- Crush injuries from blast injuries are particularly signif-
diovascular response after blast injury; the primary effect icant because untreated, they can progress to rhabdomyol-
takes place within seconds, while the secondary effect ysis, renal failure, and death from acidosis and extreme
takes several hours to develop (7,69). In general, blasts metabolic derangements (64). Rhabdomyolysis can also
can cause cardiac damage comparable to that caused by occur without overt crush injury and can arise from
Blast Injuries 7

prolonged forced positions, such as those encountered by Another common, nonphysical form of quaternary
blast victims trapped in enclosed spaces after structural injury is acute stress reaction, which is thought to affect
collapse (64,73). The diagnosis of rhabdomyolysis is approximately 20% of casualties in terrorism-associated
confirmed with elevated creatine kinase in serum or the blasts (9). Acute stress reactions are a normal reaction
presence of myoglobin in urine (64). to intense stress and are characterized by impaired
Traumatic amputations or limb avulsions occur in 1% response to external stimuli; victims can experience
to 3% of blast victims (74,75). These injuries, particularly tremors, hyperventilation, sweating, decreased awareness
blast-associated amputation proximal to the wrist or and ability to listen, overwhelming depression, anxiety,
ankle, signify poor prognosis, as they suggest likely anger and guilt, and might frequently re-experience the
serious concomitant internal injury (12). As few as 1% traumatic event (9). Symptoms of acute stress reaction
to 2% of these patients live long enough to receive hospi- may or may not proceed along the continuum toward
tal care (10,45). Furthermore, the amputated parts, if acute stress disorder or post-traumatic stress disorder.
present, are rarely salvageable (12). Early psychiatric support can prevent this progression (9).

CLINICAL IMPLICATIONS OF SECONDARY GENERAL MANAGEMENT OF BLAST INJURIES

BLAST INJURY
In general, all blast injury victims need to be managed
Penetrating secondary blast injury of the chest and first following standard advanced trauma life support
abdomen are common blast injuries, particularly in urban (ATLS) algorithms (44). After the patient is stabilized,
bombings (9). Suicide bombers often plan to maximize the organ systems specifically affected by blast injury
injury by adding various items such as nails and screws should be more specifically evaluated, with particular
to their explosive charge (9). These projectiles can result attention paid to the lethal manifestations of PBI of the
in a myriad of consequences, ranging from superficial to thorax and abdomen (44).
lethal wounds, depending on their velocity and shape (9).
These fragments generally fly with great force and can Ears
cause occult penetrating wounds concealed by hair or
clothing (76). These victims may walk in to the ED appar- Because acoustic trauma is a common blast injury,
ently well, yet have penetrating injuries that can threaten routine otoscopy is mandatory for all blast casualties
their life (76). (9). Specific treatment of TM rupture consists of sterile
Another consideration involving secondary blast irrigation and the removal of internal debris. While surgi-
injury is that blast fragments can carry environmental cal closure is recommended if the rupture is greater than
debris into a wound (77). Human shrapnel is another one third of the TM, the treatment for most eardrum
consideration, particularly for suicide bombings; bone perforation is simply conservative care and the prevention
chips generally behave as other projectiles, but can addi- of additional damage (44,79).
tionally create numerous emotional, ethical, as well as in-
fectious consequences for both patients and health care Eyes
providers alike (9,78).
Routine ophthalmologic evaluation is also mandatory for
CLINICAL IMPLICATIONS OF TERTIARY AND all blast casualties as eye injuries, even minor ones, such
QUATERNARY INJURY as foreign bodies and smoke particles, are common after
blasts (9). Liberal referral for more extensive screening is
Generally, tertiary blast injury is similar to other mecha- encouraged with any findings of decreased visual acuity
nisms of blunt trauma, but in combination with other cat- (12).
egories of injury associated with blasts, caring for these
victims can be more complex than those with isolated Lungs
blunt trauma (9).
Burns are a common presentation of quaternary injury. Pulmonary blast injuries are notoriously difficult to
They can vary from superficial burns to deep second- and manage, as they can present with characteristics of acute
third-degree burns (9). The superficial ‘‘flash’’ burns are respiratory distress syndrome (ARDS) as well as air embo-
typically caused by the explosion flame and can affect lism (12). Generally, lung contusions can be treated with
large body areas at once. Deeper burns are typically supportive care. Intubation is indicated for those with blast
caused by fires ignited by the explosion and generally injuries who are unstable or who require emergency sur-
affect variable amounts of body surface area, depending gery (1). PPV is beneficial in that it can correct respiratory
on exposure time to the flames (9). distress and ameliorate hypoxemia, but it can also cause
8 Z. R. Mathews and A. Koyfman

barotrauma or arterial air embolism (44,80). Blast victims should be resuscitated after standard ATLS protocols and
with severe lung injury also commonly require elevated assessed for possible surgical intervention (71).
positive end-expiratory pressure (PEEP) in addition to While evidence of intestinal perforation can be noted
PPV (51). High PEEP, however, can aggravate already on x-ray study, ultrasound, or computed tomography
friable lung parenchyma and may result in pneumothorax (CT), none of these modalities are able to diagnose other
or other complications (51). primary GI blast injuries, such as intestinal contusion (7).
If mechanical ventilation is utilized for primary blast Contusions of the bowel are notable as they can occasion-
lung injury, it is critical that a lung protective strategy is em- ally result in delayed ‘‘secondary perforation’’ of the in-
ployed (7). Peak airway pressures should be minimized by testine (7,44). Studies suggest that most of these
adjusting respiratory rate, tidal volume, I:E ratio, and inspi- secondary perforations develop 3 to 5 days after initial
ratory flow rate (7). In general, low inspiratory pressure injury, but occasionally develop up to 2 weeks later
with avoidance of PEEP is ideal, but patients that are diffi- (84). For this reason, a high level of suspicion is essential
cult to ventilate may require higher airway pressures (1,55). to making this diagnosis.
Permissive hypercapnia can also be considered as a means Esophageal perforation should also be considered in
to decrease peak inspiratory pressure, but cannot be used in blast victims who present with chest pain, dyspnea, or
patients with neurologic injury (1,81). subcutaneous emphysema (85). Diagnosis of this injury
When conventional mechanical ventilation is unable to would be made by esophagram, and primary repair,
maintain adequate oxygenation in a blast lung injury although not always required, is the most common
victim, advanced ventilator support technologies that treatment (85).
have been helpful for treating primary blast lung injury
include different types of pressure-controlled ventilation, Brain
jet ventilation, nitric oxide, and high-frequency oscillatory
ventilation (9,55,82). These modes confer the benefit of The ideal treatment of blast brain injury is at this time (7).
overcoming hypoxemia without increasing PEEP A 2007 study by Earle et al. suggests that cerebrovascular
excessively (55). However, there is a paucity of data to resuscitation is optimized when i.v. fluid is limited (49).
determine which mode is preferable, and benefit has only This study used anesthetized swine with blast injuries
been suggested through case reports (7,51,54). Prone to the head and chests due to blot guns. While longer-
position has also been suggested to improve oxygenation, term studies are still required, this study found that
but is likely impractical during the management of blast limiting i.v. fluid after resuscitation to standard mean
victims in the emergency department (51). Extracorporeal arterial pressure and cerebral perfusion pressure targets
membrane oxygenation (ECMO) provides an alternate with mannitol and pressor therapy after polytrauma atten-
method of providing cardiac and respiratory support to pa- uated intracranial hypertension and allowed maintained
tients who are severely ill. However, its use requires brain oxygenation (49).
caution, as the only case report documenting the applica- There are multiple areas of controversy regarding sec-
tion of ECMO in this setting also detailed the patient’s ondary penetrating injury to the head, including indica-
death due to pulmonary hemorrhage attributed to the tions for removal of bony or foreign fragmentation and
required systemic anticoagulation (55). extent of debridement (64).
Although not commonly suggested in current litera-
ture, the placement of empiric bilateral thoracostomy Cardiovascular System
tubes was advocated previously for primary blast lung
injury as a preventive measure, and benefit has reportedly When blast-related cardiac dysfunction is suspected,
been seen in specific cases (22,54,83). However, current inotropic support should be provided in lieu of overly
thinking is that this practice is unnecessary in the aggressive fluid infusion, as associated lung injury is
absence of pneumothorax, but may be considered common (62).
before air transportation of lung PBI victims (7). Optic fundoscopy, echocardiogram, and CT head are
When resuscitating blast victims, it is important to be unfortunately all frequently nondiagnostic for air embo-
aware that aggressive i.v. hydration can cause pulmonary lism, so treatment can be initiated empirically if there is
edema in those with blast injury of the lung (6,7,11). clinical concern for this diagnosis. Treatment is generally
supportive in nature, and its goal is primarily trapping of
the responsible air within the left ventricular apex to pre-
GI Tract vent subsequent air emboli. This can be done by placing
the patient in simultaneous left lateral decubitus and
The emergent management of GI blast injuries is similar Trendelenburg position (head down, feet up, on left
to the management of general abdominal trauma; patients side) (7). It is for what length of time this position should
Blast Injuries 9

be continued (7). Patients with air embolism typically Infectious Disease Considerations
reach their nadir of oxygenation within the first 24 h,
and it is important to have 100% oxygen administered; Blast victims will often have multiple soft-tissue lacera-
hyperbaric oxygen can also be used to decrease the size tions. Unlike simple thermal burns that do not require
of the gas bubble, although this therapy has not been stud- prophylactic antibiotics, blast-related lacerations require
ied extensively (1,7,86,87). If the patient requires PPV, antibiotics to cover environmental contaminants, particu-
further embolization may be limited by minimizing larly gram-positive organisms (54,96). Those with
peak inspiratory pressure (7). wounds breaching the abdominal cavity also require
coverage for gram-negative and anaerobic organisms
(54).
Musculoskeletal System
Blood-borne infections, such as hepatitis B virus, hep-
atitis C virus, and human immunodeficiency virus, pose a
The management of blast-induced skeletal injuries in-
potential hazard for blast victims as well as prehospital
cludes plain films to evaluate for fracture and foreign
and hospital providers, given the large amount of blood-
bodies, tetanus prophylaxis, and broad-spectrum antibi-
shed and secondary fragments associated with blasts (22).
otics if the fracture is open (88). For the many blast vic-
The U.S. Department of Health and the UK Health Pro-
tims that present with fractures, early fixation (typically
tection Agency currently recommend standard individu-
external) is advocated (64). Like with an extremity injury
alized assessment for those splashed with blood as well
of any cause, it is also important to consider the possibil-
as an accelerated vaccination schedule for victims of
ity of compartment syndrome (7).
penetrating blast injuries who are unvaccinated against
The treatment of small fragment wounds due to blasts
hepatitis B (22,97).
remains a controversial subject (1). Several studies have
assessed a conservative approach to wound management
Radiologic Considerations
consisting only of irrigation, tetanus, and antibiotics
(1,89–91). These studies suggest that wounds may be
In approaching the care of victims of a radiologic-
cared for conservatively if they involve only soft tissue
dispersal device, or ‘‘dirty bomb,’’ medical personnel
without violation of peritoneum, pleura, or major
are advised to take standard precautions as well as wear
vascular structures, are <2 cm in diameter, are not
personal protective equipment (PPE), including scrubs,
obviously infected, and are not the result of a mine blast
gown, surgical mask, waterproof shoe covers, eye protec-
(as these are often grossly contaminated) (1).
tion, and double gloves (1). There is no direct radiation
In a blast-related mass casualty event, each victim can
risk to providers if appropriate precautions are taken;
suffer from multiple penetrating fragments. While some
consequently, critical injuries should be treated before
advocate comprehensive imaging to recognize occult en-
victims are formally decontaminated (1,98,99). Dust on
try wounds secondary to metal fragments, currently there
the victim is the primary source of contamination and
is no consensus regarding the optimal use of x-ray study
consequently undressing and disposing of the patient’s
or pan-CT in those with multiple small projectile-induced
clothing removes approximately 90% of contamination
penetrating wounds, many of whom remain asymptom-
(1,100). If a potentially radioactive fragment is present,
atic (9,76). In this situation, it is reasonable to
providers should use forceps to remove it while limiting
hospitalize hemodynamically stable victims with
their exposure time, keeping as much distance as
fragment penetration for observation and later
possible, and utilizing PPE and a body shield if
exploration and reassessment (51). As with other trauma,
possible (1).
repeat physical examinations are generally reliable
(51,92–95). Imaging such as chest x-ray study and CT
EXTERNAL SIGNS TO GUIDE TRIAGE: ARE
should be considered for those with penetrating wounds
THERE PREDICTORS OF BLAST LUNG INJURY
to the head, neck, or trunk.
AND INTRA-ABDOMINAL BLAST INJURY?

Renal System Significant blast injuries can occur with minimal external
injury, which has raised interest as to whether there are
As mentioned previously, blast injury patients can external signs that can predict blast lung and intra-
develop rhabdomyolysis. Similar to treatment of rhabdo- abdominal blast injury (11,14). It was previously thought
myolysis of other causes, the treatment for these patients that because lower pressures are required to perforate the
includes aggressive hydration, alkalinization of urine, TM than to damage other internal organs, that TM
forced diuresis with mannitol, as well as possible hemo- perforation could predict patients who potentially had
dialysis for renal failure (64). more serious forms of PBI. Cadaver studies indicate that
10 Z. R. Mathews and A. Koyfman

the average pressure required for perforation of the adult severely injured blast victims in the Israeli terrorist
TM is 137 kPA, while other organs are often injured in bombing incidents they studied, both of whom suffered
the 400 kPA range (31). However, multiple studies have from significant distracting injuries at initial
now shown that TM perforation is actually a poor predictor presentation (51). It is now generally believed that most
of blast injury, possibly because many explosions today patients with PBI of the lung develop associated signs
(particularly combat explosions and those from IEDs) and symptoms that become apparent shortly after
have pressure increases at an uneven rate (31). It has presentation (45).
been shown that serious PBI can occur without TM perfo-
ration. As mentioned previously, in one sentinel study in
IMAGING FOR BLAST INJURIES
2009 by Harrison et al., the absence of TM perforation
missed detection of up to 50% of those with lung PBI General Imaging Considerations
(43). Furthermore, several studies, including that by Lei-
bovici et al. in 2009, show that lone TM rupture in blast Generally, it is suggested in the literature that all critically
victims does not suggest occult PBI of the lung, or neces- ill blast victims receive routine x-ray studies of the cervi-
sarily poor outcomes for the patient (45). As a result, they cal spine, chest, and pelvis, as well as additional imaging
recommend that in resource-limited situations, those with as needed for penetrating injury (12,102). These sources
isolated TM perforation be discharged after chest x-ray do not specifically address it, but presumably as with
study and a brief observation period (45). The appropriate other trauma scenarios, cervical spine CT is preferable
amount of observation time is not determined. to plain films if there is a high likelihood of injury.
One caveat to this is that findings involving TM
rupture as a poor predictor for PBI may not apply to vic- Chest Imaging
tims of conventional blasts (43). Traditionally, bombs and
explosions extend outward as a sphere from a central All blast victims thought to have PBI of the lung warrant a
source. IEDs, on the other hand, and other newer forms chest x-ray study, particularly if surgical intervention is
of blasts, are continually changing and often have shaped required for concomitant secondary or tertiary blast in-
charges; for instance, the energy from an IED extends juries (7). As mentioned earlier, blast lung appears both
outward as a cone (43). For this reason, with IEDs and on chest film and CT as bilateral fluffy infiltrates that
other new explosives it is feasible for the TM to encounter resemble a ‘‘butterfly’’ or ‘‘bat wing,’’ areas of opacity
less blast energy than other organs, and in these scenarios, that initially begin and extend out from the hilum but
TM rupture is understandably not a reliable predictor of spare the margins of the lung (1,7). While the
occult blast injury (43). Another limitation of some of development of these abnormalities may be delayed,
these studies is that several involved professional sol- they are traditionally thought to develop within 2 h of
diers, who generally have protective equipment, unlike blast exposure, while newer evidence (as mentioned
the average civilian; this might spare injury to the TM here) suggests that delayed presentations are unlikely
in a way that is not directly translatable to the average (71). Blast lung findings on chest x-ray study are usually
blast victim (43). abrupt in onset and rapidly clear; persistent pulmonary
Aside from a ruptured TM, other specific signs that findings on imaging suggest a more significant underly-
have been hypothesized to signify potentially significant ing disease such as ARDS, pneumonia, or aspiration
blast exposure include ‘‘hypopharyngeal petechiae or ec- (44). Ecchymosis between intercostal spaces (called
chymoses, fundoscopic evidence of retinal artery air ‘‘zebra stripes’’ or ‘‘rib overprint’’) may be encountered
emboli,’’ and subcutaneous emphysema (44). Recent with injuries caused by large blast loads, where rib mark-
studies suggest that more accurate indicators of serious ings are visible on the injured lung compared with the un-
internal blast injury include external injuries to 4 or affected side (1).
more body areas, ‘‘greater than 10% total body surface Although it is important to do a chest x-ray study in
area burns, skull and facial fractures, and penetrating any patient suspected of having primary blast lung injury,
injury to the head and torso’’ (7,13,101). it has not been found necessary to perform a screening
Much of the interest in identifying predictors of chest x-ray study in asymptomatic patients. It was previ-
serious blast injury stems from the idea that blast victims ously thought that a screening chest film could anticipate
might harbor life-threatening internal injuries that are not respiratory failure in asymptomatic patients, but this has
apparent during initial assessment, such as blast lung. never been proven in the literature (51). Furthermore, as
However, several studies show that this rarely happens mentioned here, it is no longer commonly believed that
(45,51,55). For instance, Alfici et al. in 2006 found that blast injury evolves over many hours, rendering this clin-
primary and secondary survey in the ED was only ical question of anticipatory x-ray study less relevant
unable to identify the gravity of injuries in 2 of 63 (51,103).
Blast Injuries 11

Brain Imaging care’’ is utilized during an MCI, where presumed hemo-

thorax or pneumothorax are treated empirically with a
Blast injuries to the brain are generally not visible with thoracostomy tube with plans for a later chest x-ray study
routine imaging and Bochicchio et al. in 2008 found unless the patient’s condition does not improve or
that only half of the patients with this pathology have worsens (9). Similarly, CT use should also be limited
an abnormal CT of the head (66). Consequently, it is for use in making critical management decisions, specif-
advisable to entertain a diagnosis of PBI of the brain ically for those with presumed intracranial injury with
based on clinical presentation, regardless of CT results low or declining GCS, and for only select chest and
(7,66). abdominal injuries. All others should be admitted and
obtain delayed studies as needed (9).
Eye Imaging One of the more tedious tasks after blast injury is as-
sessing numerous limb fractures and shrapnel penetra-
CT is regarded as the gold standard to assess the blast- tions in generally nonurgent trauma patients after MCI
injured globe, particularly for penetrating trauma, but it (9). For the most part, suspected fractures can be
has limitations; in cohort studies, the sensitivity of CT managed initially with coverage of open wounds, tempo-
for clinically occult open-globe injuries ranged from rary splinting, antibiotic prophylaxis, and tetanus immu-
71% to 75% (60,104,105). Explosive debris is also nization until more thorough assessment is possible (9).
often nonmetallic, which may further reduce sensitivity Like other stable patients who are awaiting studies, these
(60,106). That said, CT should always be performed patients can also be transferred to the floor for delayed
before a possible magnetic resonance imaging (MRI) to definitive care; during an MCI, this will assist in freeing
assess the globe, as a metallic ocular foreign body may much-needed resources in an overburdened ED (9).
cause severe injury with MRI (22). While it is generally important to ration imaging and
Ultrasound can also provide rapid assessment of the other studies during MCIs, it is also important to be
globe. A case series by Ritchie et al. in 2012 that assessed wary of concealed injuries, particularly after suicide
29 patients with suspected intraocular blast injury in bombings, which tend to be associated with large numbers
Afghanistan suggests that ultrasound may be as good as of penetrating metallic charges. One case report of a 14-
CT at detecting ocular blast injuries, although the CT year-old blast victim was notable for a nail found buried
used in the study was a lower resolution than that typi- within the girl’s brain, resulting from a completely con-
cally used in the United States or United Kingdom (60). cealed penetrating wound hidden within the mouth (76).
Overall, ultrasound appears to be a cheap possible alter-
native to CT to assess ocular injury. Ritchie et al. report PROCEDURES
that limited use of ocular ultrasound for penetrating blast Chest Tubes
injury may be due to concerns about pressure on an open
globe causing further damage, but they advise that the Blast victims who respond inadequately to intubation and
study may be appropriately performed with minimal mechanical ventilation, particularly in MCI situations
pressure to the globe (60). where imaging is not readily available, should have bilat-
eral chest tubes placed for presumed pneumothorax (51).
Multiple Casualty Incident Imaging Some providers go farther than this to suggest that all
severely injured blast victims who require PPV should
The primary difference between the management of pa- have bilateral thoracostomy tubes placed empirically,
tients in traditional trauma settings vs. a mass casualty however, this practice has never been supported in litera-
setting is that laboratory tests and radiology studies are ture (9).
generally not freely available; consequently, in an multi- Extreme caution must be taken in the event of tube
ple casualty incident (MCI) these services should be used thoracostomy. Contused lung, which characterizes blast
wisely and kept free for victims with the most critical in- lung injury, is friable by nature and can easily bleed
juries (51). (51). Even successful tube placement can lead to delayed
Many of our recommendations for MCI management lung injury through the form of pressure lacerations (51).
comes from Israel, where blast incidents and other
MCIs are all too frequent. In the Israeli experience, few ED Thoracotomy
imaging studies are performed in the ED during an
MCI (9). For instance, many recommend obtaining a While ED thoracotomy is sometimes indicated for pa-
chest x-ray study at key diagnostic junctures only, when tients who present in extremis, this procedure is discour-
a patient’s clinical picture is not explained by physical ex- aged in those with severe blast injury to the lung, as the
amination alone (9). The idea of ‘‘minimal acceptable damaged lung parenchyma and associated bleeding will
12 Z. R. Mathews and A. Koyfman

prevent successful aortic clamping (51,93). Alfici et al. 15. Cullis IG. Blast waves and how they interact with structures. J R
Army Med Corps 2001;147:16–26.
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thoracotomy, blood in the endotracheal tube can predict blast injury. Br J Surg 2010;98:168–79.
severe blast lung and may dictate whether ED 17. Kocsis JD, Tessler A. Pathology of blast-related brain injury. J
Rehabil Res Dev 2009;46:667–72.
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18. Ho AM. A simple conceptual model of primary pulmonary blast
ED thoracotomy should not be performed during an injury. Med Hypotheses 2002;59:611–3.
MCI as it would likely represent ‘‘futile care’’ and misal- 19. Wightman JM, Gladish JL. Explosions and blast injuries. Ann
Emerg Med 2001;37:664–78.
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Blast Injuries 15

ARTICLE SUMMARY
1.Why is this topic important?
Partially due to the increasing frequency of both do-
mestic and international terrorist bombing attacks, it is
prudent for all emergency physicians to be knowledgeable
about blasts and the spectrum of associated injuries.
2.What does this review attempt to show?
Describe blast physiology, types of blast injuries asso-
ciated with each body system, and manifestations and
management of each injury.
3.What are the key findings?
Blast injuries are typically divided into primary to qua-
ternary injuries. Different body systems are affected and
managed differently. Despite previous dogma, multiple
studies now show that tympanic membrane perforation
is a poor predictor of other blast injury. More accurate in-
dicators of serious internal blast injuries include injuries
to four or more body areas, ‘‘greater than 10% total
body surface area burns, skull and facial fractures, and
penetrating injury to the head and torso.’’ Contrary to pre-
vious belief, those with primary blast injury of the lung
seem to manifest associated signs and symptoms shortly
after presentation. Routine prophylactic bilateral chest
tube insertion, previously advocated by some, is generally
unnecessary in the absence of pneumothorax, but may be
considered prior to air transportation of lung PBI victims.
4.How is patient care impacted?
In a mass casualty situation, those with isolated
eardrum rupture may be discharged after a brief period
of observation. As those who develop primary lung injury
generally manifest symptoms earlier than previously
thought, asymptomatic patients do not need admission
to observe for development of pulmonary symptoms.