Blast injury

A blast injury is an injury caused by an explosive blast. Blast injuries are divided into four main types, with a fifth type for illnesses caused by the blast, and a sixth type for the effects of psychological trauma after the blast such as Post-traumatic Stress Disorder (PTSD).^[1]

Blast injury
Classification and external resources
Secondary blast injuries to both legs
eMedicine	emerg/63
MeSH	D001753

Explosions

Explosive fragmentA broken piece of a pressure cooker used to make a homemade bomb used at the 2013 Boston Marathon. Broken pieces of a bomb sent flying by the explosion can cause blast injuries as well as the explosion itself.

Blast environmentRedirection of blast force of a terrorist bomb placed in public area trashcan designed to reduce risk potential. The environment in which an explosion occurs is one of the factors in determining blast injuries.

The type of injury and how severe it is depends on different things. This includes the type of explosion, the force of the explosion, the environment where the explosion happens, and how close the person is to the explosion.

An explosion results from the rapid release of energy. Explosions fall into four general categories:

Chemical:

A chemical explosion is the result of a rapid chemical reaction or change of state which creates a lot of heat and usually gas. There are various types of chemical explosions including natural gas explosions, dust explosions and those caused by explosives.

Explosives are categorized as high-order explosives or low-order explosives and they each cause different injury patterns. Only high-order explosives produce a shock wave.

• High-order explosives detonation causes the explosive material to change into a highly pressurized gas which travels at supersonic speeds creating a 'blast wave' (over-pressurization shock wave). Examples include TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil.
• Low-order explosives deflagrates or burns at a subsonic rate (below 3,300 feet per second), so it does not have the over-pressurization supersonic schock wave. Examples include pipe bombs, gunpowder, and most pure petroleum-based bombs such as Molotov cocktails.^[2]

Mechanical

Electrical

Nuclear

Injury classification

Types of blast injuriesA person may suffer multiple injuries and from more than one category of blast injury. They may have ruptured ear drums, wounds from penetrating fragments (shrapnel), fractured legs or traumatic amputation, as well as burns of varying degrees and inhalation injuries. Injuries from more than one category are common and are referred to as combined injuries.^[3]

Blast waveIn this image a blast wave from a conventional explosion is clearly visible.

Blast wave spreading outAn HE explosion creates gas which spreads outward from the point of detonation.

Primary blast injuryThe blast wave causes primary blast injuries such as blast lung. In this fatal case both lungs have hemorrhaged. There were barely any external signs of injury, death was due solely to internal injuries from the blast wave.^[4] Blast lung is the most common fatal primary blast injury in people who survive the initial explosion.^[5]

Blast injuries are divided into four classes of physical trauma primary, secondary, tertiary, and quaternary. A fifth category, the quinary injuries, are those caused by toxic substances associated with the blast.

Primary injuries

Primary injuries are caused by the explosion's shock waves. Air and fluid-filled internal organs are most commonly affected, but the blast wave may also cause external injuries such as traumatic amputation.

The structures of the internal ears are most often affected by the blast wave, with perforated ear drums the most common injury. The most common fatal injury in victims who survive the initial blast is blast lung. Blast lung can result in pulmonary contusions, bleeding and fluid build-up in the lungs with damage to airways and blood vessels.

Secondary injuries

Secondary blast injury Shrapnel wounds from an Improvised Explosive Device (IED).

Most casualties in an explosion are caused by secondary blast injuries. These injuries may be caused by flying fragments of the explosive device and other objects within the blast zone. These objects may strike any part of the body resulting in penetrating trauma. The severity of the penetrating trauma depends on the size of the object, the depth of penetration, and the part of the body hit.

Secondary blast injuries are common in deliberate explosions such as those caused by terrorist bombs. The bombs are often designed with objects such as nails, or ball bearings packed in and around the explosive device to act as shrapnel.

These injuries may also occur in accidental explosions - such as may occur in an industrial accident - when objects in the environment affected by the blast, such as shattered glass act like shrapnel.

Tertiary injuries

Displacement of air by the explosion creates a blast wind that can throw victims against solid objects. Injuries resulting from this type of traumatic impact are referred to as tertiary blast injuries. Tertiary injuries may present as some combination of blunt and penetrating trauma, including bone fractures and coup contre-coup injuries.

Young children, because they weigh less than adults, are at particular risk of tertiary injury.

Quaternary injuries

Quaternary injuries include flash burns, crush injuries from falling debris and inhalation injuries, which may make existing respiratory conditions such as asthma and COPD worse.

Quinary injuries

This category of blast injury has been added fairly recently to classify injuries, which often results in a hyperinflammatory state^[6] due to exposure to the environmental contaminants associated with the various types of explosive blasts including, bacteria, chemicals and radiation (dirty bombs) as well as adverse tissue reaction to fuel and metals in the blast.

Psychological trauma

The psychological trauma which may occur in explosive blast survivors includes post traumatic stress disorder (PTSD). A concussion sustained in a blast may also be a risk factor for developing PTSD independent of a person's psychological reaction to the witnessed event. Psychological trauma may also occur in the complete absence of physical injuries.

Neurotrauma

Tertiary blast injury

Coup contrecoup (Fr. 'blow counterblow') injuries to the brain. An injury occurs at the point of the skull's impact, the brain then bounces back and hits the rear of the cranial vault causing a second injury. The front to back mechanism of injury is more common, but it may also happen in a side to side manner.

Neurotrauma can occur due to the mechanisms of one or more blast injury categories. Bleeding from injured organs such as lungs or bowel causes a lack of oxygen in all vital organs, including the brain. Damage of the lungs reduces the surface for oxygen uptake from the air, reducing the amount of the oxygen delivered to the brain. Tissue destruction initiates the synthesis and release of hormones or mediators into the blood which, when delivered to the brain, change its function. Irritation of the nerve endings in injured peripheral tissue and/or organs also significantly contributes to blast-induced neurotrauma.

Individuals exposed to blasts often have loss of memory for events before and after explosion, confusion, headache, impaired sense of reality, and reduced decision-making ability. People with brain injuries from explosions often develop sudden, unexpected brain swelling and cerebral vasospasm despite continuous monitoring. The first symptoms of blast-induced neurotrauma (BINT) may occur months or even years after the initial event, and are categorized as secondary brain injuries.^[7] The broad variety of symptoms include weight loss, hormone imbalance, chronic fatigue, headache, and problems in memory, speech and balance. These changes are often debilitating, interfering with daily activities. Because BINT in blast victims is underestimated, valuable time is often lost for preventive therapy and/or timely rehabilitation.^[7]

References

1. Ian Greaves, Keith Porter, Timothy J. Hodgetts, Malcolm Woollard: Emergency care: a textbook for paramedics. Saunders Ltd.; 2 edition (2006) p.218 ISBN 0702025860
2. CDC: Explosions and Blast Injuries: A Primer for Clinicians
3. Ryan's Ballistic Trauma: A Practical Guide. Eds. Brooks A.J., Clasper J., Midwinter M., Hodgetts T. J., Mahoney P. F. Springer; 3rd Ed.(2011) p.52 ISBN 1848821239
4. Rossi T, Boccassini B, Esposito L, et al. Primary blast injury to the eye and orbit: finite element modeling. Invest Ophthalmol Vis Sci. 2012 Dec 7;53(13):8057-66. doi: 10.1167/iovs.12-10591. PMID 23111614
5. Traumatic Brain Injury: Methods for Clinical and Forensic Neuropsychiatric Assessment CRC Press; 2 edition (2007) p.11 ISBN 084938138X
6. Kluger Y, Nimrod A, Biderman P, et al. The quinary pattern of blast injury. Am J Disaster Med. 2007 Jan-Feb;2(1):21-5.PMID 18268871
7. Cernak, I., and L. J. Noble-Haeusslein. 2010. Traumatic brain injury: An overview of pathobiology with emphasis on military populations. J Cereb Blood Flow Metab 30(2):255-266.

Other websites

• Conventional Warfare: Ballistic, Blast and Burn Injuries Archived 2013-02-22 at the Wayback Machine