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ABSTRACT
Current trends in global terrorism mandate that emergency medical services, emergency medicine and other acute care clinicians have a basic understanding of the physics of explosions, the types of injuries that can result from an explosion, and current management for patients injured by explosions. High-order explosive detonations result in near instantaneous transformation of the explosive material into a highly pressurized gas, releasing energy at supersonic speeds. This results in the formation of a blast wave that travels out from the epicenter of the blast. Primary blast injuries are characterized by anatomical and physiological changes from the force generated by the blast wave impacting the body's surface, and affect primarily gas-containing structures (lungs, gastrointestinal tract, ears). "Blast lung" is a clinical diagnosis and is characterized as respiratory difficulty and hypoxia without obvious external injury to the chest. It may be complicated by pneumothoraces and air emboli and may be associated with multiple other injuries. Patients may present with a variety of symptoms, including dyspnea, chest pain, cough, and hemoptysis. Physical examination may reveal tachypnea, hypoxia, cyanosis, and decreased breath sounds. Chest radiography, computerized tomography, and arterial blood gases may assist with diagnosis and management; however, they should not delay diagnosis and emergency interventions in the patient exposed to a blast. High flow oxygen, airway management, tube thoracostomy in the setting of pneumothoraces, mechanical ventilation (when required) with permissive hypercapnia, and judicious fluid administration are essential components in the management of blast lung injury.
Key words: blast injury; explosions; terrorism; acute lung injury.
PREHOSPITAL EMERGENCY CARE 2006;10:165-172
BACKGROUND
Current patterns in worldwide terrorist activity have increased the potential for casualties related to explosions to occur beyond the battlefield. The United States Department of State reported over 500 international terrorist bombings between 2001 and 2003, resulting in over 4,600 deaths,1-3 and over 7,000 terrorist bombings worldwide between 1968 and 1999.1 In addition, the U.S. Federal Bureau of Investigation has documented 324 confirmed terrorist bombing incidents between 1980 and 2001 in the United States,4 with over 21,000 total bombing incidents (actual, accidental, attempted) between 1988 and 1998.5 In 2005, there were 758 worldwide terrorist events, of which 399 were bombings.6
Explosions have the potential to inflict multisystem life-threatening injuries (blast injuries) on many persons simultaneously and...