Primary Problem:

• Ruptured lung tissue

Secondary Problems:
• Ruptured esophagus, stomach or bowel wall
• Ruptured tympanic membranes (TMs) and sinus injury
Introduction:
High-explosive (HE), thermobaric, and nuclear detonations cause extreme compression
of molecules in surrounding air or water creating thin bands of locally high overpressure,
which are propagated away from the origin of the explosion as a blast shock wave. Most
casualties within the injury radius of a HE detonation will have common penetrating
(Figure 1 & Figure 2), blunt, and burn (Figure 3) injuries managed no differently than
similar non-blast trauma.
When the blast wave arrives at the surface of an object (vehicle, structure, or human
body), it is transmitted into that object as a stress wave (Figure 4). As the blast wave
separates from the stress wave due to the latter moving slower through objects than the
blast wave moves around them, pressure differentials cause forces that accelerate surfaces
(Figure 5). When transmitted into the human body, the shock wave causes stress-induced
tears at air-tissue interfaces (Figure 6), which result in internal bleeding, weakening of
tissue resistance to additional insults, and possible rupture with escape of air from the
respiratory tract or spillage of gastrointestinal (GI) contents.
Massive hemoptysis can compromise the airway. Management of any associated
penetrating, blunt, and thermal trauma will not be discussed in this chapter.
Geographical Distribution:
Worldwide. In addition to its association with combat and acts of terrorism, blast injuries
may occur as a result of industrial or training accidents.
Seasonal Variation:
None.
Risk Factors:
The closer a casualty is to an explosion, the more likely he will receive primary blast
injury (PBI) from the effects of blast overpressure alone, particularly if behind cover and
shielded from ballistic trauma.
• Personnel in enclosures (buildings, ships, armored vehicles, etc.) are at greater
risk, regardless of whether detonation occurred inside or outside the enclosure.
• Personnel treading water are at higher risk for abdominal than thoracic blast
injury from underwate explosion.
• Fully submerged personnel are at equal risk of combined thoracic and abdominal
blast injury, as are personnel in open air, but equivalency occurs at three times
 distance from explosion underwater compared to open air.
• Body armor increases the risk of PBI, but decreases the risk of secondary blast
injury from fragments, shrapnel, and debris due to its ballistic protection of vital
structures.
• Tertiary blast injury occurs when the high-velocity blast wind generated by
pressure differentials accelerate personnel to tumble along the ground, strike solid
objects (Figure 7), or impale themselves on other objects. Secondary and tertiary
mechanisms result in conventional blunt and penetrating trauma.
Associated Procedures:
• Tourniquet application
• Endotracheal intubation
• Cricothyroidostomy
• Needle thoracentesis
• Tube thoracostomy
• Positive-pressure ventilation (PPV)
• Selective pulmonary intubation.

Lung GI Tract Ear

Hemorrhage: Hemorrhage: Middle ear:

• Pulmonary contusion • Hematoma leading to obstruction • Ruptured tympanic membrane (TM)

• Hemoptysis • Upper or lower GI bleeding • Temporary conductive hearing loss

• Hemothorax • Hemoperitoneum Inner ear:

Escape of Air: Escape of Contents: • Temporary sensory hearing loss

• Pneumothorax • Mediastinitis • Permanent sensory hearing loss

• Pulmonary pseudocyst • Peritonitis

• Arterial gas embolism (AGE)

Symptoms Acute (0-2 Hours) Sub-Acute (2-48 Hours) Chronic (>48 Hours)
Constitutional
• Dyspnea • Progressively
Worsening Dyspnea
• Malaise
• Fever
• Apathy
 • Amnesia
Localized Persistent Hearing Loss
• Pleuritic Chest Pain • New or Progressive
Chest Pain
• Non-productive cough
• Productive Cough
• Cardiac Chest Pain
• Bilious Emesis
• Abdominal Pain
• New or Progressive
Abdominal Pain
• Hematochezia

• Hematemesis
• Nausea

• Ear Pain
• Urge to Defecate

• Hearing Loss
• Tinnitus

• Vertigo

• Balance Problems

• Eye Pain

• Visual Changes

• Focal Numbness

• Paresthesias

Focused Questions

Figure 6: Chest x-ray showing small fragment wounds

and primary blast injury of the lung resulting in pulmonary
contusions demonstrated as infiltrates under the left
chest wall. From the Textbook of Military Medicine, part
I, volume 5, page 302, figure 9-2.

Figure 7: Picture of the inside of an office space

overlooking the rear of the US Embassy after the
bombing in Nairobi, Kenya, in 1998. Several casualties
were near the window at the moment of detonation.
Thus, they received primary blast injury from the blast
wave itself, secondary blast injury from fragments of the
truck carrying the device and glass, and tertiary blast
injury from being propelled into objects. Note the head-
high, arcing blood smear on the wall.

From Lt Col Wightman’s personal photographs.

Quantity –
• Are you short of breath? (Pulmonary contusion inhibits oxygen diffusion and
requires more effort to inhale. Pneumothorax and hemothorax decrease the
volume of air that can be inspired. Shock will cause the sensation of dyspnea due
 to poor tissue perfusion.)
• Do you have chest pain? (Chest pain indicates the possibility of penetrating or
blunt trauma, pneumothorax, or myocardial ischemia or infarction due to coronary
AGE.)
• Do you have abdominal or testicular pain, nausea, urge to defecate, or blood in
your stools? (Penetrating and blunt abdominal trauma cause pain, but PBI of air-
containing structures in the GI tract may cause any of the listed symptoms.)
• Do you have eye pain or problems with your vision? (Evaluate for penetrating or
blunt eye trauma as described in the chapter on Ophthalmology.)
• Do you have ear pain or problems with your hearing? (Ruptures of TMs occur
commonly but are not life-threatening, unless the casualty cannot hear life-saving
commands or communications.)
Quality –
• How bad is the [symptom above]? (The severity of any single symptom or
combination of symptoms must be evaluated relative to the casualty’s ability to
carry out his duties and either facilitate or hamper mission accomplishment.)
Duration –
• Did the [symptom above] occur at the time of the blast or develop later? (Any
positive finding indicates injury, but new symptoms appearing over time usually
represents deterioration.)
Alleviating or Aggravating Factors –
• How much exertion is required to cause any shortness of breath? (Dyspnea at rest
indicates shock due to external or internal hemorrhage, pneumothorax, or serious
pulmonary contusion. The more exertion required to elicit dyspnea, the less lung
injury is likely.)
Signs Acute (0-2 Hours) Sub-Acute (2-48 Hours)
Inspection
• Penetrating trauma

• Traumatic amputation

• Seizure activity

• Respiratory difficulty

• Hemoptysis

• Pharyngeal petechiae

• Tongue blanching

• Mottling of non-dependent skin

 • Inadequate chest-wall expansion

• Abrasions
Auscultation
• Asymmetric Breath Sounds • Newly Asymmetric Breath Sounds

• Rales

• Wheezes
Palpation
• Subcutaneous Emphysema • New or progressive abdominal
tenderness
• Abdominal Tenderness
• Abdominal rigidity or rebound
tenderness
• Spinal deformity or Tenderness
Percussion
• Asymmetrical Chest Percussion
Other
• Altered Mental Status • Fever

• Focal Neurologic Deficit • Delayed Shock

Using Basic Tools

Figure 8: Traumatic amputation of the foot caused by a

small anti-personnel mine. Although this picture was
taken in Vietnam, this injury is typical of small landmines
scattered throughout the Balkans and other parts of the
world. Because there are no metal parts, virtually all
effects are due to the stress wave fracturing the bone
and the blast wind ripping off the foot. From the
Textbook of Military Medicine, part I, volume 5, page 46,
figure 1-65.

Figure 9: Traumatic amputations of both lower

extremities caused by a large anti-personnel mine.
Ballistic and thermal trauma can be seen, as well as
massive contamination from dirt and straw. From the
Textbook of Military Medicine, part I, volume 5, page
172, figure 5-9.

Figure 10: This Ranger has been placed in the coma

position with his left side down, his body rotated halfway
between the left-lateral decubitus and prone positions,
and his head at same the same level as his heart.

This places his airway in a position of protection such

that his tongue will naturally fall away from his
oropharynx and blood, secretions, or emesis may drain
by gravity. There is minimal restriction of his respiratory
efforts. If he has a pulmonary contusion, more posterior
alveoli may be aerated in this or the supine position.

It also places his coronary arteries in their lowest position

to protect against coronary AGE and his head at lowest
risk for both cerebral AGE and secondary swelling.

Note how his right elbow and knee provide support, so

that he does not have to be actively maintained in this
position by an attendant.

From Lt Col Wightman’s personal photographs.

General:
• Identify sites of life-threatening external hemorrhage first. (#1 cause of
preventable death on battlefield.)
• Categorize dyspnea by its severity at rest or by the degree of exertion that causes
it. (Do not purposefully exert the casualty just to see how much exertion elicits
dyspnea.)
• Altered mental status may be transient or not. (May be due to head trauma,
shock, or cerebral AGE.)
Vital Signs:
• Tachycardia indicates stress from external or internal hemorrhage, hypoxia,
exertion, dehydration, or anxiety.
• Bradycardia is inappropriate but may be transient following a blast-induced
vasovagal reaction stimulated by suddenly increased intra-pulmonary pressures.
• Irregular heart rhythm may indicate cardiac irritability from shock or coronary
AGE. Rapid, shallow respirations are common after blast exposure, regardless of
the degree of lung injury, but can also indicate other thoracic damage, shock,
exertion, or anxiety.
• Hypotension may result from hemorrhage, other causes of shock, or a vasovagal
reaction.
Inspection:
• Identify external abrasions, contusions, penetrating wounds (Figure 1 & Figure 2),
and traumatic amputations (Figure 8 & Figure 9)
• Watch for inadequate chest-wall movement.
• Look for central and peripheral cyanosis (indicating hypoxia) and well-
demarcated mottling or blanching of the tongue or areas of skin (indicating
AGE).
• Otorrhea or bleeding from the ears indicates TM rupture or basilar skull fracture.
Auscultation:
• Listen for asymmetrical breath sounds, poor air movement, and wheezing.
Auscultation of bowel sounds is not necessary in the field.
Palpation:
 • Subcutaneous emphysema indicates an open external wound or rupture of an air-
containing internal structure.
• Abdominal tenderness may indicate internal hemorrhage or GI tract rupture.
• Palpation of the spine or extremities may be appropriate to decide if the casualty
can move under his own power or needs to be transported in an immobilized
position.
Percussion:
• When the environment is quiet enough, percussion may facilitate detection of air
or fluid in the chest.
Clinical Tests:
• A detailed neurological examination may identify subtle deficits.
• The possibility of AGE should be evaluated as described in the chapter on Diving
Medicine.
Pulse Oximeter:
• A SPO2 < 95% on room air indicates some degree of lung injury, inadequate
respirations, shock, or exposure to a chemical agent such as cyanide.
• See the Assessment section of this chapter on using pulse oximetry to categorize
the severity of blast lung injury.
Using Advanced Tools
Stool Guaiac:
• If casualties with primary bowel injury have bleeding, it is usually gross
hematochezia, but guaiac-positive stool indicates possible occult penetrating,
blunt, or blast trauma.
Ophthalmoscope:
• Magnification allows close inspection of the possibility of penetrating anterior-
eye trauma.
• Visualizing hemorrhage or a foreign body on funduscopic examination or the
absence of a red reflex indicates posterior-eye trauma.
• If air is noted in retinal vessels, it proves AGE.
Otoscope:
• Look for ruptured TM.
• Significant debris in the external canal should be left alone.
Cardiac Monitor:
• Evaluate dysrhythmias occurring secondary to hypoxia, shock, or coronary AGE.
Hemoglobin & Hematocrit:
• May be a useful baseline before travel to altitude or to assess slow hemorrhage
during evacuation.
Prediction of Respiratory Problems
Insignificant pulmonary injury may be defined as no dyspnea with exertion after 1 hour
of rest. Significant pulmonary blast injuries may be classified as mild, moderate, or
severe based on pulse oximetry. This may help predict the likelihood of complications,
requirement for positive-pressure ventilation (PPV), and need for higher-than-normal
positive end-expiratory pressure (PEEP).
Mild Moderate Severe

• SPO2 > 75% on room air • SPO2 > 90% on 100% oxygen • SPO2 < 90% on 100% oxygen

• Unlikely to need PPV • Likely to need conventional PPV • Likely to need unconventional PPV

• Normal PEEP if PPV initiated • PEEP of 5-10 cmH2O usually needed • PEEP > 10 cmH2O usually needed

• Pneumothoraces occur • Pneumothoraces common • Pneumothoraces almost universal

• Bronchopleural fistulae rare • Bronchopleural fistulae common

Blast injuries more likely to be initiated or exacerbated by decreased ambient external

pressure on the casualty are pneumothorax, AGE, and bowel-wall stretching. Reasses
frequently!
Differential Diagnosis
Rapid Unconsciousness –
• Penetrating or blunt brain or cardiac trauma
• Vasovagal syncope
• Cerebral or cardiac AGE
• Chemical nerve-agent or cyanide inhalation
Airway Compromise –
• Altered mental status
• Penetrating or blunt face or neck trauma
• Inhalation injury
 • Massive hemoptysis
• Foreign-body aspiration
Ventilatory Insufficiency –
• Pulmonary contusion
• Pneumothorax (all types)
• Rib fractures
• Bronchopleural fistula
• Chemical-agent or biological-toxin exposure
Shock –
• External or internal hemorrhage
• Tension pneumothorax
• Hypoxia from pulmonary injury
• GI bleed (more often lower)
• Coronary AGE
Focal Neurological Deficits –
• Head injury
• Spinal injury
• Peripheral nerve injury
• Cerebral or spinal AGE
Ruptured TMs –
• Primary blast overpressure injury
• Basilar skull fracture
Plan
If IV fluid is administered for controlled hemorrhage with shock or uncontrolled
hemorrhage with altered mental status, bolus with one quarter the usual amount
(crystalloid or hetastarch) and reevaluate to avoid exacerbating lung or brain injury.
Repeat boluses as necessary.
Procedures for Suspected Arterial Gas Embolism
 • Essential: Administer high-flow supplemental oxygen. Use an aviator’s mask
for extra pressure, if needed and available. Evacuate to a hyperbaric chamber as
soon as possible. Pressurize the evacuation aircraft’s cabin to the atmospheric
pressure at the destination, if using air transportation and it is technically possible
in the aircraft used.
• Recommended: Place the casualty in the coma position with his left side down
(halfway between the left-lateral decubitus and prone positions) and his head at
the same level as his heart (Figure 10).
Procedures for Massive Hemoptysis Compromising Airway
• Essential: Perform selective intubation of the least injured side using the
algorithm provided (Figure 11). Use the lumen of the endotracheal tube to
facilitate gas exchange in and out of the lung with lighter bleeding. Use the cuff
to prevent blood from the side of heavier bleeding crossing into the mainstem
bronchus of the better lung.
Procedures for Suspected Tension Pneumothorax
• Essential: Perform a needle thoracentesis to relieve life-threatening shock.
• Recommended: Perform a tube thoracostomy (chest tube), if air is aspirated
during needle thoracentesis, but respiratory difficulty and hemodynamic
compromise are not relieved. Although tube thoracostomies are generally not
recommended during Tactical Field Care for penetrating trauma, severe
pulmonary blast injuries can cause direct communications between large airways
and the pleural space (bronchopleural fistula) where a 14-gauge catheter cannot
evacuate air out of the pleural space faster than it enters.
Treatment of Suspected Pulmonary Contusion
• Primary: Stop all activity. Administer high-flow supplemental oxygen, if it is
available. Initiate PPV only if absolutely necessary.
• Alternative: Wait at least 1 hour. Resume tasks as tolerated.
• Primitive: Only undertake activities at the lowest practical level of exertion
(slower movement, less weight carriage, etc.).
Procedures for Ventilatory Assistance
• Essential: Relieve tension pneumothorax. Seal open pneumothorax (sucking
chest wound). Allow spontaneous breathing whenever possible. Place casualty in
the position he can breathe best.
• Recommended: If positive-pressure ventilation (PPV) becomes required, use
mouth-to-mask or bag-valve-mask/tube with slower and less-forceful delivies
than are often used with other traumatic causes of respiratory problems.
Impact 750M Portable Ventilator (if available and operator qualified)
Initial Settings:
1. Connect high-pressure hose from oxygen source to 50-psi inlet
2. FIO2 will be 1.00 (100%) unless blender is used

3. Set mode to synchronized intermittent mandatory ventilation (SIMV)

4. Set respiratory rate to 12 breaths/minute (1 breath every 5 seconds)
5. Calculate tidal volume as 8 mL/kg
6. Set inspiratory time to 1 second (I:E ratio equals 1:4 over 5 seconds)
7. Set inspiratory flow to 8 mL/second for every kg of body weight
8. Attach PEEP valve to exhalation port, if needed
9. Test on balloon before attaching to airway adjunct
Persistent Hypoxemia: Double-check that the definitive airway is still in place and its
cuff is intact. Ensure oxygen is being delivered to the ventilator unit. Change the PEEP
valve to a greater PEEP (up to 10 cmH2O).

Peak Inspiratory Pressures > 35 cmH2O: Double-check that the definitive airway is in
place. Evaluate for tension pneumothorax, and correct if present. Increase I:E ratio by
proportionally increasing inspiratory time and decreasing inspiratory flow (e.g., 4 mL/sec
per kg of body weight for 2 sec). Consider selective intubation and independent lung
ventilation with half the tidal volume.
Treatment of Vasovagal Syncope:
• Primary: Place the casualty’s head at the level of his heart and elevate his lower
extremities.
• Alternate: Wait until casualty awakens. Unlike syncope from fright, this may
take up to 2 hours in a blast-injured casualty.
Treatment of GI Bleeding: Same as outlined in the chapter on Gastrointestinal Problems.

Treatment of Possible GI Tract Rupture

• Primary: NPO. Maintenance IV fluid. Cefoxitin or ceftriaxone IV or IM.
Evacuate DELAYED for surgical care within 4 hours. Monitor for peritonitis and
sepsis. Prochlorperazine or promethazine IV or IM, if needed to prevent recurrent
vomiting.
• Alternative: Maintenance PO water, if no IV and evacuation time > 4 hours.
 Ciprofloxacin and metronidazole PO, if parenteral cephalosporins not carried or
casualty is allergic to them. Virtually any antibiotic coverage is better than
nothing when time to definitive care is prolonged.
Treatment of Mediastinitis, Peritonitis, or Sepsis
• Primary: One of two parenteral combinations: 1) cefoxitin (or ceftriaxone) AND
metronidazole (or clindamycin); or 2) ampicillin/sulbactam (or piperacillin) AND
gentamicin (or tobramycin).
• Alternative: Oral combination of ciprofloxacin AND metronidazole.
Treatment of TM Rupture
• Primary: Do not attempt removal of foreign debris. Prevent water and other
non-sterile material from entering the ear canal. Manage pain as indicated.
• Empiric: Prophylactic antibiotics are not indicated. If infection of the TM
(myringitis) develops, instill ophthalmological (for the eye) gentamicin 4 drops
(not ointment) 4 times a day for 10 days. Otological (for the ear) suspensions for
otitis externa are contraindicated when the TM is ruptured.
• Alternative: Amoxicillin/clavulanate or ciprofloxacin PO, if ophthalmological
antibiotic drops are not available.
• Return Evaluation: Inspect the area surrounding the ear, the external ear itself,
the ear canal, and the TM daily for redness, swelling, or purulent drainage. Pain
when gently pulling up and back on the pinna or pressing on the cartilage just in
front of canal also indicates otitis externa.
• Consultation Criteria: The casualty should ideally be seen by an ear, nose, and
throat (ENT) specialist within 3 days, or sooner if significant debris is in the
canal. Up to 2 weeks is acceptable, if no infection develops.
Evacuation Destination
• CASEVAC from the tactical environment to a higher level of medical care, then
MEDEVAC to more definitive care. The destination chosen should consider the
following needs based on suspected diagnoses:
• Head Injury: Facility with neurosurgery – URGENT-SURGICAL. Intensive care
at the same facility is desirable.
• Penetrating Torso Trauma: Facility with general surgery – URGENT-
SURGICAL. Cardiothoracic and vascular surgery are desirable.
• Arterial Gas Embolism: Facility with hyperbaric chamber – URGENT. Other
trauma services at the same facility are desirable.
• Pulmonary Contusion: Facility with intensive care – URGENT. Pulmonary and
surgery services are desirable.
 • GI Tract Rupture: Facility with general surgery – PRIORITY. A pulmonary
service is desirable.
• TM Rupture: Any facility with physician – ROUTINE. An ENT service is
desirable.
Notes
• AMS is most likely due to penetrating or blunt head trauma or shock from
bleeding, but two unique features of blast injury are less common causes: 1) blast
overpressure on the lungs can cause vasovagal syncope with bradycardia and
hypotension, which may last minutes to hours even with conventional treatment;
and 2) stress-induced tears in lung tissue may allow air into the pulmonary veins,
which can then be ejected to the cerebral or coronary circulation causing a stroke
or heart attack, respectively.
• Transient amnesia is common after any loss of consciousness caused by
explosions.
• Pharyngeal petechiae (but not TM rupture) predict a higher likelihood of
pulmonary contusion.
• Make sure the casualty can be easily moved between sitting and lying positions
for respiratory management.
• Avoid PPV unless absolutely necessary, because it increases the risks for
pneumothorax and arterial gas embolism. AGE is the most common cause of
death in immediate survivors and often occurs when PPV is initiated.
• It is better to place a possibly unneeded chest tube than have a tension
pneumothorax during transportation.
• Development of a tension pneumoperitoneum affecting respirations is rare, but
may require a 14-gauge needle paracentesis in the midline just above the
umbilicus for decompression.
• Vertigo is usually due to head injury, not blast effects on the inner ear. Meclizine
can improve symptoms but can also sedate, thus impairing the casualty’s ability to
function and making assessment of AMS more difficult.
• Morphine should be withheld in bradycardia and given with caution in respiratory
difficulty.
• Evaluate for the necessity of a tetanus immunization booster.