Hospital Management
All patients evacuated from an area close to the explosion should be examined for effects of PBI lung, ear and abdomen even in the absence of other external injuries.
Shrapnel injuries; crush injuries and burns are treated as per standard surgical protocols.
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Tympanic membrane Injuries: The TM is considered more vulnerable than the lung tissue for effects of the blast wave. It is generally accepted that human tympanic membranes begin to rupture at pressures as low as 5 psi (35 kPa) and that majority at 15 psi (104 kPa) [8]. Thus it has traditionally been believed that in the absence of pulmonary symptomatology if the TM is intact, it is highly unlikely that the patient has pulmonary injury. However a recent study of 647 survivors has contradicted this belief [9]. A close correlation to PBI lung or intestinal PBI was not seen.
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Over 80% of tympanic membrane perforations caused by blast are likely to heal spontaneously. Large perforations (> 80% surface area) are less likely to heal without surgery [10].
Pulmonary PBI (“Blast Lung”) would present with symptoms of dyspnoea, cough (dry to productive with frothy sputum) haemoptysis, and chest pain or discomfort (typically retrosternal). Clinical findings will include tachypnoea, cyanosis, reduced breath sounds and dullness to percussion, coarse crepitations, rhonchi features of pneumothorax or haemo-pneumothorax, subcutaneous emphysema and retrosternal crunch (pneumomediastinum). Patients with blast lung are at risk of pulmonary barotrauma and if there is evidence of tension pneumothorax, it should be decompressed immediately. All patients should receive oxygen at high flow rate (9-15 litres per minute) and injudicious fluid administration avoided.
A chest radiograph is mandatory in all patients exposed to blast which may indicate diffuse infiltrates within the first few hours, progress till 24-48 hours and subside within seven days. A delayed picture of the same occurring after 48 hours may be due to complications of blast lung such as ARDS or pneumonia.
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Severity of the blast lung may require positive-pressure ventilation with high positive end-expiratory pressure, though with the attendant risk of air-embolism. Various strategies to reduce effects of lung barotrauma include reversion to spontaneous breathing as soon as possible with intermittent mechanical ventilation and CPAP [13]. High frequency ventilation with low airway pressures is recommended for patients with suspected bronchopleural fistula [12].
Blast lung patients are similarly at risk during evacuation by air in partially pressurized military aircraft to larger centres.
Acute Gas Embolism: may be seen clinically as fundoscopy findings, cardiac arrhythmias and CNS or cardiac ischemia. Pulmonary tissue disruptions cause air to move into the arterial system. Management is largely symptomatic and supportive with 100 percent oxygen inhalation. Hyperbaric oxygen therapy has been shown to be effective in patients with early signs of neurological symptoms even when started after 20- 24 hours in stable patients [13].
Abdominal and Pelvic PBI: Air and fluid containing structures are particularly prone for blast injuries with the fixed parts of the colon and mesentery being at the highest risk of perforation and bleeding. Subcapsular haematomas of the solid organs, lacerations, retroperitoneal haematomas, mesenteric ischemia and testicular ruptures have also been described. Patients present with abdominal pain, rectal pain and tenesmus and features of ileus at later stage. Suspicion of bleeding and perforation warrants early exploration. Small bowel contusions > 15 mm diameter and colonic contusions > 20 mm diameter at exploration are at higher risk and may need segmental resection. Smaller contusions have lesser chances of late bleed. Focused abdominal sonography in trauma (FAST) has limited role in the detection of bowel or mesenteric injuries but can be useful for detecting fluid collections and some solid organ injuries. Recent studies have supported supplemental imaging using computed tomography and angiography when feasible in civilian set up with limited casualties [14].
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Category: WHO
