Common Blast Injury Types and Treatments

Yesterday marks the 25^th anniversary of the Oklahoma City bombing that occurred on 04/19/1995.  This Medical Monday installment is dedicated to the victims, the families, and the first responders (many of whom I currently serve with) who answered the call in one of the most iconic moments in our nation’s history.  The topic for this week is blast injuries.  We will be discussing different types of injuries sustained from a blast and treatment for those types of injuries.  We will also discuss some safety considerations for response to events that have an explosion potential.  In addition to serving as a tactical paramedic for our SWAT team, I am also assigned to our agency’s bomb squad.  This assignment has allowed for unique training opportunities as well as a more in-depth perspective when it comes to blast injuries.

We will start out by addressing the four different mechanisms of injuries that occur from a blast event.  

• Primary – Primary injuries are caused by the pressure wave generated by an explosion.  The injuries from this mechanism of the explosion mostly involve hollow organs.  Your lungs, intestines, stomach are some examples of hollow organs.  The primary phase of the blast can also cause a ruptured ear drum as well as a concussion / traumatic brain injury.  
• Secondary – Secondary injuries are caused by shrapnel and any other type of flying debris.  Any part of the body is susceptible to this type of injury.  
• Tertiary – Tertiary injuries stem from the body being thrown by the wave of the blast.  For example, if you are thrown by the blast against a wall and break your arm, this would be considered a tertiary injury.  
• Quaternary – This type of injury encompasses any type of injury or illness that is not covered by the aforementioned mechanisms.  The quaternary mechanism also includes any complications from any of the injuries or illness that occur because of the blast.  For example, if you receive a bad cut because of something that struck you (Secondary Injury) and that cut becomes infected, the infection is considered a quaternary injury.

You may be wondering how difficult it is to treat all of these different types of injuries.  Now is a good time to point out that trauma is trauma.  With few exceptions, you treat blast injuries that you encounter just as you would with any other type of trauma that you might come across in the performance of your regular duties.  Stop any massive bleeding.  Make sure that the patient’s airway is open.  Place a chest seal over any holes between the neck and the stomach all of the way around the patient’s body.  Evaluate again for any ongoing bleeding.  Cover the patient and keep them warm to prevent or to treat shock!!!  Evaluate the patient in more detail to see if anything has been missed.  Reassess your interventions.    

Now for the exception!  If you notice that you or someone else that has been involved in a blast event has developed even a minor cough, it is critical that you or they be evaluated at an emergency room.  It is easy to think that the cough is because of the dust particles that have gotten into the airway, however the lungs may have incurred an injury called blast lung.  An x-ray will show if this injury has occurred and allow for the hospital staff to begin treatment.  

In responding to a scene where the potential of an explosion exists, it is critically important to remember that time, distance, and shielding are our friends.  It is obvious that the further you are from an explosion, and the more protection that you have between you and the explosion, the better off you are.  Be mindful of reflective pressure.  Imagine that you are on scene of a potentially explosive incident, and you take cover behind your patrol car that is parked next to a building.  The pressure of the explosion will go over the patrol car, hit the building, and the energy will be reflected onto you.  It is something to consider when arriving onto the scene.  Another thing to be acutely aware of is secondary devices that may be in the area.  Even if the response does not include a terrorism aspect, many times the likelihood of additional explosions is still present.  Do not become complacent.  

A special note for members of a bomb squad or SWAT team…It is a good practice to have a medical information form on file and readily available for each member of the team.  This form should be updated yearly at minimum.  The information on this form should include the team member’s following information:

• Full name
• SSAN
• Emergency contact information
• Drug allergies
• Current medications to include supplements
• Past surgical history
• Pertinent medical history (High blood pressure, cardiac issues, high cholesterol, etc.)
• Special notes (Power of attorney, Advanced directive, etc.)

It is also important to have a rehabilitation plan in place.  This will keep members hydrated, warmed up or cooled down depending on the season, and rested during extended events.  For most agencies, a conversation with your local fire department or EMS agency can help organize the rehabilitation plan before an event occurs.  

One last point before we wrap up this installment.  The Murrah Federal Building bomber was captured by an Oklahoma State Trooper by the name of Charlie Hangar.  Trooper Hangar conducted a traffic stop on the suspect due to the vehicle he was driving having no license plate.  While Trooper Hangar was conducting his investigation, he observed that the suspect was concealing a handgun underneath a windbreaker.  Trooper Hangar made the arrest having no idea that he had just arrested the most wanted man in America.  I have had the privilege of attending Trooper Hangar’s account of the events of that fateful day.  I believe that Trooper Hangar exemplified the type of attention to detail police work that SCT tirelessly promotes.  

As always if you have any questions or comments, please leave them below.  If there is a topic for Medical Monday that you would like to see addressed, please let me know!