Managing patients with blast injuries can challenge emergency department operations, as patients can present in multiple waves, with occult or delayed injuries, and by personal transport, without standard prehospital care. Rapid and effective triage and evaluation includes approximation of blast proximity, determination of the category of blast – primary to quinary – and assessment of the body systems that are most likely to be injured from the type, location, and mechanism of the blast.
Our recent issue Diagnosis and Management of Blast Injuries in the Emergency Department reviews the physics of the various types of explosions, how this affects the types of injuries that may be seen, and recommended treatments. Best-evidence recommendations are made for decision-making for observation, admission, or discharge.
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Here are a few key points:
- Explosive events can result from terrorist bombings, industrial and construction accidents, planned avalanches, and fireworks. The increase in injuries and fatalities is primarily due to homemade/recreational explosives.
- Low-order explosives include gunpowder, pipe bombs, Molotov cocktails, and smokeless and black powder. These more often produce fragmentation injuries and thermal burns.
- High-order explosives include TNT, ammonium nitrate, fuel oil, dynamite, and nitroglycerine. These typically produce higher temperatures over a shorter period of time, and produce a overpressure blast wave.
- Exposure to peak overpressure in a confined space (eg, a vehicle or underwater) produces greater injury.
- Primary blast injury in closed spaces has a high likelihood for tympanic membrane rupture; however, it has a low sensitivity and specificity as a biomarker in blast injuries as a whole.