Pathophysiology

Blast injuries traditionally are divided into 4

categories: primary, secondary, tertiary, and
miscellaneous also called quaternary
injuries.
A patient may be injured by more than one
of these mechanisms.
A primary blast injury is caused solely by the
direct effect of blast overpressure on tissue.
Air is easily compressible, unlike water. As a
result, a primary blast injury almost always
affects air-filled structures such as the lung,
ear, and gastrointestinal (GI) tract.

Pathophysiology

A secondary blast injury is caused

by flying objects that strike people.
A tertiary blast injury is a feature of
high-energy explosions. This type
of injury occurs when people fly
through the air and strike other
objects.
Miscellaneous quaternary blast
related injuries encompass all
other injuries caused by
explosions.

Mechanisms of Blast Injury

Category

Characteristics

Body Part Affected

Types of Injuries

Primary

Unique to HE, results from

the impact of the overpressurization wave with
body surfaces.

Gas filled structures

are most susceptible lungs, GI tract, and
middle ear.

Blast lung (pulmonary

barotrauma)
TM rupture and middle
ear damage
Abdominal hemorrhage
and perforation - Globe
(eye) ruptureConcussion (TBI without
physical signs of head
injury)

Secondary

Results from flying debris

and bomb fragments.

Any body part may be

affected.

Penetrating ballistic
(fragmentation) or blunt
injuries
Eye penetration (can be
occult)

Tertiary

Results from individuals

being thrown by the blast
wind.

Any body part may be

affected.

Fracture and traumatic

amputation
Closed and open brain
injury

Quaternary

All explosion-related
injuries, illnesses, or
diseases not due to
primary, secondary, or
tertiary mechanisms.
Includes exacerbation or
complications of existing

Any body part may be

affected.

Burns (flash, partial, and

full thickness)
Crush injuries
Closed and open brain
injury
Asthma, COPD, or other
breathing problems from

Thoracic PBI produces the following

unique cardiovascular response :
- A decrease in heart rate, stroke
volume and cardiac index
- The normal reflex increase in
systemic vascular resistence does
not occur so blood pressure falls
- If this response is not fatal, recovery
usually occurs within 15 minutes to 3
hours

Hospital Management
Airway and ventilation
management.
Supplemental Oxygen
PEEP/CPAP - watch for air emboli.
Positive pressure ventilation and
general anesthesia has been
reported to increase mortality in
blast injury.
Surgery should be postponed 24 48 hours whenever possible.

 Consider abdominal films in all

patients with significant blast
injury.
CT Scan Abdomen/Pelvis for
patients with appropriate signs
and symptoms.
Hearing in both ears should be
tested at bedside.

 Wound Management:
Tetanus status.
Local exploration.
Delayed primary closure.
IV followed by oral
antibiotics for all but the
most trivial wounds.