Introduction

The spectrum of injuries inflicted in blast injury is unique and variable. They range from simple pellet to multiple organ system injury with fatal consequences. There are multitude of factors governing the type and pattern of injuries inflicted in blasts. Victims are of any age, sex creed, caste and color and can be single or many.

Epidemiology

Frequency depends on political stability.

Location

Types of blast injuries

Primary blast injury

Secondary blast injury

Tertiary blast injury

Quaternary blast injury

Quinary Blast Injury

Gastrointestinal injuries

There is a myriad of abdominal insults of blast injuries. Clinicians managing blast injury victims have to be aware of the spectrum of injuries inflicted. This valuable awareness and dedicated care will save precious human life. Each type of blast injury produces unique pattern of injury. A misdiagnosis can add iatrogenic surgical trauma. Patient usually presents with features of peritonitis. Gas containing viscera, intestine and stomach are most commonly affected by blasts. Liver and spleen damage are somewhat less. Mesenteric vessel damage presents as haematoma. In addition, direct trauma can account for many injuries due to deceleration₄ Blast effects on intestine are by primary, secondary and tertiary wave. Most of the patients present with unexplained tachycardia, falling blood pressure and signs of increasing peritonism. Diagnostic laparotomy findings in intestinal injury is perforation. Perforation is ragged and with ecchymosis of the surroundings. Gastric perforation is not uncommon. Sometimes if the primary blast wave is strong traversing solid visceral organ can tear tissue and present with hemaperitonuem, among solid organs liver is more susceptible. In tertiary and secondary injuries, the direct traumatic contact can present wt any abdominal injury, gastric and intestinal perforation, splenic and liver tear, diaphragmatic injury mesenteric tears and retroperitoneal hematoma. Renal injuries are not commonly encountered. Sometimes pellets can go deep and patients present with haematuria. Pellets can penetrate deep into bladder. Genitals can be hit by pellets Sometimes visceral perforation may develop upto 24-48 hours later; however delays of upto 14 days have been reported₄ Victims having abdominal penetrating blast injury crate diagnostic dilemma for clinician. Track follow from superficial or deep inside, sometime getting lodged in viscera. Multiplicity is often noticed with other body parts. Gastro intestinal blast injury more commonly occurs after blast wave propagation in water. Gastro intestinal hemorrhage and perforation is most common in the lower small intestine or caecum where gas accumulates

Associated injuries

The lung is characterized by contusion in blast and is hall mark of blast injury₅(Pizov).Contusions are often multiple and bilateral. Clinical manifestation is hypoxia, severity consistent with grade of contusion. Sometimes in lung contusion inadequate response to mechanical ventilation is attributed to be by pneumothorax and thoracostomy is indicated. Urgent thoractomy should be done in patients with excessive bleeding in the thoracotomy tube. There is risk of developing ARDS after blast injury. This occurs with multiple assaults with combined blast injury inhalational injury, significant soft tissue injury multiple long bone fractures prominent soft tissue injury and those requiring massive transfusions₅. Similar to gastrointestinal injury, heart and blood vessels are prone to injury by wave effect and direct effect. Cardiac ischemia and coronary vessel embolization are manifestations of cardiac involvement. Blast wave induced micro thrombi formation in blood vessels may contribute to DIC. Rarely cardiac blast injury present with features of hemorrhage in the epicardium, myocardium, or papillary muscle. Tympanic membrane damage is most sensitive to blast injuries but is rarely looked for. It is easily ruptured in a blast₆ But hearing loss can occur without tympanic membrane rupture₇. A victim having less than 80% of membrane perforation heals of its own with 10% of perforation per month. Previously eardrum perforation was considered marker of delayed onset of pulmonary and gastrointestinal injuries but has been refuted₈ Ossicular bone disruption can add further to hearing loss. Traumatic amputations are seldom seen in blast victims. An additive of primary blast wave, secondary and tertiary blast wave has been proposed₉

Management

Management starts at the site of scene but one has to be keen observer and aware of specific features of blast injuries₁₀. Any time any moment one can have to manage blast causalities single or multiple. It is the need of time to be aware, trained and be able to apply care and management of blast victims. Trauma care should be given according to advanced trauma life support guidelines₁₁. An effective triage system should be applied. A reverse triage system can swamp the emergency services and add to morbidity and mortality. Understanding the mechanism of injury and treatment issues and the potential long-term morbidity of primary blast injuries will enhance survival₁₂

In a country where modern emergency facility is lacking the tradition can be put in use. A bleeding should be stopped by piece of cloth, a fractured limb can be splinted by card board or duppata, and a cart can be used to move victim in nearby emergency service.

Correspondence to

Dr.Imtiaz Wani Post graduate Surgery Shodi Gali Amira Kadal, Srinagar Kashmir, India, 190009. Ph. No: 9419904864 e-mail : imtazwani@yahoo.com