Blast Injury First Aid

Understand that blast injuries are classified into four types:

Primary blast injury: Caused by the overpressure wave from the explosion itself. Affects air-filled organs (lungs, ears, gastrointestinal tract). Victims may appear unharmed externally but suffer internal damage including blast lung (pulmonary barotrauma), tympanum rupture, and abdominal injuries. These are often silent killers—lack of visible wounds does not indicate lack of serious injury.

Secondary blast injury: Results from fragmentation and shrapnel propelled by the blast. Creates penetrating wounds with debris embedded in tissues. Multiple wounds are common and may be life-threatening.

Tertiary blast injury: The victim is thrown by the blast force, resulting in blunt trauma, fractures, head injuries, and crush injuries.

Quaternary blast injury: All other effects including thermal burns, respiratory damage from inhalation of toxic products, and crush syndrome.

Before treating any casualty, ensure scene safety. Check for secondary devices (additional explosives placed to injure first responders). Do not approach the scene until you are certain it is safe.

Do not enter a blast scene until you have confirmed there is no immediate danger of secondary explosions.

In multi-casualty incidents, apply the Simple Triage And Rapid Treatment (START) protocol:

1. Immediate (Red tag): Casualties requiring immediate life-saving intervention—severe hemorrhage, airway compromise, altered mental status, severe respiratory distress.
2. Delayed (Yellow tag): Serious injuries that can wait 1–2 hours for treatment—fractures, moderate bleeding controlled by direct pressure, conscious but with moderate injuries.
3. Minor (Green tag): Walking wounded with minor injuries—abrasions, minor fractures without neurovascular compromise.
4. Expectant (Black tag): In austere triage, those with injuries incompatible with available resources—massive head trauma with exposed brain, evisceration beyond repair, apnea despite airway positioning.

Triage rapidly (seconds per casualty) to prioritize resources. Mark casualties clearly so others know their status. Retriage periodically as conditions change.

Triage decisions are difficult but necessary to save the maximum number of lives. Do not waste resources on salvage cases if immediate casualties need intervention.

External hemorrhage from secondary (shrapnel) and tertiary (blunt trauma with lacerations) injuries is the leading preventable cause of death in trauma.

For limb bleeding:

• Apply direct pressure with a clean cloth or improvised dressing.
• If bleeding continues, apply a tourniquet 2–3 inches above the wound (between elbow and wrist for arm; between groin and knee for leg). Write the time applied on the tourniquet or patient's skin.
• Improvised tourniquets: wide cloth or belt applied very tightly to cut off blood flow to the limb.

For trunk or neck bleeding:

• Do not apply a tourniquet.
• Apply firm direct pressure with gauze or cloth for 10–15 minutes without releasing to check.
• For large wounds, pack the wound with gauze or clean cloth, maintaining pressure.
• If bleeding continues, apply a pressure dressing (elastic bandage over gauze).
• Elevate the limb if possible and tolerated.

For wounds with embedded objects:

• Do not remove the object—it may be tamponading (blocking) the bleeding.
• Apply pressure around the object.
• Stabilize the object with bulky dressings to prevent movement.

Tourniquets are safe for extended periods (6+ hours) in extremity trauma. Do not delay application due to fear of limb loss—uncontrolled bleeding is immediately life-threatening.

Blast lung (primary blast injury to the thorax) is caused by the overpressure wave compressing and rupturing lung tissue. It is often silent—casualties may have minimal external signs but are dying internally.

Signs and symptoms:

• Dyspnea (shortness of breath) or rapid breathing.
• Chest pain or tightness.
• Hemoptysis (coughing up blood or blood-tinged sputum).
• Cyanosis (bluish skin) in severe cases.
• Altered mental status from hypoxia.

Management:

• Position the casualty sitting upright or semi-upright to ease breathing.
• Keep the casualty as still as possible—exertion worsens air leak and internal bleeding.
• Do not allow the casualty to walk or exert themselves; transport on a litter if available.
• Administer oxygen if available.
• Monitor for tension pneumothorax (unilateral breath sounds, tracheal deviation, hypotension). If suspected, perform needle decompression.
• Avoid aggressive fluid resuscitation, which can worsen pulmonary edema.

Blast lung can be delayed—casualties may seem initially well but deteriorate over hours. Suspect it in any blast casualty with dyspnea.

Blast lung victims may deteriorate rapidly. Keep them calm and still. Transport to definitive care urgently.

Penetrating chest wounds from shrapnel are immediately life-threatening due to pneumothorax (collapsed lung) or hemothorax (blood in the chest cavity).

Assessment:

• Unequal breath sounds (one side quiet, the other normal).
• Severe dyspnea and hypoxia.
• Hypotension and signs of shock.
• Visible wound to the chest wall.

Immediate treatment:

• For a sucking chest wound (air moves in and out of the wound with breathing), apply an improvised chest seal:
  • Use sterile gauze or plastic sheeting (part of a bag, waterproof material).
  • Tape it on three sides only, leaving one corner or edge untaped. This acts as a one-way valve, allowing air to escape but not enter.
  • If plastic is unavailable, use the cleanest available material.
• For small wounds without an obvious air leak, apply an occlusive dressing (fully taped on all four sides) and monitor.
• Keep the casualty upright if conscious, to prevent blood pooling in the lungs.
• Administer oxygen if available.

Do not delay treatment for a perfectly sealed dressing. An imperfect seal is better than a delay that allows continued air leak.

A sucking chest wound is immediately life-threatening. Seal it immediately. Tension pneumothorax requires emergency needle decompression by inserting a large-bore needle at the midclavicular line between the 2nd and 3rd ribs.

Primary blast injuries also affect ears and the GI tract, often without obvious external signs.

Ear injuries:

• Tympanum (eardrum) rupture is common in blast survivors within 5 meters of the detonation.
• Signs: bloody drainage from ear, hearing loss, vertigo (dizziness).
• Do not insert anything into the ear canal. Do not attempt to clean or pack the ear.
• Place a loose, clean cloth over the ear to prevent infection.
• Evacuate for specialist evaluation.

Abdominal injuries:

• Primary blast can rupture hollow organs (bowel) without external wounds.
• Signs: abdominal pain, distension, vomiting, signs of internal bleeding.
• Keep the casualty NPO (nothing by mouth).
• Monitor for shock (rapid pulse, pale skin, altered mental status).
• Treat shock by elevating legs and keeping the casualty warm.

Evacuation priorities:

• Immediate (Red): All casualties with hemorrhage, airway compromise, blast lung, penetrating chest wounds, shock.
• Delayed (Yellow): Casualties with moderate injuries and stable vitals.
• Move casualties away from the blast scene before treating, to reduce risk of secondary device injury.
• If possible, document the time of injury and treatments provided for handover to definitive care.
• Reassess casualties regularly during evacuation, as conditions can deteriorate.

Multiple casualty incidents are chaotic. Prioritize evacuation of Red-tagged casualties. Do not spend excessive time on individual casualties if others are waiting for life-saving interventions.