Diagnosis and Management of Blast Injuries in the Emergency Department (Trauma CME) -
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Publication Date: February 2023 (Volume 25, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 02/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Authors

Tung-Lin Jesse Yuan, DO

Assistant Professor of Emergency Medicine, Rutgers New Jersey Medical School; Assistant EMS Medical Director, University Hospital, Newark, NJ

Navin Ariyaprakai, MD, FAEMS, FACEP

Clinical Associate Professor, Rutgers Health New Jersey Medical School; Program Director, EMS & Disaster Medicine Fellowship, Rutgers Health Newark Beth Israel Medical Center; Associate EMS Medical Director, RWJBarnabas Health Mobile Health EMS, Newark, NJ

Peer Reviewers

Derrick Tin, MD

Associate Professor, Critical Care, the University of Melbourne, Victoria, Australia; Faculty, Disaster Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA

Benjamin von Schweinitz, MD, FACEP

Assistant Professor of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL

Abstract

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. This issue 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.

Case Presentations

CASE 1

EMS and local police issue a notification that an explosion has occurred at an elementary school. Within an hour, the first patient arrives: a 29-year-old woman with torso and extremity lacerations…

The patient arrives by personal vehicle.
She has no other complaints and no medical history. Her vital signs are: heart rate, 110 beats/min; blood pressure, 110/80 mm Hg; and oxygen saturation, 97% on room air.
You give her medication for pain control and a tetanus booster, and repair her extremity lacerations.
On re-evaluation, she says she feels better, though you wonder whether it is safe to discharge her or if there might be delayed sequelae of the blast that need to be watched for . . .

CASE 2

The next patient is a 10-year-old boy, brought in by EMS…

The boy says that he was crouching on the ground when the explosion occurred.
His heart rate is 84 beats/min; blood pressure, 100/82 mm Hg; and oxygen saturation, 98% on room air. He is complaining of bilateral tinnitus and diminished hearing. He denies any direct head trauma or loss of consciousness. His examination is remarkable for bilateral tympanic membrane rupture; otherwise, he has no other signs of traumatic injuries and no neurological deficits.
You wonder whether you should order a head CT, and if he‘s discharged, what instructions should be given to the parents...

CASE 3

EMS informs you that there has been a second explosion near a school bus, and they are bringing in a 62-year-old man…

The injured man presents with shortness of breath. His heart rate is 118 beats/min, and blood pressure, 134/92 mm Hg. He is hypoxic at 87% on room air, with increased respiratory effort, and you note that he is bleeding from his ears bilaterally.
A police officer reports that the blast occurred in the back of the bus while the driver was in his seat.
Which category of blast injury likely caused this patient’s symptoms? What kind of injury pattern and pathophysiology would you be most concerned about?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.