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Primary Blast Injury

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Primary Blast Injury: Update on diagnosis and treatment Crit Care Med 2008; 36:[Suppl.]:S311–S317
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  • 1. Primary Blast InjuryUpdate on diagnosis and treatmentCrit Care Med 2008; 36:[Suppl.]:S311S317

2. 1. Primary blast injuries: injuries due solely to theblast wave2. Secondary blast or explosive injury: primarilyballistic trauma resulting from fragmentationwounds from the explosive device or theenvironment3. Tertiary blast or explosive injury: result ofdisplacement of the victim or environmentalstructures, is largely blunt traumatic injuries4. Quaternary explosive injuries: burns, toxins, andradiologic contamination 3. The blast wave enters the body creating two typesof energy, stress waves and shear waves. Stress waves are longitudinal pressure forcesthat move at supersonic speeds and create aspalling effect at airtissue interfaces, much likeboiling water, resulting in severe microvasculardamage and tissue disruption. Shear waves are transverse waves that causeasynchronous movement of tissue and possibledisruption of attachments. 4. The organs most likely affected by primary blastinjury are the ears, lungs, and colon or gas-filledorgans with the damage originating at the tissuegas interface. Ruptured tympanic membrane, ossiculardisruption, alveolar hemorrhage, cerebral,coronary, retinal and lingual air emboli, rupturedviscus with pneumoperitoneum, and vagallymediated bradycardia, apnea, and hypotensionare among the early signs of severe primary blastinjury. 5. The absence of perforation of the tympanicmembrane and lack of petechiae in theoropharynx have been said to mediate againstprimary blast injury of internal organs in themajority of cases. The presence of oral petechiae and perforatedtympanic membrane together, this can be avaluable triage tool to alert the physician to keepa patient for further observation. 6. BlastInjuryOcularInjuryAuralInjuryPulmonaryInjuryCardio-vascularInjuryTraumaticAmputationsBrainInjury 7. 10% of all blast survivors have significant eyeinjuries. Symptoms of ocular injury include pain or irritation,altered vision, periorbital swelling, contusion, orforeign body sensation in the case of injuryresulting from fragments. Ophthalmic physical examination findings includeconjunctival hemorrhage, diminished visual acuity,hyphema, globe rupture, presence of foreign body,or lid lacerations. 8. Ophthalmology consultation should be obtainedfor suspected globe injuries, corneal foreignbodies or abrasions, orbital fractures, retinaldetachments, hyphema, intraocular foreign bodies,corneal or eyelid burns, lid lacerations,subconjunctival hemorrhage, or head injuries thatinvolve the orbit or may compromise vision 9. Tympanic membrane rupture is the most commonprimary blast injury, 947% of explosion-injuredpatients had tympanic membrane rupture. The most common symptoms of auditory injuryare hearing loss, tinnitus, pain, and dizziness. All explosion victims should be evaluated with anotoscopic examination not as a means ofscreening for other primary blast injuries, butsimply to diagnose tympanic membrane ruptureand ensure proper evaluation and treatment. 10. Blast lung injury is the most common fatal injuryamong initial survivors of explosions. The incidence of pulmonary blast injury ranging from3% to 14%. This may result in minor or massive parenchymalhemorrhage, pulmonary edema, pneumothorax, or airembolism from alveolovenous fistulas. Symptoms and signs include tachypnea, dyspnea,cyanosis, and hemoptysis. On physical examination, the patient may havediminished breath sounds and crepitance resultingfrom subcutaneous air. Hypoxia (oxygen saturation

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