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Bomb explosion wounds and its management

TAREQ SALAHUDDIN
Bomb explosion is an increasing social problem in our country. So many people are injured by this type of accident. Sometimes there are conditions of acute emergency to manage the victims of bomb blast. Recently we had a very bad experience of bomb blast in a political meeting. Now we should have knowledge about the management of bomb blast.
Effects of bomb blast
A bomb is a container filled with an explosive mixture. When an explosion occurs, the explosive materials produce a large volume of gas and release a large amount of energy. A person can be injured by an explosion in a number of ways.
Heat effect: The temperature of explosive gases can exceed 20000C, causing heat cramps, heat stroke, heat exhaustion etc. The radiated heat can cause flash burns.
Flame effect: It causes extensive burn which involve irregular area of skin to a different degree.
Smoke and gas effect: Some bomb produce irrespirable gases like CO, H2S, SO2 etc. If a bomb explodes in a confined space, enough CO is produced to cause asphyxia.
Splinter effects: Causes different type of wounds.
Sound effect: The tympanic membrane may rupture with haemorrhage in the ear.
Air blast: An explosion produces a shock wave. This shock wave of very high pressure can hurt the victim against a wall or toss him through the air causing blunt force injuries. Entering into the body it causes reactive pulmonary oedema
(collection of fluid) which is called blast lung.
The shock wave passes through the body. The homogenous tissue (liver and muscle) are not damages, but alveolar septa are torn, producing haemorrhage and respiratory embarrassment. This causes reactive pulmonary oedema and blood stained froth is found in the air passages. This specific pulmonary injury of air blast is demolished.
Disruptive effects: If the victim is almost in contact with a large bomb he may be blown to pieces e.g. when the victim is carrying it.
Falling masonry: In high powered bomb explosion, a building is demolished. The person inside the building sustain multiple injuries and die from traumatic asphyxia.
Other effects: Subperitoneal haemorrhage and tearing of abdominal may occur. Intracranial haemorrhage, pneumothorax, ruptures stomach and bowel. Systemic air embolism may also occur from air which enters the pulmonary veins after damage of lungs.
Mechanism of explosive blast injury
The explosive pressure that accompanies the bursting of bombs or shells ruptures their casing and imparts a high velocity to the resulting fragments. These fragments have the potential to cause even more devastating injury to the tissue than bullets. They are unstable to flight and may tear through tissue at high speed in a tumbling fashion. In addition, all explosives are accompanied by a complex blast wave.
A mass movement of air or dynamic pressure results from the
rapidly expanding gases at the centres of the explosion which displaces air at supersonic (greater than the speed of sound in air) speed.
When the body is impacted by a blast pressure wave, it couples into the body and sets up a series of stress waves which are capable of injury, particularly at air-fluid interfaces. Thus injury to the ear, lungs, heart and to a lesser extent, the gastrointestinal tract is notable.
General management
The structures injured by the primary blast wave, in order of prevalence are the middle ear, the lungs and the bowel. However the most common urgent clinical problem in survivors is usually penetrating injury caused by blast-energised debris and fragments from the casing of the exploding device. Many of those exposed will have blunt, blast and thermal injuries in addition to more obvious penetrating wounds. Some cases are associ-
ated with multiple wounds of varying severity affecting a limb.
First of all the injured person should go to the casualty or emergency department of a hospital . If the wound is not so severe, a physician simply can give the treatment in his/her chamber or dispensary. But sometimes hospital management may be needed which cannot readily be realised by the victim. So they must consult a doctor after the bomb attack.
It may not always be practical to explore every wound at first surgery. The larger and deeper wounds should have priority of management due to the more serious consequences of infection.
In many blast injuries one cannot be sure of complete wound excision and therefore it is imperative that all blast wounds should be left open at the end of the initial operation and delayed primary closure performed 4-6 days later.
Regional management
Here one is particularly concerned with identifying specific injuries caused by the primary blast wave.
Auditory system: Blast damages the hearing in three ways. There may be rupture of the tympanic membrane, dislocation of the ossicles or widespread disruption of the inner ear. The latter is sometimes accompanied by permanent deafness. It should be remembered that the likelihood of ear damage depends on the angle between the incident blast wave and the external auditory meatus. Although deafness is a certain indicator of exposure to significant blast loading its absence does not imply the absence of blast injury to other system.
Respiratory system: The impacting primary blast wave may cause a rapid inward movement of the chest wall and result in underlying pulmonary contusion. In the casualties it is probable that the initial blast wave couples into the chest resulting in stress wave which spread out, reflect and reinforce at tissue interfaces.
An inflammatory cascade ensures resulting in a post-blast respiratory insufficiency. In severe cases respiratory insufficiency may be further precipitated by overtransfusion with electrolyte solutions.
Blood gas analysis confirms arterial hypoxia (deficiency of oxygen) and a raised partial pressure of CO2. Most Clinicians agree with the guidelines listed below -l Avoid over-hydration while maintaining vital organs perfusion.
l Administer high-flow oxygen (12 lit/min) with mask and rebreathing bag.
l Carry out arterial blood analysis to assess need for further measures.
l Resort to mechanical ventilation early to ensure adequate oxygenation.
l Corticosteroids should be avoided.
Gastrointestinal tract: Perforation of the stomach, small intestine and caecum is more common. The clinical presentation is one of increasing abdominal pain accompanied by signs of peritonism and often gas under the diaphragm. In cases where signs are few but the risks are high, ultrasonography, CT, diagnostic peritoneal lavage and laparoscopy should be considered.
The eye: The eye should be examined in both the primary and secondary surveys, yet injury is easily missed. Conjunctival haemorrhage following blast exposure may herald a more serious underlying problem. The pupil must be carefully examined and any abnormality, distortion of the iris or the presence of a hyphema for example should be investigated by an opthalmologists.
Psychological effects
One of the most important impact of bomb blast is its psychological effect. Children and cardiac patients should not observe the ugly scenery of the victim of bomb blast. The most hazardous impact affects the victim of bomb blast and their family members. They need the social and mental support. Sometimes they suffer from severe depression. Counselling is very much helpful in these conditions. If there is any critical problem they should consult a psychiatrist.