Recovery from blast lung injury: one-year follow-up

Blast Lung Injury in Children: Injury Patterns and Associated Organ Injuries

BACKGROUND

Bombings are the most common cause of civilian deaths in wars, and unfortunately, a large proportion of civilian victims are children.

OBJECTIVE

This study aimed to evaluate the frequency of blast lung injury (BLI), to evaluate lung injury patterns on tomographic images, and to document the relationship between blast lung and mortality in children exposed to the blast effect.

METHODS

Thirty-six children (25.3% of pediatric patients brought to our hospital with blast injury) with BLI were included in the study. The pediatric trauma score evaluations made in the emergency department in the first admission were recorded. Lung injury findings in the computed tomography images of the patients were examined, and injuries detected in other systems were recorded.

RESULTS

The most common lung injury pattern was contusion (right: 69.4%, left: 80.6%). The incidence of brain damage (52.4%) and intra-abdominal injury (76.2%) in children with low pediatric trauma score value was statistically significantly higher ( P = 0.049, P = 0.017, respectively). There was no statistically significant correlation between the presence of lung injury, injury patterns, and mortality. The incidence of brain damage in deceased patients (61.5%) was statistically significantly higher than the incidence of brain damage in surviving patients (26.1%) ( P = 0.036). Low pediatric trauma score was observed in 11 (84.6%) of the deceased children and in 10 (43.5%) of the survivors ( P = 0.016). The mean age of children with hemothorax in the right lung was statistically significantly lower than those without ( P = 0.014).

CONCLUSION

Our findings revealed that pediatric BLI is common after a blast, that it is associated with other system injuries, and that a multimodal radiological approach is required in child victims.

Relationship between clinician documented blast exposure and pulmonary function: a retrospective chart review from a national specialty clinic

Background

Service member exposure to explosive blast overpressure waves is common with considerable attention to traumatic brain injury (TBI) and neuropsychological sequalae. Less is known about the impacts on the respiratory system, particularly long-term effects, despite vulnerability to overpressure. Using a national registry, we previously observed an independent relationship between self-reported blast exposure and respiratory symptoms; however, the impact on objective measures of pulmonary function is poorly understood.

Methods

307 Veterans referred to our national specialty center for post-deployment health concerns underwent a comprehensive multi-day evaluation that included complete pulmonary function testing (PFT), occupational and environmental medicine history, neuropsychological or psychological evaluation. We developed an a priori chart abstraction process and template to classify Veterans into blast exposure groups: (1) none, (2) single-mild, or (3) multiple-mild. This template focused primarily on clinician documented notes of blast related TBI that were used as proxy for blast overpressure injury to thorax. PFT variables characterizing flow (FEV₁%; %∆FEV₁), volume (TLC%), diffusion (DL_CO%) and respiratory mechanics (forced oscillometry) were selected for analysis.

Results

Veterans (40.5 ± 9.7 years; 16.3% female) were referred 8.6 ± 3.6 years after their last deployment and presented with considerable comorbid conditions and health problems (e.g., 62% post-traumatic stress, 55% dyspnea). After chart abstraction, Veterans were assigned to none (n = 208), single mild (n = 52) and multiple mild (n = 47) blast exposure groups. Among the blast exposed, clinicians documented 73.7% were < 50 m from the blast and 40.4% were physically moved by blast. PFT outcome measures were similar across all groups (p value range: 0.10–0.99).

Conclusions

In this referred sample of deployed Veterans, PFT measures of flow, volume, diffusion, and respiratory mechanics were not associated with clinician documented blast exposure per the retrospective chart abstraction methodology applied. Yet, these clinical findings suggest future research should determine and assess distinction between Veteran recollections of perceived blast experiences versus overpressure wave exposure to the respiratory system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02071-0.

Ankara bombing: distribution of injury patterns with radiological imaging

Purpose

To describe and explain the blast injuries and imaging findings in the Ankara terrorist explosion that took place on October 10, 2015.

Material and methods

A total of 77 patients who underwent radiologic imaging were classified as primary, secondary, tertiary, and quaternary, according to the injury type. The patients were evaluated based on body regions, such as head and neck, thorax, abdomen, lower extremity, and upper extremity.

Results

Blast lung injury was identified in one patient and tympanic membrane perforation in seven patients, as the primary injury. Sixty-two of 77 patients had secondary blast injuries caused by shrapnel. The blast injuries were observed in the head and neck (16/77, 20.7%), thorax (11/77, 14.2%), abdomen (16/77, 20.7%), lower extremity (48/77, 62.3%), and upper extremity (5/77, 6.4%). Vascular injuries were seen in eight cases, of which seven were in the lower extremities.

Conclusions

The most common blast injury pattern was of a secondary type in the current study. Lower extremities were the significantly more affected body region, probably due to the bomb exploding at ground level. In mass casualty events, radiologic imaging is located at the centre of patient management.

The Feasibility of Venovenous ECMO at Role-2 Facilities in Austere Military Environments

INTRODUCTION

Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been gaining use to bridge the recovery from acute respiratory distress syndrome (ARDS) refractory to conventional treatment. However, these interventions are often limited to higher echelons of military care. We present a case of lung salvage from severe ARDS in an Afghani soldier with VV-ECMO at a Role-2 (R2) facility in an austere military environment in Afghanistan.

CASE

A 25-year-old Afghani soldier presented to an R2 facility with blast lung injury and multiple penetrating injuries following an explosion. The patient underwent immediate damage control laparotomy. The abdomen was left open for subsequent washouts and ongoing resuscitation. Due to his ineligibility for evacuation and worsening ARDS, despite 5 d of conventional ventilation strategies, he was started on VV-ECMO. The patient had immediate improvements in oxygenation, which continued for 10 d. Moreover, he underwent three transportations to the operating room without accidental decannulation or disruption of the VV-ECMO device. Despite significant improvements, the patient expired on postoperative day 15, due to an overwhelming intra-abdominal sepsis.

CONCLUSION

As future advancements are sought, VV-ECMO may become a consideration for casualties with severe ARDS at the point of injury and at lower echelons of military care.

[Terrorist attack trauma - an individual entity of polytrauma : A 10-year update]

The incidence of terrorist attacks is increasing worldwide, and they have also become a permanent threat in European cities. Due to its complexity, terrorist attack trauma places high demands on the strategy of surgical treatment. The combination of various mechanisms, explosions and gunshot injuries, with the characteristic pressure (blast) damage and a high proportion of penetrating trauma with simultaneous burns are characteristic features. Unlike in military conflicts, injuries to people of all ages and without ballistic body protection (body armor) are to be expected. The mechanism of the attack and its local conditions are of relevance for the assessment of the situation and the expected injury patterns. Thus, suicide attacks result in several times higher numbers of fatalities and casualties. Explosions on free ground lead to different types of injury than those in closed or semi-enclosed spaces. The treatment principles of the Advanced Trauma Life Support (ATLS®) are based on the intrahospital care of casualties as well as damage control strategies with trigger factors. In order to prepare and educate clinics and surgeons in Germany for such scenarios, various course formats of the professional societies, the German Society for General and Visceral Surgery (DGAV) and the German Society for Trauma Surgery (DGU) have now been established.

The role of neutrophil gelatinase-associated lipocalin (NGAL) in the detection of blast lung injury in a military population

PURPOSE

To study the relationship between serum neutrophil gelatinase-associated lipocalin (NGAL) and military blast and gunshot wound (GSW) to establish whether potential exists for NGAL as a biomarker for blast lung injury (BLI).

METHOD

Patients from the intensive care unit (ICU) of the Role 3 Medical Treatment Facility at Camp Bastion, Helmand Province, Afghanistan were studied over a five month period commencing in 2012. Age, mechanism, trauma injury severity score (TRISS) and serum NGAL were recorded on ICU admission (NGAL1). Serum NGAL (NGAL2) and PaO₂/FiO₂ ratio (P/F ratio2) were recorded at 24h.

RESULTS

33 patients were injured by blast and 23 by GSW. NGAL1 inversely correlated with TRISS (p=0.020), pH (p=0.002) and P/F ratio 2 (p=0.009) overall. When data was stratified into blast and GSW, NGAL1 also inversely correlated with P/F ratio 2 in the blast injured group (p=0.008) but not GSW group (p=0.27).

CONCLUSION

Raised NGAL correlated with increased severity of injury (worse survival probability i.e. TRISS and low pH) in both patient groups. There was an inverse correlation between admission NGAL and a marker of blast lung injury (low P/F ratio) at 24h in blast injured group but not GSW group that warrants further investigation.

Air blast injuries killed the crew of the submarine H.L. Hunley

The submarine H.L. Hunley was the first submarine to sink an enemy ship during combat; however, the cause of its sinking has been a mystery for over 150 years. The Hunley set off a 61.2 kg (135 lb) black powder torpedo at a distance less than 5 m (16 ft) off its bow. Scaled experiments were performed that measured black powder and shock tube explosions underwater and propagation of blasts through a model ship hull. This propagation data was used in combination with archival experimental data to evaluate the risk to the crew from their own torpedo. The blast produced likely caused flexion of the ship hull to transmit the blast wave; the secondary wave transmitted inside the crew compartment was of sufficient magnitude that the calculated chances of survival were less than 16% for each crew member. The submarine drifted to its resting place after the crew died of air blast trauma within the hull.

Blast Injuries

BACKGROUND

Blast injuries in the United States and worldwide are not uncommon. Partially due to the increasing frequency of both domestic and international terrorist bombing attacks, it is prudent for all emergency physicians to be knowledgeable about blasts and the spectrum of associated injuries.

OBJECTIVE

Our aim was to describe blast physiology, types of blast injuries associated with each body system, and manifestations and management of each injury.

DISCUSSION

Blast injuries are generally categorized as primary to quaternary injuries. Primary injuries result from the effect of transmitted blast waves on gas-containing structures, secondary injuries result from the impact of airborne debris, tertiary injury results from transposition of the entire body due to blast wind or structural collapse, and quaternary injuries include almost everything else. Different body systems are affected and managed differently. Despite previous dogma, multiple studies now show that tympanic membrane perforation is a poor predictor of other blast injury.

CONCLUSIONS

Blast events can produce a myriad of injuries affecting any and every body system. All emergency physicians should be familiar with the presentation and management of these injuries. This knowledge may also be incorporated into triage and discharge protocols guiding management of mass casualty events.

Challenges in management of blast injuries in Intensive Care Unit: Case series and review

Blast injuries are rare, but life-threatening medical emergencies. We report the clinical presentation and management of four bomb blast victims admitted in Intensive Care Unit of Trauma center of our hospital in 2011. Three of them had lung injury; hemothorax (2) and pneumothorax (1). Traumatic brain injury was present in only one. Long bone fractures were present in all the victims. Presence of multiple shrapnels was a universal finding. Two blast victims died (day 7 and day 9); cause of death was multi-organ failure and septic shock. Issues relating to complexity of injuries, complications, management, and outcome are discussed.

What the Intensive Care Doctor Needs to Know about Blast-Related Lung Injury

Explosions are currently the primary cause of military combat injuries. A minority of civilian trauma is also caused by explosions. People hurt by explosion are likely to present with complex injuries. The aim of the article is to explain the mechanism underlying these injuries and the associated physiology to help the intensive care clinician manage these casualties properly. The generic term ‘blast injury’ is applied to a collection of injuries caused by explosion. Components of blast injuries have precise definitions relating to the elements of the explosion that caused the injuries: primary blast injury is due to a shock wave, secondary blast injury is caused by fragments and debris colliding with the victim and tertiary blast injury is due to the casualty being thrown against solid objects. Primary blast injury results in damage principally in gas-containing organs, eg the lungs (blast lung) and can lead to impaired pulmonary gas transfer and hypoxaemia. Secondary blast injuries are often penetrating and can lead to haemorrhage while tertiary blast injuries are often blunt and involve substantial tissue damage. Survivors of explosions in confined spaces are more likely to exhibit primary blast injury than those injured in open spaces. The current military approach to immediate management is to apply the C ABC principle (arrest catastrophic haemorrhage first and then deal with airway, breathing and circulation) to achieve Damage Control Resuscitation. Early administration of blood products (plasma as well as red cells) is advocated for those suffering significant haemorrhage. Initial resuscitation is hypotensive to minimise risk of dislodging nascent clots. However, if evacuation is protracted (longer than one hour) then consideration should be given to improving blood flow / oxygen delivery by adopting a revised normotensive blood pressure target to reverse the deleterious consequences of the hypotensive shock state. Animal studies have shown that titrating FiO2 to a target SaO2 of 95% can improve survival and ‘buy time’ during hypotensive resuscitation. Ventilator strategies should use a lung-protective approach with permissive hypercapnia if necessary. Blast casualties are often a challenging group of patients needing expert, tailored, care. Outcome can be good especially in young, otherwise fit, casualties with more than 96% surviving to ICU discharge, although this figure may be lower with a mixed civilian group.

Primary blast injuries--an updated concise review

Blast injuries have been increasing in the civilian setting and clinicians need to understand the spectrum of injury and management strategies. Multisystem trauma associated with combined blunt and penetrating injuries is the rule. Explosions in closed spaces increase the likelihood of primary blast injury. Rupture of tympanic membranes is an inaccurate marker for severe primary blast injury. Blast lung injury manifests early and should be managed with lung-protective ventilation. Blast brain injury is more common than previously appreciated.

Pulmonary contusion: an update on recent advances in clinical management

Pulmonary contusion is a common finding after blunt chest trauma. The physiologic consequences of alveolar hemorrhage and pulmonary parenchymal destruction typically manifest themselves within hours of injury and usually resolve within approximately 7 days. Clinical symptoms, including respiratory distress with hypoxemia and hypercarbia, peak at about 72 h after injury. The timely diagnosis of pulmonary contusion requires a high degree of clinical suspicion when a patient presents with trauma caused by an appropriate mechanism of injury. The clinical diagnosis of acute parenchymal lung injury is usually confirmed by thoracic computed tomography, which is both highly sensitive in identifying pulmonary contusion and highly predictive of the need for subsequent mechanical ventilation. Management of pulmonary contusion is primarily supportive. Associated complications such as pneumonia, acute respiratory distress syndrome, and long-term pulmonary disability, however, are frequent sequelae of these injuries.

Blast injuries

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

Blast Lung Injury

Current trends in global terrorism mandate that emergency medical services, emergency medicine and other acute care clinicians have a basic understanding of the physics of explosions, the types of injuries that can result from an explosion, and current management for patients injured by explosions. High-order explosive detonations result in near instantaneous transformation of the explosive material into a highly pressurized gas, releasing energy at supersonic speeds. This results in the formation of a blast wave that travels out from the epicenter of the blast. Primary blast injuries are characterized by anatomical and physiological changes from the force generated by the blast wave impacting the body's surface, and affect primarily gas-containing structures (lungs, gastrointestinal tract, ears). "Blast lung" is a clinical diagnosis and is characterized as respiratory difficulty and hypoxia without obvious external injury to the chest. It may be complicated by pneumothoraces and air emboli and may be associated with multiple other injuries. Patients may present with a variety of symptoms, including dyspnea, chest pain, cough, and hemoptysis. Physical examination may reveal tachypnea, hypoxia, cyanosis, and decreased breath sounds. Chest radiography, computerized tomography, and arterial blood gases may assist with diagnosis and management; however, they should not delay diagnosis and emergency interventions in the patient exposed to a blast. High flow oxygen, airway management, tube thoracostomy in the setting of pneumothoraces, mechanical ventilation (when required) with permissive hypercapnia, and judicious fluid administration are essential components in the management of blast lung injury.

Management of blast injuries and shock lung

PURPOSE OF REVIEW

Blast injuries have always occurred both in civilian life and as acts of war or terrorism. Nowadays, the risk of being involved in an explosion has increased even for those living in countries with no previous experience of such events. It is our intention that this review is of assistance to those providing emergency/critical care to patients who have sustained blast injuries.

RECENT FINDINGS

Exposure to blast may indirectly produce physiological insults such as bradycardia, hypotension, tissue hypoxia and oxidative stress. The use of early goal-directed therapy might be important in minimizing such insults. Explosions in an enclosed environment are associated with increased risk of pulmonary blast injury and also air and fat embolism. Mechanical ventilation after pulmonary blast injury is associated with barotrauma and the use of lung protective strategies previously recommended in acute lung injury may be beneficial.

SUMMARY

The potential for blast to cause injury depends on the nature of the explosive and environment in which the blast occurs. Soft tissue injury with environmental contamination is frequent. Optimal antimicrobial cover and strategies such as selective digestive decontamination may be advantageous. Early surgery should follow the principles of 'damage control'. Blast injury often leads to severe sepsis/systemic inflammatory response, multiple organ dysfunction and prolonged critical illness. In this clinical scenario, recent studies have shown improved outcome with the use of activated protein C, steroid replacement and aggressive control of blood glucose but have been less convincing regarding the use of immuno-nutrition.

Blast lung injury: clinical manifestations, treatment, and outcome

BACKGROUND

Blast lung injury (BLI) is a major cause of morbidity after terrorist bomb attacks (TBAs) and is seen with increasing frequency worldwide. Yet, many surgeons and intensivists have little experience treating BLI. Jerusalem sustained 31 TBAs since 1983, resulting in a local expertise in treating BLI.

METHODS

A retrospective study of clinical and radiologic characteristics, management, and outcome of victims of TBAs sustaining BLI who were admitted to ICU during December 1983 to February 2004. Long-term outcome was determined by a telephone interview.

RESULTS

Twenty-nine patients met inclusion criteria. Hypoxia and pulmonary infiltrates in chest x-ray were sine qua non for the diagnosis. Seventy-six percent required mechanical ventilation, all within 2 hours of admission. One patient died. Seventy-six percent had no long-term sequelae.

CONCLUSIONS

Most patients with significant BLI injury require mechanical ventilation. Late deterioration is rare. Death because of BLI in patients who survived the explosion is unusual. Timely diagnosis and correct treatment result in excellent outcome.

Bronchial tear in a child after a liquid petroleum gas tank explosion

Humans have been exposed to blast effects since the invention of gunpowder and explosives. Bronchial injury because of an explosion is a rare but lethal injury that requires prompt recognition and treatment. In this article, we present a case of a bronchial tear after an explosion.

Very early increase in nitric oxide formation and oxidative cell damage associated with the reduction of tissue oxygenation is a trait of blast casualties

Background. In our previous experimental studies, we found evidence for the increase of nitric oxide (NO) formation immediately after blast injury. In the present study we investigated whether NO overproduction was a trait for the period immediately after blast injury in humans. Concomitant metabolic disturbances were also studied, and compared to the alterations in other traumatized patients. Methods. Blast casualties (group B, n = 13), surgical patients with the hip replacement or fractures, not exposed to blast effects (group S, n = 7) and healthy volunteers as controls (group C, n = 10), were examined. Both arterial and venous blood samples were taken within 6 hours, and 24 hours after blast injuries or surgical procedures, respectively. Plasma levels of nitrite/nitrate (NOx), superoxyde anion (O2.-), sulfhydrils (SH), malondialdehyde (MDA) as well as acid-base status and other biochemical parameters (glucose, urea, creatinine, total proteins, albumin) were measured. Results. Significant, but transient increase in plasma NOx levels occurred only in group B. It was associated with the significant increase of hemoglobin oxygen (sO2) saturation of the venous blood and the concomitant decrease of its arterial - venous difference. In group S the venous sO2 decreased, its arterial - venous difference increased, while NOx levels were within the control limits. In both groups, other parameters of arterial acid-base status were kept within the control limits throughout the examined period. The decrease of SH levels were similar in the examined groups, while the increase of O2 .- was greater in group B. Conclusion. Early NO overproduction was a trait of blast injuries in humans, contributing to the reduction of tissue the oxygenation and intensifying the oxidative cell damage that had to be considered in the therapy of casualties with blast injuries. These alterations were different from those observed in other surgical patients without blast injuries.