Emergency Management

• Expect an "upside-down" triage - the most severely injured arrive after the less injured, who bypass EMS triage and go directly to the closest hospitals.
• Double the first hour's casualties for a rough prediction of total "first wave" of casualties.
• Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty location from police, fire, EMS, ICS Commander, regional EMA, health department, and reliable news sources.
• If structural collapse occurs, expect increased severity and delayed arrival of casualties.

Expected Injuries

• Blast injuries may be present in any casualty exposed to an explosive force.
• Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute abdomen or blood poisoning are present.
• Standard penetrating and blunt trauma to any body surface is the most common injury seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. "Blast Lung" is the most common fatal injury among initial survivors.
• Blast lung presents soon after exposure. It can be confirmed by finding a "butterfly" pattern on chest X-ray. Prophylactic chest tubes (thoracostomy) are recommended prior to general anesthesia and/or air transport.
• Auditory system injuries and concussions are easily overlooked. The symptoms of mild traumatic brain injury and post traumatic stress disorder can be identical.
• Isolated eardrum rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries.
• Air embolism is common, and can present as stroke, myocardial infarction, acute abdomen, blindness, deafness, spinal cord injury, or limping. Hyperbaric oxygen therapy may be effective in some cases.
• Consider the possibility of exposure to inhaled toxins and poisonings from explosions.
• Wounds can be grossly contaminated. Consider delayed primary closure and assess tetanus status. Ensure close follow-up of wounds, head injuries, eye, ear, and stress-related complaints.
• Communications and instructions may need to be written because of ringing of the ear and sudden temporary or permanent deafness.