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The first victims who arrive in hospitals from events like the April 19, 1995, bombing of the Alfred P. Murrah Building in Oklahoma City tend to be less seriously injured.

Imagine a crowded shopping mall the day after Thanksgiving, the frantic start of the unofficial holiday shopping season. Holiday carols ring through the main atrium as harried shoppers rush to make their purchases. In the midst of it all stands a lone suicide bomber, a harness packed with C-4 explosives hidden beneath his winter clothing.

With the push of a button, the vest explodes. The bomber dies instantly, as do the dozen people standing closest to him. Scores more are struck down by the blast and flying shrapnel — the bomber had embedded nails and screws in the C-4 to inflict maximum damage. In the blink of an eye, a horrific terrorist tactic that has become frighteningly common in many parts of the world claims victims on American soil.

Blast injuries remain relatively uncommon in the United States, but events overseas and the still-fresh memories of September 11, 2001, suggest that it may be only a matter of time before we start to see more of them here. Will nurses and other health care professionals be ready to deal with these unique and complex wounds?

“Failure to prepare because we do not want to think that the bombing of civilian targets can happen in our communities is no longer acceptable,” says Elizabeth Bridges, RN, PhD, CCNS, assistant professor of bio­ behavioral nursing and health systems, University of Washington School of Nursing, and clinical nurse researcher, University of Washington Medical Center, both in Seattle. “Preparation is also important because there are other causes of explosions, such as industrial accidents. These events can happen in our own backyard and rapidly overwhelm a small medical facility.”

Wide variety of wounds

When an explosion occurs, regardless of whether it’s an accident or a terrorist act, every nurse in a medical facility will be involved in caring for blast victims, says Bridges, a retired Air Force nurse. “Following an explosion, the majority of injuries are either subcritical wounds that require short-term hospitalization or minor wounds that can be treated in outpatient settings,” she explains. “Thus, nurses from mental health and primary care to acute/critical care will all be involved in the care of these individuals. In addition, nurses in the community will be integral in the initial care of the less seriously injured and in following up on individuals who have been directly or indirectly affected by the event.”

Explosions, regardless of cause, can cause multilayered, complex injuries. According to Bridges, these can be divided into four levels —

• Primary: As the high-pressure blast wave passes through the body, it can rupture air-fluid interfaces and cause injury to the eardrums (tympanic rupture), lungs (pneumothorax, contusion/hemorrhage, arterial air embolism), and the wall of the gastrointestinal tract (delayed abdominal perforation). The patient may also present with a concussion or mild traumatic brain injury.
• Secondary: Secondary blast injuries are the most common types of injury after an explosion and are generally soft-tissue traumas and fractures caused by fragments, either from the explosion itself or from debris displaced by the blast. Secondary injuries may cause significant blood loss.
• Tertiary: The third level of injury is due to the explosion’s blast wind, which can be hurricane force in a large explosion. Victims tumble along the ground, suffering abrasions and contusions, or they may experience blunt trauma from being thrown against a structure, falling after being blown off a balcony, or being hit by a motor vehicle.
• Quaternary: The fourth level of blast injury includes flash burns, crush injuries, injuries due to exposure to toxic chemicals or dust, and psychological trauma.

On examination, most external injuries are relatively obvious, but internal damage may be more difficult to determine, says Julie Benbenishty, RN, BA, an ICU nurse at Hadassah Medical Organization in Jerusalem.

“We may see what appears to be a perfectly intact young man, only to discover via x-ray that his lung tissue has exploded,” says Benbenishty, who has cared for many blast victims in Israel. “The patient may be conscious and smiling and may even talk for a few minutes, but the patient is doomed. In cases like that, even emergency personnel at the scene may not know that anything is wrong.”

In addition, foreign objects embedded in explosives can continue to travel through the body long after the initial blast. Benbenishty recalls a 23-year-old woman who was struck in the head by a small bolt that penetrated the left temporal lobe, crossed the brain to the right occipital lobe, and drifted to the left frontal lobe over a matter of weeks. “The damage continues long after the initial blast,” she says.

Immediate concerns