It Can Happen Here
Nurses need to be prepared for the complex
injuries massive explosions cause.

By Don Vaughan
March 14, 2005

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

Bridges says care must focus on life and limb at the scene of a blast injury. “Following the bombing in Oklahoma City [the April 19, 1995, bombing of the Alfred P. Murrah Federal Building], the most common interventions in the field were spinal immobilization, field dressings, and intravenous fluids,” she says. “A very small number of patients required intubation or cardiac resuscitation.”

Bridges says nurses and other health care professionals should follow the current recommendations for field care after blast injuries by remembering the ABCs — airway/ breathing (oxygen, intubation), cervical spine stabilization, circulation (hemorrhage control via direct pressure or with a tourniquet), and stabilization of fractures.

With mass casualties, care in the ED should focus on the rapid triage of patients and the initial treatment of life- or limb-threatening injuries, Bridges says. Examples include advanced trauma life support resuscitation, definitive airway/ventilation, empiric tube thoracotomy, control of external bleeding with direct pressure, focused abdominal sonography for trauma, a CT scan of the head for patients with a low or deteriorating Glasgow Coma Scale score to rule out a mass lesion, temporary stabilization of fractures, decompression of the stomach and bladder, treating potential tetanus, administering antibiotics, and covering the wounds.

“Blood product administration in the emergency department may be delayed in lieu of taking the patient straight to the operating room,” Bridges says. “During a mass-casualty event, the use of routine radiographs, MRI, or angioplasty is not recommended. Depending on the number of casualties, surgical procedures may be damage-control only, such as ... stopping hemorrhage.”

Pattern plans

An important factor in planning care for patients with blast injuries is to recognize the typical pattern of how patients will arrive at the hospital after a disaster. “Generally, 50% of patients will come by private transportation,” Bridges says. “In Oklahoma City, the first casualties arrived within five minutes of the blast in a red Corvette, with the owner shuttling victims to the hospital. These initial victims tend to be less seriously injured, have not been triaged or received any initial care, and can overwhelm a medical facility, especially if it is near the site of the incident.”

Bridges says to expect a second wave of more seriously injured patients. To estimate the number of expected casualties, the Centers for Disease Control and Prevention suggests counting the number of patients who arrive within the first hour, then doubling that number.

“Recognition of this patient flow pattern is also important in planning staffing,” Bridges adds. “Although everyone wants to be involved in the initial response to a disaster, it is important to prepare for the continued care of those admitted to the hospital.”

Triaging blast victims

Rapid triage in the ED is vital when handling a multipatient blast event, says Elizabeth Bridges, RN, PhD, CCNS, assistant professor of biobehavioral nursing and health systems, University of Washington School of Nursing, and clinical nurse researcher, University of Washington Medical Center, both in Seattle. “The general principle underlying triage is ‘the greatest good for the greatest number of casualties,’” she says. “This requires not only deciding who gets treated first, but also the maximization of available resources, which may lead to a decision to transfer a patient from your facility.”

The goal of triage, Bridges says, is to rapidly identify patients who are “immediate.” This includes patients with airway compromise that can be managed with an artificial airway; those who are comatose; and those with penetrating torso trauma, vascular trauma, major limb deformity, or deep partial- or full-thickness burns.

“There are individuals who, sadly, will die no matter what we do,” Bridges says. “Following an explosion, individuals who present with amputations with no signs of life or no respiration/pulse and dilated pupils were most likely very close to the explosion and have suffered fatal internal injuries. They should be triaged as ‘expectant.’”

In a mass-casualty situation, attempts to resuscitate expectant casualties with CPR or open-chest thoracotomy are generally futile and will take care away from the immediate casualties, Bridges says. “Triage is not an easy decision,” she adds. “During exercises, the health care providers who will be responsible for triage should be guided and educated regarding what injuries are or are not survivable after an explosion.”

Don Vaughan is a freelance writer.