A terrorist bomb blast, a real challenge for any tertiary care health provider.

Multiple casualties and the complex set of injuries in survivors of a terrorist bomb blast poses a real challenge to health care providers. We are presenting three such cases, first case suffered a fracture of both bone lower limb bilaterally along with head injury (foreign bodies were impacted in the scalp and brain parenchyma). Following primary resuscitation, patient shifted to operation theatre after a quick computerized tomography scan and external fixator applied in general anesthesia using the rapid sequence induction. No active neurosurgical intervention was done. As this patient had acute post-traumatic stress response, he was subjected to low pressure hyperbaric oxygen therapy (pressure of 1.5 ATA for 60 min a day for 10 days) and group counseling. He had good recovery except one lost a limb because of extensive neurovascular damage due to blast. Second case had much more extensive damage involving multiple organ systems. He had blast lung, big cerebrovascular hemorrhage along with gut perforation. Despite best possible surgical and intensive care interventions, patent developed multiple organ failure and unfortunately we lost our patient. Third case was of a right sided globe rupture resulted from blast induced flying foreign bodies. After primary survey and initial resuscitation evisceration done for the damaged eye and patient later on discharged with necessary instruction (including warning signs) for follow-up.

INTRODUCTION

Terrorism is one of the global challenges that are being faced by humanity. As the rate of terrorism increases, it is important for health care providers to become familiar with the management of injuries inflicted by blasts and explosions. Another unfortunate incident occurred when recently a powerful briefcase bomb planted by terrorist went outside a busy public place.

We are reporting three cases of the blast injuries among those who were admitted in our institution. These case studies illustrate the varied clinical presentations of such blast injuries involving multiple organs. Certain issues pertaining the complexity of such injuries and mass casualty management are discussed.

CASE REPORTS

Case 1

This is a case of a 41-year-old bomb blast victim who suffered a fracture of both bone lower limb bilaterally (grade IIIc) along with head injury, multiple soft tissue injuries and many foreign bodies impacted in scalp (Secondary injuries type). After quick primary survey (following the Advanced Trauma Life Support (ATLS) principles, i.e., ABCDE's), resuscitation with oxygen and warm i/v fluids for hypovoluemia and hypothermia done. Adequate analgesia administered and finally decontamination followed by limbs splintage was applied.

Patient was shifted to operation theater (OT) after a quick computerized tomography (CT) scan of head and chest. External fixator was applied to both legs under general anesthesia using “drug assisted” and cricoid pressure technique. Standard monitoring with measurement of heart rate, electrocardiography, non-invasive blood pressure, peripheral pulse oxygen saturation, end-tidal capnography and temperature done. Before induction urinary and gastric catheters were inserted. Intraoperative adequate warm crystalloids and crossed match blood were administered along with antibiotics and tetanus prophylaxis. Patient was given 30,000 units of anti-gas gangrene serum in infusion (with prior test dose). X-ray chest and pelvis (anteroposterior [AP] view) were taken along with CT head. CT scan of the head showed multiple foreign bodies in the scalp and in right temporal region with multiple small hemorrhagic contusions [Figure 1]. No active neurosurgical intervention was done. As this patient was showing various sign and symptoms of acute post-traumatic stress response and hence after taking proper written and informed consent he was subjected to low pressure hyperbaric oxygen therapy (HBOT) and along with group counseling as a prophylactic measure against the development of post-traumatic stress disorder (PTSD). He was subjected to a pressure of 1.5 ATA for 60 min a day for 10 days. Antiepileptic prophylaxis for 10 days was also given. During his course of recovery in intensive care unit (ICU), on the 5th post-operative day patient developed gangrenous changes in left foot for which below knee amputation was done under regional anesthesia as his prior Doppler scan were equivocal. His condition progressed well after that in trauma ICU and later he was shifted to orthopedic ward.

Figure 1

Computerized tomography scan of head showing multiple foreign bodies in scalp and in right temporal region with multiple small hemorrhagic contusions

Case 2

This 35-year-old man sustained one of the most serious set of injuries, as he got fractures of both bone in lower limb (grades - right leg IIIb and left leg II) and right forearm, burst abdominal injury (ileal perforation), an open chest wound with reduced air entry (right side) and a severe head trauma (both primary and secondary injuries type). Following the rapid primary survey, resuscitation and further treatment was rendered based on ATLS principles. As his initial Glasgow Coma Score was E1V1M3 (total - 5), he was immediately intubated after preoxygenation maintaining manual inline stabilization of the cervical spine, but positive pressure ventilation was avoided. Pupillary examination revealed right side pupil middilated and slightly reacting. For open chest wound which was initially covered with sterile occlusive dressing (only three sides taped), intercostal drain insertion was secured remote from the wound site in 5th intercostal space just anterior to midaxillary line. Adequate positive pressure ventilation ensured to prevent hypoxia. Two wide bore peripheral venous lines secured and warm crystalloids given rapidly to prevent hypovoluemic shock. Blood samples send for grouping and cross matching along with emergency blood investigations including sample for arterial gas analysis. As soon the patient got stabilized (after full resuscitation and splintage of broken limbs), he was shifted for a quick CT scan and X-chest and pelvis (AP view). CT scan showed large hemotoma in temporal and fronto-parietel extending to bilateral lateral and III ventricle, effacement of right lateral ventricles with midline shift of 9.5 mm, a metallic foreign body in right temporal region measuring about 10 mm × 6 mm, fracture right temporal-parietal bone with multiple foreign bodies in scalp right side [Figure 2]. Then he was shifted to trauma OT for laprotomy. Analgesics and tetanus prophylaxis given. Ileal perforation was repaired in two layers under general anesthesia with “assisted drug” with cricoid pressure technique. All standard monitors were applied for measuring basal parameters including both arterial and central venous pressure measurements. Before induction urinary and gastric catheters were inserted. After few hours, he underwent right tempo-parietal craniectomy with evacuation of intracranial hematoma. After some time in ICU, he gradually becomes more and more hemodynamically unstable. By this time, the patient had already received 15 units of whole blood and along with few units of packed red blood cells (fresh frozen plasma) and platelets. Refractory hypotension and intermittent hypoxemic episodes were complicating his critical state. Ionotrops with full mechanical ventilatory support was given, but his condition remain critical and septicemia kept on increasing despite optimal antibiotic treatment. Repeat CT head show hemorrhagic contusion along with intraventricular bleed. On the 7th day, patient developed frank acute respiratory distress syndrome (ARDS) along with features suggestive of disseminated intravascular coagulation (DIC). For severe hypoxemic episodes lung recruitment strategy in the form of “extended sighs” with optimal positive end-expiratory pressure (PEEP) was used. All recommended supportive measures for DIC were applied. Unfortunately despite our best efforts, on 8th day patient develop cardiac arrest from which he could not be revived.

Figure 2

Computerized tomography scan showing large hemotoma in temporal and fronto-parietel extending to bilateral lateral and III ventricle with midline shift of 9.5 mm, fracture right temporal-parietal bone with multiple foreign bodies in scalp

Case 3

This 35-year-old male bomb blast victim was admitted with multiple abrasions over right thigh, lacerated wound over right hand and a serious ocular injury in the form of a deep perforated wound of the right eye probably caused by a tangentially flying sharp foreign body (secondary injuries type). As he was fully oriented and conscious at that time, a quick primary survey along with a brief history to know the sequence of events and mode of injury was done. After primary resuscitation and sterilization, patient was immediately sent for quick CT scan. Unnecessary eye manipulations were avoided and only a sterile eye dressing was applied. Although analgesics were given at resuscitation room, antibiotics and tetanus prophylaxis were given in OT by anesthesiologist. Microscopic eye examination revealed right sided globe rupture with tear in sclera, prolapsed and profusely bleeding cillary body [Figure 3]. Left side eye examination was insignificant with mild conjuctival redness.

Figure 3

Computerized tomography scan showing right side globe rupture with tear in sclera and prolapsed cillary body

He was planned for emergency evisceration. General anesthesia using assisted drug with cricoid pressure given for the above planned surgery. Scleral cavity evacuated and an implant was kept. In the post-operative period, patient remains stable and progressed very well. He was discharged after 2 weeks and told to come regularly for follow-up.

DISCUSSION

Coordination between pre-hospital personnel and hospital trauma team is vital, so that after pre-hospital stabilization victims can be immediately shifted to nearest verified trauma center. If pre-hospital triage is not done properly then there are chances that after such mass casualty victims with very low chances of survival may arrive first and can exhaust available care resources before arrival of less injured salvageable victims. This implies the very essential role of pre-hospital triage.

Bomb blast victims tend to be more severely injured and take up more resources. Mayo and Kluger[1] in Israel found the number of severely injured (injury severity score ≥16) was 3 times higher and for those with Glasgow Coma Scale score ≤5 the figure was 4 times higher. A shock/blast wave when encounter tissues of different densities, they create differential pressure forces and eventual shearing at tissue interfaces, resulting in severe tissue damage.[2] Therefore, hollow organs containing air tend to be injured more by shock/blast waves.

Four patterns of injuries[34] have been described according to the mode of injury. Primary injuries occur when the initial blast wave strikes the victim's body. Secondary injuries are sustained by the victim when flying objects such as debris, glass, concrete and metal shrapnel hit the victim's body. Tertiary type of injury occurs when people fly through the air and strike other objects. Other miscellaneous injuries that occur thereafter are termed quaternary injuries (chemical burns, smoke inhalation and crush injuries).

The trauma team should manage such patients using a systematic approach, such as that of ATLS course. Explosions can produce classic injury patterns from blunt and penetrating mechanisms to several organ systems. Understanding these crucial differences is critical.[5]

All elective and non-urgent patients are to be cleared from the hospital, in particular from the emergency departments. Pulmonary barotrauma is the most common fatal primary blast injury. Other complications include pulmonary contusion, systemic air embolism, thrombosis and DIC.

Isolated eardrum perforation in survivors of explosions does not appear to be a marker of concealed pulmonary blast injury nor of a poor prognosis. Therefore, in a mass casualty victims having isolated eardrum perforation from explosions may safely be discharged from the hospital after chest radiography and a brief observation period.[67]

ARDS as seen in the third case. Positive pressure ventilation itself in such cases can cause air embolism especially in hemodynamically unstable cases. Hence it is important to first stabilize the patient with medications. Reduce the tidal volume to limit peak inspiratory pressure <35 cm of H2O and plateau pressure to 30 cm of H2O. For only severe hypoxemic episodes, lung recruitment strategy are occasionally advised and only if patient is hemodynamically stable.[89]

All critically-ill patients require chest, cervical spine and pelvic radiographs, as well as radiographs based on the site of penetrating wounds. Unstable, critically-ill patients should be transferred straight to the operating theater to treat the cause without a need for imaging.

Long-term management of such victims is equally important. Referral to neurology and ENT should be considered for follow-up care. Exposure to blasts may result in mild traumatic brain injury and predispose to PTSD.[1011] Patients with residual symptoms should be referred to neurologists and psychiatrist as required.

In our case, about one-third of the victims were showing features of blast related mental stress in the form of moderate to severe anxiety, depression, sleep disturbances including hyper arousal and nightmares. HBOT treatment is the definitive procedure for arterial gas embolism (AGE) and cerebral AGE.[1213] Hyperbaric oxygen may be of some benefit in the treatment of blast-related post-concussive symptoms.[14]

We tried this therapy (HBO) in some of such victims with mixed results (result of that “prospective Cohart case study” will be presented in separate article). Although insufficient data exist to make a definitive recommendation, HBOT may be of some benefit in the treatment of blast-related post-concussive symptoms. Ocular injuries are mostly secondary blast injuries, resulting from flying fragments and debris. In severely injured eyes, the visual prognosis remains poor despite development of advanced microsurgical techniques and better methods of visual rehabilitation.[15]

CONCLUSION

As seen, the very complex injury patterns in bomb blast victim's possess a great challenge to treat. The core trauma team should work in a coordinated manner to ensure doing maximum good to maximum of victims. The management of both physical and psychological trauma needs immediate attention.