Clinical Pathways
Clinical Pathways
Respiratory Compromise
Respiratory Compromise

Respiratory Compromise

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Decision

Signs of respiratory compromise?

Yes

  • Provide supplemental oxygenation
  • Initiate definitive airway if no improvement
  • Administer pain control
  • Consult specialist
  • Admit

(Class I)

Background

Lungs have a higher threshold of 30 psi before damage will occur. As a reference, a simple dry ice bomb (in which dry ice is placed in a plastic soda bottle) can produce >100 psi. Blast lung is caused by tearing, hemorrhage, contusion, and edema in the lungs, with resultant ventilation-perfusion mismatch. Pulmonary barotrauma is the most common fatal primary blast injury and has among the highest mortality of all blast injuries. In a retrospective study of 29 patients, Avidan et al reported that 76% of patients with blast lung injury required mechanical ventilation. Of the ventilated patients, 32% had a PaO2/FiO2_{2} (partial pressure of oxygen, arterial/fraction of inspired oxygen ratio) <60; 18% between 60 and 100; 23% between 101 and 200; and 18% >200. The remainder of patients had missing data. The worst PaO2 /FiO2 occurred within the first 24 hours, for all ventilated patients. Of the patients who did not require mechanical ventilation, the lowest PaO2 /FiO2 was >200. Data on associated injuries were also reported, with 86% of patients with blast lung injury sustaining ruptured tympanic membranes.13^{13} It is important to note that body armor does not protect against barotrauma in primary blast injury.

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Kapur GB, Hutson HR, Davis MA, et al. The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response. J Trauma. 2005;59(6):1436-1444. (Retrospective; 36,110 bombings)
  2. Bureau of Alcohol, Tobacco, Firearms and Explosives. United States Bomb Data Center (USBDC) Explosives Incident Report (EIR). 2021. Accessed January 10, 2023. (Retrospective; national data)
  3. American College of Emergency Physicians. Bombings: Injury Patterns and Care. Accessed January 10, 2023. (Web-based course)
  4. Born CT, Briggs SM, Ciraulo DL, et al. Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents. J Am Acad Orthop Surg. 2007;15(8):461-473. (Review) DOI: 10.5435/00124635-200708000-00003
  5. Mallonee S, Shariat S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387. (Retrospective; 759 patients)
  6. Leibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41(6):1030-1035. (Retrospective; 297 patients)
  7. Halpern P, Tsai MC, Arnold JL, et al. Mass-casualty, terrorist bombings: implications for emergency department and hospital emergency response (Part II). Prehosp Disaster Med. 2003;18(3):235-241. (Review) DOI: 10.1017/s1049023x00001102
  8. Magnus D, Khan MA, Proud WG. Epidemiology of civilian blast injuries inflicted by terrorist bombings from 1970-2016. Defence Technology. 2018;14(5):469-476. (Meta-analysis)
  9. Gates JD, Arabian S, Biddinger P, et al. The initial response to the Boston Marathon bombing: lessons learned to prepare for the next disaster. Ann Surg. 2014;260(6):960-966. (Retrospective; 281 patients)
  10. Wolf SJ, Bebarta VS, Bonnett CJ, et al. Blast injuries. Lancet. 2009;374(9687):405-415. (Review) DOI: 10.1016/S0140-6736(09)60257-9
  11. Ho AM. A simple conceptual model of primary pulmonary blast injury. Med Hypotheses. 2002;59(5):611-613. (Descriptive model)
  12. Okpala N. Management of blast ear injuries in mass casualty environments. Mil Med. 2011;176(11):1306-1310. (Review)
  13. Avidan V, Hersch M, Armon Y, et al. Blast lung injury: clinical manifestations, treatment, and outcome. Am J Surg. 2005;190(6):927-931. (Retrospective; 29 patients)
  14. Bala M, Rivkind AI, Zamir G, et al. Abdominal trauma after terrorist bombing attacks exhibits a unique pattern of injury. Ann Surg. 2008;248(2):303-309. (Retrospective; 181 patients)
  15. Guy RJ, Kirkman E, Watkins PE, et al. Physiologic responses to primary blast. J Trauma. 1998;45(6):983-987. (Prospective; 20 rats)
  16. DeWitt DS, Prough DS. Blast-induced brain injury and posttraumatic hypotension and hypoxemia. J Neurotrauma. 2009;26(6):877-887. (Review)
  17. Rodriguez UA, Zeng Y, Deyo D, et al. Effects of mild blast traumatic brain injury on cerebral vascular, histopathological, and behavioral outcomes in rats. J Neurotrauma. 2018;35(2):375-392. (Prospective, in-vivo rats)
  18. Kapur GB, Pillow MT, Nemeth I. Prehospital care algorithm for blast injuries due to bombing incidents. Prehosp Disaster Med. 2010;25(6):595-600. (Editorial discussion)
  19. Jacobs LM, Wade D, McSwain NE, et al. Hartford Consensus: a call to action for THREAT, a medical disaster preparedness concept. J Am Coll Surg. 2014;218(3):467-475. (Consensus document)
  20. Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37. (Retrospective; 165 patients)
  21. Kragh JF, Jr., Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1-7. (Prospective survey; 232 patients)
  22. King DR, Larentzakis A, Ramly EP. Tourniquet use at the Boston Marathon bombing: lost in translation. J Trauma Acute Care Surg. 2015;78(3):594-599. (Retrospective; 152 patients)
  23. Ramasamy A, Midwinter M, Mahoney P, et al. Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury. 2009;40(12):1342-1345. (Retrospective; 90 patients)
  24. Hyldmo PK, Vist GE, Feyling AC, et al. Is the supine position associated with loss of airway patency in unconscious trauma patients? A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2015;23:50. (Meta-analysis; 16 publications)
  25. Hyldmo PK, Horodyski MB, Conrad BP, et al. Safety of the lateral trauma position in cervical spine injuries: a cadaver model study. Acta Anaesthesiol Scand. 2016;60(7):1003-1011. (Prospective; 5 cadavers)
  26. Hyldmo PK, Horodyski M, Conrad BP, et al. Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver? Am J Emerg Med. 2017;35(11):1630-1635. (Prospective cadaver)
  27. Blake WE, Stillman BC, Eizenberg N, et al. The position of the spine in the recovery position--an experimental comparison between the lateral recovery position and the modified HAINES position. Resuscitation. 2002;53(3):289-297. (Prospective; 38 patients)
  28. Newgard CD, Fischer PE, Gestring M, et al. National guideline for the field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg. 2022;93(2):e49-e60. (Guideline)
  29. Alfici R, Ashkenazi I, Kessel B. Management of victims in a mass casualty incident caused by a terrorist bombing: treatment algorithms for stable, unstable, and in extremis victims. Mil Med. 2006;171(12):1155-1162. (Retrospective editorial; 467 patients) DOI: 10.7205/milmed.171.12.1155
  30. Hogan DE, Waeckerle JF, Dire DJ, et al. Emergency department impact of the Oklahoma City terrorist bombing. Ann Emerg Med. 1999;34(2):160-167. (Retrospective; 388 patients)
  31. Arnold JL, Halpern P, Tsai MC, et al. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med. 2004;43(2):263-273. (Systematic review; 8364 patients) DOI: 10.1016/s0196-0644(03)00723-6
  32. Mayorga MA. The pathology of primary blast overpressure injury. Toxicology. 1997;121(1):17-28. (Review)
  33. Almogy G, Mintz Y, Zamir G, et al. Suicide bombing attacks: can external signs predict internal injuries? Ann Surg. 2006;243(4):541-546. (Retrospective; 154 patients)
  34. Hoz SS, Al-Sharshahi ZF, Dolachee AA, et al. Blast-induced traumatic brain injuries: experience from the deadliest double suicide bombing attack in Iraq. World Neurosurg. 2021;145:e192-e201. (Retrospective; 75 patients)
  35. McDermott M, Duffy M, Percy A, et al. A school based study of psychological disturbance in children following the Omagh bomb. Child Adolesc Psychiatry Ment Health. 2013;7(1):36. (Survey; 1945 children)
  36. Verfaellie M, Lafleche G, Spiro A, et al. Neuropsychological outcomes in OEF/OIF veterans with self-report of blast exposure: associations with mental health, but not MTBI. Neuropsychology. 2014;28(3):337-346. (Prospective; 127 patients)
  37. Preston J. “Nerves Are Rattled After Bomb Threats at Pitt.” The New York Times. Accessed January 10, 2023. (News article)
  38. Radziwon A. “’Really Came Together’: Pitt Community Reflects on 2012 Bomb Threats.” The Pitt News. 2022. Accessed January 10, 2023. (News article)
  39. Brunner J, Rocha TC, Chudgar AA, et al. The Boston Marathon bombing: after-action review of the Brigham and Women’s Hospital emergency radiology response. Radiology. 2014;273(1):78-87. (Retrospective; 40 patients)
  40. Van Vugt R, Keus F, Kool D, et al. Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients. Cochrane Database Syst Rev. 2013;2013(12):CD009743. (Systematic review; 396 references)
  41. Sorkine P, Szold O, Kluger Y, et al. Permissive hypercapnia ventilation in patients with severe pulmonary blast injury. J Trauma. 1998;45(1):35-38. (Prospective; 17 patients)
  42. Miller IS, McGahey D, Law K. The otologic consequences of the Omagh bomb disaster. Otolaryngol Head Neck Surg. 2002;126(2):127-128. (Retrospective; 138 patients)
  43. Ritenour AE, Wickley A, Ritenour JS, et al. Tympanic membrane perforation and hearing loss from blast overpressure in Operation Enduring Freedom and Operation Iraqi Freedom wounded. J Trauma. 2008;64(2 Suppl):S174-S178. (Retrospective; 436 patients)
  44. Chapman LE, Sullivent EE, Grohskopf LA, et al. Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2008;57(Rr-6):1-21. (Guideline)
  45. Nunziato CA, Riley CJ, Johnson AE. How common are civilian blast injuries in the national trauma databank, and what are the most common mechanisms and characteristics of associated injuries? Clin Orthop Relat Res. 2021;479(4):683-691. (Retrospective; 968,834 patients) DOI: 10.1097/CORR.0000000000001642
  46. Jaffe DH, Peleg K. Terror explosive injuries: a comparison of children, adolescents, and adults. Ann Surg. 2010;251(1):138-143. (Retrospective; 837 patients)
  47. Hamele M, Poss WB, Sweney J. Disaster preparedness, pediatric considerations in primary blast injury, chemical, and biological terrorism. World J Crit Care Med. 2014;3(1):15-23. (Review)
  48. Tovar MA, Pilkington RA, Goodwin T, et al. Pediatric blast trauma: a systematic review and meta-analysis of factors associated with mortality and description of injury profiles. Prehosp Disaster Med. 2022;37(4):492-501. (Systematic review and meta-analysis; 38 articles, 222,638 injuries)
  49. Harrison CD, Bebarta VS, Grant GA. Tympanic membrane perforation after combat blast exposure in Iraq: a poor biomarker of primary blast injury. J Trauma. 2009;67(1):210-211. (Prospective; 167 patients)
  50. Xydakis MS, Bebarta VS, Harrison CD, et al. Tympanic-membrane perforation as a marker of concussive brain injury in Iraq. N Engl J Med. 2007;357(8):830-831. (Prospective; 682 patients)
  51. Garner J, Watts S, Parry C, et al. Prolonged permissive hypotensive resuscitation is associated with poor outcome in primary blast injury with controlled hemorrhage. Ann Surg. 2010;251(6):1131-1139. (Prospective; in-vivo pigs)
  52. Schreiber MA, Meier EN, Tisherman SA, et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015;78(4):687-695. (Randomized controlled trial; 192 patients))
  53. Brown JB, Cohen MJ, Minei JP, et al. Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg. 2013;74(5):1207-1212. (Prospective; 1216 patients)
  54. Lowell A, Suarez-Jimenez B, Helpman L, et al. 9/11-related PTSD among highly exposed populations: a systematic review 15 years after the attack. Psychol Med. 2018;48(4):537-553. (Systematic review; 20 articles)
  55. Feder A, Costi S, Rutter SB, et al. A randomized controlled trial of repeated ketamine administration for chronic posttraumatic stress disorder. Am J Psychiatry. 2021;178(2):193-202. (Randomized controlled trial; 30 patients)
  56. Finnegan AP, Cumming PA, Piper ME. Critical incident stress debriefing following the terrorist bombing at Army Headquarters Northern Ireland. J R Army Med Corps. 1998;144(1):5-10. (Prospective; 407 patients)
  57. Leibovici D, Gofrit ON, Shapira SC. Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury? Ann Emerg Med. 1999;34(2):168-172. (Prospective; 647 patients)
  58. Ashkenazi I, Olsha O, Turegano-Fuéntes F, et al. Tympanic membrane perforation impact on severity of injury and resource use in victims of explosion. Eur J Trauma Emerg Surg. 2017;43(5):623-626. (Retrospective review)

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