Primary blast injuries.

Injury from explosion may be due to the direct cussive effect of the blast wave (primary), being struck by material propelled by the blast (secondary), to whole-body displacement and impact (tertiary), or to miscellaneous effects from burns, toxic acids, and so on. Severe primary blast injury is most likely to be seen in military operations but can occur in civilian industrial accidents or terrorist actions. Damage is seen almost exclusively in air-containing organs--the lungs, the gastrointestinal tract, and the auditory system. Pulmonary injury is characterized by pneumothorax, parenchymal hemorrhage, and alveolar rupture. The last is responsible for the arterial air embolism that is the principle cause of early mortality. Treatment for blast injury is similar to that for blunt trauma. The sequalae of air embolization to the cerebral or coronary circulation may be altered by immediate hyperbaric therapy. Use of positive pressure ventilatory systems should be closely monitored as they may increase the risk of air embolism in pneumothorax. Morbidity and mortality may be increased by strenuous exertion after injury and by the wearing of a cloth ballistic vest at the time of the blast.