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Bomb blast injuries

Article  in  Journal of Punjab Academy of Forensic Medicine and Toxicology · January 2011

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 J Punjab Acad Forensic Med Toxicol 2011; 11(1)

BOMB BLAST INJURIES

Dr. Puneet Khurana,Assistant Professor,Department of Forensic Medicine, Christian Medical College, Ludhiana
Dr. JSDalal, Professor & Head, Department of Forensic Medicine, Christian Medical College, Ludhiana.

Article history Abstract

Received 12 Sept, 2010
Bomb Blast injuries are becoming very common due to ever
Received in revised form 22 Feb, 2011
increasing acts of terrorism. Every person from medical field
Accepted on 28Feb, 2011
or law enforcement agencies should be well conversant about
Available online March 25, 2011
the pattern, severity, mechanism, nature of injuries as they
Corresponding author
have to deal with hundreds to thousands of victims with
different types of injuries. Following article is going to be very
Dr. Puneet Khurana
helpful in understanding mechanism of various types of
Assistant Professor,Department of Forensic Medicine,
injuries and their medico legal importance.
Christian Medical College, Ludhiana

Phone: +919855424114
Email: puneet_era@yahoo.co.in
Keywords:Bomb Blast injuries;explosions ©2011 JPAFMAT. All rights reserved

Introduction 1. Surroundings & Medium in which it explodes.

Bomb blast injuries to civilians are becoming
increasingly common over the last two decades mainly
due to terrorist attacks and are not only confined to wars
but also become pandemic with ever increasing acts of
terrorism though the incidences are sporadic. A blast
injury is the result of physical trauma sustained in an
explosion. Explosions cause life-endangering unique type
of injuries involving multi organ system especially lungs &
central nervous system in single or multiple victims
simultaneously thereby producing mass casualties.
Classification of Explosive: [1, 2, 3]
1. High-order explosives (HE) as a result of
detonation produces almost instantaneous
high pressure rapidly expanding gases
which compress the surrounding air
resulting into supersonic over
pressurization shock or blast wave followed
by negative pressure (suction) wave which
lasts for about 5 times. Examples: -
Trinitrotoulene (TNT), C-4, Semtex,
nitroglycerin, dynamite and ammonium
nitrate fuel oil (ANFO).
2. Low-order explosives (LE) undergo
deflagration instead of detonation thereby
releasing slow energy as compared to HEs
resulting in subsonic explosion lacking over-
pressurization blast wave Examples: -Pipe
bombs, gunpowder and most pure
petroleum-based bombs such as Molotov
cocktails or aircraft improvised as guided
missiles.
Factors
The magnitude of damage depends on:-
2. The distance from the incidence.
3. Pressure wave & its duration.
4. Amount and composition of the explosive
material.
Mechanism of Injuries [2, 3, 4, 5, 6, 7, 8]
Primary
Unique to HE -results from the impact of the
over pressurization wave with body surfaces. Gas filled
structures are most susceptible as air is easily
compressible than water.
 lungs, GI tract, Ear, Eye, Brain
 Blast lung (pulmonary barotrauma)
 Abdominal haemorrhage and perforation
 TM rupture and middle ear damage
 Globe (eye) rupture
 Concussion
Secondary
Results from flying debris, broken glass, loose
pieces and bomb fragments any body part can be
affected. Penetrating ballistic (fragmentation) or blunt
injuries
 Eye penetration (can be occult)
Tertiary
Tertiary results from individuals being thrown by
the blast wind due to high energy explosion. Any body part
can be affected
 Fracture and traumatic
amputation,

37
 J Punjab Acad Forensic Med Toxicol 2011; 11(1)
 Closed and open brain injury
Quaternary
All explosion-related injuries, illnesses or
diseases not due to primary, secondary, or tertiary
mechanisms.
 Includes exacerbation or complications of
existing conditions e.g. on 9/11 the crash of two
jet airplanes into the World Trade Centre
created a relatively low-order pressure wave
resulting into fire and building collapse
producing thousands of mortalities. Any body
part can be affected -
 Burns (flash, partial, and full thickness)
 Crush injuries
 Closed and open brain injury
 Asthma, COPD, or other breathing problems
from dust, smoke, or toxic fumes
 Angina
 Hyperglycaemia
 Hypertension
Discussion
Selected Blast Injuries
Respiratory system [1, 2, 6, 9, 10, 11, 12]
 The Blast lung (Pulmonary barotraumas) the
most common fatal primary blast injury.
 “Butterfly” pattern on chest X-ray is the
characteristic of blast lung.
 Bronchopleural fistulae, pneumo-thoraces,
pseudocyst formations.
 ARDS and air embolism
 Diffuse lung damage even after two days.
 Pulmonary blast injury carries the highest
mortality and morbidity and consumed the most
resources in the major bombings.
Ear [13, 14, 15, 16]
 Deafness.
 Rupture/ perforation of Tympanic Membrane
 Fracture/ dislocation of ossicles
 Cochlear damage
 Foreign body in ear
 Long-term ENT sequel--- vertigo/ tinnitus,
dizziness and ear pain.
Central nervous system [1, 17, 18, 19, 20, 21]
•Headache, fatigue, poor concentration, lethargy,
depression, anxiety, insomnia, loss of memory
•Closed and open brain injury
•Intracranial, subdural and extradural haemorrhages
•Stroke
•Spinal cord injury
38
Abdominal Injury[1, 2, 3, 6]
 Symptoms: Abdominal pain, nausea, vomiting,
hematemesis, rectal pain, tenesmus, testicular
pain, unexplained hypovolemia.
 Acute/delayed signs of peritonitis
 Mesenteric shear injuries.
 Blunt trauma to the abdomen can cause solid
organ injuries like liver, renal and splenic
contusion, lacerations and haemorrhage.
Medico legal aspects
Forensic personnel should be familiar with the
pattern and severity of injuries so that the proper injury
report in case of survivors and post mortem report in
cases of death of persons can be prepared and collect
properly any foreign body (shrapnel, empty shell etc.) and
hand over to investigation officer. Sometimes forensic
personnel have to give opinion regarding time of injuries
so that actual and needy should get the benefit of state
machinery and ex gratia announced by the government.
One such incident took place in Shingar bomb blast in
Ludhiana (2008) where our department saved the money
of state by giving the exact time of injury as a person came
to emergency with alleged history of injuries sustained as
a result of above bomb blast but the wound was infested
with maggots with pus points at places so the time of the
injury did not coincide with the timing of bomb explosion
so no financial help but treatment was given thereby
saving the state money. Forensic personnel should have
eagle’s eyes to catch the moles.
Conclusions
 Blast injuries are not confined to the battlefield
but are pandemic
 Seal the hospital entrances and scan the hospital
properly to prevent the tactic of setting of dual
explosion to produce more mortalities as first
explosion for civilians and second for caregivers
and rescuers.
 Consider exposure to carbon monoxide, cyanide,
or methemoglobin-forming toxins in industrial as
well as terrorist explosion.
 Penetrating/blunt trauma to anybody surface is
the most common injury seen among survivors.
 Patients should require 4-6 hours of observation.
 Radiological imaging of the head, chest and
abdomen will help with the early identification
 J Punjab Acad Forensic Med Toxicol 2011; 11(1)
of blast lung injury, head injury, abdominal
injury, eye and sinus injuries, as well as any
penetration by foreign bodies.
 Isolated TM rupture is not a reliable marker of
morbidity.
 Delay the primary closure in contaminated
wound and give tetanus toxoid and anti-tetanus
serum.
Conflict of interest
None declared
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