1. Primary blast injuries are the injuries to the hollow gas-filled organs like the lungs, ear drum or intestines leading to their rupture. These occur as a direct result of the impact of the over pressurized blast wave on the body.
2. Secondary blast injuries occur due to flying debris and bomb fragments leading to penetration or penetrating injuries such as to the eyes.
3. Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures as a result of the fall.
4. Quaternary blast injuries are due to direct effect of burn or crush injuries.
The most important triage to manage blast injuries is not to waste energies and resources on patients with non-serious injuries. The first thing is to check for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non-serious injury.
All patients exposed to a blast must have eardrum examination as the first step. If the ear drums are intact, the patient can be discharged with first-aid treatment. If ear drum is ruptured, an X-ray chest should be done immediately. All such patients should be observed for eight hours as primary blast injuries are notorious for delayed presentation.
Doctors should therefore focus only on two exams: otoscopic ear exam and pulse oximetry. Blast lung injury is unlikely without tympanic or ear membrane rupture. This is used as a screening procedure for admitting a patient. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent.
Half of all initial casualties seek medical care over first hour. Double this number after one hour and you will know the total casualties. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs.
Always expect upside down triage as the most severely injured arrive after the less injured who self-transport to the closest hospitals.
With the increasing use of explosives in terrorist events in our country in recent times, doctors, especially Emergency Doctors, should undergo orientation training every six months so that they are prepared and better equipped to manage several casualties all at one time.
About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Chairman Ethics Committee Delhi Medical Council, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association and Past Academic and Research Wing Heads IMA.
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