Operational Medicine 2001
Care of Blast Injuries Under Fire 

Primary Problem: Casualty unable to help himself while he and teammates are under fire

Secondary Problems:

• Unconsciousness due to vagal reflexes or arterial gas embolism

• Traumatic amputations in casualties close to detonation point

• Penetrating trauma from fragments, shrapnel, and miscellaneous debris

• Blunt trauma from casualty being displaced by blast wind

Introduction:  

Most casualties within the injury radius of high-explosive (HE) detonation will have common penetrating, blunt, and burn injuries managed no differently than similar non-blast trauma.  Although blast overpressure can also cause occult injuries to intra-thoracic and intra-abdominal organs, these are not immediately important when personnel are under effective hostile fire.

Movement Under Fire

Should you or teammate move from position of cover to attend or retrieve casualty?  (Predetermined hand signals may be used to communicate with conscious casualties.  Binoculars may help assess unconscious casualties from concealed site.)

Focused Questions (if attend casualty)

Quantity – 

• Where does it hurt?  (May help identify location of wounds with potentially exsanguinating external hemorrhage.)  

• Can you breathe OK?  (Chest injuries may be managed when in Tactical Field Care, so degree of respiratory difficulty may help decide urgency of movement to cover.)

Quality – 

• Can you shoot back or make it to cover?  (Degree to which casualty can function will determine what he can do under his own power.  In addition to penetrating or blunt injuries, shortness of breath may be limiting factor.)

Objective

Using Basic Tools

General:  

• Altered mental status (AMS) may range from confusion to coma.  

• Seizures may occur.

Inspection:  

• Identify sites of life-threatening external hemorrhage first.  

• Traumatic amputation and penetrating vascular injury are common in casualties close to blasts. May range from tips of digits to entire limbs, but volume of bleeding is critical parameter.

Auscultation:  

• Not necessary while under fire. 

Palpation:  

• Palpation may be necessary to identify major hemorrhage in low-light environment.

• Rapid palpation of spine or extremities may be appropriate to decide if casualty can move under own power.

Assessment

Rapid Decision-Making

• Significant respiratory distress and external hemorrhage are only medical reasons for going to casualty, but risks to personnel must be weighed against risks to mission accomplishment if injured or killed.  

• Possibility of additional injury to casualty (lack of cover during firefight, drawing enemy attention by movement) is also consideration.  

• Unconsciousness alone is not a reason to expose additional personnel to danger.  

• If there is no respiratory distress or arrest, the casualty’s airway is temporarily intact.  

• Vasovagal syncope will resolve on its own.  

• Penetrating head and torso trauma, arterial gas embolism (AGE), and seizures cannot be managed under fire.

Differential Diagnosis

• Immediate loss of consciousness or seizures may indicate release of chemical nerve agent or cyanide.

Plan

Immediate Actions

• Essential:  Return fire as directed or required.  Take cover or otherwise prevent injury to additional personnel.  Don chemical-biological-radiological (CBR) protection, if appropriate.

• Recommended:  Make tactical decision whether or not to have casualty move to cover or have other personnel attempt retrieval of casualty.

Procedures                          

• Essential:  Stop life-threatening external hemorrhage with tourniquet on any bleeding extremity.

• Recommended:  Move casualty to cover so direct pressure can be applied to bleeding wounds in other locations.

Notes

• “The best medicine on the battlefield is fire superiority.”  Casualties may receive additional wounds and uninjured personnel may become casualties, if not behind cover during hostile fire.

• Very little treatment can be accomplished until transition into Tactical Field Care.

• AMS is most likely due to penetrating or blunt head trauma or shock from bleeding, but two unique features of blast injury are less common causes: 

  • Blast overpressure on lungs can cause vasovagal syncope with bradycardia and hypotension, which may last minutes to hours even with conventional treatment.

  • Stress-induced tears in lung tissue may allow air into pulmonary veins, which can then be ejected to cerebral (stroke) or coronary circulation (heart attack).

• If AGE is suspected, place in coma position with left side down (halfway between left-lateral decubitus and prone) and head at same level as heart.

This section contributed by Lt Col John Wightman, USAF, MC

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Operational Medicine 2001
Health Care in Military Settings

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