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Lesson

Blast Injury in the Field

10 min Trauma Skip to quiz

Objective: Confirm the scene is safe first. Then use MARCH, which puts massive hemorrhage before the airway. Expect lung and bowel injury even when the skin looks intact.

Why this matters

The explosion may be over, but the scene may not be safe. A second device, fire, gas, or a building that is still coming down can still kill you. Military teaching separates care while the scene is unsafe from care after it is safe. Do not stay in an unsafe area to bandage a minor wound. If the scene is not safe, you do not have a patient yet.

Key points
  • If the scene is not safe, it is not your patient yet. Think about a second device, collapse, fire, and gas.
  • After the scene is safe, MARCH still sets the order: massive hemorrhage, then airway, then respirations, then circulation, then hypothermia.
  • Blast lung can show up as shortness of breath, low oxygen, or cough after a blast, even when the chest wall looks normal. Give oxygen. If you must ventilate, use gentle breaths. Positive-pressure ventilation can worsen blast lung. Go to a trauma center.
Verbalize
  • Is the scene safe? If not, this is not our patient yet.
  • MARCH still sets the order of care.
  • Intact skin does not mean intact lungs.

Clinical sequence

  1. Confirm the scene is safe before you approach. Do not walk into an uncleared blast site to bandage a minor wound.
  2. Then use MARCH: massive hemorrhage, airway, respirations, circulation, then hypothermia.
  3. Treat blast lung when the patient is short of breath, hypoxic, or coughing after a blast, even if the chest wall looks normal. Give oxygen. If you must ventilate, use careful volumes. Go to a trauma center.

Teaching points

  • Primary blast is the pressure wave. It hits organs that hold gas: ears, lungs, and bowel. Intact skin does not mean intact lungs. A ruptured eardrum is a clue. It is not the whole exam. Still examine the lungs and the belly.
  • Secondary blast is fragments and flying debris. Those wounds need tourniquets and wound packing.
  • Tertiary blast means the patient was thrown. Think traumatic brain injury and fractures.
  • Quaternary blast is everything else the explosion caused: burns, crush, and inhalation. See the burn and crush lessons.

Common errors

  • Focusing on one dramatic wound while an artery is still bleeding nearby.
  • Ventilating with breaths that are too large or too fast, which can worsen blast lung. That is an injury we cause.
  • Forgetting a second device or a structure that is still collapsing.

Practice

One-minute check

An outdoor explosion leaves two patients. One is missing a foot. One has a normal-looking chest wall and severe shortness of breath. Say whether the scene is safe, then the order of care for both.

Related: Massive hemorrhage first, Burns.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. First question at a blast scene is:
2. Normal chest wall after a blast plus severe shortness of breath:
3. After the scene is safe, care order is still:
4. A ruptured eardrum (tympanic membrane) after a blast is:
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