Chest
Volume 115, Issue 1, January 1999, Pages 165-172
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Clinical Investigations in Critical Care
Blast Lung Injury From an Explosion on a Civilian Bus

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Objective

To assess clinical signs and management of primary blast lung injury (BLI) from explosions in an enclosed space and to propose a BLI severity scoring system.

Design

Retrospective analysis.

Patients

Fifteen patients with primary BLI resulting from explosions on two civilian buses in 1996.

Results

Ten patients were extremely hypoxemic on admission (Pao2 < 65 mm Hg with oxygen supplementation). Four patients remained severely hypoxemic (Pao2/fraction of inspired oxygen (Fio2) ratio of < 60 mm Hg) after mechanical ventilation was established and pneumothoraces were drained. Initial chest radiographs revealed bilateral lung opacities of various sizes in 12 patients (80%). Seven patients (47%) had bilateral pneumothoraces and two patients had a unilateral pneumothorax. Five (33%) had clinically significant bronchopleural fistulae. After clinical and laboratory data were collected, a BLI severity score was defined based on hypoxemia (Pao2/Fio2ratio), chest radiographic abnormalities, and barotrauma. Severe BLI was defined as a Pao2/Fio2 ratio of< 60 mm Hg, bilateral lung infiltrates, and bronchopleural fistula; moderate BLI as a Pao2/Fio2 ratio of 60 to 200 mm Hg and diffuse (bilateral/unilateral) lung infiltrates with or without pneumothorax; and mild BLI as a Pao2/Fio2 ratio of> 200, localized lung infiltrates, and no pneumothorax. Five patients developed ARDS with Murray scores > 2.5. Respiratory management included positive pressure ventilation in the majority of the patients and unconventional methods (ie, high-frequency jet ventilation, independent lung ventilation, nitric oxide, and extracorporeal membrane oxygenation) in patients with severe BLI. Of the four patients who had severe BLI, three died. All six patients with moderate BLI survived, and four of five with mild BLI survived (one with head injury died).

Conclusions

BLI can cause severe hypoxemia, which can be improved significantly with aggressive treatment. The lung damage may be accurately estimated in the early hours after injury. The BLI severity score may be helpful in determining patient management and prediction of final outcome.

Section snippets

Patients

On February 25 and March 3 in 1996, two terrorist bombs exploded on civilian buses in Jerusalem, immediately killing 47 passengers at the site of the explosion. Eighteen survivors were admitted to our hospital. One was dead on arrival. Two patients had no lung injury, and the 15 remaining patients with varying degrees of BLI were included in the study. Data were gathered from the reports of the medical teams who rendered primary care at the scene, the records from the admitting area of the

Results

Fifteen patients (11 men) who suffered from different degrees of BLI were admitted to our hospital (Table 2). The median age was 29 years (range, 18 to 53 years). Ten patients presented with significant hypoxemia during the first hours after blast injury (Table 3). All but one of the patients were intubated within 2 h after the explosion (Table 2). The only patient (patient 14) who did not require intubation during the first few hours after explosion had an uneventful follow-up (Table 2). In

Discussion

In this retrospective study, the clinical features of BLI in victims who were treated following two explosions on civilian buses in 1996 are presented. To the best of our knowledge, this is the largest group of patients with BLI described in the literature. Previous reports of BLI consist of descriptions of radiographic findings, epidemiologic information, or case reports.1, 13, 17, 18, 19 The present study focused on analysis of BLI during the first 24 h after injury because this is the most

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