Primary blast mechanism (**Primary blast** — overpressure wave injures **gas-filled organs**: **tympanic membrane (TM) rupture**, **pulmonary barotrauma (blast lung)**, GI perforation (rare in children), concussion/TBI without external head trauma; severity ↑ with **enclosed space** proximity and closer distance to detonation (ATLS, WHO mass casualty/blast, pediatric trauma consensus))
Initial assessment (ABCDE + scene) (ATLS primary survey · **scene safety** — secondary devices/explosives · document **distance from blast**, **enclosed vs open air** (enclosed = worse primary blast) · structural collapse risk · **mass casualty triage** — START/JumpSTART or local MCI protocol when resources overwhelmed (ATLS, WHO, ERC))
First-line therapy
Oxygen • inhaled
Duration: PRN · High-flow O₂ if SpO₂ <94% or respiratory distress — nasal cannula, non-rebreather, or HFNC per institutional protocol; target SpO₂ ≥94%; wean when stable (ATLS, ERC, WHO)
• **Blast lung recognition:** tachypnea, hypoxia, hemoptysis, subcutaneous emphysema, decreased breath sounds, pneumothorax — may present without external chest trauma; symptoms can worsen over 24–48 h (ATLS, WHO blast injury guidance).
• **Ventilation precautions:** if blast lung suspected — **avoid excessive positive pressure**; use **lowest effective PEEP**; lung-protective tidal volume **6–8 mL/kg** IBW if intubated; consider permissive hypercapnia per ARDS/trauma protocols (ATLS, WHO, pediatric critical care).
• **TM assessment:** auscultate tympanic membranes when clinically stable — TM rupture may occur **without external ear trauma**; document hearing; ENT referral for persistent hearing loss (ATLS, pediatric blast injury reviews).
• **CXR/CT chest indications:** any respiratory symptoms, abnormal chest exam, or **primary blast exposure in enclosed space** — even if initially asymptomatic; repeat imaging if clinical deterioration (ATLS, WHO).
• **Observation minimum 24 h** for high-risk primary blast without initial symptoms — enclosed-space exposure, close proximity, hemoptysis, or abnormal initial CXR; delayed pneumothorax and ARDS may develop 24–48 h post-injury (pediatric trauma practice, WHO).
Max 1000 mg/dose · Duration: PRN · 10 mL/kg bolus only for **proven hypovolemia/shock** — avoid routine aggressive fluid resuscitation in isolated blast lung; reassess after each bolus (ATLS, WHO)
• **PICU admission:** intubation/mechanical ventilation for blast lung; hemodynamic instability; severe TBI; ARDS; multi-organ failure (ATLS, ERC, pediatric critical care).
• **ENT consultation:** documented TM rupture, persistent hearing loss, vertigo, or otorrhea after blast exposure — hearing assessment when stable (ATLS, pediatric blast reviews).
• **Avoid fluid overload:** in isolated blast lung — **cautious crystalloid** only for demonstrated hypovolemia; excess fluids may worsen pulmonary edema/ARDS (ATLS, WHO blast injury).
• **Psychosocial support (quaternary):** blast events are psychologically traumatic — address child and caregiver distress; child-life/psychology referral as available (WHO mass casualty, pediatric disaster medicine).
Enter weight on Kids to calculate doses
Clinical notes
• ABCDE + scene safety: ATLS primary survey; assess distance from blast and enclosed-space exposure; mass casualty triage when resources overwhelmed — START/JumpSTART or local MCI protocol (ATLS, WHO, ERC).
• Primary blast: TM rupture and blast lung are hallmark injuries — auscultate TM when stable; blast lung signs include tachypnea, hypoxia, hemoptysis, subcutaneous emphysema, pneumothorax (ATLS, WHO).
• Ventilation: **limit positive pressure** if blast lung suspected — lowest effective PEEP; chest decompression for tension pneumothorax; intubate only if failing O₂/ventilation (ATLS, WHO).
• Imaging: CXR/CT chest for respiratory symptoms, abnormal exam, or enclosed-space primary blast; serial exams mandatory — delayed pneumothorax and ARDS may develop 24–48 h (ATLS, pediatric trauma).
• Admission: primary blast with respiratory symptoms or enclosed-space exposure; observe ≥24 h if high-risk without initial symptoms; PICU for intubation, instability, ARDS, severe TBI (ATLS, WHO, ERC).
• ATLS — Advanced Trauma Life Support (blast injury and pediatric trauma) (2024)
• WHO — Mass casualty and blast injury management (2022)
• ERC — European Resuscitation Council Guidelines (paediatric trauma and oxygen) (2021)
+ 2 more
• AAP — Pediatric disaster and trauma preparedness principles (2024)
