Blast Injuries - An Introduction
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In order to support US military personnel, it is essential to uncover the pathobiology of mild bTBI and develop improved treatment options. Modern combat will continue to cause bTBI, decreasing fighting strength to the point a combat team cannot accomplish mission objectives. Explosive blast overpressure creates a dynamic environment, which can cause complex injuries in multiple organ systems [ 5 , 9 , 10 , 11 ]. Brain injury due to explosive blast exposure is often overlooked. Realizing this, the Department of Defense DoD mandates that any service member exposed to a mandatory event such as a blast, vehicle collision, head injury, and so on, to be screened for concussion, followed by a neurologic evaluation.
Furthermore, categorizing and describing the different types of blast-induced head injury must continually evolve in order to better diagnose and treat the injuries. Categorization of bTBI can initially be described as open or closed based upon the integrity of the skull and overlying tissue. Open head injury OHI indicates that the skull has been fractured.
This can be by a foreign body, such as a bomb fragment or bullet, or from depressed skull fragments pushed into the skull interior by impact. Bomb case fragments, shrapnel, and debris are all types of explosive ejecta, which can penetrate the brain, resulting in a pTBI. When severe, brain tissue is violated, extrusion of brain matter and cerebrospinal fluid CSF are often noted at the site of penetration [ 11 ]. The resulting hemorrhage, edema, and macerated tissue are hallmarks of pTBI [ 11 ]. Further evaluation by CT imaging often indicates blood along the wound tract [ 11 ].
Presentation of the OHI may be as apparent as brain herniation or more subtle such as a linear skull fracture with intact skin and mild swelling.
Imaging of Blast Injuries to the Lower Extremities Sustained in the Boston Marathon Bombing
Closed head injury CHI is much more common. Most typically, it is due to blunt force. This causes the head to move. The brain moves slower than the head because it is surrounded by fluid, that is, CSF. This lag causes the faster moving skull to strike the brain, leading to a contusion. During an explosive blast, the detonation generates an overpressure shock wave that moves rapidly through the air, striking the head.
The pressure is transmitted through the skull to the brain. Consequently, the patient has an intact skull but underlying damage to the brain parenchyma. Both categories of bTBI can be caused by multiple injury mechanisms. There are five injury mechanisms which contribute to bTBI individually or in combination: primary, secondary, tertiary, quaternary, and quinary injuries [ 13 , 14 ]. Differential density of juxtaposed body structures can result in reflective waves and turbulent spalling effects within the tissue [ 16 ].
Finally, quinary contaminant injury is due to environment infection from soil bacteria in the ejecta or detonation radiation contamination [ 14 ].
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Clinical identification of bTBI and severity stratification are based on post-event signs and clinical symptoms. Open head injury is considered a severe injury, while CHI severity can be classified as mild, moderate, or severe. Mild bTBI is the most common explosive blast injury affecting US warfighters and is largely a diagnosis of exclusion. As with concussion, majority of mild bTBI patients recover within hours to days [ 18 ].
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Often, warfighters are not aware they have suffered a bTBI or endure the symptoms to continue the mission and support fellow warfighters. It is important for all combat medical staff from the squad level to the company level and above to educate the team on the importance of prompt reporting and evaluation of those exposed to blast. Initial evaluation is the most important in order to determine severity of the injury and avoid obfuscating the classification with worsening PCS symptoms. Prompt medical evaluation of initial bTBI allows determination of timing for recovery, ensuring avoidance of a second head injury [ 9 ].
A head injury occurring within the recovery window can cause life threatening second impact syndrome SIS [ 11 ]. Military first providers are given the military acute concussion evaluation MACE as a screening tool. This is a paper-and-pencil clinical device that tests for alterations in attention, consciousness, memory, and orientation.
If concussed, patients are then placed into a Concussion Care Center for recovery. Guidelines for Concussion Management from the American Academy of Neurology lists recommended recovery periods [ 19 ]. A step-wise approach to rest, rehabilitation, and recovery is conducted in the Military Concussion Care Centers. Basically, patients are educated on their condition and reassured that they will likely recover quickly.
Adequate sleep and rehydration are important. Behavior health issues such as post-traumatic stress disorder PTSD are also addressed.
Once symptoms abate, the patient is allowed to resume mild physical activity and cognitive tasks. This progresses until the patient is able to conduct full physical and cognitive activities without symptom manifestation without the need for any medications. PCS is a set of symptoms headaches, nausea, balance or coordination deficits, slurred speech, confusion, sensitivity to noise, sensitivity to light, tinnitus that usually resolve within days to weeks after blast exposure.
A subset of PCS suffers may continue to have persistent or chronic symptoms. Clinical data from blast-exposed veterans indicate that these criteria are inadequate to properly diagnose blast-related PPCS and that more focused testing is required [ 22 ]. Post-traumatic stress disorder and mild bTBI share many common symptoms such as difficulty in concentration, sleep disturbances, and mood alteration.
However, there are differences. For example, bTBI patients typically complain of headaches and vertigo, whereas PTSD patients much less commonly complain of headaches and vertigo. The American Psychiatric Association DMS V describes post-traumatic stress disorder as a mental health condition triggered by witnessing, experiencing, or learning a traumatic event.
Symptoms of PTSD may include severe anxiety, flashbacks, nightmares, and uncontrolled thoughts about the event. Avoidance of stimuli about the event is common. Alteration in arousal may include outbursts, difficulty in concentration, hypervigilance, exaggerated startle response, and sleep disturbances [ 24 ]. Due to the extreme situations in which blast injuries occur, it is not surprising to find that mild bTBI and PTSD afflict the blast-injured patient.
Diagnosis of mild bTBI has been difficult due to limited understanding of its pathobiology. Inability to identify brain structural and functional changes in mild bTBI is a further complication. Negative imaging with persistent symptoms likely indicates an injury below the limit of resolution of the image scanner.
High-resolution imaging studies and electrophysiology recordings are two noninvasive tools that may aid in diagnosis of mild bTBI. Cortical thinning on MRI scans has been noted in 11 active-duty military persons with a diagnosis of mild bTBI at an average of 1-month post-injury. Cortical thinning was identified in the superior temporal and superior frontal gyri and two areas in lateral orbitofrontal gyrus [ 25 ]. Another study of 38 veterans diagnosed with bTBI measured cortical thickness utilizing a T1 weighted 3-T MRI with 1-mm isotropic resolution and 8-channel birdcage head coil.
The purpose of this article is to make those researchers who are currently undertaking blast-related research endeavors, or those who plan to enter the field, aware of some of the basic tenants of blast-related research as it affects the central nervous system with particular emphasis on the brain. The challenges inherent in this area of research are numerous, but these obstacles further emphasize the need for substantial and cooperative work to be done for the benefit of Service members, Veterans, and their families. Skip to main content.
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Jessica I Tilghman. Sidney R Hinds, II. Article information. Article Information Volume: Article first published online: September 12, ; Issue published: January 1, Received: May 28, ; Accepted: August 02, Email: sidney. Keywords Blast , traumatic brain injury , concussion , biomarkers , radiation , biodosimetry. Open in new tab. Download in PowerPoint.
Historical Aspects. Mechanisms of Head Trauma. Ballistic head trauma. Blunt head trauma.
Explosive Blast Mild Traumatic Brain Injury
Primary blast-induced head trauma. Acceleration mechanisms. Direct cranial transmission.