What’s in Your All-Hazards Plan?

In Boston they were prepared. Are you?

Blast and burn injuries require special consideration. The event may be categorized as one involving high-order explosives (HE) or low-order explosives (LE), which produce different patterns of injury. Examples of HE include TNT, C4, Semtex, nitroglycerin, dynamite and ammonium nitrate fuel oil (ANFO). High-order explosive incidents result in large numbers of casualties and major structural damage. Examples of LE include pipe bombs, gunpowder and most pure petroleum-based bombs such as Molotov cocktails and aircraft improvised as guided missiles. Lower-order incidents can result in high numbers of casualties, as on 9/11/01, but more typical events will produce a smaller number of victims, some with survivable wounds. There will be some with burn injuries requiring expedient burn care.

Blast injuries are categorized into four types.

  • Primary blast injuries are caused by the atmospheric pressure of the blast wave. Organs most affected are gas-filled structures such as the lungs, GI tract and middle ear. Other injuries may include the central nervous and cardiovascular systems.
  • Secondary blast injuries result in penetrating trauma from flying debris and bomb fragments. Devices may incorporate additional projectiles to increase secondary injuries. Improvised devices may include nails, ball bearings, nuts and bolts and/or metal debris. In the Middle East, larger devices have been improvised that also distribute chemical hazards including cyanide and tanks of chlorine gas. Any system of the body may be affected by secondary injury.
  • Tertiary blast injuries occur when the patient’s body is propelled by the blast wave into walls or scene debris. This results in additional blunt or penetrating trauma, fractures, amputations and brain injuries.
  • Quaternary injuries include the inhalation of dust, smoke, carbon monoxide and other chemicals, exacerbation of pre-existing medical conditions, thermal burns from gases or secondary fires, and crush injuries resulting from entrapment under collapsed structures.

Burn injuries are particularly devastating in the patient who has also been exposed to a blast, so burn patients must be covered, warmed, cleaned of any gross debris and transported to a prepared hospital.


The best EMS major incident response program comes from excellent day-to-day delivery of care, combined with commonsense preparedness and an excellent relationship with hospitals, law enforcement and regional public health officials. Expansion of a few physical assets, understanding of the regional resources that can be utilized for major incidents, and routine use of an incident management system will lay the necessary groundwork for a major terrorist incident response. System leaders must consider the adaptation of triage efforts and response, with security and responder safety issues becoming an immediate consideration.

This article is courtesy of Cygnus Business Media sister publication EMS World. Visit them at http://www.emsworld.com.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. He was assistant fire chief and medical director for District of Columbia Fire and EMS. Jim also served as chair of ASTM Task Group E54.02.01, which develops standards for hospital preparedness under Committee E54 on Homeland Security Applications. He spent 32 years as a firefighter and EMT.