The wounding patterns of blast injuries are well known to any military medic who has served recently on operations, with Improvised Explosive Devices (IEDs) constituting a significant proportion of the casualties on the battlefields of Iraq and Afghanistan. Sadly the IED threat is no longer confined to war zones, with a series of high profile, mass-casualty IED terror events occurring in places of mass gathering in first-world countries in recent years.

Terrorists have come to favour explosives because of their proven ability to inflict mass casualties, cause fear and disruption in the community, and attract media interest (ANZCTC 2016).

Recent mass-casualty events of international significance include the Boston Marathon bombing of April 2013, the Charlie Hebdo shootings of January 2015 and the November attacks in Paris the same year. More recently we have seen the airport bombings in Brussels and Istanbul, and once again another mass-casualty terrorist attack in Nice, France when a truck drove into crowds on 14 July 2016, killing 84 people and injuring in excess of 300 more.

Turkish President Recep Tayyip Erdogan made the following poignant statement on the day of the Istanbul Airport bombing:

 “The bombs that exploded in Istanbul today could have gone off at any airport in any city around the world” (, 2016)

With that thought in mind, it is important that first responders and civilian medical staff have an understanding of the patterns of injury associated with blasts, as to be best prepared for the very real possibility that a mass-casualty incident occurs in their city. There are some outstanding lessons to be learned from the experiences of the French medical responders in the wake of the multisite terror attacks around Paris in November 2015 (Hirsch M 2015), and I encourage readers to pursue that reference. This article presents an overview of the specific wounding patterns of blasts to better inform medical responders of the constellations of injury patterns following blasts, as to be able to manage not only the obvious, but also the unseen life-threatening injuries.

Injuries from IED blasts occur from a variety of different mechanisms relating to the specific causative mechanism. It is internationally accepted that there are four distinct phases of blast injury (CDC 2016), which are presented below. Naturally these specific injury patterns don’t occur in isolation, and will occur concurrently in the blast-injured patient. It is however useful to study them in isolation, and it is important for the treating medical team to be aware of the less obvious internal injury profiles associated with blast injuries. For the first responder, the highest priority is always stopping catastrophic bleeding.

Primary Blast Injury