Terrorist attacks are on rise all around the World. The explosive blast attack whether in enclosed or open space is the most favoured by terrorists. All blast injuries lead to multi system injuries and both civilian as well as military surgeons must be aware of the complexities of such injuries, in order to effectively manage such terrorist attacks. This paper tries to review the literature as regards the mechanisms, pathophysiology and management of blast injuries in general. Abbreviations ARDS (adult respiratory distress syndrome); BLI (Blast Lung Injury); BSA (Body surface area); CT (Computerized Tomography); DPL (Diagnostic Peritoneal Lawage); FAST (focused abdominal ultrasound); IED (Improvised Explosive Device) Introduction There has been increasing causalities from Terrorist blast injuries all around the world. Last decade itself has seen 10 fold increase in terrorist bombings(1) . Bombings in enclosed spaces whether in the transport network (July 11 2006 Mumbai, July 7 2005 London) or night clubs as in Bali 2002) all indicate that surgeons whether from civilian or military cadre must be prepared and experienced to manage effectively and early such blast related injuries.Previously such blast injuries occurring in war were managed by military surgeons but now since the scenario has shifted to civilian hospitals, the civil surgeon is a central component for mass causality situation management. Very few civilian surgeons are familiar with the effect of blast injury. In order to provide the optimal care, respond swiftly and to recognize and manage life threatening injuries in a chaotic and confronting situation(2), the surgeon must be familiar with effects of blast injury. In this paper we try to analyze the mechanism, pathophysiology of blast injuries with particular focus on surgical management of specific injuries and triage system applicable in such situations. In particular the author shares his experience with blast injury management from his home state of Jammu and Kashmir which is in state of terrorist violence for more than one decade.Terrorist bombings target innocent civilian population and the random nature of such attacks, with extreme variability lead to extensive soft tissue damage with involvement of multiple body systems which adds to this complexity. Biophysics of Blast Injuries Terrorists worldwide have been commonly using bombs, grenades, and recently improvised explosive devices (IED). IED's are commonly being used in urban warfare and one of the favourite explosive devices used by terrorists in state of Jammu & Kashmir, India.The IED's are relatively cheap to manufacture with high mutilating effect and casuality rate(3) . The blast explosion leads to expansive shock wave with initial component of high pressure wave arising from release of gases followed by negative pressure wave due to air being sucked back towards the site of explosion(4) . Such blast waves cause pressure / fragmentation and incendiary effects(5,6). Injuries caused by explosive blast were classified by Zuekerman(7) during world war according to the physical effects on the body caused by released energy. Primary Injury : results from interaction of the blast shock wave with the body that is barotraumas. Gas filled organs such as lung, tympanic membrane and gut are most vulnerable(8). This is due to dynamic pressure changes occurring at the air-liquid interfaces. Rupture of Tympanic membrane is the commonest injury which occurs at as low as 3 p.s.i above atmospheric pressure(9) . Secondary Injury : also referred to as fragmentation injury results from the collision of energized fragments or blast projectiles with the body. Such projectile injuries can be metal fragments from explosives such as IED or glass pieces and are the commonest cause of injuries in urban blasts. Tertiary Injuries : result from the displacement of whole body or body parts by the blast energy causing acceleration and deceleration injury and soft-tissue destruction
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