Management of an Unexploded Intracorporeal Firework in a Low Resource Setting: Case Report and Tips.

Surgical removal of unexploded ordnance has been described in literature, usually in the context of the military. We describe a case of a 31-year-old gentleman who presented with a traumatic fireworks injury resulting in an unexploded three-inch aerial shell lodged in his left upper thigh. The sole regional Explosive Ordinance Disposal (EOD) expert was not available, so a local pyrotechnic engineer was contacted and he helped in identification of the firework. The firework was removed without the use of electrocautery, irrigation, or metal instrument contact after skin incision. The patient recovered well after prolonged wound healing. Creativity needs to be employed in low resource settings to identify all available resources that can impart knowledge when medical training is not enough. People with knowledge of explosives can be, as in our case, local pyrotechnics engineer or can be local cannon enthusiasts, veterans, or active military personnel at a nearby military base.

Explosive eye injuries: characteristics, traumatic mechanisms, and prognostic factors for poor visual outcomes.

BACKGROUND: Explosions can produce blast waves, high-speed medium, thermal radiation, and chemical spatter, leading to complex and compound eye injuries. However, few studies have comprehensively investigated the clinical features of different eye injury types or possible risk factors for poor prognosis. METHODS: We retrospectively reviewed all consecutive records of explosive eye injuries (1449 eyes in 1115 inpatients) in 14 tertiary referral hospitals in China over 12 years (between January 2008 and December 2019). Data on demographics, eye injury types, ocular findings, treatments, and factors affecting visual prognosis were extracted from a standardized database of eye injuries and statistically analyzed. RESULTS: Mechanical ocular trauma accounted for 94.00% of explosion-related eye injuries, among which intraocular foreign bodies (IOFBs) resulted in 55.17% of open globe injuries (OGIs) and contusion caused 60.22% of close globe injuries (CGIs). Proliferative vitreous retinopathy (PVR) was more common in perforating (47.06%) and IOFB (26.84%) than in penetrating (8.79%) injuries, and more common with laceration (24.25%) than rupture (9.22%, P < 0.01). However, no difference was observed between rupture and contusion. Ultimately, 9.59% of eyes were removed and the final vision was ≤ 4/200 in 45.82% of patients. Poor presenting vision [odds ratio (OR) = 5.789], full-thickness laceration of the eyeball ≥ 5 mm (OR = 3.665), vitreous hemorrhage (OR = 3.474), IOFB (OR = 3.510), non-mechanical eye injury (NMEI, OR = 2.622, P < 0.001), rupture (OR = 2.362), traumatic optic neuropathy (OR = 2.102), retinal detachment (RD, OR = 2.033), endophthalmitis (OR = 3.281, P < 0.01), contusion (OR = 1.679), ciliary body detachment (OR = 6.592), zone III OGI (OR = 1.940), and PVR (OR = 1.615, P < 0.05) were significant negative predictors for poor visual outcomes. CONCLUSIONS: Explosion ocular trauma has complex mechanisms, with multiple eyes involved and poor prognosis. In lethal level I explosion injuries, eyeball rupture is a serious condition, whereas contusion is more likely to improve. In level II injuries, IOFBs are more harmful than penetrating injuries, and level IV represents burn-related eye injuries. PVR is more associated with penetrating mechanisms than with OGI. Identifying the risk predictors for visual prognosis can guide clinicians in the evaluation and treatment of ocular blast injuries.

Military Exposures Predict Mental Health Symptoms in Explosives Personnel but Not Always as Expected.

OBJECTIVE: The aim of this study was to determine the unique and combined associations of various military stress exposures with positive and negative mental health symptoms in active duty service members. MATERIALS AND METHODS: We investigated 87 male U.S. Navy Explosive Ordnance Disposal (EOD) technicians (age M ± SE, range 33.7 ± 0.6, 22-47 years). Those who endorsed a positive traumatic brain injury diagnosis were excluded to eliminate the confounding effects on mental health symptoms. Using a survey platform on a computer tablet, EOD technicians self-reported combat exposure, deployment frequency (total number of deployments), blast exposure (vehicle crash/blast or 50-m blast involvement), depression, anxiety, posttraumatic stress, perceived stress, and life satisfaction during an in-person laboratory session. RESULTS: When controlling for other military stressors, EOD technicians with previous involvement in a vehicle crash/blast endorsed worse mental health than their nonexposed counterparts. The interactions of vehicle crash/blast with deployment frequency and combat exposure had moderate effect sizes, and combat and deployment exposures demonstrated protective, rather than catalytic, effects on negative mental health scores. CONCLUSIONS: Military stressors may adversely influence self-reported symptoms of negative mental health, but deployment experience and combat exposure may confer stress inoculation.

Injury modelling for strategic planning in protecting the national infrastructure from terrorist explosive events.

Terrorist events in the form of explosive devices have occurred and remain a threat currently to the population and the infrastructure of many nations worldwide. Injuries occur from a combination of a blast wave, energised fragments, blunt trauma and burns. The relative preponderance of each injury mechanism is dependent on the type of device, distance to targets, population density and the surrounding environment, such as an enclosed space, to name but a few. One method of primary prevention of such injuries is by modification of the environment in which the explosion occurs, such as modifying population density and the design of enclosed spaces. The Human Injury Predictor (HIP) tool is a computational model which was developed to predict the pattern of injuries following an explosion with the goal to inform national injury prevention strategies from terrorist attacks. HIP currently uses algorithms to predict the effects from primary and secondary blast and allows the geometry of buildings to be incorporated. It has been validated using clinical data from the '7/7' terrorist attacks in London and the 2017 Manchester Arena terrorist event. Although the tool can be used readily, it will benefit from further development to refine injury representation, validate injury scoring and enable the prediction of triage states. The tool can assist both in the design of future buildings and methods of transport, as well as the situation of critical emergency services required in the response following a terrorist explosive event. The aim of this paper is to describe the HIP tool in its current version and provide a roadmap for optimising its utility in the future for the protection of national infrastructure and the population.

Blast-Related Traumatic Brain Injuries Secondary to Thermobaric Explosives: Implications for the War in Ukraine.

Blast-related traumatic brain injury (bTBI) is a significant cause of wartime morbidity and mortality. In recent decades, thermobaric explosives have emerged as particularly devastating weapons associated with bTBI. With recent documentation of the use of these weapons in the war in Ukraine, clinicians and laypersons alike could benefit from an improved understanding behind the dynamic interplay between explosive weaponry, its potential for bTBI, and the subsequent long-term consequences of these injuries. Therefore, we provide a general overview of the history and mechanism of action of thermobaric weapons and their potential to cause bTBI. In addition, we highlight the long-term cognitive and neuropsychiatric sequelae following bTBI and discuss diagnostic, therapeutic, and rehabilitation strategies, with the aim of helping to guide mitigation strategies and humanitarian relief in Ukraine. Thermobaric weapons produce a powerful blast wave capable of causing bTBIs, which can be further classified from primary to quaternary injuries. When modeling the hypothetical use of thermobaric weapons in Odessa, Ukraine, we estimate that the detonation of a salvo of thermobaric rockets has the potential to affect approximately 272 persons with bTBIs. In addition to the short-term damage, patients with bTBIs can present with long-term symptoms (e.g., post-traumatic stress disorder), which incur substantial financial costs and social consequences. Although these results are jarring, history has seen radical advancements in the understanding, diagnosis, and management of bTBI. Moving forward, a better understanding of the mechanism and long-term sequelae of bTBIs could help guide humanitarian relief to those affected by the war in Ukraine.

[Lesions of the cortical part of the auditory analyzer in explosive injury]. / Narusheniya korkovogo otdela slukhovogo analizatora pri vzryvnoi travme.

A survey of 48 victims aged 19-36 years with explosive trauma and combined damage to the auditory system was conducted to assess the level of damage to nerve structures by analyzing the bioelectric activity of the cerebral cortex. All patients underwent electroencephalography (EEG). It is established that akubarotrauma of explosive genesis almost always leads to lesions of the function of the cortical part of the auditory analyzer. Desynchronized activity on the EEG after acubarotrauma is a favorable prognostic sign, indicating only functional disorders of the cortical part of the auditory analyzer. On the contrary, EEG changes of an organic type of cortical or stem nature are an unfavorable prognostic factor, usually accompanied by sensorineural hearing loss with prolonged and incomplete hearing recovery. Promising drugs for the treatment of otoneurological disorders are antihypoxants, in particular, derivatives of triazine indole, which affect the molecular mechanisms of hypoxia development.

Injuries, treatment, and impairment caused by different types of fireworks; results of a 10 year multicenter retrospective cohort study.

OBJECTIVES: The primary aim of this study was to evaluate the number of patients reported to a hospital with injuries from consumer fireworks in the months December-January in the past 10 years, and to describe the association between the type of fireworks, injury pattern, treatment, and permanent impairment. METHODS: A multicenter, retrospective, observational case series. Patients were selected from two hospitals in the Southwest Netherlands: a level 1 trauma center and a specialized burn center. All patients with any fireworks-related injuries treated between December 1 and January 31, during 2007 (December) to 2017 (January), were eligible for participation. The primary outcome was the number of patients with any type of injury caused by fireworks. The secondary outcome measures were patient and injury characteristics, treatment details, and whole person impairment (WPI). The percentage WPI expresses a patient's degree of permanent impairments as a result of fireworks-related injuries. RESULTS: Of the 297 eligible patients, 272 patients were included. From 2007 to 2017, between 21 and 40 patients were treated, and no clear increase or decrease was observed in the number of patients and in the number of patients per type of fireworks. Explosive fireworks mainly caused upper extremity (N = 65; 68%) injuries, while rockets (N = 24; 41%) and aerials (N = 7; 41%) mainly affected the head/neck. Decorative fireworks predominantly resulted in burns (N = 82; 68%), and explosive fireworks in soft tissue lacerations (N = 24; 25%), fractures (N = 16; 17%), and amputations (N = 14; 15%). Patients injured by explosive and homemade fireworks were most often admitted to a hospital (respectively N = 24; 36% and N = 12; 80%), and resulted in the highest proportion undergoing surgical procedures (respectively N = 22; 33% and N = 7; 47%). WPI found in this study was between 0 to 95%, with a median of 0%. In 34 (14%) patients, the injuries resulted in a WPI of ≥1%, mostly as a result of explosive fireworks (N = 18; 53%). CONCLUSION: This study found no increase or decrease in the number of patients treated in two specialized hospitals. Explosive and homemade fireworks could be considered as most dangerous, as they result into the most hospital admissions, surgical procedures, and into the most injuries with permanent impairment as a result.

Severe Fireworks-Related Injuries: Demographic Characteristics, Injury Patterns, and Firework Types in 294 Consecutive Patients.

OBJECTIVES: The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults. METHODS: We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older. RESULTS: Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died. CONCLUSIONS: Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

Multiple breath washout: A noninvasive tool for identifying lung disease in symptomatic military deployers.

RATIONALE: Military deployments to austere environments since November 9, 2001 may put "deployers" at risk for respiratory disease. Sensitive, noninvasive tools for detecting large and small airways injury are needed to identify early disease and help inform management for this at-risk population. OBJECTIVES: We examined multiple breath washout (MBW) as a tool for identifying deployment-related airways disease and assessed host and exposure risk factors compared to healthy controls. METHODS: Between March 2015 and March 2020, 103 healthy controls and 71 symptomatic deployers with asthma and/or distal lung disease completed a questionnaire, spirometry and MBW testing. SAS v. 9.4 was used to compare MBW parameters between deployers and controls via univariate analyses and adjusted for demographic factors using multiple linear regression. MEASUREMENTS AND MAIN RESULTS: Deployers were significantly more likely than controls to have an abnormal lung clearance index (LCI) score indicating global ventilation inhomogeneity. Adjusting for sex, smoking status, smoking pack-years and body mass index, LCI scores were significantly more abnormal among those with deployment-related asthma and distal lung disease compared to controls. The unadjusted variable Sacin (a marker of ventilation inhomogeneity in the acinar airways) was higher and thus more abnormal in those with both proximal and distal airways disease. Deployers who reported more frequent exposure to explosive blasts had significantly higher LCI scores. CONCLUSIONS: This study demonstrates the utility of MBW in evaluating exposure-related airways disease in symptomatic military personnel following deployment to austere environments, and is the first to link exposure to explosive blasts to measurable small airways injury.

Pulmonary injury risk curves and behavioral changes from blast overpressure exposures of varying frequency and intensity in rats.

At present, there are no set guidelines establishing cumulative limits for blast exposure numbers and intensities in military personnel, in combat or training operations. The objective of the current study was to define lung injury, pathology, and associated behavioral changes from primary repeated blast lung injury under appropriate exposure conditions and combinations (i.e. blast overpressure (BOP) intensity and exposure frequency) using an advanced blast simulator. Male Sprague Dawley rats were exposed to BOP frontally and laterally at a pressure range of ~ 8.5-19 psi, for up to 30 daily exposures. The extent of lung injury was identified at 24 h following BOP by assessing the extent of surface hemorrhage/contusion, Hematoxylin and Eosin staining, and behavioral deficits with open field activity. Lung injury was mathematically modeled to define the military standard 1% lung injury threshold. Significant levels of histiocytosis and inflammation were observed in pressures ≥ 10 psi and orientation effects were observed at pressures ≥ 13 psi. Experimental data demonstrated ~ 8.5 psi is the threshold for hemorrhage/contusion, up to 30 exposures. Modeling the data predicted injury risk up to 50 exposures with intensity thresholds at 8 psi for front exposure and 6psi for side exposures, which needs to be validated further.

Fear expressions of dogs during New Year fireworks: a video analysis.

A high proportion of pet dogs show fear-related behavioural problems, with noise fears being most prevalent. Nonetheless, few studies have objectively evaluated fear expression in this species. Using owner-provided video recordings, we coded behavioural expressions of pet dogs during a real-life firework situation at New Year's Eve and compared them to behaviour of the same dogs on a different evening without fireworks (control condition), using Wilcoxon signed ranks tests. A backwards-directed ear position, measured at the base of the ear, was most strongly associated with the fireworks condition (effect size: Cohen's d = 0.69). Durations of locomotion (d = 0.54) and panting (d = 0.45) were also higher during fireworks than during the control condition. Vocalisations (d = 0.40), blinking (d = 0.37), and hiding (d = 0.37) were increased during fireworks, but this was not significant after sequential Bonferroni correction. This could possibly be attributed to the high inter-individual variability in the frequency of blinking and the majority of subjects not vocalising or hiding at all. Thus, individual differences must be taken into account when aiming to assess an individual's level of fear, as relevant measures may not be the same for all individuals. Firework exposure was not associated with an elevated rate of other so-called 'stress signals', lip licking and yawning.

Combined Penetrating Keratoplasty Followed by Pars Plana Vitrectomy for Firecracker Induced Bilateral Corneal and Intraocular Foreign Body: A Case Report.

Firecracker induced open globe injury is a big challenge for ophthalmic surgeons. Its association with the intraocular foreign body makes the diagnosis and treatment even more difficult resulting in poor anatomical and visual outcomes. We report a case of a 35-year-old male who presented with bilateral, multiple corneal and intraocular foreign body due to firecracker explosion. His vision was limited to hand movement in both eyes. Combined penetrating keratoplasty and cataract surgery were done in both eyes followed by pars plana vitrectomy for intraocular foreign body removal. The final best-corrected visual acuity of the patient stood to be 6/6 and 6/9 in the right and left eye respectively. The encouraging result in our case prompts ophthalmologists for a timely stepwise multidisciplinary approach in all open globe injuries with intraocular foreign body cases having poor initial acuity.

"Don't Blast": blast-in-place (BiP) operations of dumped World War munitions in the oceans significantly increase hazards to the environment and the human seafood consumer.

The seas worldwide are threatened by a "new" source of pollution: millions of tons of all kind of warfare material have been dumped intentionally after World War I and II, in addition to mine barriers, failed detonations as well as shot down military planes and sunken ship wrecks carrying munitions. For example, in the German parts of the North and Baltic Sea approximately 1.6 million metric tons of toxic conventional explosives (TNT and others) and more than 5000 metric tons of chemical weapons are present. Such unexploded ordnance (UXO) constitutes a direct risk of detonation with increased human access (fisheries, water sports, cable constructions, wind farms and pipelines). Moreover, after more than 70 years of resting on the seabed, the metal shells of these munitions items corrode, such that chemicals leak out and distribute in the marine environment. Explosive chemicals such as TNT and its derivatives are known for their toxicity and carcinogenicity. In order not to endanger today's shipping traffic or the installation of pipelines and offshore plants by uncontrolled explosions, controlled blast-in-place (BiP) operations of these dangerous relics is a common practice worldwide. However, blast-in-place methods of in situ munitions disposal often result in incomplete (low-order) detonation, leaving substantial quantities of the explosive material in the environment. In the present free field investigation, we placed mussels (Mytilus spp.) as a biomonitoring system in an area of the Baltic Sea where BiP operations took place and where, by visual inspections by scientific divers, smaller and larger pieces of munitions-related materials were scattered on the seafloor. After recovery, the mussels were transferred to our laboratory and analyzed for TNT and its derivatives via gas chromatography and mass spectroscopy. Our data unequivocally demonstrate that low-order BiP operations of dumped munitions in the sea lead to multiple increases in the concentration of TNT and its metabolites in the mussels when compared to similar studies at corroding but still encased mines. For this reason, we explicitly criticize BiP operations because of the resulting environmental hazards, which can ultimately even endanger human seafood consumers.

The liberalization of fireworks legislation and its effects on firework-related injuries in West Virginia.

BACKGROUND: Fifteen states, including West Virginia, have liberalized their laws concerning fireworks possession and sale. Effective June 1, 2016, House Bill 2852 enabled all Class C fireworks to be sold within the state. The effects of this policy on fireworks-related injuries requiring immediate medical care are unknown. The purpose of this study was to determine whether this policy may have affected the fireworks-related injury rate and/or injury severity. METHODS: Data were collected from the electronic medical records of patients treated by West Virginia University Medicine between June 1, 2015-May 31, 2017. The pre and post law periods were defined as June 1, 2015-May 31, 2016 and June 1, 2016-May 31, 2017, respectively. Fireworks-related injuries were identified via International Classification of Disease Clinical Modification codes and by free text searches of the electronic medical records. The rate of injuries pre and post-legislation were compared by Exact Poisson Regression, while demographic characteristics and injury severity were compared via Fisher's Exact tests. RESULTS: 56 individuals were treated for fireworks-related injuries during the study period. The majority of patients were over 25 years of age (64%) and male (77%). Most of the injuries occurred within 7 days of a celebrated U.S. holiday (64%), and 28% were severe in nature. Age, sex, and injury severity did not significantly differ pre and post law passage. The injury rate per 100,000 patients was 39% higher after the law was enacted (p = 0.3475; incidence rate ratio 1.39, 95% Confidence Interval 0.74, 2.68). CONCLUSION: The law increasing access to Class C fireworks may have affected the injury rate, but not injury severity among treated patients. Effective, evidence-based, public health interventions applicable to all age groups may be warranted particularly around national holidays. This study may inform other states looking to amend their legislation.

Firework-related blast injury to the hand and treatment algorithm.

Firework injuries, which most commonly affect hands, are increasing in frequency and severity. We present a pictorial case of a devastating hand injury following a firework explosion in a young male patient. The blast resulted in splaying of the hand with multiple fractures, neurovascular compromise and soft tissue loss. Reconstruction involved a third-ray amputation, fracture fixation, nerve and soft tissue repair resulting in an adequate hand with near-normal appearance. Firework-related hand injuries pose a significant surgical challenge due to the combination of burn and blast forces that can compromise the function of intact vessels and nerves making salvage and reconstruction particularly difficult. Here, we propose a treatment algorithm based on current literature. Our case demonstrates, what initially appeared to be an unsalvageable injury can be reconstructed to produce a functional hand if appropriate surgical measures are taken.

Blast exposure interacts with genetic variant 5HTTLPR to predict posttraumatic stress symptoms in military explosives personnel.

The first of its kind, this study determined whether blast exposure interacts with genetic variant 5HTTLPR to predict posttraumatic stress (PTS) symptoms in 78 military explosives operators. In all models, blast-exposed 5HTTLPR S carriers registered definitively higher PTS symptoms in comparison to non-exposed S carriers, as well as exposed and non-exposed LL carriers (all p < 0.01). All findings were robust to confounding influences of age and traumatic brain injury diagnosis. Not only is blast exposure prevalent in EOD personnel, but it also interacts with genetic predisposition to predict trauma symptoms in this unique, at-risk military population.

Owner perceptions and management of the adverse behavioural effects of fireworks on companion animals: an update.

Aims: To provide updated results on the adverse behavioural effects of fireworks on companion animals in New Zealand, measures that owners use to mitigate these effects, and opinions on a ban on the sale of fireworks. Method: A cross-sectional survey of companion animal owners in New Zealand was conducted between 2 November and 5 December 2016 using an online survey. The survey was modelled after a similar study conducted in 2006. Owners were asked to provide information on the types and severity of behaviours observed in their animals that were frightened by fireworks, what they did for their frightened animals and whether they would support a ban on the sale of fireworks. Results: There were 4,293 respondents who completed the online survey and they owned 15,871 companion animals, of which 11,750 (74.4%) were frightened of fireworks. For the 7,464 fearful animals with individual data available, the most commonly reported adverse behaviours were hiding (5,287; 70.8%), shivering (4,058; 54.3%) and cowering (3,324; 44.5%). Owners reported that 345 animals had been physically injured as the result of fireworks. Of 3,682 owners with frightened animals, 2,649 (71.9%) had not sought help or treatment for their animal. Frightened animals were mostly kept inside (3,479/7,464; 46.%) or comforted (2,112/7,464; 28.2%). Of all 4,325 respondents, 3,631 (84.0%) were supportive of a ban on the private sale of fireworks, with 370 (8.6%) against and 315 (7.3%) undecided. Owners with ≥1 animal that was fearful towards fireworks were more likely to support a ban (3,137/3,412; 91.9%) than owners whose animals were not afraid (466/561; 83.1%) (OR = 2.32; 95% CI = 1.80-2.98). Conclusion and Clinical Relevance: Among respondents to this survey, many owners of companion animals reported that their animals were adversely affected by fireworks, but few of them sought advice about strategies to mitigate the impacts. The majority of respondents supported a ban on the private sale of fireworks. Campaigns to raise public awareness of treatment strategies for managing fear behaviours during anticipated fireworks displays may be beneficial.

Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Science and the CBRNE Science Medical Operations Science Support Expert (CMOSSE).

A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.

Dose-Dependent Pulmonary Injury Following Nitrogen Dioxide Inhalation From Kinepak™ Detonation.

BACKGROUND: Nitrogen dioxide (NO2) is a pulmonary irritant produced as a byproduct of bacterial anaerobic metabolism of organic materials, and is also produced as a byproduct of explosive detonations. Significant NO2 exposure results in free-radical-induced pulmonary injury that may be delayed up to 3-30 h after exposure and can progress to acute respiratory distress syndrome (ARDS) and death. Here we present a case series of 3 patients with dose-dependent pulmonary injury consistent with NO2 inhalation following exposure to fumes from detonation of an ammonium nitrate/nitromethane (ANNM) explosive device. CASE REPORTS: Three individuals presented to the emergency department over the course of 16 h, beginning approximately 16 h after exposure to fumes from an ANNM explosive device. Patient 1, with the most significant exposure, developed ARDS necessitating intubation and mechanical ventilation. Patient 2 exhibited hypoxia and findings concerning for diffuse airway inflammation, but ultimately required only supplemental oxygen. Patient 3, with the least exposure, had imaging abnormalities but required no intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Respiratory distress is a common presenting complaint to the emergency department. Because of the delayed presentation and the potential for progressive worsening of symptoms associated with NO2 exposure, it is important that emergency physicians be aware of the multiple potential means of exposure and consider this diagnosis in the proper clinical context. Patients with suspicion of NO2-related lung injury should undergo more extended observation than their initial clinical presentation may suggest.