Most bomb injuries involve combinations of thermal and orthopedic injuries. If possible, definitive surgery should be delayed for at least 24 h if there is suspicion of primary blast lung injury (Bellamy. and. Zajtchuk 1991; S.tap.cZY.n.s.k.i 1992.; Ka.r.m.y.-Jo.n.e.s..MM 199.4.). If laparotomy is required, and the abdomen has suffered a thermal injury, the midline approach is best. The wound can be closed with stainless steel retention wires, which can be adjusted to allow for intra-abdominal swelling and, hopefully, prevent intra-abdominal hypertension. If a colostomy is required, it should not be matured until abdominal distension begins to diminish ( Fig 3). If a pulmonary blast injury is suspected, high-pressure ventilation and high-altitude aeromedical transport should be avoided if possible to prevent air embolism. The treatment of air embolism is supportive, with hyperbaric oxygen providing some benefit.
Fig. 3 (a) A patient who sustained second- and third-degree burns to his abdomen and chest from a parcel device. He also received penetrating injuries from metal fragments and presented with omental evisceration. (b) The abdomen was explored through a midline approach. The wound was closed with stainless steel retention sutures (another option would be to use a Silastic bag). The ostomy was not matured initially.
Land mines often result in traumatic amputations. Aggressive debridement and close monitoring of the wound are necessary. Grenade injuries can usually be managed similarly to shotgun injuries as debridement is not always required.
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