Through the crack of a blast, light of care found its way—Multisite Blast injury in a Farmer from Improvised Explosive Device: A Nursing Perspective
Leema Rebbekal Rosy1, Princy2, Esthar Rani3
1Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu
2Nursing In-charge, Kauvery Hospital, Tennur, Trichy, Tamil Nadu
3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu
Abstract
Blast injuries are rare in rural healthcare settings and present unique challenges to emergency and critical care teams. This article discusses the case of a 39 years old male with multisite puncture wounds sustained from an explosive device while intended to deter wild pigs from farmland. We highlight the nursing assessment, prioritized nursing diagnoses, collaborative management, and the role of critical care nursing in improving outcomes.
Introduction
Rural injuries involving explosive devices are uncommon but often severe. The complexity of managing such cases involves multidisciplinary coordination, rapid assessment, and skilled nursing care. This case illustrates the importance of critical care nursing in trauma management.
Background history
The patient was 39 years, married and had two female children and one male child. He was working as a driver and was maintaining his agricultural land too.
On his agricultural land, day by day, he was facing disturbances from pigs. So, one day he thought of detering all pigs from his land. So, he placed a bomb to avoid the pigs. After placing the bomb, he kept monitoring. The next day he went to the agricultural field by morning 6am. He happened to touch the bomb and that was when the bomb blasted. He sustained injuries and was immediately admitted to the hospital.
Elaboration
Blast injuries, particularly those caused by IEDs, can be classified into four categories: primary, secondary, tertiary, and quaternary.
- Primary injuriesare due to the blast wave itself, affecting organs like the ears, lungs, and gastrointestinal tract.
- Secondary injuriesresult from projectiles or shrapnel from the explosion.
- Tertiary injuriesare caused by the victim being thrown by the blast wave, leading to blunt trauma.
- Quaternary injuriesinclude burns, inhalation of toxic gases, and traumatic asphyxia.
In the case of the farmer, the injuries are likely secondary and possibly tertiary blast effects, given the use of an IED. The farmer’s injuries are a combination of puncture wounds, abrasions, and potentially dust tattooing from explosive materials. The severity and location of these injuries would depend on factors such as the type of IED used, the distance from the blast, and the presence of debris.
Case presentation
A 39 years old male farmer, who also worked as a driver, presented to the Emergency department with multiple small puncture wounds over the upper limbs, chest, abdomen and left lower limbs. The injury occurred due to the unexpected detonation of a crude explosive device originally planned to deter pigs from his farmland.
The patient was alert upon arrival with stable vitals, but subsequently developed desaturation. His wound pattern indicated a low-grade but widely dispersed blast injury caused by embedded small metal projectiles.
Nursing Assessment
Airway and Breathing: Patient airway RR-26/min, Spo2 dropped to 89% on room air. Supplemental oxygen initiated.
Circulation: Pulse 124/bpm, BP 124/82 mmhg; Capillary refill <2 seconds; bilateral peripheral pulse was felt. CV: S1S2 (+).
Disability: He can move all 4 limbs. He was drowsy (mild) and restless but his GCS was 15/15. His GRBS value was 115mg/dl.
Exposure: Multiple puncture wounds with minor bleeding, no active arterial bleeding noted.
The CT Scans of chest & abdomen plain and contrast study showed: –
- Multiple radiopaque foreign bodies in chest & abdomen as described.
- Bilateral hemothorax.
- Bilateral pneumothorax (Left > Right).
Provisional diagnosis
Blast injury/Penetrating injury. Bilateral hemothorax. No free fluid.
Team assessment and interventions
Upon the patient’s arrival in the Emergency Department, a multi-disciplinary team approach was initiated promptly to ensure comprehensive care. The Emergency Room physician activated the trauma response and conducted an initial primary and secondary survey using the ABCDE protocol. As the patient presented with desaturation and multiple injury sites, a coordinated discussion with key departments was followed:
Emergency Physician Assessment
The ER physician did the initial evaluation and prioritized airway and breathing, given the desaturation. Although the patient was hemodynamically stable, supplemental oxygen was immediately provided, and the patient was kept under close observation for any signs of respiratory compromise. The physician noted a pattern of puncture wounds and suspected the presence of embedded foreign bodies, prompting further investigation.
Radiology Team Involvement
CT imaging of the chest, abdomen, and pelvis revealed multiple radio-opaque foreign bodies scattered across the thoraco-abdominal region. Significant findings include bilateral hemothorax and bilateral pneumothorax, with more extensive involvement on the left side. These findings confirmed the extent of internal trauma and guided the surgical and pulmonology teams in prioritizing management strategies. Radiological input was critical in identifying hidden injuries and ensuring comprehensive trauma assessment.
Surgical Gastroenterologist Assessment and Interventions
The presence of abdominal puncture wounds and signs of desaturation raised the suspicion of possible intra-abdominal injury. Although initial vitals were stable, the mechanism of injury and the potential for internal organ damage prompted urgent surgical evaluation.
Clinical Examination and Findings
The surgical enterologist performed a focused abdominal examination and found, tenderness and guarding behavior over the left hypochondriac and epigastric regions. Multiple superficial and deep puncture wounds across the abdomen, based on the high likely of internal injury, the surgical team recommended immediate exploratory surgery.
Emergency Laparotomy
The patient was taken to the operating theatre under emergency conditions. Intraoperative findings revealed: removal of penetrating metal balls and primary closure of perforation, 3 intra peritoneal metal balls; two causing small boiled perforation and one lying in small bowel mesentery. 4 metal balls removed from various site in partial wall under C arm guidance. 1 metal ball close to IVC in right sub diaphragmatic region couldn’t be identified by palpation.
Postoperative Plan and Nursing Implications
The patient was transferred to the Critical Care Unit for close monitoring postoperatively, NPO status was maintained initially, with gradual introduction of oral feeds intake based on bowel sounds and recovery. Broad-spectrum IV antibiotics were administered to prevent peritonitis; vital signs, abdominal girth, and drain output were monitored hourly by the nurses ensuring timely administration of analgesics and antibiotics. Respiratory physiotherapy was performed to prevent postoperative complications, wound site care was carried out with strict aseptic precautions, early ambulation was encouraged once hemodynamically stable, in-coordination with the physiotherapist.
Family Communication and Support
The surgical team, along with the critical care nurse, explained the surgical findings, the nature of the injury, and the need for ongoing monitoring to the patient’s family. Counselling was provided on wound care, dietary progression, and signs of potential complications.
Pulmonologist
Given the patient’s initial desaturation and chest involvement from the blast injury, a pulmonologist was consulted to evaluate possible respiratory compromise, including blunt chest trauma, pneumothorax, pulmonary contusion, or inhalation injury.
Clinical Evaluation
The pulmonologist conducted a focused respiratory examination and noted reduced air entry in the left lower chest. There were no signs of tracheal deviation, crepitus, or flail segments. The patient had a productive cough but no hemoptysis. Breath sounds were mildly diminished at the left base.
Imaging and Diagnostics
The pulmonologist reviewed the chest X-ray and CT thorax, which showed pneumothorax, hemothorax and soft tissue contusions, subcutaneous metallic foreign bodies. No lung parenchymal injury or pulmonary edema was observed.
Interventions and Recommendations:
- Initiated oxygen therapy via face mask to maintain SpO2 >94%.
- Advised chest physiotherapy and incentive spirometry to prevent atelectasis and promote lung expansion.
- Recommended close monitoring for delayed pulmonary complications such as infection, effusion, or ARDS (Acute Respiratory Distress Syndrome).
- Suggested serial ABG (Arterial Blood Gas) monitoring and SpO₂ tracking.
- Bronchoscopy + Bilateral ICD Placement done.
Intensivist and Critical Care Nursing Team
The intensivist was involved to assess the need for ICU admission due to the desaturation episode and the potential for delayed blast-related complications such as compartment syndrome, pneumothorax, or secondary infection. Based on stable hemodynamics and oxygen saturation improvement with supplemental oxygen, the decision was made to monitor the patient in ICU unit.
Following the emergency laparotomy, the patient was shifted to the Intensive Care Unit (ICU) for postoperative management. He was on mechanical ventilation due to intraoperative instability and respiratory distress secondary to bilateral pneumothorax and hemothorax. The intensivist led a detailed evaluation of the patient’s hemodynamic status and respiratory parameters.
The critical care nursing team provided continuous monitoring of vital parameters, ventilator settings, ABG results, and drain outputs. Nurses performed regular oral care, maintained strict asepsis during suctioning and line access, and coordinated care with the multidisciplinary team. Early signs of weaning readiness were communicated to the intensivist, and family members were kept updated about the patient’s progress.
Surgical Management
Emergency Laparotomy: Removal of penetrating metal balls and primary closure of perforation: Three intra peritoneal metal balls, two causing small boiled perforation and one lying in small bowel mesentery. Four metal balls removed from various site. Partial wall under C arm guidance. One metal ball close to IVC in right sub diaphragmatic region wouldn’t be identified by palpation.
Pulmonology Procedure
Bronchoscopy + Bilateral ICD Placement.
Ortho procedure
Tennis nailing + K-wire fixation+ Wound exploration + Debridement + Soft tissue repair.
Plastic Procedure
Discussion
Blast injuries in rural settings are uncommon and often results from accidental or improvised explosive devices, in this case, the patient’s intention to deter wild pigs from damaging his crops led to the unfortunate of a crude explosive, which detonated unexpectedly and caused a multisite injury. The uniqueness of this case lies not only in the nature of the injury but also in the psychosocial gaps that contributed to the event.
From a nursing standpoint, the case highlighted several critical responsibilities: initial triage, focused assessment, early identification of complications, coordination with interdisciplinary teams, and continuous monitoring. The emergency nursing team quickly recognized signs of desaturation, indicating a possible chest involvement despite initially stable vitals. The decision to initiate oxygen therapy and prepare for potential airway support was crucial in preventing hypoxic complications.
A significant challenge in blast injuries is the risk of embedded foreign bodies and the potential for internal injuries that are not immediately apparent. Nurses played a pivotal role in preparing the patient for imaging studies, providing prophylactic care and managing pain through prescribed analgesics.
The psychological impact of such trauma was also inevitable. The patient experienced anxiety related to both the injury and the underlying stressors—namely, the ongoing damage to his farmland and the perceived need to take drastic action. The nursing team role in emotional reassurance and therapeutic communication helped to reduce the patient’s anxiety and fostered trust in the care process.
In conclusion, this case exemplifies the multifaceted role of nurses in trauma care—combining clinical acumen, compassionate support, patient education, and interdisciplinary coordination to deliver holistic care.
Nursing Diagnosis
- Problem: Impaired skin integrity
Etiology: Related to blast injury
As evidenced by: Multiple puncture wounds. - Problem: Impaired gas exchange
Etiology: Thoracic injury
As evidenced by: Desaturation, SpO₂ 86% - Problem: Actual infection
Etiology: Related to open wounds and presence of foreign bodies
As evidenced by: Multiple puncture wounds. - Problem: Acute pain
Etiology: Related to tissue injury
As evidenced by: Pain score – 10 - Problem: Anxiety
Etiology: Related to traumatic incident and hospitalization
As evidenced by: Patient looks dull and fearful
Nursing management
Our team powerfully managed this patient after completing the surgery. He was shifted to critical care unit, monitored by using noninvasive BP, pulse rate and skin temperature and colour, capillary refill time, pulse oximeter and invasive therapy when required.
The following interventions and management steps were implemented:
- Initiation of lung-protective mechanical ventilation strategy
- Placement of bilateral intercostals chest drains to manage pneumothorax and hemothorax
- Administration of broad-spectrum IV antibiotics and analgesics
- Hemodynamic monitoring with vasopressor support as required
- Sedation management to ensure ventilator synchrony and patient comfort
- Electrolyte and fluid balance monitoring
- Nutritional support via nasogastric tube
The patient had pain (his pain score was 6) Temp. 98.4°F; PR: 98b/mts; RR: 24b/mts; SpO2: 97% with O2 support; BP: 100/70 mmHg. Immediately provided the analgesics and positioned comfortably.
Monitor intake and output hourly. Initially after surgery he was on NPO and RT continuous. Fluids were administered through IV first for NPO & dehydration.
IVF NS & RL was given at 100 ml/hr. After NPO, slowly started sips of water then changed to clear liquids followed by full oral liquids then soft diet. Finally, after taking good oral feeds IVF were stopped.
ICD and drains monitored daily. After collections reduced the DT was removed. Pulmonologist assessed and removed the ICD’s then advised to take chest X-ray. Plastic team and ortho team changed the dressing. Physiotherapy was also provided on daily basis. Patient’s health status was improved, and extubated form ventilator support, and transferred from critical to ward.
Health education
Medication
Educated the patient and family members regarding taking medicines regularly on time.
Doctors, nurses and dietitians educated on post-operative diet to avoid nutritional deficiency.
Pain is often for surgical patient. Surgeon recommended some analgesics like Tab. Pyrigesic 1gm TDS, Tab. Cyclopam BD.
Constipation is a concern, so the consultant advised Syp. Cremaffin Plus 10ml Hs and educated to take fiber rich diet.
Advice on activity
- Avoid driving for few months and resume after consultation.
- Avoid heavy lifting.
- Perform deep breathing exercise and respirometry exercise.
- Go for a walking to relax
Wound care
- Change dressing as per doctor’s advice.
- Don’t wear tight cloths.
- Wear clean washed loosened cloths.
- Keep the surgical site clean and healthy.
- Note, for any redness, swelling, warmth or any discharge from surgical site they may need immediate medical attention as soon as possible.
Psychological support
Emotional and psychological support to the patient and their family members was given. Provided best practices and care, so the patient and their family members were well satisfied. The patient’s health status was improved and we obtained good outcomes.
Nurse as a good counselor
Timely patient condition was explained to the family members. Nursing team gave emotional and psychological support to patient and family members. Provided coordination and better communication with other team members. Finally, patient health was improved and attained positive outcomes. Hence, he was discharged.
Conclusion
This case highlights the complex clinical and ethical challenges associated with blast injuries caused by non-definitive explosive devices in rural setting. The patient survival and recovery was made possible through rapid multidisciplinary intervention including surgical pulmonological radiological and intensive care expertise.
Nursing care played a vital role throughout –initial support to critical post-operative monitoring and family education. This case emphasizes the importance of early identification of internal injuries effective interdisciplinary communication and adherence to evidence-based nursing practices
