Bomb or explosion-blast injuries are likely to be increasingly encountered as terrorist activity increases and pre-hospital medical care improves. We therefore reviewed the epidemiology, pathophysiology and treatment of primary blast lung injury. In addition to contemporary military publications and expert recommendation, an EMBASE and MEDLINE search of English speaking journals was undertaken using the medical subject headings (MeSHs) ‘blast injury’ and ‘lung injury’. Review articles, retrospective case series, and controlled animal modelling studies published since 2000 were evaluated. 6-11% of military casualties in recent conflicts have suffered primary blast lung injury but the incidence increases to more than 90% in terrorist attacks occurring in enclosed spaces such as trains. The majority of victims require mechanical ventilation and intensive care management. Specific therapies do not exist and treatment is supportive utilizing current best practice. Understanding the consequences and supportive therapies available to treat primary blast lung injury are important for anaesthetists.

Prolonged hypotensive resuscitation is not compatible with survival after primary blast. Casualties most likely to be in this category are those injured by blast in confined spaces or by enhanced blast weapons. The risk of rebleeding associated with normotensive resuscitation needs to be balanced with the metabolic derangement associated with hypotensive resuscitation.

Damage Control Resuscitation (DCR) is a novel concept that draws together a series of technical and organisational advances in combat casualty care. It is consistent with and encapsulates the established concept of damage control surgery (DCS).