Report: The Human Cost of Overpressure—The Silent Devastation of Blast-Induced Barotrauma in Gaza

01 April, 2025

The ongoing conflict in Gaza has witnessed the repeated deployment of high-yield explosives—most notably 2,000-pound air-dropped bombs, heavy artillery shells, and other forms of modern military ordnance—within some of the most densely populated civilian areas on Earth. These explosive devices, designed for conventional battlefield use, are now being unleashed in urban neighbourhoods, refugee camps, and civilian shelters, where the concentration of people significantly amplifies their lethality.

Beyond the visible devastation—collapsed buildings, scorched streets, and civilian casualties—these weapons unleash intense and often invisible forces that result in profound internal trauma. One of the most severe and under-recognised consequences is blast-induced barotrauma, a complex clinical condition caused by the rapid and extreme changes in air pressure produced by the blast wave. Unlike shrapnel or blunt-force injuries, blast-induced barotrauma damages the body from within, affecting air-filled organs like the lungs, ears, and gastrointestinal tract, as well as the brain and central nervous system, even in the absence of external wounds.

This report explores the medical implications of such injuries in the Gaza context, drawing on peer-reviewed medical literature, field reports, and data from conflict medicine specialists. It aims to shed light on the long-term impact of this type of trauma on civilians—particularly children—who are surviving repeated exposure to heavy bombardment without adequate access to advanced medical care or long-term rehabilitation. This report also underscores the urgent need for humanitarian corridors, trauma-informed emergency response, and a reassessment of the legal and ethical implications of using such weapons in civilian zones.

Mechanisms of Blast-Induced Barotrauma

When a high-order explosive—such as a 2,000-pound bomb or artillery shell—detonates, it produces a supersonic blast wave composed of an abrupt spike in atmospheric pressure (overpressure), immediately followed by a vacuum-like drop (under pressure). This pressure fluctuation occurs over milliseconds, creating a phenomenon that the human body is physiologically unprepared to absorb.

The primary blast wave is responsible for primary blast injuries—a unique category of trauma that does not result from flying debris or blunt force, but rather from the intense compression and decompression forces acting on air-filled and gas-containing structures within the body. The organs most vulnerable include:

  • The Ears: The tympanic membranes (eardrums) are extremely sensitive to changes in pressure. Ruptured eardrums, hearing loss, tinnitus, and vertigo are common outcomes. A study published in the Journal of the Royal Army Medical Corps noted tympanic membrane rupture rates of up to 76% in individuals exposed to nearby high-yield blasts.

  • The Lungs: The lungs are particularly susceptible due to their large surface area and air-filled alveoli. Barotrauma may lead to pulmonary contusions, alveolar hemorrhage, pneumothorax (collapsed lung), or even arterial air embolism. According to the U.S. Centers for Disease Control and Prevention (CDC), pulmonary injuries are the most lethal form of primary blast injury and can result in immediate or delayed respiratory failure.

  • The Gastrointestinal Tract: While less commonly fatal, the intestines and stomach can also suffer perforation, haemorrhage, or ischemia due to pressure wave transmission through the abdominal cavity. This risk is elevated when the victim is in a seated or crouched position, as the abdomen is compressed by surrounding musculature.

  • The Brain and Central Nervous System: Blast waves can traverse the skull and impact brain tissue even without direct trauma. This may result in traumatic brain injury (TBI), diffuse axonal injury, and long-term neuropsychiatric effects such as PTSD, depression, or cognitive impairment. Emerging research, including studies from military conflict zones in Iraq and Afghanistan, increasingly suggests that blast-related TBI can occur independently of impact injuries, making it more difficult to diagnose and treat, especially in low-resource settings.

The urban context of Gaza compounds these effects. Buildings, alleyways, and narrow streets act as reflective and amplifying surfaces—bouncing and magnifying the energy of the shock wave, leading to a phenomenon known as “complex blast exposure.” Individuals inside shelters, schools, or homes may face higher internal injuries than those in open areas due to the compression and containment of the blast wave within closed environments.

In children, these effects are even more catastrophic. Their smaller lung volume, thinner skulls, and underdeveloped nervous systems make them particularly vulnerable to multi-organ damage. Furthermore, the emotional and psychological toll of such trauma—especially when repeated over weeks or months—can result in long-term developmental impairment.

Clinical Manifestations

Blast injuries present with a wide range of clinical features, primarily affecting air-filled and delicate anatomical structures. The following are the principal organ systems impacted by primary blast waves, with particular emphasis on the implications for civilians—especially children—in densely populated conflict zones like Gaza.

Auditory Injuries

The auditory system is among the most sensitive to sudden pressure fluctuations. The tympanic membrane (eardrum) can rupture at overpressures as low as 5 psi, serving as a clinical marker for potential underlying blast injuries. In paediatric patients, auditory injury can hinder speech development and learning.

Rupture is often accompanied by:

  • Sensorineural hearing loss, both temporary and permanent

  • Tinnitus (ringing in the ears)

  • Vertigo and balance disorders due to damage to the vestibular apparatus

  • Otorrhagia (bleeding from the ear canal) in severe cases

Pulmonary Injuries

Blast lung is the most lethal primary blast injury and occurs at overpressures starting around 15 psi. These injuries may not be immediately visible on examination and require access to imaging such as chest X-rays or CT scans, resources often lacking in field conditions.

Common clinical findings include:

  • Pulmonary contusions (bruising and bleeding of lung tissue)

  • Pneumothorax (collapsed lung due to alveolar rupture)

  • Haemothorax (accumulation of blood in the pleural cavity)

  • Subcutaneous emphysema and mediastinal emphysema

  • Arterial air embolism, a life-threatening condition caused by alveolar rupture allowing air to enter the bloodstream, particularly dangerous during patient transport

Gastrointestinal Injuries

Although less commonly recognised, the gastrointestinal tract is highly susceptible to barotrauma due to its air-filled segments. In field hospitals or besieged areas, the lack of diagnostic imaging often results in delayed diagnosis, increasing the risk of sepsis and mortality.

Common clinical findings include:

  • Mucosal lacerations and bleeding

  • Bowel perforations, particularly of the colon and jejunum

  • Mesenteric shear injuries

  • Delayed-onset peritonitis, due to initially unrecognised micro-perforations

Traumatic Brain Injury (TBI)

Blast waves can cause primary blast-induced neurotrauma, even in the absence of blunt trauma or external head injury. This occurs due to the transmission of energy through the skull and soft tissues. Lack of neuroimaging and neurosurgical services in Gaza further exacerbates the long-term outcomes of TBI in children.

Common clinical findings include:

  • Mild TBI (concussion): headaches, confusion, memory loss

  • Moderate to severe TBI: cerebral contusions, intracranial hemorrhage, and diffuse axonal injury (DAI)

  • Post-concussive syndrome: lasting cognitive dysfunction, irritability, and depression

  • Pediatric vulnerability: children have thinner skulls and less myelinated neurons, increasing the risk of lasting neurocognitive impairment

Ophthalmic Injuries

The eyes, due to their exposed position and fluid-filled anatomy, are highly prone to blast damage. Injuries range from superficial to vision-threatening, Children, who often cannot shield their eyes in time, face a particularly high risk of permanent vision loss in blast events. ​

Common clinical findings include:

  • Globe rupture and corneal lacerations

  • Retinal detachment

  • Optic nerve trauma and ischemic optic neuropathy

  • Intraocular foreign bodies from secondary blast fragments

  • Burn injuries from accompanying thermal exposure

Gaps in Medical Infrastructure

The medical infrastructure in Gaza has been pushed far beyond the limits of collapse. The relentless bombardment of civilian areas using high-yield explosives has not only overwhelmed the healthcare system with mass casualties, but has also systematically dismantled the very facilities and resources needed to respond to trauma on such a scale. Without urgent international intervention to rebuild and resupply Gaza’s healthcare infrastructure, the long-term health outcomes for blast survivors—particularly children—will continue to deteriorate, leading to preventable deaths, life-long disability, and enduring psychological trauma.

The following critical gaps undermine the immediate and long-term medical response to blast-induced injuries:

Severe Shortages in Essential Medical Equipment

Hospitals across Gaza, particularly in the north, are operating with dire shortages of life-saving equipment. There is a critical lack of:

  • Oxygen supplies – essential for the management of pulmonary blast injuries, especially those involving lung contusions, pneumothorax, and respiratory failure.

  • CT scanners – vital for assessing internal injuries, particularly traumatic brain injuries, internal haemorrhaging, and complex thoracoabdominal trauma.

  • Surgical capacity – both in terms of operating theatres and sterile environments, as well as access to anaesthetics and blood products necessary for emergency intervention.

  • Trained trauma personnel – including emergency physicians, trauma surgeons, anaesthesiologists, and intensive care specialists. The attrition of staff due to repeated attacks on hospitals has exacerbated this shortage.

Destruction of Healthcare Infrastructure

Ambulance services and hospitals themselves have become targets. According to reports from health authorities and humanitarian organisations:

  • Dozens of ambulances have been hit, rendering emergency medical evacuations delayed or impossible in many areas.

  • Major hospitals, such as Al-Shifa and Kamal Adwan, have suffered repeated shelling, occupation, and forced evacuations.

  • Field hospitals and temporary clinics are insufficient to provide the level of care required for polytrauma patients, especially in the case of children suffering multiple-system blast injuries.

Absence of Post-Trauma Rehabilitation

Even when patients survive the acute phase of their injuries, there is almost no infrastructure in place for follow-up care. This includes:

  • Physical rehabilitation – critical for children and adults who have suffered amputations, spinal injuries, or other mobility-limiting trauma.

  • Mental health and psychosocial support – nearly non-existent, despite widespread cases of post-traumatic stress disorder (PTSD), acute grief, and psychological distress in survivors.

  • Long-term monitoring – essential for complications such as chronic pain, lung fibrosis, neurological deterioration, and vision or hearing loss.

Long-Term Consequences

The physical and psychological toll of blast-induced injuries in Gaza extends far beyond the moment of impact. Survivors—especially children—face a lifetime of challenges stemming from both the initial trauma and the collapse of medical infrastructure.

Chronic Physical Impairments

Children exposed to high-intensity blast waves are at increased risk of long-term physiological complications, including:

  • Chronic lung disease such as bronchopulmonary dysplasia or pulmonary fibrosis, resulting from blast-induced lung trauma, prolonged oxygen deprivation, or inadequate critical care.

  • Permanent hearing loss and vestibular dysfunction due to ruptured tympanic membranes and cochlear damage, impairing communication and cognitive development.

  • Mobility loss, including paralysis or limb amputation, caused by direct trauma or secondary complications such as infections and delayed surgical intervention.

Developmental Delays

Blast exposure during early childhood—a critical period for neurodevelopment—has devastating consequences. Prolonged hypoxia (oxygen deprivation), malnutrition, and emotional trauma can lead to:

  • Cognitive delays, including difficulty with memory, attention, and problem-solving.

  • Speech and language impairments, often exacerbated by untreated hearing loss and a lack of therapeutic support.

  • Interrupted education, due to displacement, injury, or the destruction of schools, further entrenching cycles of poverty and marginalisation.

Psychological Trauma and Mental Health Impact

Repeated exposure to violence, the loss of family members, and displacement creates a perfect storm for psychological distress. The compounded effect of these long-term consequences risks creating a generation of children whose health, development, and future potential have been irreparably harmed. For many children in Gaza:

  • Post-Traumatic Stress Disorder (PTSD) is compounded by the absence of safe spaces or access to mental health care.

  • Anxiety, depression, and behavioural disorders are common, and without therapeutic intervention, these conditions may persist into adulthood.

  • Orphaned or unaccompanied children face heightened vulnerability to exploitation and long-term emotional detachment, especially those evacuated without consistent caregivers.

Humanitarian and Legal Implications

The widespread use of high-yield explosives in densely populated civilian areas in Gaza raises urgent humanitarian and legal concerns. The patterns of injury, scale of civilian casualties, and destruction of essential infrastructure point to serious violations of international law.

Violations of International Humanitarian Law (IHL)

  • Indiscriminate attacks and disproportionate use of force in areas with high concentrations of civilians violate the fundamental principles of IHL, including distinction and proportionality.

  • Targeting of medical facilities, ambulances, schools, and shelters—which are protected under the Geneva Conventions—constitutes a grave breach and may amount to war crimes.

  • Denial of humanitarian access and the deliberate obstruction of medical evacuations contravene the obligation to ensure care for the wounded and sick, regardless of combatant status.

Obligations Under the Geneva Conventions

  • As signatories to the Fourth Geneva Convention, States have an obligation to protect civilians during armed conflict, particularly children, the sick, and the wounded.

  • Article 147 classifies the unlawful destruction of property and the wilful killing or causing great suffering to protected persons as grave breaches of the Convention.

  • Common Article 1 obligates all parties—not just those directly involved in hostilities—to ensure respect for the Conventions, including through accountability and legal action where violations occur.

Accountability and Global Responsibility

  • The international community must act to prevent impunity for violations and uphold the rights of victims, including through independent investigations and referral to international legal bodies.

  • Donor nations, humanitarian actors, and UN agencies also bear a responsibility to ensure sustained support for medical evacuation, psychological care, and reconstruction of civilian infrastructure.

The humanitarian crisis in Gaza is not just a moral emergency—it is a legal one. Without meaningful enforcement of international law, the protection it affords becomes symbolic rather than substantive.

A Call to Action: The Urgent Need for International Intervention

The ongoing humanitarian crisis in Gaza requires urgent intervention to address the immediate and long-term needs of civilians, particularly the most vulnerable—children—who have borne the brunt of the conflict. The following recommendations outline key actions that the international community, governments, and humanitarian organisations must take to alleviate the suffering and address the medical and infrastructure challenges in Gaza.

Call for Immediate Ceasefire

  • Immediate cessation of hostilities is essential to prevent further loss of life, particularly among children and civilians. A ceasefire will provide a window for humanitarian aid, medical evacuations, and reconstruction efforts to begin. This is an essential first step in ensuring the protection of civilians and allowing for the stabilisation of the humanitarian situation in Gaza.

Establishment of Medical Evacuation Corridors

  • Creation of secure medical evacuation corridors is critical to ensure that those suffering from blast-induced barotrauma and other injuries can receive the specialised care they need. These corridors should be facilitated by international organisations and monitored to guarantee the safe passage of injured civilians, particularly children, to neighbouring countries such as Egypt, Israel, or further to Europe.

  • International and regional bodies, such as the United Nations and the World Health Organisation (WHO), should coordinate with local authorities to ensure these routes are safe and free from obstruction by ongoing military operations.

Deployment of International Trauma Response Teams

  • In response to the overwhelming medical needs, international trauma response teams should be urgently deployed to Gaza. These teams, consisting of trauma surgeons, critical care specialists, psychologists, and rehabilitation experts, should be prepared to support the local medical community, assist in trauma surgery, and provide care for those with long-term injuries such as amputations and head trauma.

  • The World Health Organisation (WHO), Médecins Sans Frontières (MSF), and other humanitarian organisations should mobilise quickly to provide trained personnel and resources to support local hospitals that are operating beyond capacity.

Funding for Paediatric Prosthetics, Oxygen Supplies, and Rehabilitation

A funding mechanism must be established to ensure the immediate supply of paediatric prosthetics, essential oxygen therapy, and rehabilitation services for survivors, especially children who have suffered amputations or severe lung injuries.

  • Paediatric prosthetics should be prioritised to enable children to regain mobility and independence, significantly improving their quality of life.

  • Oxygen supplies are critical for patients with blast-induced pulmonary injuries, including those suffering from pulmonary contusions or haemothorax.

  • Rehabilitation services must be expanded, particularly for children with long-term developmental delays due to trauma, hypoxia, or neurological damage. This includes physical therapy, speech therapy, and psychosocial support to assist with mental health recovery and address the developmental challenges children face as a result of their injuries.

—End—